Value of patient experience:Hospitals with higher patientexperience scores havehigher clinical qualityExecutive summaryWith the market shift towards value-based and patientcentered models of care, improving patient experienceis an increasingly common focus for hospitals. Goodpatient experience is an intrinsically valuable goal, andpayers are increasingly emphasizing patient experienceas part of care quality.1 Patient experience scores—reflecting factors as diverse as a hospital floor’s noiselevel throughout the night and how well nurses anddoctors communicate with patients—have become keyhospital performance measures.In Deloitte's 2016 report The value of patient experience:Hospitals with better patient-reported experienceperform better financially, we found that higher patientexperience scores are associated with higher hospitalprofitability, and that this association is strongestfor aspects of patient experience most likely to beassociated with better clinical care (in particular,nurse staffing engagement).Since improving patient experience can likelyaddress attributes of care that promote and increasequality, 2,3 these results suggest that improvementsin patient experience scores might be associatedwith increased clinical quality. However, patientexpectations do not always map to clinical qualityindicators. Patients sometimes value amenities morethan clinical ability.4 As a result, improvements inpatient experience might not always be associatedwith improvements in clinical quality.5Although many consumers value both clinical qualityand care experience when choosing a hospital, thelink between patient experience and hospital qualityhas not been well studied.6 The literature on the topicis rather limited, and has largely focused on selectedclinical outcomes such as readmissions andmortality rates. 7 To gain greater insight into this topic,the Deloitte Center for Health Solutions conductedregression analyses to examine the associationbetween patient experience scores and a broadrange of hospital clinical quality measures (bothprocess of care [POC] measures as well as clinicaloutcomes). We controlled for numerous hospital andmarket characteristics that can also affect hospitalperformance, including hospital ownership, location,teaching status, payer and patient case mix. Ouranalyses point to two main findings:Hospitals with higher patientreported experience ratings havebetter process of care qualityscores. Hospitals receiving “excellent”(9 or 10 out of 10) patient experienceratings have better clinical qualityscores for all 18 process of care measures that weanalyzed compared to hospitals receiving “low” (0 to 6out of 10) ratings. For instance, a 10-percentage-pointhigher score in the number of respondents giving ahospital an “excellent” experience rating is associatedwith a 20-minute lower emergency department (ED) waittime relative to hospitals receiving a “low” rating.Hospitals with higher experienceratings have better scores forsome, but not all, clinical outcomes.Hospitals receiving “excellent” patientexperience ratings have lowerreadmission and mortality ratescompared to hospitals receiving “low” experience ratings.High-scoring hospitals, however, don’t always have lowerhospital-acquired infection (HAI) rates. Such resultssuggest that patients might find it difficult to infer qualityfor care outcomes that are less obvious, or that are
Value of patient experience: Hospitals with higher patient experience scores have higher clinical qualityinfrequently encountered, such as HAIs at surgical site. Italso could indicate that the variation in outcomes betweenhospitals is small because most hospitals have alreadymade considerable progress in reducing HAIs.We also performed additional analyses to studypotential factors that might underlie the associationbetween experience scores and hospital clinical quality.The results indicate that:Clinical quality measures thatare more visible to patients aremore strongly associated withpatient experience. Clinical qualitymeasures that are more visible andtangible for patients, such as ED waittimes and readmissions, are more closely associatedwith patient experience ratings.Communication with nurses andrelevant discharge informationenhance patient experience,and are strongly associatedwith clinical quality. Experiencescores pertaining to nursecommunication and discharge information have thestrongest association with the largest number ofclinical quality measures.Hospitals’ participation invalue-based care models,such as accountable careorganization (ACO) affiliationand bundled-paymentarrangements, may strengthenthe association between patient experience andhospital clinical quality. Our regression analysesdetermined that ACO affiliation and paymentincentives tied to quality—such as bundledpayments—might strengthen and reinforce theassociation between patient experience and clinicalcare quality domains such as ED and surgical care.2Hospital executives face multiple priorities andresource demands, and may question the businessvalue of analyzing and acting upon patient experiencedata. Along with our prior work on the associationbetween patient experience and hospital profitability,these new findings help strengthen the business casefor patient experience. Moreover, our findings pointto particular aspects of care that hospital leadersmight want to prioritize for investments in toolsand mechanisms that engage consumers and helpimprove patient experience.Hospitals with higher patientreported experience ratingshave better process of carequality scores. Further, hospitalswith higher experience ratingsalso have better scores for some,but not all, clinical outcomes.
Value of patient experience: Hospitals with higher patient experience scores have higher clinical qualityIntroductionWith the appearance of a market shift towards valuebased and patient-centered models of care, improvingpatient experience—along with efforts to improveclinical quality, and reduce the cost of care— is anincreasingly common tactic for hospitals. Althoughimproving patient experience can be valuable unto itselfand regarded as distinct from improving clinical quality,the two concepts are often interrelated. Payers, forinstance, increasingly emphasize patient experience as acore element of care quality.8 In tying hospital Medicarepayments to experience scores under the Value BasedPurchasing Program, for example, the Centers forMedicare and Medicaid Services (CMS) noted: “Deliveryof high-quality, patient-centered care requires usto carefully consider the patient’s experience in thehospital inpatient setting.” 9Although consumers often value both inpatient clinicalquality and the care experience when choosing ahospital, the link between these two factors has notbeen studied closely.10 Literature on the topic is ratherlimited, and has largely focused on clinical outcomessuch as readmissions and mortality rates.11In this study, we analyzed the association betweenpatient experience scores and a broad range of widelyused clinical quality measures (both outcome and POCmeasures) reported to CMS. We found that hospitalswith higher experience ratings generally have betterclinical quality scores, particularly for process of caremeasures. Combined with the results of our previousstudy, which documented the association betweenpatient experience and hospital profitability, these newfindings provide evidence to help make the businesscase for increased focus on patient experience. Thatcould help guide hospitals in prioritizing investmentsin tools and mechanisms that engage consumers andhelp improve patient experience.Hospitals with higher patientreported experience ratings havehigher POC quality scoresTo examine the relationship betweenpatient experience and hospital clinical quality, wecombined hospital-level patient experience ratings fromthe most widely used hospital experience survey—theHospital Consumer Assessment of Healthcare Providersand Systems (HCAHPS)—with clinical outcome and POCquality measures from CMS.12 In the HCAHPS survey, only ranges of scores arepublicly reported, so the main HCAHPS metricsthat we used in our analyses are the percentage ofrespondents giving a hospital a rating of 9 or 10 outof 10 (“excellent” rating), 7 or 8 out of 10 (“moderate”rating), or 0-6 out of 10 (“low” rating). See sidebar onthe following page or the appendix for details. For quality measures, we selected a broad range ofPOC and outcome measures based on conversationswith subject matter experts, data availability, andinclusion in key Medicare reimbursement programs,such as the Value-based Purchasing (VBP) andhospital star rating programs. See sidebar on thefollowing page or the appendix for details.“Delivery of high-quality, patientcentered care requires us tocarefully consider the patient’sexperience in the hospitalinpatient setting.”—Centers for Medicare and Medicaid Services (CMS)3
Patient experience and clinical quality measures included in the studyPatient experience measuresMeasures from the HCAHPS survey that show patient-reported scores measuring patients’ perception of hospital care.In our study, we use the global measure capturing patients’ overall rating of the hospital on a scale of 0 to 10.POC measuresMeasures that show if the patients received timely, effective, and preventive hospital clinical services to get best resultsfor certain common conditions, medical emergencies, or surgical procedures. We classify these measures into thefollowing five categories:ED timeliness of careSurgical process of carePreventive care Median time spent in ED beforeinpatient admission Percentage of surgery patientsappropriately kept on beta-blockers Percentage of patients assessedand given influenza vaccination Median ED visit duration Percentage of surgery patients giventhe right kind of antibiotic to helpprevent infectionEffectiveness of care Median time spent in ED before receivingpain medication for broken bones Median time spent in ED before beingseen by a health care professional Percentage of patients who left theED before being seen Percentage of surgery patients whoseurinary catheters were removed onthe first or second day after surgery Percentage of patients treatedto prevent blood clots Percentage of stroke patientstreated to prevent blood clots Percentage of patients treated at theright time for blood clots after surgery Percentage of ICU patients treatedto prevent blood clotsInformation/education Percentage of patients whose preventiveantibiotics were stopped at right time Percentage of patients who receivedstroke education Percentage of patients who receivedwarfarin therapy discharge instructions Percentage of newborn deliveriesscheduled earlier than medicallynecessary Percentage of pneumonia patientsgiven most appropriate antibioticOutcome of care measuresMeasures that show what happened after patients with certain conditions received hospital care.We classify these measures into the following three categories:MortalityReadmissionsHospital Acquired Infections (HAI) Acute Myocardial Infarction (AMI)30-day mortality rate AMI 30-day readmission rate Central line-associated bloodstreaminfections (CLABSI) in ICUs and select wards Heart failure 30-day mortality rate Pneumonia 30-day readmission rate Heart failure 30-day readmission rate Pneumonia 30-day mortality rate Catheter-associated urinary tract infections(CAUTI) in ICUs and select wards Surgical site infections (SSI) fromcolon surgery SSI from abdominal hysterectomySource: Deloitte analysis of measures from CMS “Hospital Compare” dataset, 2008-20144
Value of patient experience: Hospitals with higher patient experience scores have higher clinical qualitySince we would expect hospital characteristics and localmarket conditions to influence the association betweenpatient experience and hospital clinical quality, weused a regression analysis framework (see appendix)to control for them. Hospital characteristics includehospital size, urban/rural location, ownership type,teaching status, being part of a system, case and payermix. We also took into account local market (hospitalreferral region [HRR]) characteristics. This approachallowed us to compare changes in quality scores andexperience ratings between 2008 and 2014 at hospitalswith similar characteristics.Regression results reveal that hospital patientexperience ratings and quality scores for clinical POCmeasures are positively correlated. Hospitals receiving“excellent” (9 or 10 out of 10) and “moderate” (7 or8 out of 10) experience ratings have better qualityscores for virtually all POC measures that we analyzed,compared with hospitals receiving “low” (0-to-6 out of10) experience ratings (Figure 1).Moreover, the magnitude of the association betweenexperience scores and quality metrics, as depicted bythe darker shade in Figure 1, is largest for hospitalsreceiving “excellent” experience ratings. For instance,a 10 percentage point increase in the number ofrespondents giving a hospital an “excellent” rating isassociated with a 1.5 percentage point higher numberof stroke patients treated properly to prevent bloodclots, and with a 20-minute shorter ED wait time fromarrival to admission—relative to hospitals receivinga “low” rating. For hospitals receiving “moderate”ratings, an increase of 10 percentage points in thenumber of respective respondents is associated witha higher number of stroke patients appropriatelytreated to prevent blood clots (by 0.6 percentagepoints) and with a 15-minute lower ED wait timebetween arrival and admission, respectively, relativeto “low” rated hospitals.Regression results reveal thathospital patient experienceratings and quality scores forclinical POC measures arepositively correlated.5
Value of patient experience: Hospitals with higher patient experience scores have higher clinical qualityFigure 1. Hospitals with higher experience ratings have better process of care quality scoresProcess of care measureInformation/educationPreventive careHospitals with“excellent”ratingsPercentage of patients who received stroke educationPercentage of patients who received warfarin therapy discharge instructionsPercentage of patients assessed and given influenza vaccinationPercentage of surgery patients given beta-blockersSurgical processof carePercentage of surgery patients given the right kind of antibiotic (infection)Percentage of surgery patients whose urinary catheters were removed appropriatelyPercentage of patients treated at the right time for blood clots after surgery(Shorter) median time from arrival in ED to inpatient admission(Shorter) median ED visit durationED timeliness ofcare(Shorter) median time to pain medication for patients with broken bones(Shorter) door to diagnostic evaluation timePercentage of patients who left the ED before being seenPercentage of patients who received treatment to prevent blood clotsPercentage of stroke patients who received treatment to prevent blood clotsEffectiveness ofcarePercentage of ICU patients who received treatment to prevent blood clotsPercentage of patients whose preventive antibiotics were stopped at the right timePercentage of (fewer) newborn deliveries scheduled earlier than medically necessaryPercentage of pneumonia patients given most appropriate antibioticPositive association between higher ratings in patient experience and higher quality performance in the indicated quality metricNote: Darker shade of blue indicates a higher strength of associationSource: Deloitte analysis of HCAHPS and quality measures from CMS, and hospital characteristics from Truven and the AHA annual survey database.See appendix for a description of
reported experience ratings have better process of care quality scores. Hospitals receiving "excellent" (9 or 10 out of 10) patient experience ratings have better clinical quality scores for all 18 process of care measures that we analyzed compared to hospitals receiving "low" (0 to 6 out of 10) ratings. For instance, a 10-percentage-point-