Patient experience-of-care measures have been identified as critical for increasing the quality of care in the U.S. Expanding patients’ involvement in their own care has shown to improve health outcomes.1,2 Access to reliable, meaningful, and understandable health care information empowers patients to determine which providers offer high-value care and to make health care decisions that are aligned with their personal needs.
The National Quality Strategy (NQS), part of the Affordable Care Act (ACA), sets priorities to guide local, state, and national efforts to improve the quality of health care in the U.S. The NQS aims to provide better, more affordable care, includes person- and family-centered care as one of its top priorities3; and gives precedence to the inclusion of validated patient experience-of-care survey measures in national payment, quality improvement, and public reporting programs. This column summarizes the benefits and application of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS).
What is the purpose of S-CAHPS?
To offer surgical patients and surgeons valid and reliable information on patient experience of care, the American College of Surgeons (ACS), in partnership with other surgical and anesthesia organizations, sponsored the development of the S-CAHPS. The S-CAHPS is a patient experience-of-care survey measure specifically tailored for surgical patients. The S-CAHPS survey was developed by working with patients to report on the full experience of surgical care, including their experience with the surgeon, the anesthesiologist, and the facility. The data gathered through S-CAHPS assist consumers in identifying a high-quality surgeon and help surgeons to better understand and ultimately improve patient care.
What does S-CAHPS measure?
In 2007, the ACS, in partnership with other surgical and anesthesia organizations, reviewed the Clinician and Group CAHPS (CG-CAHPS), which measures patients’ perceptions of care in the physician office setting, and concluded that it did not adequately capture information that is relevant to patients’ assessment of surgical care. As a result, the surgical and anesthesia groups and the Agency for Healthcare Quality and Research’s (AHRQ) CAHPS Consortium collaborated to create a CAHPS survey to assess surgical patients’ experiences and thereby identify opportunities to improve quality of care, surgical outcomes, and patient experience. CAHPS is a multi-year initiative of AHRQ to support and promote the assessment of consumers’ experiences with health care.4 AHRQ is an agency of the U.S. Department of Health and Human Services that seeks to improve the quality, safety, efficiency, and effectiveness of health care services by supporting research that helps people make informed decisions.
The development of the survey followed the standardized and evidence-based methods that are used in the creation of all CAHPS surveys. The S-CAHPS expands on the CG-CAHPS Survey, which focuses on primary and specialty care, by incorporating domains that are relevant to surgical care, including informed consent, anesthesia care, and postoperative follow-up. The survey assesses surgical patients’ experiences before, during, and after surgical procedures and focuses on concerns that patients identified as most important to their experience. Specifically, the S-CAHPS survey captures data on such issues as how well patients were prepared for their operation, how well the surgeon communicated with them about what to expect when having an operation, and what information was provided to aid in recovery. The use of this type of standardized surgical care survey is critical in comparing individual practice against benchmarks.
To develop the S-CAHPS survey, six patient focus groups were formed to identify important quality issues inherent in patients’ experiences of surgical care. Nine surgical specialties—colon-rectal, ophthalmology, general, orthopaedic, plastic, otolaryngology, thoracic, urology, and vascular—participated in the main field test. The S-CAHPS Technical Advisory Panel included 21 representatives of various surgical specialty societies.
How is S-CAHPS used to measure quality?
The S-CAHPS is the only National Quality Forum (NQF)-endorsed measure designed to assess surgical quality from the patient’s perspective. The NQF endorses quality measures through scientific and evidence-based review and a multi-stakeholder consensus development process with the aim of improving quality of care. Measures that the NQF endorses are rigorously reviewed to determine whether they meet certain criteria, including the ability to make significant gains in health care quality, scientific acceptability, usability, feasibility, and reliability. NQF endorsement confirms that the survey meets the “gold standard” in quality measurement. The NQF endorsed the S-CAHPS as a measure that includes six composite measures and one single-item measure (see Figure 1). Composite measures summarize categories of experiences, thereby shortening the report, which makes it easier for consumers to understand. (Figure 2 provides an example of a composite measure included in the S-CAHPS.)
|NQF-endorsed S-CAHPS survey measures|
|S-CAHPS composite measures:|
|Information to help you prepare for surgery (2 items)|
|How well surgeon communicates with patients before surgery (4 items)|
|Surgeon’s attentiveness on day of surgery (2 items)|
|Information to help you recover from surgery (4 items)|
|How well surgeon communicates with patients after surgery (4 items)|
|Helpful, courteous, and respectful staff at surgeon’s office (2 items)|
|S-CAHPS single item:|
|Rating of surgeon (1 item)|
|NQF-endorsed S-CAHPS Composite|
|How well surgeon communicates with patients after surgery|
|1. After your surgery, did this surgeon listen carefully to you?|
|2. After your surgery, did this surgeon spend enough time with you?|
|3. After your surgery, did this surgeon encourage you to ask questions?|
|4. After your surgery, did this surgeon show respect for what you had to say?|
|Response options: Yes, definitely; Yes, somewhat; No|
Why should surgeons use S-CAHPS?
Surgeons can be confident that survey results will accurately assess patients’ surgical care experiences because S-CAHPS was developed in consultation with patients using the most sophisticated, valid, and reliable methodologies available in survey and measurement science. An important distinction when comparing patient experience versus patient satisfaction is that patient experience measures aspects of care that are actionable for surgical quality improvement. And because the survey instrument, protocol, analysis, and reporting are standardized, surgeons can benchmark and compare their performance with that of their peers.
Surgeons may customize the S-CAHPS survey by adding survey items that are specific to their patients and practice. However, the core survey must be used in its entirety in order to be comparable with other S-CAHPS data. The S-CAHPS survey may be used in both the inpatient and outpatient setting.
Where are CAHPS surveys being used?
The implementation of patient experience-of-care measurement is a priority for national payment and public reporting programs. The Centers for Medicare & Medicaid Services (CMS) has included the CG-CAHPS survey in the Physician Quality Reporting System (PQRS) as a measure that may be applied to the physician value-based payment modifier (VM) under the quality-tiering option for PQRS reporters, and as a measure that may be reported for large group practices on the CMS Physician Compare website. The American Board of Surgery (ABS) has also elected to participate in the PQRS Maintenance of Certification Incentive Program. In order to be eligible for the incentive payment associated with that program, a surgeon must submit data on patient experience-of-care surveys. Following are descriptions of how CAHPS surveys have been incorporated into quality improvement programs.
How does my practice use CAHPS when applying the VM?
The Affordable Care Act (ACA) requires staged implementation of a VM to physicians enrolled in the Medicare program. The VM will be applied to specific physicians and groups of physicians starting in 2015 and to all physicians and groups of physicians by 2017. Under this program, physicians who report through PQRS have a few reporting options, including a quality-tiering option that calculates the VM based on a quality-of-care composite score and a cost composite score. For those who choose the quality-tiering option, PQRS patient experience measures are included as one of the domains of the quality composite, as illustrated in Figure 3. Currently, CG-CAHPS is the only patient-experience-of-care measure in the PQRS program, and thus the only measure of its type that can be used to calculate the VM. The ACS has emphasized to CMS that it is critical that the measures included in the quality-tiering composite are valid, reliable, and applicable to all health care professionals, to avert the unintended consequence of misclassifying a physician’s care and unfairly affecting payment.5
Where can surgical patients get information on patient experience of care? Is CAHPS information reported on Physician Compare?
Physician Compare is a website that provides information to consumers to help them make better-informed health care decisions and to encourage physicians to maximize performance.6 In support of consumer choice and value-based purchasing, the ACA requires CMS to publicly report patient experience-of-care measures on Physician Compare. As early as 2014, CMS will include the names of physicians who earned a PQRS Maintenance of Certification (MOC) Payment Incentive on Physician Compare and will post performance information collected through the PQRS Group Practice Reporting Option (GPRO) Web interface, which applies to groups of 100 or more providers, and for groups that participated in the Accountable Care Organization GPRO. For similar reasons for concerns regarding the inclusion of measures that could misclassify a physician’s care and impact payment, it is critical that CMS select measures that accurately attribute patient care so that patients can select physicians who truly deliver high-value care.
Can I report CAHPS as part of MOC?
During 2013 and 2014, physicians who participate in PQRS have the opportunity to earn an additional 0.5 percent incentive payment through the PQRS MOC Payment Incentive Program. Physicians may participate by (1) satisfactorily submitting data on quality measures under PQRS for a 12-month reporting period, and (2) reporting “more frequently than is required” to qualify for or maintain board certification.7 As part of this program, the ABS will submit information from a patient experience-of-care survey. The ABS has applied in 2013 for CMS approval of its MOC program for the PQRS MOC Incentive and will include S-CAHPS as a patient experience-of-care survey option. For more information on the submission process, contact the ABS.
The CG-CAHPS is the first step in the implementation of patient experience-of-care measures across physician-level CMS programs. The Hospital CAHPS (H-CAHPS) has been used nationally since 2008 for facility-level patient experience of care.8 The ACS has recommended the future inclusion of S-CAHPS for the VM, Physician Compare, and PQRS, stressing that the CG-CAHPS is not equally meaningful to surgical patients, and is an inappropriate patient experience-of-care survey for surgeons and surgical groups.
The S-CAHPS assesses care by focusing on aspects of surgical quality that are important to patients and for which patients are the best source of information. As patient experience-of-care measures are increasingly incorporated into public reporting and payment programs, it is especially important that the patient-centered instruments chosen accurately reflect patient experience and are meaningful to both consumers and surgeons. For more information and to access the survey, visit the ACS website.
- Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med. 1985;(102):520-528.
- Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995;(152):1423-1433.
- U.S. Department of Health and Human Services. 2012 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care. Available at: www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf. Accessed June 3, 2013.
- Agency for Healthcare Quality and Research. CAHPS. Available at: http://cahps.ahrq.gov/about.htm. Accessed June 3, 2013.
- Centers for Medicare & Medicaid Services. Value-based payment modifier. Available at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. Accessed June 3, 2013.
- Byers R, Estella C, Adams S. Centers for Medicare & Medicaid Services: Public reporting, Physician Quality Reporting System (PQRS), Group Practice Reporting Option (GPRO), and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Presented at: Surgical Quality Alliance Meeting, March 2013, Washington, DC.
- Centers for Medicare & Medicaid Services. 2013 Physician Quality Reporting System (PQRS) maintenance of certification program incentive. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Maintenance_of_Certification_Program_Incentive.html. Accessed June 3, 2013.
- Agency for Healthcare Research and Quality. HCAHPS fact sheet reference. Available at: www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%20May%202012.pdf. Accessed June 3, 2013.
- Centers for Medicare & Medicaid Services. Quality-tiering methodology, physician value-based payment modifier under the Medicare physician fee schedule 2013 final rule. Available at: www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/Presentation-QRUR-112012.pdf. Accessed June 3, 2013.