C A L I FOR N I A H EALTH C ARE F OU NDATION Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting April 2011 Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting Prepared for California HealthCare Foundation by Marjorie Ginsburg Kathy Glasmire Center for Healthcare Decisions April 2011 About the Authors Marjorie Ginsburg is the executive director and Kathy Glasmire is the associate director of the Center for Healthcare Decisions (CHCD). CHCD is a nonprofit, nonpartisan organization whose purpose is to advance health care that reflects the values and priorities of an informed public. CHCD specializes in designing and conducting deliberative processes to identify the societal perspective when health care resources are limited and trade-offs are inevitable. Acknowledgments The authors thank consultants Shoshanna Sofaer, Dr.P.H., and Judith Hibbard, Dr.P.H., for their counsel in the development of the discussion tool. They are also grateful for the assistance of numerous CHART Board members, staff, and consultants in providing sound advice in project development. About the Foundation The California HealthCare Foundation works as a catalyst to fulfill the promise of better health care for all Californians. We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more information, visit us online at www.chcf.org. ©2011 California HealthCare Foundation Contents 2 I. Introduction 3 II. Research Methodology and Data Summary Data Collection and Analysis Discussion Group Process Prioritizing Quality Domains Prioritizing Within Domains — “Drill-Downs” 7 III. Findings Patient Safety Treatment Skill Responsive to Patients Good Value Study Limitations 1 3 IV. Conclusions Target Improvement Efforts to High Priority Domains Spotlight Patient Safety Use the Term “Quality” with All Domains Consider Efficiency Carefully Elicit the Public’s Voice 1 5 Endnotes I. Introduction W hat are consumers ’ priorities in terms While there has been valuable research on how of hospital quality, and does the public have a role in individuals experience hospital care and what is driving quality improvement efforts? These questions important to them, there is little information on how were posed in early 2010 by leaders working in the people as community members rank the different California hospital quality improvement arena. Since quality domains.6 – 8 Peter Pronovost and Ruth Faden 2007, performance data from California hospitals underscored the relevance of community input in have been publicly available on a Web site under a 2009 JAMA commentary. Writing about patient the direction of a multi-stakeholder collaborative, safety, they said “public engagement is essential to the California Hospital Assessment and Reporting form effective and legitimate public policies that Taskforce (CHART).1, 2 Its goal is to improve the involve moral values and social tradeoffs.” 9 quality of care by motivating hospitals to take The study described in this paper was intended corrective actions in quality areas that are below par, to help close the gap in information about how the and by prompting consumers to use the information public — in their dual roles as potential hospital when choosing a hospital. patients and as community members — thinks Although public reporting of quality measures about and uses quality information. The results are has been undertaken by various entities in the wake intended to help providers set priorities for corrective of the 2001 Institute of Medicine (IOM) report action and to provide new insights for those involved “Crossing the Quality Chasm,” the public’s use in public reporting. Following is a summary of of hospital report cards has been minimal.3, 4 The the methodology and data summary, findings, and authors of “Choosing a Health Care Provider: The conclusions of the research. Role of Quality Information,” found no studies that “link the dissemination of information to consumers choosing higher quality providers.” 5 To help CHART leaders evaluate the usefulness of its work to consumers, the Center for Healthcare Decisions (the Center) conducted a study to: (1) determine how Californians view the relative significance of four IOM quality domains; and (2) identify the characteristics within these domains that are most important to consumers. The four domains studied are clinical effectiveness, patient safety, responsiveness to patients, and efficiency. 2 | C alifornia H ealth C are F oundation II. Research Methodology and Data Summary T he C enter conducted 11 discussion Based on this testing, the names of the quality groups between June and September 2010 domains were revised to be more accessible to a lay throughout California. Participants were asked to audience. The domain known as clinical effectiveness consider the two study priorities from two different became Treatment Skill, efficiency became Good vantage points: Value, and the patient experience was renamed Responsive to Patients.11 The term patient safety did ◾◾ From the perspective of individual consumers; not change. and ◾◾ From the perspective of the general public Data Collection and Analysis concerned about hospital services in their The discussion groups of eight to 12 people each community. were conducted in diverse locations in California: Chico, Fresno, Los Angeles, Oakland, Sacramento, A two-hour interactive small-group process San Diego, and Sunnyvale. Of the 108 participants, that incorporated ranking exercises was used to half had recent inpatient hospital experience. Health understand how consumers prioritize quality care workers were excluded. Recruiters aimed to indicators. The process focused on four of the IOM include individuals of diverse ethnicity, education, quality domains: clinical effectiveness, patient safety, and income. One session was conducted in Spanish patient experience, and efficiency.10 The first three with Hispanic residents; one with Medicaid were reported on CalHospitalCompare.org and were beneficiaries; and one with individuals age 65 and typically components of other Web sites as well. older on Medicare. Participants received stipends For the project, the domain of “efficiency” was ranging from $75 to $100, varying by custom and added at the request of purchasers and health location. Nine were held in formal focus group plans concerned that hospitals do not necessarily facilities and the others in community settings.12 demonstrate a higher quality of care that would The demographic characteristics of all participants justify higher-than-average costs. are shown in Table 1 on the following page. The researchers created examples of hospital- Experienced facilitators conducted the sessions based patient care that illustrated the different and took detailed notes; the sessions were also domains of quality. The exercise of ranking patient audiotaped and transcribed. Project leaders analyzed care problems from least to greatest concern was used the qualitative data by consolidating the meeting to prompt participants to weigh competing priorities notes according to subjects and themes, validated by and then to explain their choices to others in their reviewing the transcriptions. The written responses to group. the ranking exercises provided the quantitative data To make sure the examples were easy to grasp to for analysis. those with no hospital experience, cognitive testing sessions were conducted with two separate groups. Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 3 Table 1. Demographic Characteristics of Discussion Group Participants (n=108) ho spi tal pati en t Age gr oup per c ent i n t h e pas t y ea r ? percen t 18 to 29 1% Yes 51% 30 to 39 26% No 49% 40 to 49 23% Ethn i c backg ro u n d 50 to 59 23% African-American 18% 60 and older 27% Asian/Pacific Islander 7% Gender Caucasian 46% Male 50% Hispanic or Latino 25% Female 50% Other (Native American) 4% E ducation le vel c ompleted Ho u seho ld i n co m e Less than high school 6% Less than $20,000 26% Some high school 4% $20,000 to $40,000 18% High school graduate 27% $40,000 to $60,000 25% Some college 33% $60,000 to $80,000 20% 4-year college degree 19% $80,000 to $100,000 3% Post graduate 11% $100,000 or more 8% Discussion Group Process Table 2. Importance of Having a Choice of Hospital Question: Imagine you need to be admitted to a hospital for The three-part sessions were designed to gradually tests and possibly treatment. Though this is not an emergency, shift participants from thinking about hospital you’ll be in the hospital for a few days. Since there are several quality from their own experiences to considering hospitals in your community, how important is it to you to have a choice about where you are admitted? (n=108) quality priorities from the perspective of community 72% If I were given a choice, I would request a members. certain hospital (or avoid a certain hospital). The facilitators began by asking participants 26% Choice of hospital is important to me but to indicate the importance of hospital choice if not essential. they were to be a patient. The responses they gave 2% Choice of hospital is not important to me at all. (Table 2) became the basis for a semi-structured open-ended discussion about the hospital attributes At the end of this discussion, participants they think about while describing why hospital reviewed short written descriptions of the four choice is or is not an important feature of their quality domains that would be the focus of the health care. remainder of the session. These descriptions were: 4 | C alifornia H ealth C are F oundation ◾◾ Responsive to patients. Does hospital staff Table 3: Composite Results of Prioritizing the Four Quality Domains meet patients’ individual needs with clear Instruction: Imagine that these examples were about you or communication, personal respect, and timely someone in your family. Rank these types of hospital quality pain relief? problems in the order of greatest concern to you (1 is highest, 4 is lowest). (n = 108, The numbers below represent the mean scores; the lower the score, the higher the priority.) ◾◾ Patient safety. Does hospital staff protect patients from harmful mistakes and avoidable accidents? 2.5 Responsive to patients George was 68 years old and in the hospital for serious kidney problems. Worried that he might lose all kidney ◾◾ Good value. Since patients sometimes pay part function, he and his wife were frustrated when the of the hospital bill, are the hospital charges doctors and nurses gave them no information about his condition, even though they asked repeatedly. They felt reasonable compared to other hospitals? “invisible” and that no one there cared. ◾◾ Treatment skill. Do doctors and nurses treat 1.9 Patient safety Joyce was an active 75 year-old who had her broken hip patients’ medical problems in ways that medical repaired. The surgery went well, but before she could experts have determined to be most successful? go home, she developed a life-threatening infection because her urinary catheter had not been taken care of properly by the nurses. Transferred to the ICU, it took two weeks to recover. This slowed her recovery from Prioritizing Quality Domains the hip surgery. Facilitators provided participants with a handout 3.7 Good value with each of the four quality domains illustrated by 33 year-old Barbara delivered her first baby, and everything turned out fine. But she was dismayed when a patient vignette. Each participant ranked them in she received her part of the hospital bill. She learned the order in which they would be of greatest concern that this hospital regularly charges 25 percent more if they or a family member were going to be in a than other hospitals even though the medical care is the same. She will have to pay $1,000 more than if she had hospital. Patient-specific examples were used to make been in another hospital. it easier to visualize how these domains could actually 2.0 Treatment skill affect individuals. The goal was to make the domains 49 year-old Frank suddenly was very weak on his left side. Rushed to the hospital, doctors said he had a seem real and not simply an abstract concept. stroke. After several delays, he received an IV that may The vignettes described examples of poor quality reverse the stroke. But this hospital had a “poor” rating last year because there were frequent delays in stroke rather than high quality care, so that participants treatment. So Frank is less likely to recover from this would understand how quality problems can be stroke than are patients at other hospitals. manifested in a hospital setting and what the consequences to patients might be. Participants Prioritizing Within Domains —  completed their individual rankings on their “Drill-Downs” handouts and then indicated their choices using an In the last step of the process, participants had electronic audience response system. This approach a chance to look more closely at the individual provided an immediate composite ranking for each domains. This part of the session was intended to quality example, shown on a projection screen. get a more nuanced understanding of the aspects Results were a visual indication of the relative of individual quality domains that were especially importance of each of the four domains when troublesome. It helped isolate quality characteristics evaluated by all the participants in that session (see that could be the basis for improvement activities. Table 3). Participants then discussed their rankings. To adhere to the limited time available, each group Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 5 did the drill-down exercise with just two of the four 2.0Surgery mistakes: Mistakes often occur in operating rooms due to inattention to detail. Surgical tools are left quality domains. The four drill-downs were coupled inside the patient, or a surgeon operates on the wrong in different ways among the groups. Table 4 shows all part of or even the wrong patient. Mistakes are usually caught before harm is done, yet the impact on some four of the drill-down exercises. Each one has three may be significant. examples that participants ranked from 1 (highest 1.7Preventable infections: Patients can be exposed to priority) to 3 (lowest priority). infection in the hospital when equipment is not cleaned properly, when rooms are not carefully cleaned between In the introduction to this task, participants were patients, and when staff fail to wash their hands before asked to imagine that the mayor appointed them to a and after they visit each patient. local committee that is making recommendations to GOOD VALUE (n = 48) improve hospital care in their community. Their role 1.5Delays and stalls: Some hospitals do not provide care was to advise on the order in which various quality in an organized, efficient manner, e.g., the lab only runs certain tests once a day or communication is slow due to problems should be tackled, keeping in mind the paper medical records. The result is wasted time, longer needs of everyone in the community. hospital stays, and higher costs, but without better patient care. Table 4. Drill-Down Rankings of Problems, by Domain 1.9Unnecessary treatment: In some hospitals, doctors order more tests, scans, and procedures than are Instruction: The mayor appointed you to a local committee that needed for excellent patient care, e.g., back surgery is making recommendations to improve hospital care in your often does not get good results for seniors. Going community. This committee will help hospitals decide which through a needless operation may be wasteful, quality issues should be tackled first. Read the three examples dangerous, and contribute to increased costs of health below and rank them 1, 2, and 3 in the order that you regard insurance for everyone. them as a priority for improvement, with 1 being highest priority. (The numbers below represent the mean scores; the lower the score, 2.6Pricey but not better: Hospital charges vary the higher the priority.) considerably; in one a hip replacement may cost $25,000 and another may charge $40,000. If medical RESPONSIVE TO PATIENTS (n = 50) care is no better and results no different, these higher prices are not a “good value” for individuals who pay 1.6 Adding to patients’ discomfort: Hospital stays are part of the cost or for companies that pay for health usually difficult for patients when, for example, the insurance for their employees. patient’s room is noisy, staff is slow to help patients who need assistance, or when pain medication is needed. TREATMENT SKILL (n = 58) 1.6Communicating poorly: Sometime doctors, nurses, 1.9Diabetes complications: Diabetes can lead to or other staff do not always keep patients or families severe infections, requiring hospital care to prevent well informed about their treatment, do not involve amputations. While some hospitals provide highly skilled them in decisions about their care, or do not give diabetes care, not all hospitals control these infections, clear information to help patients understand what is resulting in more patients having amputations that happening. permanently affect their activities. 2.8Ignoring family needs: Some hospitals know the 1.2Heart problems: When patients with long-term heart importance of family presence and provide services to problems need intensive medical treatment or surgery, make it easier — such as an available cafeteria, a place some doctors and nurses are better than others in giving to sleep if needed, convenient parking. When hospitals the correct treatments at the right time. When hospitals do not provide such basic services, it can make a do not perform as well, their patients may develop stressful time even worse. worse heart problems or have a greater chance of dying. PATIENT SAFETY (n = 60) 2.9Knee replacements: Knee replacement can make a big difference in controlling pain, allowing patients 2.3 Wrong meds: Medication errors happen in different to walk normally, and be athletic again, yet not all ways — the doctor writes the wrong dose; the hospitals perform at the same high standard. Patients pharmacist puts the wrong drug in the bottle; the with less-expert surgeons or not enough rehab therapy nurse gives the wrong drug to the wrong patient. may have to get another operation or live with more Some errors cause no harm or are easy to fix, but limitations. some cause lasting injury or death. 6 | C alifornia H ealth C are F oundation III. Findings When participants talked about hospital gave for ranking these four as they did, as well as the quality during the opening discussion of why choice reasons for their priorities in the drill-down exercise of hospital is important, they presented a variety (Table 4). of hospital characteristics based on their personal experience. They mentioned issues such as clean Patient Safety patient rooms, thoughtful staff, close to home, good Participants ranked the Patient Safety domain as food, nurses who keep them informed, reasonable the highest priority. Participants viewed safety, first waiting times in ERs, attentive care, respect, and and foremost, as “life or death.” While patient safety medical treatment that worked well. Most started was rarely mentioned during participants’ initial with the assumption that physician care would be discussion of hospital choice, once presented as a good; there were few references to patient safety quality domain, it generated considerable discussion. problems that could threaten their health or to It is one thing to have the doctor provide less-than- efficiency measures (good value) that could affect ideal care, but consumers did not want to come their pocketbooks. While all four domains were out of the hospital worse than when they entered. referenced in some fashion, the dominant themes Those who gave safety the highest ranking tended to of their experiences were those that were in the believe that more harm could come to patients from Responsive to Patients domain. mistakes than from poor treatment skill and that there were more opportunities for safety measures to “go wrong.” Participants also saw this as an area where they had very little control, which intensified I assume the government is going their conviction that these problems must be mitigated as quickly as possible. to do their job, and shut them down if they’re really bad. You know, if something’s wrong, and they’re on the road to recovery, As shown in Table 3, the quality domains of highest priority were Patient Safety and Treatment and something else becomes wrong Skill, and many participants voiced how difficult because of somebody screwing it was to decide which of these two were more important. By contrast, Responsive to Patients was something up? No! That is really, commonly the third choice, and Good Value was really not okay with me. rarely deemed important. The descriptions below include the predominant reasons that participants Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 7 But the reality is you can get over The surgery mistakes sound like they’re bad feelings, you can get over paying the most preventable by just following extra money. The ones where it the damn stupid checklist. has long-term, possibly, permanent But surgical mistakes, that’s more ramifications, to me, are the most human error. There’s a lot of hands serious. They must rank top. that have to travel through for someone to receive wrong meds —  When Patient Safety was examined during the from one end to the other. drill-down exercise, the three types of safety problems (see Table 4) brought intense debate. The scores were Preventable infections, kind of acts like very close because participants regarded all three as dangerous and saw the potential for any patient a pyramid. If one person gets it, that to be affected. Although Patient Safety seemed to person is going to spread it on to several be a novel concern for most of them, participants grasped the significance of these problems more other people. Whereas the other two, it easily than they did, for example, Treatment Skill. really only affects that individual. While participants debated which of the three types of safety problems were most harmful, there was considerable consistency in the characteristics they regarded as problematic. The high-priority problems were those that 1) can have a devastating impact on Treatment Skill the individual patient; 2) can affect a large number of Some saw Patient Safety and Treatment Skill as patients; 3) are those over which patients have little closely aligned, even inseparable, and participants control or influence; and 4) are easily correctable. struggled over which one was the higher priority. For example, preventable infections were on Those who viewed Treatment Skill as higher average a higher priority than wrong medications commonly noted that it is the main reason a person because participants believed they had greater goes to the hospital, thus it is always the aspect of potential for harming more people. Although surgical hospital care that has highest priority. Others who mistakes were sometimes viewed as potentially more ranked this one higher felt poor Treatment Skill had catastrophic to the individual patient than the other a greater (and more lasting) impact on the patient’s examples, participants also thought they probably medical well-being than the other domains, and happened less often than other safety problems. without good skill nothing else seemed important. When it was not highest priority, it was because they 8 | C alifornia H ealth C are F oundation regarded Treatment Skill as the responsibility of the The participants that addressed the Treatment doctor, not the hospital. Skill drill-down were far more in agreement about Although the examples describe Treatment Skill as priorities than were those assessing the Patient Safety a medical team responsibility, most study participants examples. As shown in Table 4, the heart example still assumed it was the individual physician who ranked highest. Participants were quite consistent controlled this. While some participants knew in their belief that the heart was the key to life specific examples of low-quality Treatment Skill, this and that everything else was subsidiary. They also domain did not have the intensity of discussion of believed that hospitals’ most important function others. As one person put it, “we don’t always know was to save lives, and since heart problems were when the skill isn’t good.” Thus, although Treatment often emergency situations — when patients had no Skill was critically important, it may not be what choice of hospital — this was their highest priority. worried them the most. As many participants noted, The other medical scenarios were usually elective “We start with the assumption that we will get good and patients had time to shop around. With a heart medical care.” A number of people regarded poor attack, patients had to hope that the closest hospital Treatment Skill as more likely to be a result of simple was capable of handling their medical crisis. human error and thus more forgivable. This was in contrast to Patient Safety where they regarded these errors as a function of sloppy, inattentive actions that should be easy to correct. Death, dismemberment, and discomfort. You’ve got to go in the right order. I rate Treatment Skill first, and Patient Safety second.… I feel like Yet 21 percent of participants gave diabetes complications the highest ranking. Their reasons Treatment Skill is dealing with what included that diabetes was just as life-threatening as you have, so that’s a concrete thing, heart disease; it leads to many other health problems; they believed it affects more people; and many with “I have this problem, I’m going to the lower socio-demographic characteristics are impacted. hospital for it.” Now, Patient Safety, By comparison, knee replacements were deemed virtually inconsequential. While acknowledging the to me, seems like accidents. Maybe I’ll frequency of this operation, participants viewed this have an accident, maybe I won’t. It’s nonetheless as an optional service; patients would not die if treatment skill was not optimal; and patients more of a risk assessment for me. had responsibility for researching which doctors and hospitals provide good quality care. Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 9 Responsive to Patients The three types of problems shown in Table 4 Study participants commonly mentioned problems elicited a debate about physical and emotional well- related to this domain in the initial discussion about being and their relevance to patients. Whereas many choice of hospital, yet they ranked this domain third believed that physical discomfort has a great impact (out of four) in importance. They still regarded this on patients’ ability to recover quickly, others were just domain as a high priority, but it did not rise to the as passionate that communication is key to patients same level as Patient Safety and Treatment Skill —  feeling they are in control of the situation. For both of which had a tangible impact on the physical many, the inclusion of timely pain medication in the health and well-being of patients. example of patient discomfort brought this problem Nevertheless, those who ranked it at or near the to the top of their list. Many viewed physical needs top often had particularly vivid stories of poor care. as more important than other forms of discomfort. Typical comments: “This is what you remember Although the Patient Safety discussion elicited the about being in the hospital, when they treat you like most animated concern regarding the well-being of cattle;” “If I can’t ask the doctor questions, how am I patients, Responsive to Patients brought forth many going to have confidence”?; and “I go to the hospital examples and experiences that clearly had long- for treatment; I don’t want to be put in the corner standing impact on the individuals affected. and ignored.” Despite their strong familiarity with the topic, most still ranked it lower than skill and safety and acknowledged they were doing so. “You You never hear so much about have some control over this — you can scream and jump up and down — but you have no control over all the good experiences. But when Treatment Skill or Patient Safety.” somebody’s had a bad experience, you remember that hospital. I put down number 3 on Response to It’s hard to describe when you haven’t Patients, but that bothers me more been in that position. Because exactly than the other things. Now, it’s not what (he) is describing, when the more important, but if I’m not treated little things don’t work for you, with respect, that bothers me then you don’t trust the system. more than anything. 10 | C alifornia H ealth C are F oundation There was little doubt that the needs of the family had the most examples of problematic cost-sharing as were secondary to those of the patient. Even those a factor in choosing a hospital. who had extensive experience as family members of hospitalized patients felt strongly that all the effort should be put towards helping the patient get well, not “coddling” the family. And it’s easy to say [not to consider One interesting observation was that participants in the Spanish-language and Medicare sessions the expense] if we’re privileged enough ranked Responsive to Patients higher than did other to not have to worry about paying for demographic groups. This domain perhaps speaks to the particular vulnerability of these populations in anything. Or that I can go anywhere the hospital environment. and receive the best quality care. Good Value But, in this area, and across the With only a few exceptions, participants ranked country, there are a lot of people Good Value the lowest of the four quality domains in terms of importance to them as patients and that don’t get that option. consumers. Even those who had experience with high out-of-pocket expenses believed that this is much less important than the other three domains. Common comments were, “You can’t compare life with money” When given the opportunity to look at specific and “It doesn’t matter how much you pay if you get examples of Good Value problems, participants did good treatment.” One participant complained, “Why not disregard these as meaningless. Yet the rationale is this even on the list? We are talking about life and for their rankings of these examples continued to be death, not talking about money!” Some believed oriented to patient care rather than unjustified costs. that higher costs were associated with better care The problem “pricey but not better” was the or that there might be justifiable reasons that the lowest priority because its impact was solely related hospital had to charge more. In particular, they put to the cost of the care, with no obvious clinical the responsibility on the patients to research the cost detriment to the patient. Both “delays/stalls” and question in advance. “unnecessary treatment” suggested that patients may Yet not all participants were dismissive of this be adversely affected by these examples of poor value, domain. Recognizing that some people may not and these were the issues that concerned participants have generous health plans, an individual’s share of the most. Interestingly, “unnecessary treatment” cost might be very important to them. Noted one was the only one that explicitly cited examples participant wryly in reference to affordability, “The of possibly harmful care — yet “delays/stalls” quality of the care isn’t going to matter if you are ranked higher. While some participants provided not getting treated.” While the Spanish-speaking testimony of the wastefulness and potential harm Hispanic group also agreed that this was a lower of unnecessary treatment, others voiced skepticism priority than the other domains, these participants that “too much treatment” is a bad thing, and they Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 11 would rather risk too much care than not enough. Study Limitations It was clear, however, that the main aspect that It should be noted that the research had certain participants focused on was the effect the examples limitations due to the small sample size, relatively had on patients’ health and well-being. Financial brief duration of sessions, and difficulty that a small considerations alone were not of high interest. minority of participants had in understanding the domains. Nevertheless, the vast majority understood what was being asked and responded with clarity, consistency, and logic. The discussions When it says, for example, back surgery were animated, relevant to the issues, and reflected “often does not get good results….” considerable consumer interest. The sessions’ two-hour time frame meant But you know what? I’m suffering! that many of the nuances of what constitutes an important quality problem — such as how I’ll use this just as an example: often these problems actually occur, the extent to which problems result in significant patient Veterinarians. I have two vets by my harm, and populations that are disproportionately house. One charges about triple what affected — were not presented to participants in the descriptions. Detailed in-depth deliberative the other one charges for everything. discussions would likely require a multi-session But they both do fine work. format with community members over a longer period. The more costly the hospital, the greater chance of better care. Although Good Value was consistently the area of lowest concern, most participants still felt it was appropriate to have hospitals improve this quality domain. While many with health insurance will not regard this as a critical element for their decisionmaking, patients without insurance (or with high deductibles or coinsurance) may find reporting on this domain useful. 12 | C alifornia H ealth C are F oundation IV. Conclusions L ike all health care stakeholders , effectiveness. Hospitals may not be anxious to put hospitals must decide where to put their time a spotlight on patient safety, but helping consumers and resources to measure and improve quality. appreciate the importance of this domain means The priorities voiced in the research groups giving it the attention that is warranted. have implications for those developing quality improvement standards and those whose role is to Use the Term “Quality” with share quality information with the public at large. All Domains Following are some conclusions and suggestions for While the IOM specified that quality care has six hospitals and reporting organizations. attributes, many reporting organizations’ Web sites and communications only use the term “quality” Target Improvement Efforts to High in association with clinical effectiveness. We found Priority Domains that, like the IOM, consumers regard the domains In establishing their priorities for QI, hospitals of clinical effectiveness, patient safety, and responsive should keep in mind the two domains that the public to patients all as quality issues; Web sites and other regards as highest priority: patient safety and clinical communications should do so as well. effectiveness. Particularly important within those two domains are: emergency, life-saving clinical Consider Efficiency Carefully care; safety problems that may affect many patients; While consumers seemed least enthusiastic about the and clinical or safety problems that could have a efficiency domain (and do not consider it a “quality” devastating impact on individuals. Consumers are issue), purchasers and health plans are not likely to particularly concerned about those quality issues ignore it. If rising health care costs increase patients’ where they feel there is little they can do as patients hospital cost-sharing burden dramatically, this to control them (such as hospital infections). quality domain may gain greater consumer attention. While the patient experience ranked lower in Discussion group participants also suggested that priority, it is the quality domain that patients know efficiency information is more valuable at the time about personally, and it affects their perception of the of open enrollment; bringing potential cost-sharing total quality of care. It may not be as important as issues to consumers at that time might have a bigger patient safety and clinical effectiveness, but it is the impact. most visible domain and should be carefully tracked. Elicit the Public’s Voice Spotlight Patient Safety This study sheds light on consumer priorities across Reporting organizations should emphasize the hospital quality domains, but there are foundational significance of patient safety by reporting it as a issues that also need a deliberative public process. separate and distinct quality domain, underscoring As health care costs continue to soar, identifying that it is as relevant to good patient care as is clinical priorities for QI must take into account the relative Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 13 costs and benefits of alternative approaches. State or national organizations with a broad focus on QI will need to take the lead in eliciting public input on some of the more nuanced trade-offs such as: How to balance great harm to a few versus lesser harm to many; how to remedy quality problems that disproportionately affect certain populations; how to weigh very costly remedies against other needs in terms of resource use. The public should be key participants in conversations about these ethical and societal health care dilemmas. 14 | C alifornia H ealth C are F oundation Endnotes 1. CHART is a nonprofit organization formed by leaders 10. According to the IOM report, health care must also be from health plans, hospitals, purchasers, and consumer timely and equitable. organizations with initial funding from California 11. This domain directly reflects patients’ responses to their HealthCare Foundation. It reports hospital quality hospital care. Hospital ratings on this are based on a measures on the Web site www.calhospitalcompare.org. national standardized survey called Hospital Consumer 2. For the most part, the hospital data shown on the Assessment of Healthcare Providers and Systems Web site are gathered from state and national sources. (HCAHPS), conducted under the auspices of the Agency CHART has responsibility for what is collected and for Health Care Research and Quality. See www.cms.gov. how it is collected, following widely accepted standards 12. When sessions are held outside the geographic territory of for accuracy and objectivity. The Web site —  the recruitment firm, community organizations are used www.calhospitalcompare.org — is operated by the to find appropriate participants and to host the sessions. California HealthCare Foundation in collaboration with CHART. 3. Institute of Medicine, “Crossing the Quality Chasm: A New Health System for the 21st Century,” see www.iom.edu. 4. Kaiser Family Foundation, Agency for Healthcare Research and Quality. “Update on Consumers’ Views on Patient Safety and Quality Information, 2006.” Available at www.kff.org. 5. Harris, K.M., M.B. Buntin. “Choosing a health care provider: The role of quality information,” The Robert Wood Johnson Foundation. Research Synthesis Report 14, May 2008. pg.11 www.rwjf.org. 6. Sofaer, S., C. Crofton, E. Goldstein, E. Hoy, J. Crabb. “What do Consumers Want to Know about the Quality of Care in Hospitals?” Health Research and Educational Trust, DOI: 10.111/j.1475-6773.2005.00473.x 7. Sofaer, S., K. Firminger. “Patient Perceptions of the Quality of Health Services.” Annu. Rev. Public Health. 2005; 26:513 – 59. 8. Faber, M., M. Bosch, H. Wollersheim, S. Leatherman, R. Grol. “Public Reporting in Health Care: How Do Consumers Use Quality-of-Care Information?” Medical Care. 2009; 47(1): 1– 8. 9. Pronovost, P.J., R.R. Faden. “Setting Priorities for Patient Safety: Ethics, Accountability and Public Engagement.” JAMA. 2009; 302 (8):890 – 91. Consumers’ Priorities for Hospital Quality Improvement and Implications for Public Reporting | 15 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org