Under the Value-Based Purchasing (VBP) formula, hospitals receive performance-based bonuses or penalties based, in part, on the patient experience of care domain. Up to 30% of a hospital’s total performance score (one of the measures for the VBP calculation) is based on customer satisfaction. A survey conducted by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is the basis of the patient experience of care domain.
The HCAHPS is a national standard process designed to measure the patient’s perceptions of their hospital experience. The HCAHPS survey is mandatory (except for specific Critical Access Hospitals that can choose to voluntarily participate) and is published for public view through Centers for Medicare & Medicaid Services (CMS) Hospital Compare registry. This means that the entire world can see how a hospital’s patient experience ratings compare to other regional hospitals, as well as state and national averages (www.medicare.gov/hospitalcompare).
Patient satisfaction and experience of care is impacting virtually every aspect of hospital operations. Recently, a group of hospital emergency department directors formed a task force to address the rising incidence of prescription drug overdoses. One of the strategies proposed to try to reduce these occurrences was to have all hospitals pledge to refer patients in the emergency department (ED) with chronic pain management issues to specialists instead of prescribing narcotic pain relievers. One ED physician director commented that strategy would be a hard sell to ED doctors unless patients seeking pain medications could be classified as “no info” patients, negating the possibility that the patient would receive a HCAHPS survey. The concern was that a portion of hospital income is derived from the patient satisfaction scores. If patients don’t get their pain prescription, they could rate the experience negatively and negatively impact the satisfaction score and the hospital’s income.
As a result of this focus on the patient experience of care, many hospital systems are adding a new C-suite member to their team. They have always had positions such as chief executive officer, chief operating officer, chief medical officer and chief nursing officer. But now, many are adding the chief experience officer (CXO). Cleveland Clinic was the first major academic medical center to make patient experience a strategic goal and to appoint a CXO, and one of the first to establish an Office of Patient Experience.1 CXOs do not typically come from the healthcare industry, but rather from organizations that do customer service well, such as the Marriott Corp.
Why patient experience should matter to EMS
EMS providers need to pay particular attention to this growing focus on patient satisfaction and experience of care for several reasons.
1. Our patients care. We typically get zero points for the clinical care we provide. Patients assume that since we arrived at their medical emergency in mobile intensive care units when they called 9-1-1, we have clinical expertise. We get bonus points from the patient’s perspective when we are nice to them–when we communicate well and explain everything we are doing, when we ensure their pain is controlled, when we worry about their pets after we take their master to the hospital, or as was recently demonstrated, when the fire crew stays on scene and finishes laying the sod the homeowner could not finish due to chest pain he experienced after laying only three pallets.
2. Our payers care. Our largest healthcare payer is providing bonuses or penalties based on satisfaction scores. It won’t be long before other payers follow suit. In fact, CMS has accelerated using quality and outcome-based metrics program for physicians. These bonuses and penalties were scheduled to start in 2017, but CMS moved this implementation date up to 2016, due in large part to the improvements in patient-centered care and outcomes fostered through the assessment of bonuses or penalties to hospitals based on HCAHPS scores. EMS benefits are paid through Part B of Medicare, the same part from which physicians are paid. CMS has notified the EMS industry that we will be undergoing a review of the ambulance fee schedule this year. On Sept. 24, the Office of Inspector General released its report on the growth in Medicare payments to the ambulance industry from 2002 and 2011.2 The report places us in an interesting position as we move into those discussions with Medicare. If you have not read the report, we strongly urge you to do so.3 See also the related story in this issue.
3. Our healthcare stakeholders care. Ask any hospital administrator what their top-box HCAHPS scores are for their facility, and they will know. The top-box is the most positive response to HCAHPS survey questions. The top-box response is “always” for five HCAHPS composites (communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, and communication about medicines) and two individual items (cleanliness of hospital environment and quietness of hospital environment); “yes” for the sixth composite (discharge information), “9” or “10” (high) for the overall hospital rating, and “would definitely recommend” for the recommend hospital item.
EMS has an impact on the hospital’s HCAHPS scores. If we aggravate the patient on the way to the hospital, it may affect the score that patient gives the entire hospital. Similarly, if we are the last people to interface with the patient as they are leaving the hospital (discharge home, for example) and we leave a less-than-favorable impression, it may impact the hospital’s score when the patient receives an HCAHPS survey in the mail three days later.
4. It may be one of the only quality metrics we have. EMS has had a difficult time proving value to the customer. Few peer-reviewed studies prove that because the patient with a fractured ankle, or abdominal pain, or dislocated shoulder, etc. went to the hospital by ambulance, the patient’s outcome was different than it would have been otherwise. In today’s new healthcare world, we need metrics that we can use to prove value to the payer. It’s probable that externally conducted and verified patient experience scores may help as part of an overall set of clinical metrics that we can use to demonstrate value.
5. We need to bend the perception curve. EMS is not viewed by our payers or other financial stakeholders as providers of medical care. We are viewed as transportation. That is why we are not paid if we do not transport. Perhaps if we begin to think of ourselves as healthcare providers, and measure the same factors as healthcare providers (clinical outcomes, patient satisfaction) instead of response times, people will think of us and pay us as healthcare providers.
The challenge for EMS
Historically, we have not done a great job measuring the patient’s experience with our services. While many agencies send out customer opinion surveys, the surveys are not typically conducted by an outside agency and they most often are response cards mailed to patients that come back to the agency. In-house surveys are better than nothing, but they bring suspicion of bias, as opposed to third-party surveys conducted by an external agency–similar to the way CMS requires the HCAHPS surveys be conducted. It would be much better to have an external agency do the survey, provide us a summary and then even benchmark our performance to other agencies.
We also invest little time training our field providers, call center personnel and business office staff on how to deliver exceptional customer service. How much time is invested in teaching customer service compared to how much time we spend teaching how to resuscitate a cardiac arrest victim or how to apply a traction splint? Why is it we spend so much time teaching our people how to do things to our customers, and virtually no time how to do things for our customers? They may apply a traction splint once in their career, but they interact with patients on every call.
Thankfully, the National Association of Emergency Medical Technicians (NAEMT) developed a course on the Principles of Ethics and Personal Leadership (PEPL) which teaches EMS personnel how to make sound ethical decisions, prevent conflict and how to be EMS ambassadors.4
The time is now
We are arguably at the most pivotal time in our young profession. The ACA has provided EMS an unprecedented opportunity to become part of the healthcare system, a move that many of us have dreamed of for decades. We need to pay attention to the changing dynamics of the environment in which we operate. The factors that currently impact hospitals, doctors and other healthcare providers will also impact us sooner than we think. Take the time to help shape our future, and how we participate in this new healthcare system.
It’s time to really focus on the patient and the patient’s experience with our service.
RESOURCES
1. Cleveland Clinic Office of Patient Experience, http://my.clevelandclinic.org/patients-visitors/patient-experience/ default.aspx.
2. McCallion T. (Oct. 11, 2013) OIG Report: Utilization of Medicare Ambulance Transports, 2002-2011. EMS Insider . Retrieved on Oct. 28, 2013, from http://emsinsider.com/ems-articles/oigreport-utilization-of-medicare-ambulance-transports-2002-2011/.
3. Department of Health and Human Services Office of Inspector General, http://oig.hhs.gov/oei/reports/oei-09-12-00350.pdf
4. NAEMT Principles of Ethics and Personal Leadership, http://www.naemt.org/education/pepl/pepl.aspx
