1. 1. Confirming and Supplementing CAHPS® Communication Items Using Feedback from High-Performing Physicians. Ron D. Hays, Ph.D., Professor of Medicine and Health Services, UCLA. Denise D. Quigley, Ph.D., CAHPS Quality Improvement Team, RAND. AHRQ Conference. September 11, 2012 (8-9:30am session)(

2. 2. Presentation Outline. Why focus on doctor-patient communication? Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective? Feedback from high-performing physicians Summary and implications

3. 3. Presentation Outline. Why focus on doctor-patient communication? Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective? Feedback from high-performing physicians Summary and implications

4. 4. Doctor-Patient Communication Is Critically Important to Patients. Good communication skills are among the qualities most desired Doctor listens to patient concerns, Doctor explains health problems clearly,. Effective communication is key to positive patient-doctor relationships. Patient reports about communication are strongly associated with global ratings.

5. 5. Communication Measures used to Improve Patient Experience. Quality improvement. Element of pay-for-performance systems Recognition as a patient-centered medical home.

6. 6. Presentation Outline. Why focus on doctor-patient communication? Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective? Feedback from high-performing physicians Summary and implications

7. 7. CAHPS Surveys Address Communication from Patient Perspective. During CAHPS development, consumers identify important aspects of care. Patients are the best or only source of information for most measures. Clinician and Group (CG) CAHPS topics include. doctor-patient communication. access. coordination of care. courtesy and helpfulness of office staff. overall rating of doctor.

8. 8. Physicians Have Invaluable Perspective on Communication Items. As CAHPS stakeholders, physicians are consulted during CAHPS survey development. But physicians are not interviewed about best practices related to communication.

9. 9. We Asked High-Performing Physicians…, How well do the CAHPS survey items capture the important elements of doctor-patient communication?

10. 10. Existing Collaboration with Health Plan Facilitated Exploratory Study. Health plan. Has 72,000 adult, commercial HMO members. Administers CAHPS clinician-group survey annually (2005-2012). Uses CAHPS for P4P, Q. I., and reporting. Was interested in physician perspective. Gave us physician-level CAHPS data and contact information. Permitted us to contact their physicians.

11. 11. High-Performing Physicians on CAHPS were Identified 2008 CAHPS data. 20,141 patients among 259 primary care physicians (46% response rate). Calculated overall z-score (0-100 score). Average of CAHPS composites (access, communication, office staff) and global rating of physician. Rank ordered the 259 doctors by z-score.

12. 12. Physician Interviews. Contacted the 40 highest-ranked doctors; interviewed 11 physicians who were willing. Used a semi-structured, open-ended protocol with 36 questions. Basic information about practice. Philosophy of providing good care. Communication behaviors during patient visits. Office practices related to communication. Taped and transcribed interviews.

13. 13. Themes Coded…, Coded the content of the interviews for important themes. Created unique counts of codes per physicians; found 16 themes. Two researchers independently coded the presence or absence of each of the 16 themes. Calculated a pooled kappa to assess inter-rater agreement for 16 themes (0.72).

14. 14. … and Compared Themes to Behaviors Captured in CAHPS Survey Items. Core CAHPS items. Doctor-patient communication. Supplemental CAHPS items. Health information and promotion. Shared decision-making. Patient-centered medical home items. Cultural competence. Health literacy. Health information technology.

15. 15. Presentation Outline. Why focus on doctor-patient communication? Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective? Feedback from high-performing physicians Summary and implications

16. 16. Physicians Identified 16 Behaviors that Support Communication. 9 mentioned by more than 7 of 11 physicians. 6 of 9 most frequently mentioned behaviors captured in current CAHPS items. 3 behaviors identified for further survey item development.

17. 17. Nine Behaviors Mentioned Frequently (n = 11 physicians).(n = 11 1. Employ office staff with good people skills (91%) 2. Use non-verbal communication (82%) 3. Involve office staff in communication with patients (82%) 4. Spend enough time with patients; don’t act hurried (73%) 5. Listen carefully (73%) 6. Provide clear, simple explanations (64%) 7. Greet patients by shaking hands, introducing self (64%) 8. Ask social or personal questions; track and follow this information (64%) 9. Devise action plans/next steps at each visit (64%)

18. 18. CAHPS Captures Six of the Nine Behaviors. 1. Employ office staff with good people skills 2. Use non-verbal communication 3. Involve office staff in communication with patients 4. Spend enough time with patients; don’t act hurried 5. Listen carefully 6. Provide clear, simple explanations 7. Greet patients by shaking hands, introducing self 8. Ask social or personal questions; track and follow this information 9. Devise action plans/next steps at each visit

19. 19. Presentation Outline. Why focus on doctor-patient communication? Do CAHPS surveys capture important elements of doctor-patient communication from physician perspective? Feedback from high-performing physicians Summary and implications.

20. 20. Summary of Findings. CAHPS survey items capture many of the communication behaviors most frequently mentioned by high performing physicians. Three aspects of communication are not captured by current CAHPS items. Non-verbal communication. Greeting the patient. Tracking personal information about the patient.

21. 21. Possible Next Steps Testing and developing additional patient experience-of-care measures Nonverbal communication Physician greeting and introducing self to patient and family Physician tracking of personal information about patient Further research is important to understand additional value and association with other patient experience measures

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