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Margarita Hurtado, PhD, MHS American Institutes for Research (AIR)

What Can Patients Tell Us To Improve In-Center Hemodialysis Care? & What Can Patients Tell Us About the Cultural Competency Of The Care They Receive?. Margarita Hurtado, PhD, MHS American Institutes for Research (AIR). AHRQ 2007 Annual Conference Rockville, September 27, 2006.

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Margarita Hurtado, PhD, MHS American Institutes for Research (AIR)

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  1. What Can Patients Tell Us To Improve In-Center Hemodialysis Care?&What Can Patients Tell Us About the Cultural Competency Of The Care They Receive? Margarita Hurtado, PhD, MHS American Institutes for Research (AIR) AHRQ 2007 Annual Conference Rockville, September 27, 2006

  2. Using CAHPS Surveys to Improve the Dialysis Experience

  3. Acknowledgements: ICH-CAHPS QI Team • AHRQ: • David Stevens • Beth Kosiak • CAHPS Grantees: • AIR: Margarita Hurtado • RAND: Denise Quigley and Donna Farley • Harvard: Paul Cleary & Susan Edgeman-Levitan • Westat: Lise Rybowski • CMS: National and ESRD Network Staff

  4. Patient Interviews: A “Typical” Day at the Dialysis Center “I’m in very early in the morning and I usually don’t stay in the waiting room very long. [I am in] as soon as they open the door. The first thing we do is weigh us. And then they put us in a chair, give us a blood pressure test, and then we get the needles put in. We get a blanket.... I’m on for 3 hrs and 15 min., and then another ½ hour before the bleeding stops.” - A patient

  5. The ICH-CAHPS QI Demonstration • Examined Using CAHPS Survey Data for QI • 4 ESRD Networks: New England(#1), Mid-Atlantic (#5), Texas (#14), Intermountain(#15) • 7 Dialysis Centers: 2 partner w/ each Network/Grantee team; 1 with Network 15 • 3 Grantees: American Institutes for Research, RAND, Harvard • Products: • Provider Report • QI Projects • Lessons Learned Report

  6. Evaluation of the QI Demonstration • Pre and Post CAHPS Survey Measures • Interviews with Network staff • 2 site visits to dialysis centers • Interviews with dialysis center staff & patient representatives • Lessons learned report across all sites

  7. Participating Dialysis Centers • Experience with quality improvement. 4 with limited experience, 2 with moderate experience, and 1 with extensive experience • Size (13 - 216 chairs). 1 small, 2 mid-size, and 4 large centers • Geography. 3 in rural towns, 2 mid-sized rural towns, 1 in mid-sized urban town, 2 in mid-sized cities, and 1 large city (inner city) • Race/ethnicity of patients. 3 mostly white with some African Americans, 2 mixed, 1 mostly Latino, 1 mostly African-American and Hispanic • Ownership. 5 were owned by chains, 1 was independent, 1 was owned by a hospital

  8. QI Project Objectives • Obtain a more complete picture of the quality of dialysis care by including patients’ perspectives • Develop a report on CAHPS survey results useful to providers for QI • Examine the usefulness of the CAHPS survey results for QI purposes • Document the quality improvement strategies and interventions the dialysis centers carried out based on CAHPS survey results • Compile lessons learned

  9. What Did We Ask Patients About Their Dialysis Care? Summary Measures • Nephrologists’ Communication and Caring (7 items) • Quality of Dialysis Center Care and Operations (22 items) • Staff Communication and Caring • Staff Professionalism and Competence • Dialysis Center Operations • Providing Information to Patients (11 items) Ratings • Nephrologists • Staff • Center

  10. 1. Plan 4. Check 2. Do 3. Act Using CAHPS for Quality Improvement: The QI Cycle (PDCA)

  11. 1. Plan: Identify Opportunities for Improvement and Plan Strategy • Examine CAHPS survey results (and any differences by population subgroups) • Define potential opportunities for improvement from CAHPS survey • Define areas where need additional information to define specific areas for improvement • Establish QI team • Establish goals for improvement • Investigate potential strategies

  12. PLAN: Define potential areas for improvement How Often Dialysis Center Staff Cared About Patients as People Your center can improve compared to the national average. Patients were asked, “how often did you feel that the dialysis center staff really cared about you as a person?” The proportion of patients at your center who said “always” was 26% lower compared to the national average and 64% lower compared to the average of the top 10% of dialysis centers.

  13. 2. Do- Develop and Test Strategy • Define specific intervention(s) • Define measures to monitor progress, criteria and benchmarks • Implement interventions • Adapt/adjust interventions to organizational context

  14. 3: Check Progress and Monitor Strategy • Gather data on measures selected to monitor progress • Analyze data on measures to monitor progress • Evaluate progress made against predefined criteria • Implement further changes as needed

  15. Step 4: Act-Reassess Strategy & Respond • Implement CAHPS survey again and examine changes in scores for areas chosen • Assess what worked and what didn’t work • Modify strategy, if needed • Introduce improvements into the organization on a broader scale, as appropriate • Start the cycle again

  16. Change in Patient Ratings of Dialysis Staff for One Center

  17. What Did Patients Say After the QI Project? “The change I’ve noticed in the last 3 months is that I know the staff better than I did.” “We all fuss because we want individual TVs... I have no problem with anything we’ve had from the staff, they’re all really nice.” “They do what they can to relieve problems here, and if they can’t handle it, they send us to the hospital.”

  18. Using CAHPS Surveys for QI: Lessons Learned I • CAHPS surveys can provide useful information for QI • Need to plan for QI before the survey (over-sampling; supplemental QI items) • Consumer reports are not appropriate for QI; need item-level information • Benchmarks should include top performers, not just averages

  19. Using CAHPS Surveys for QI: Lessons Learned II • You may encounter resistance with respect to use of patients reported data for QI- be prepared with evidence on CAHPS surveys validity and reliability • LDOs usually define areas for QI and strategies and focus is on clinical measures • Most providers have not focused QI on patient experiences. They will need training • Involve patients and staff in the QI process- they know best • It is very difficult to change organizations. It takes time and perseverance.

  20. Measuring Cultural Competency From The Patient’s Perspective

  21. Acknowledgements: CAHPS CC Team • AHRQ: • Charles Darby • CAHPS Grantees: • AIR: Margarita Hurtado • Harvard: Karen Bogen • RAND: Beverly Weidmer*, Quyen Ngo-Metzer, Robert Weech-Maldonado *Lead for the intergrantee team

  22. Developing the Cultural Competence Modules • Literature Review • Development of a Conceptual Model* • Instrument Review (incl. CAHPS) • Call for Measures • Item Development and Translation • Cognitive Testing • Field Test * Ngo-Metzer et al. 2006. Cultural competency and quality of care. Available at www.cmwf.org

  23. Conceptual Framework for Culturally Competent Care Patient Factors Provider Factors A Health Care System Factors B A. Patient provider communication Respect for patients/Shared decision-making B. Experiences leading to trust/distrust Experiences of Discrimination Linguistic Competency (incl. health literacy)

  24. Cognitive Testing • Conducted in-person interviews with 18 participants in May 2007 • Participants included a mix of men and women, level of education, age, race/ethnicity, country of origin (for Spanish speakers) • Interviews conducted in English (9) and Spanish (9) • Tested items as a self-administered survey and interviewer-administered survey

  25. Overview of Items Tested • Language Access (10 items): Use and rating of interpreters, discrimination by language • Patient-Doctor Communication (10 items): Health and mental counseling, use of complementary/alternative medicine • Shared Decision Making (7 items): Alternatives, preferences, values • Discrimination (12 items)*: Insurance, race/ethnicity, language, source, how knew • Trust (7 items): truth-telling, caring, level of trust, rating, cared for you as a person • Health Literacy (41 items):** Tools; problems/concerns; self-management; medicines; forms; test results; navigation * One of these items is added to the language access **Separate project focused on this domain

  26. Revised Cultural Competence Modules and Items • Language Access (14 items) • Patient-Doctor Communication (10 items) • Shared Decision Making (5 items) • Discrimination (3 items)* • Trust (6 items) • Health Literacy (30 items) * 1 of these items is added to the language access module

  27. To Learn More About CAHPS QI and CC visit: www.cahps.ahrq.gov

  28. “The collaboration makes sense but it will take a while to understand them”

  29. Questions? Margarita Hurtado, Ph.D., M.H.S. American Institutes for Research mhurtado@air.org Tel. (301) 592-2215

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