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Patient Satisfaction/Experience Surveys and Patient Activation/Engagement Resources

HRSA’s Health Center Program Grantees must measure and assess patient satisfaction.  The information and resources below will provide health centers with goals and justifications for measuring patient satisfaction and/or patient experience, requirements for measuring patient satisfaction to become a recognized Patient-Centered Medical Home (PCMH), and examples of satisfaction surveys.   There are also information and resources to help health centers understand how activated and/or engaged patients may be more satisfied and have better experiences and health outcomes.

Please click or scroll down for:

Why Measure Patient Satisfaction or Patient Experience?
Measuring Patient Satisfaction Versus Patient Experience
Patient-Centered Medical Home (PCMH) and Satisfaction/Experience Surveys
Tools for Developing Patient Satisfaction/Experience Surveys
Reports and Articles Regarding Patient Satisfaction/Experience Surveys
What is Patient Activation and Patient Engagement?
Patient Activation and Engagement Interventions and Strategies

Why Measure Patient Satisfaction or Patient Experience?

There has been much activity and energy devoted to improving the patient experience as well as determining a way to measure the satisfaction of the patient and their experience in a health care setting.  When patient feedback is collected and acted upon in a meaningful way, the health center can achieve greater patient satisfaction.  The American Medical Association (AMA) encourages health care providers to proactively measure and respond to patient satisfaction data, and reports that practices that act on patient satisfaction data can:

  • Inform quality improvement efforts
  • Make informed staffing decisions
  • Gain a competitive edge
  • Improve patients’ health, compliance, and confidence in treatment
  • Inform contract negotiations
  • Use information to contradict negative ratings/profiles
  • Give patients a constructive outlet to provide feedback on their experience
  • Reduce malpractice suits
  • Prepare for and improve performance on federal and private initiatives
  • Show patients that their physicians care about their input.

The Health Resources and Services Administration (HRSA) requires all HRSA-funded health centers to assess patient satisfaction.  HRSA developed a sample survey form after compiling more than 300 surveys from health centers in 1999.  This form can be downloaded and utilized by all HRSA-funded health centers.  HRSA will analyze and develop a report of patient satisfaction findings for a nominal fee.  You can learn more about the HRSA satisfaction survey at:
www.bphc.hrsa.gov/policiesregulations/performancemeasures/patientsurvey/satisfactionsurvey.html.

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Measuring Patient Satisfaction Versus Patient Experience

A distinction can be made between the patient’s satisfaction and the patient’s experience.  Patient satisfaction surveys tend to ask patients subjective questions about their satisfaction with their care.  In contrast, patient experience questions relate to the patient’s objective experience during the entire health center interaction.  The patient experience is the sum of a patient’s interactions with a health center and is the patient’s perception of those interactions.

Satisfaction Questions

Patient satisfaction questions generally focus on how well a patient’s expectations are met, their preferences, and the quality of their care.  They tend to be subjective and non-specific.  Examples of satisfaction questions include:
How do you rate your doctor’s caring and concern for you?
How satisfied are you with the appointment system in your health center?
Is it easy for you to get medical care when you need it?

Multiple choice answers to satisfaction questions are also more subjective, such as:
Strongly agree, agree, neutral, disagree, strongly disagree
Very good, good, fair, poor

                Experience Questions

Experience questions relate to the patient’s actual, more objective experiences in the health center and aim to avoid value judgments and the effects of existing expectations.  Examples of experience questions include:
In the last 12 months, how many days did you usually have to wait for an appointment when you needed care right away?
In the last 6 months, how often did you see your provider within 15 minutes of your appointment time?
In the last 12 months, did anyone in your provider’s office talk with you about specific goals for your health?

Multiple choice answers to experience questions are more objective, such as:
Same day, 1 day, 2-3 days, 4-7 days, more than 7 days
Never, sometimes, usually, always

One core element of patient-centered care is an ongoing relationship with the patient’s health care provider.  This factor requires that the patient’s experience be evaluated over time rather than on a single visit.  For example, more longitudinal measures may ask about the patient’s experience over the last 6 or 12 months rather than in general or on a specific day, as in the experience question examples above.

The National Committee for Quality Assurance (NCQA) and the Agency for Healthcare Research and Quality (AHRQ) feel that patient experience data is more actionable for quality improvement and recommend the use of patient experience questions in patient surveys.  Please see the following section for Patient-Centered Medical Home (PCMH) requirements for patient satisfaction/experience surveys.

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Patient-Centered Medical Home (PCMH) and Satisfaction/Experience Surveys

The NCQA 2011 standards for becoming a recognized PCMH include more rigorous criteria for patient surveying than the prior 2008 standards.  The 2011 standards recommend a shift from patient satisfaction to patient experience reporting.  In addition to standard survey questions about access and communication, the NCQA 2011 PCMH standards require that clinics add questions addressing patient experiences with self-management support and care coordination.  NCQA 2011 standards also require that clinics:

  • Report the results of their surveys
  • Use data to identify areas for improvement
  • Specify a plan for improvement
  • Demonstrate improvement in one patient experience measure.

To be awarded full points on the 2011 NCQA PMCH application regarding patient experience reporting NCQA requires that health centers utilize the 2013 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.  See the following webpage for more information about NCQA’s PCMH requirements regarding patient experience reporting:
www.ncqa.org/tabid/1429/default.aspx.

CAHPS PCMH Survey

The CAHPS Survey is a standardized tool to measure patient perceptions of care.  The CAHPS set of survey tools was developed by the Agency for Healthcare Research and Quality (AHRQ).  You can find all the CAHPS survey tools, including the CAHPS Clinician & Group Survey – 12-Month Survey with Patient-Centered Medical Home Items on the following webpage:
www.cahps.ahrq.gov/clinician_group/.

In order to qualify for full points, the CAHPS PCMH survey must be administered by a third-party vendor.  See the following webpage for a listing of NCQA Certified CAHPS PCMH Survey Vendors:
www.ncqa.org/Portals/0/HEDISQM/Programs/SVC/2013_CAHPS_PCMH_Vendor_Web_List_12.20.2012.pdf

The benefit of utilizing the CAHPS survey is that health centers can compare their results to other PCMH recognized practices that utilize the survey under NCQA.  The downside is that the CAPHS survey can be costly for CHCs to administer, and burdensome for CHC patients to complete as the survey contains over 50 questions.  Some health centers who have received PCMH have adopted surveys other than the CAHPS survey to gain partial points on the PCMH application, and some have used hybrid surveys that incorporate some CAHPS survey questions.  Please see the following section for examples of such surveys.

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Tools for Developing Patient Satisfaction/Experience Surveys

Colorado Community Health Network (CCHN) has implemented a process whereby Colorado CHCs can continue to develop their own patient satisfaction/experience surveys and add five questions from the CAHPS survey to allow for comparison of those five questions among Colorado CHCs.  See the following document for a description of the CCHN PCMH survey process including background, approved CAHPS survey questions, goals, distribution methods, sample sizes, and timelines:
CCHN CAHPS Hybrid Survey Process 2013.pdf

Midwest Clinicians Network (MWCN) has created a revised version of the HRSA patient survey that also includes Patient-Centered Medical Home measures of satisfaction.  The MWCN Patient Satisfaction Survey is available at a low cost to MWCN members as well as non-members.  Completed surveys are processed by MWCN and reports of the results are provided at organization, site, and provider levels.  See the following webpage for more information about this survey:
www.midwestclinicians.org/services.php#patientsurveys.

American Academy of Family Physicians (AAFP) provides a short step-by-step guide on how to conduct a patient satisfaction survey.  AAFP also provides the Patient Satisfaction Survey Package, developed in partnership with Avatar International LLC.  The basic package is $150 annually per physician.  Survey results are available in real time and practice scores may be compared with other practices nationally.  See the following webpage for more information:
www.aafp.org/online/en/home/membership/initiatives/pcmh/ptexperience/patientsatisfaction/ptsatdataimprove/patientsurvey.html

American College of Physicians (ACP) provides a Patient Satisfaction Check Up: Accessing Patients’ Perceptions survey.  ACP members can access a paper survey that’s downloadable, or obtain an electronic version.  See the following website for more information:
www.acponline.org/running_practice/delivery_and_payment_models/pcmh/resources_tools/satisfaction_surveys.htm

American Medical Association (AMA) offers a patient survey process called RealTime: A Patient Satisfaction Solution.  AMA has partnered with Press Ganey who will provide support to physician practices wishing to survey patients.  Patient email addresses are entered into the AMA-Press Ganey systems after a visit, and an email, customized to the practice will be delivered to the patient.  RealTime is available to AMA members for $65 per month and to non-AMA members for $85 a month.  See the following webpage for more information:
http://medpractice.pressganey.com/

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Reports and Articles Regarding Patient Satisfaction/Experience Surveys

Building Healthier Habits in Central Washington
Gabriel Perna, Healthcare Infomatics, February 21, 2013
www.well-fx.com/building-healthier-habits-in-central-washington/

Building on Successful Patient-Centered Medical Home Transformation
Sheri Porter, AAFP News Now, June 13, 2012
www.aafp.org/online/en/home/publications/news/news-now/practice-professional-issues/20120613pcmhmakeover3.html

Confusing Terminology:  Understanding the Difference between Patient Satisfaction and Patient Experience
Rebecca Hendren, The Leaders’ Lounge, June 15, 2011
http://blogs.hcpro.com/nursemanagers/2011/06/confusing-terminology-understanding-the-difference-between-patient-satisfaction-and-patient-experience/

Measuring Patients’ Experiences with Individual Primary Care Physicians
Dana Gelb Safran, ScD, et al., Journal of General Internal Medicine, January 2006
http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.00311.x/full

Patient Experience in California Ambulatory Care
Jill Steinbruegge, MD, PhD, prepared for California Healthcare Foundation, December 2012
www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/P/PDF%20PatientExperienceCaliforniaAmbulatoryCare.pdf

Patient Satisfaction Surveys are Here to Stay
Donald L Malott, Jr., MBA, PhD, et al., Emergency Physicians Monthly, November 16, 2010
www.epmonthly.com/archives/features/patient-satisfaction-surveys-are-here-to-stay/

Sharpening Your Survey Skills: How Practices Can Measure Patient Satisfaction
Emily Berry, American Medical News (amednews.com), April 19, 2011
www.ama-assn.org/amednews/2011/04/18/bisa0418.htm

Shift to Medical Home May Not Increase Patient Satisfaction
Kevin O’Reilly, American Medical News (amednews.com), July 2, 2012
www.ama-assn.org/amednews/2012/07/02/prsa0702.htm

The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, and Less Burnout for Providers
Robert J. Reid, et al., Health Affairs, May 2010
http://content.healthaffairs.org/content/29/5/835.abstract

What Do We Really Know About Patient Satisfaction?
C. Carolyn Thiedke, MD, Family Practice Management, January 2007
www.aafp.org/fpm/2007/0100/p33.html

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What is Patient Activation and Patient Engagement?

It is still early in the process of PCMH implementation in the U.S. to determine whether or not PCMH leads to increased patient satisfaction or better patient experiences.  Current research is limited and has been conflicting.  Some studies show PCMH leads to increased patient satisfaction and better outcomes and other studies have found no connection between PCMH and increased patient satisfaction or outcomes.  Many studies and articles point out that it takes time for health centers to implement PCMH and that many of the changes made under PCMH are “behind the scenes”, administrative/organizational changes that a patient may not notice or be aware of.  There is however much research that suggests that patients who are more activated and/or engaged tend to be more satisfied and have better care experiences and outcomes.  See the following sections for more about patient activation and patient engagement and why both can be important to the overall patient experience.

                Patient Activation

Patient Activation is a term that describes the knowledge, skills and confidence that equips patients to become actively engaged in their health care.  The Patient Activation Measure (PAM) was developed by Judith H. Hibbard and colleagues from the University of Oregon in 2004.  Prior to her research on how patient activation relates to satisfaction/experience, outcomes, and costs, she developed PAM which assesses an individual’s skill and confidence for actively engaging in their care.  The original PAM was a 22-item measure.  A shorter form was created in 2005 and contains 13 items.

Following is the first study on PAM:
Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers
Judith H. Hibbard, et al., Health Services Research, 2004
www.ncbi.nlm.nih.gov/pmc/articles/PMC1361049/

The study concludes that patient activation involves four stages:
1) believing the patient role is important
2) having the confidence and knowledge necessary to take action
3) actually taking action to maintain and improve one’s health
4) staying the course even under stress

Insignia Health holds the exclusive right to PAM.  See the following webpage for more information about using PAM to assess a patients’ activation level:
www.insigniahealth.com/solutions/patient-activation-measure

Following is more research by Judith Hibbard and colleagues that has led to the interest and use of patient activation in health care settings:
Development and Test of a Short Form of the Patient Activation Measure
Judith H. Hibbard, et al., Health Services Research, 2005
www.ncbi.nlm.nih.gov/pmc/articles/PMC1361231/

What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs
Judith H. Hibbard and Jessica Greene, Health Affairs, February 2013
http://content.healthaffairs.org/content/32/2/207.full?ijkey=Hm0p/4wdLnHk6&keytype=ref&siteid=healthaff

Patients with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores’
Judith H. Hibbard, Jessica Greene, and Valerie Overton, Health Affairs, February 2013
http://content.healthaffairs.org/content/32/2/216.abstract

The studies conducted by Judith H. Hibbard and colleagues highlight the important role that patients play in determining their satisfaction and outcomes.  The studies found that patients who were more knowledgeable, skilled and confident about managing their day-to-day health and health care had lower health care costs and experienced better health outcomes

Patient Activation versus Patient Engagement

Patient activation refers to the patient’s knowledge, skills, ability, confidence and willingness to become engaged to help manage his or her own health care.

Patient engagement is defined in various manners, but more broadly refers to the combination of a patient’s activation level with interventions designed to increase activation and promote positive patient behaviors and actions.  The Center for Advancing Health defines patient engagement as “actions individuals must take to obtain the greatest benefit from the health services available to them” and notes that “engaged patients are involved in the process of care, and their behavior is as important to health outcomes as provider or policy actions”.

Articles on Patient Activation and Patient Engagement

Patient Engagement
Health Policy Brief, February 2013
www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=86

This article also includes A Multidimensional Framework for Patient and Family Engagement in Health and Health Care, developed by Kristin Carman and colleagues, which provides a continuum of engagement at the direct care level:
Consultation - patients receive information about a diagnosis
Involvement - patients are asked about their preferences of the treatment plan
Partnership and Shared Leadership - treatment decisions are made based on patients’ preferences, medical evidence, and clinical judgment.

Patient Satisfaction: The New Rules of Engagement
Holly Korda, PhD, The Health Care Blog, October 26, 2012
http://thehealthcareblog.com/blog/2012/10/26/patient-satisfaction-the-new-rules-of-engagement/#more-53752

Patient Experience vs. Patient Engagement
Ian Worden, Better Patient Engagement, July 15, 2012
www.betterpatientengagement.com/2012/07/15/patient-experience-vs-patient-engagement/

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Patient Activation and Patient Engagement Interventions and Strategies

In light of recent studies, health centers may want to consider measuring patient activation and/or implementing strategies to increase patient engagement.  Although PCMH principles have proven to create more efficiency in primary health care settings, patients may not be aware of such changes if they are not activated and engaged.  Following are reports, presentations, and articles highlighting methods that health centers can use to measure patient activation and increase patient engagement:

4 Pillars of an Effective Patient Engagement Strategy
Michelle McNickle, Healthcare Finance, May 31, 2012
www.healthcarefinancenews.com/news/4-pillars-effective-patient-engagement-strategy
A brief article describing four strategies for engaging patients

Enhancing Patient Activation: Communication Strategies
Michael G. Goldstein, MD for FDA Risk Communication Advisory Committee, May 7, 2010
www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/RiskCommunicationAdvisoryCommittee/UCM211355.pdf
Slide presentation that defines self-management support and relates such support to patient activation and sharing information with patients

Guide to Patient and Family Engagement: Environmental Scan Report
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov/qual/ptfamilyscan/ptfamily4.htm
Provides information from several sources to obtain a broad and diverse perspective on patient and family engagement including interventions and strategies

New Era of Patient Engagement Event
Health Affairs
www.healthaffairs.org/events/2013_02_06_patient_engagement/
Includes audio downloads and slides from dozens of presentations on patient engagement from the conference sponsored by Health Affairs on February 6, 2013

Why Evidence is the Basis of Coaching for Activation
Susan Prows, PhD, MPH, for Insignia Health, May 1, 2009
www.insigniahealth.com/evidence-based-medicine-why-evidence-is-the-basis-of-coaching-for-activation
Highlights the importance of evidence based medicine and how Coaching for Action, a health care coaching strategy, can help health care providers guide patients toward evidenced based best practices

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