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Crozer-Keystone Health System Switches to New Patient Survey Provider

As part of Crozer-Keystone Health System’s ongoing efforts to measure — and enhance — patient’s experience of care, the health system has partnered with a new patient experience survey provider. The health system made the change from Press-Ganey to NRC Picker (National Research Corporation), effective July 2010.

As many employees know, patient surveys help Crozer-Keystone measure patients’ experience of their care at CKHS hospitals. NRC Picker offers new opportunities to place meaningful, actionable data into the hands of department managers, staff and physicians to improve patient’s experience of care. As health systems get ready to enter the era of Value Based Purchasing [see sidebar], it becomes even more important to use feedback from patients to improve their care experience based on what is important to them.  

The NRC Picker Survey Structure

NRC Picker presented many compelling reasons for change, starting with the structure of the survey question itself.  NRC Picker’s questions focus on the patient’s experience of the care provided by the hospital staff and physicians through objective reporting, rather than subjective ratings. The questions are (staff and physician) behavior-based. In other words, the questions provide feedback on specific behaviors and actions of the staff and physicians that are expected to occur by the patient rather than simply asking the patient “how satisfied were you with your care?” 

The foundation of the NRC Picker survey process — and by extension the HCAHPS survey process — is built on the research of Harvey Picker, M.D., and Harvard Medical School. They were aware that too little emphasis was placed on the emotional and personal aspects of a patient’s care. Through their investigations, Harvard and the Picker Institute uncovered issues that matter most to patients and their families, and that would assist hospital staff in improving the delivery of care in areas that matter most to patients.

Seven years of study, conducting interviews with 8,000 patients, family members, physicians and hospital staff focused on these questions:

  • What do patients want?
  • What do patients value?
  • What helps or hinders their ability to manage their health problems?
  • What aspects of care are important to them and their families?

Insight into patient perceptions of care gained through this research was organized into the Eight Dimensions of Patient-Centered Care common to all patients facing healthcare treatment.

After the researchers identified what patients valued most, NRC Picker designed a survey instrument that not only focuses on aspects most important to patients, but also provides actionable results to hospital staff. It was learned that a more accurate rendering of the patient experience could be revealed by asking questions in an objective manner, rather than a subjective manner. 

Eileen Young, MSN, RN, the Crozer-Keystone assistant vice president responsible for this project, says, “The questions seek feedback from the patient in a way that inquires how the staff behaves towards the patient, treats the patient, and responds to and meets the needs of the patient as well as how often these behaviors occur.” 

Young explains an example of how the NRC Picker questions differ from more typical survey vendors: “A question from another survey might ask: ‘How satisfied were you with the information provided at discharge?’ The NRC Picker survey asks the question in a more objective way: ‘During your hospital stay, did someone on the hospital staff explain what to do if problems or symptoms continued, got worse or came back?’”

This question structure also serves as the foundation for the Centers for Medicare and Medicaid Services’ (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions. The HCAHPS questions, which are mandated by federal legislation, provided a standard assessment of Patient Experiences of Care for public reporting across all hospitals. The HCAHPS questions are made up of 16 questions covering four of the eight dimensions of care. Survey results are included in the public reporting of data on and will be a part of CMS’ Value-Based Purchasing. Crozer Keystone integrated the HCAPHS (CMS Healthcare Consumers Assessment of Hospital Providers Survey) questions into its existing patient satisfaction survey in 2006.

CMS used the research conducted by Picker and Harvard University to construct the HCAHPS survey. The additional NRC Picker questions that follow capture feedback in the remaining four dimensions, such as coordination of care, providing more depth to patients’ perspectives of their total care experience.


Another exciting reason to change is the ability to customize the survey to the type and setting of care. Typically, patients’ survey responses are attributed to the unit from which they were discharged. Because of this, critical care units or services such as the Operating Room traditionally received little or no specific feedback. Using demographic information provided by Crozer-Keystone, NRC Picker will add specific questions tailored to those inpatients who are admitted via a CKHS emergency department, receive care in an ICU, deliver a baby in a CKHS hospital or undergo a surgical procedure during their stay. Those specialty areas will now have unit-specific patient feedback. 

With the same focus of providing meaningful, actionable information to all units, NRC Picker also includes the full set of HCAHPS questions with every inpatient survey it sends. Finally, survey volume can be set at the unit level, ensuring all units will have a meaningful number of responses to guide their improvement plans. Overall, more responses focused on what matters most to patients should lead to better, more accurate data that can be used at the unit or physician level to improve.

The NRC Picker survey will replace the health system’s former survey tool for all inpatients and emergency department patients surveyed. In making the change, Crozer-Keystone will expand the process to include outpatient services such as short procedures, radiology, physical medicine and rehabilitation, and the health system will begin to survey home care patients with the expansion of CMS HCAHPS requirements. In short, each survey will be tailored to take each patient’s individual experience into account.

On Line Reporting Tools

NRC Picker encourages transparency, sharing patient feedback at all levels of the organization. Catalyst, NRC Picker’s web-based suite of reports and tools, provides easy access to survey results and improvement planning tools. Catalyst includes a patient experience dashboard that provides a red, yellow, green stoplight view of performance compared to goals at the unit or hospital level.  

The dashboard provides a consistent view of performance, highlighting areas of strength, weakness and opportunity. Additionally, users can set up a schedule for delivery or “push reports’ directly to e-mail inboxes. Finally, Catalyst provides users with the ability to view patient comments, trend data over time, rank order the performance of units within CKHS and against selected benchmarks.

Value-Based Purchasing

In 2012, CMS Value-Based Purchasing program (VBP) replaces the current quality reporting or ‘pay for reporting’ program with a new program that includes both public reporting and financial incentives for better performance intended to drive improvements in clinical quality, patient-centeredness, and efficiency.

The Medicare Hospital VBP Program does not increase Medicare spending, but re-allocates it among providers based on performance in clinical process of care measures or core measures, outcomes such as mortality and readmission and patient perspectives of care or HCAHPS. When the CMS VBP program begins in 2012, a portion of the hospitals’ Medicare payment will be withheld to be “earned back” based on performance in these quality measures, thereby creating an incentive for hospitals to drive improvement.

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