Perception versus practice in quality of care

Patients’ perceived quality of care varied greatly from the actual quality of care as defined by adherence to guidelines, according to a study published in the Journal of Clinical Oncology last month. Researchers surveyed 374 women receiving treatment for early stage breast cancer at New York City hospitals and asked the patients to rate the care they received. Only 55% of women indicated that they received excellent care, despite the fact that 88% of the women received care that is considered in line with the best treatment guidelines. The findings of the study could have huge implications for hospitals and other healthcare organizations, particularly as insurers use performance and quality metrics to determine reimbursement.

Several factors influenced the women’s perception of care and patient satisfaction. The ease or difficulty of obtaining initial treatment correlated to the rating of quality: 60% of women who said they received excellent care also said the process of getting care was excellent, but only 16% of women who rated care as less-than-excellent said that the process of receiving care was excellent. Race also contributed to perceptions of quality. The survey found that African-American women were less likely to report excellent care and less likely to trust their doctor than Caucasian or Hispanic women, and were more likely to say they experienced racism during the treatment process, despite the fact that there was no difference in the actual quality of medical care the women received.

Communication and interactions with medical personnel also made a difference in the perception of quality. Women who reported having good communication with their physician, a clear understanding of which staff member to turn to with questions, and generally excellent  treatment from the medical staff were more likely to rate their overall quality of care as excellent. The same group of women also felt less mistrust of the medical system.

Although this study examined only a small sample of patients, its findings can be applicable at most institutions. The researchers on the study conclude that healthcare organizations should improve the perceived quality of care by making it easier for patients to obtain care and by establishing trust between patients and healthcare staff. In both instances, clear and detailed communication could aid in improving patient perceptions.

Has your organization noticed a difference in the actual quality of care patients receive and patients’ perceptions of quality? What have you done to align the two? Post a comment below.

Create patient safety solutions that are right for you

Editor’s note: Columnist Catherine Hinz, MHA, works as a leader in patient safety at HealthEast Care System in St. Paul, MN. Hinz previously worked at PatientSafe Solutions, Inc. Hinz has also completed a patient safety internship with the Agency for Healthcare Research and Quality. The following is an excerpt of her monthly column, which can be found in its entirety in Patient Safety Monitor Journal.

Patient safety has long stood on a variety of tenets, some of which have formed the process and basis for how professionals (both leaders and clinicians) conduct improvement work. Some of these are well-known and accepted: Patient safety is a right. A high level of patient safety performance is nonnegotiable. Quality, risk, and patient safety are inseparable. A healthy culture is at the core of ideal patient safety performance.

I agree with all of these; however, there are two tenets of the patient safety movement that, while I believe do exist, I am beginning to question more as my leadership perspective evolves: that organizations do not compete over patient safety, and that sharing best practices is one of the best ways to improve across units, systems, and organizations.

Let’s first talk about competition. Historically, organizations have not experienced the shortage of resources, restricted access to capital, and flat patient volumes they are experiencing now. Therefore, the competition among organizations has never been fiercer. The uncertainty of health reform, organizational structure, and new regulations adds a layer of complexity that also has not been seen before. Regardless of the final outcome of health reform, it is certain that reimbursement will, more often than not, pit peers against each other in races of efficiency, cost reduction, and quality.

It is a certainty, then, that competition will reign even in the realm of patient safety. Organizations will discover new and better ways to avoid adverse events and near misses, and they will be incentivized in many cases not to advertise the mechanics of how they did it-no matter how ­helpful sharing these best ­practices might be for other, lagging organizations and the communities they serve. As it does now, safer care will improve reputations thanks to public reporting and greater consumerism in healthcare choices, but it will also potentially allow hospitals to retain or collect additional payment, creating more competition.

The market forces are providing the right environment for competition to be a strong contributing factor in the race for improved patient safety and zero harm, but not necessarily toward sharing practices; therefore, the idea that we should not compete in all things patient safety might not be the best path forward.

Read more.

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The many measures of patient safety and quality

Defining quality through a patient’s eyes

Editor’s note: Columnist Catherine Hinz, MHA, works as a leader in patient safety at HealthEast Care System in St. Paul, MN. Hinz previously worked at PatientSafe Solutions, Inc. Hinz has also completed a patient safety internship with the Agency for Healthcare Research and Quality. The following is an excerpt of her monthly column, which can be found in its entirety in Patient Safety Monitor Journal.

There are always times to come back to center-to return to why we work so hard to improve processes, performance, and measures like overall hospital ratings. In the sea of scores, metrics, and meetings we often drown in, we forget to come up for air and see that relationship with patients who seek care and healing from (and with) us.

As of late, I’ve spent more time learning about very specialized patient populations. These are patients who are served by disparate health systems, and who are often cared for by community or state organizations. These are patients with many needs and challenges-mental illness, chemical addiction, homelessness, and other atypical situations where the normal metrics of quality may not apply in the ways they were originally designed.

Think of the patient population suffering from traumatic brain injuries, who may now pose a substantial safety risk to themselves. This population has intensive and specific care needs, and thus they have a different set of expectations of quality, which may be defined in terms of activities of daily life and relationships with caregivers and family.

Through learning more about specialized patient populations, I’ve learned that “quality” can be ambiguous and that its true definition is a moving target. I’ve come to the conclusion that quality really needs to be dictated by the specific needs and desires of the patients and the families who care for them-not by the organizations, who are searching for a simple way to measure and ultimately pay for care.

Patient safety, while closely related to quality in many ways, is far different in that it represents freedom from accidental injury and harm.

Read more.

CAUTIs still a problem

Bit of a plug, but I think my visitors will find HCPro’s webcast on CAUTIs (catheter-associated urinary tract infections) extremely relevant, especially as CAUTIs cause 35% of all hospital-acquired infections every year, with 38,000 patient infections, and costing hospitals $400 million a year, according to an October 2011 National Quality Forum’s Partnership for Patients/ National Priorities Partnership webinar.

And don’t forget that The Joint Commission named CAUTIs a National Patient Safety Goal to be fully implemented by 2013. The Partnership for Patients also aims to reduce preventable CAUTIs by 50% by 2013.

So join nurse practitioner Mikel Gray, PhD, PNP, FNP, CUNP CCCN, FAANP, FAAN, and chief of infection prevention and 2012 APIC conference speaker Brian Koll, MD, FACP, FIDSA, for a live presentation of proven methods on CAUTI reduction, including how Beth Israel Medical Center reduced the number of CAUTIs by 83% using proven organization-wide catheter best practices such as evidence-based practice, staff education, daily need assessments, multidisciplinary teamwork, monitoring, and root-cause analysis. You’ll also get best practices to educate and train your entire staff.

Learn more here.

Just a note that now, you can buy the live audio and download the on demand version free.

HCAHPS information studied by demographics

Interestingly, a new study of HCAHPS scores shows that when you split up the survey by sex, men are more favorable in rating their care. If patients were older and sicker, the difference was even more pronounced. Women were particularly more dissatisfied than men in the area of the information they received regarding medication and discharge instructions. They also tended to rate cleanliness lower.

Unfortunately, I have a sneaking suspicion that more detailed, demographic-related information like this will be used just as marketers use TV demographics to shape their advertisements. Of course, hospitals are business, and patients are already consumers. But how far do we take that?

Studies like this, while informative, might lead to a scenario where a nurse is told how to behave one way around his or her 23-year old male patient, and another way around a 45-year-old female patient. I suppose most care providers do act differently to different demographics, but is it for hospital marketers to dictate to them exactly how to act? Do you think it will ever come to that?

I don’t blame hospitals—with HCAHPS tied to reimbursement, HCAHPS scores must be a focus of attention. I just worry that instead of it giving more power to the patient to change healthcare, healthcare will instead just react by patronizing the patient and pandering to the test.

Hospitals should turn their attention to quality, safe care that focuses on communication with each other and the patient. I believe that is more likely than any well researched marketing effort to provide positive patient satisfaction scores. What do you think about reimbursement tied to HCAHPS? Post a comment below.

The push and pull of quality initiatives

Sometimes quality can be a bit like a game of whack-a-mole. As you try to improve in one area, another area falls off the radar, gets worse, and  you winding up shifting resources every quarter, back and forth in a reaction to data. Like whack-a-mole, you keep trying to hit moving targets.

But perhaps there’s more happening behind the scenes than you think. Maybe it’s more like tug-of-war: As you pull at one quality initiative, you inadvertently cause the another one to suffer. This has more of an effect than simply shifting focus and resources away. For example: A hospital tries to reduce falls, and accidentally winds up increasing catheter-associated urinary tract infections because instead of working on mobility, staff are keeping patients in bed with catheters to ensure they don’t fall on their way to the bathrooms.

Now, here’s another one: Longer length of stay may actually reduce readmissions. As hospitals work to reduce length of stay, are they shooting themselves in the foot? An international study of 7,000 patients showed a significant relationship to length of stay and the probability of a readmission in heart failure patients. Although it’s unclear what about the extra time helps, it could be a number of things: better clinical stability, better discharge planning and patient education, etc.

My previous post that discussed how standardized quality measures might actually hurt perception of quality care is yet another example of this tug-of-war.

If one initiative hurts another, you might want to throw your hands up in the air and be done with it. But many of these complex issues have solutions, though the solutions are tough and often require more resources, especially up front: Working on mobility, which cuts falls and the need for catheters, spends nurses’ time–one of the most valuable items you can spend. Perception of care—if the care is actually good—can often be raised with better communication (e.g., explaining to a patient why a quality measure is implemented), but this again takes the time of nurses and physicians. Though harder to implement, these solutions do not harm other initiatives; instead, they coexist toward the same goal of improving patient health. Separate quality initiatives cannot be conducted in a vacuum. They all relate to one another, because they all relate to patient care.

Stop fighting these separate quality improvement battles that waste resources. (Remember, the problem might be worse than just an inefficient war strategy; one winning battle may actually be causing a loss somewhere else. And we want to fight a war against patient harm and inefficient healthcare, not each other.) Hospitals need leaders who have the ability to step back, see all the pieces of the puzzle, and take the time to think critically to coordinate these efforts toward the same goal. A well thought-out, truly patient-centered strategy may take more time and planning, but will use fewer resources and achieve better results. Work smarter, not harder!

Win-lose? Why quality measures might lead to poor HCAHPS scores

New research indicates that implementing quality measures can improve clinical outcomes but may create a lower patient perception of quality care.

Ohio State University researchers studied lots of data from all over and determined that, at least in the short-term, implementing standard quality measures might negatively hit your patient satisfaction scores.

The problem is this: Standardization is good for preventing and catching potential errors, and it’s good for tracking and benchmarking. It’s also necessary for regulatory compliance in a lot of ways. Unfortunately, this standardization sometimes overshadows the patient, who can be treated a bit like a cog in the machine instead of a unique individual.

Is this a problem in your hospital? Like most things, I think communication here is the bridge that can melt standardized processes and patient perception into a one cohesive and positive experience. For example, if you give a patient a test or medication because the quality measure indicates the patient qualifies for it, does the patient know that?

An semi-educated guess of mine is that physicians often withhold telling patients that standards, regulations, and public reporting make them prescribe or do anything. But I think if you let patients know that based on research, doing X, Y, and Z is shown to help patient like yourself, most will be appreciative and find the experience more pleasant.

Ultimately, better clinical care and standardized processes will allow for providers to have more time with patients and patients will be healthier, so it may very well smooth over in the end. Right?

What do you think? Is it communication, or are hospitals becoming too standardized and obsessed with quality measures? Or is this a blip that will pass?