Low response rates and inaccurate responses undermine CAHPS scores and reimbursement.
The paper-based CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey is being increasingly used in US healthcare as formal reporting of patient experience metrics to improve quality care and by extension driving reimbursement. However, studies using these paper-based CAHPS surveys have found response rates ranging as low as 34% to 61% – lower for female, nonwhite, younger, and limited English-proficient patients, providing evidence that certain patient subgroups are less likely to respond to traditional CAHPS surveys (1,2,3,4). In particular, patient populations already struggling with literacy, numeracy, and/or English proficiency encounter greater hardship when answering existing CAHPS questionnaires (5). Furthermore, researchers at the University of California, San Francisco (UCSF) found that the lower response rates from specific patient populations also resulted in data not representative of the diverse patient populations in healthcare settings and underscored the need for exploring new ways to engage all patients in reporting on their care.
Applying Digital Empathy™ in designing a survey that reaches a wider population with low-literacy.
The researchers wanted to test the impact of applying the principles of Digital Empathy to the exclusively text and paper-based CAHPS survey to see if surveying would become more effective. The team partnered with Tickit Health to digitize the CG-CAHPS and apply Digital Empathy to it in order to serve the needs of diverse groups of patients at San Francisco Health Network (SFHN). Annually, SFNH provides primary care to over 63,000 patients a year (35% Latino, 25% Asian, 17% black, and 17% white), and the majority of patients have Medicaid, Medicare, or are uninsured.
While preserving the integrity of the CG-CAPHS, the survey was modified to lower literacy levels by improving readability to a 5th-grade reading level, including visual imagry, shortening the survey length from 31 to 16 questions, and adding open-ended questions to capture patient-directed perspectives of care. Tickit’s visually attractive interface, characterized by colorful graphics, icons and illustrations, enhanced engagement rates to increase honesty in responses and completion of the survey.
The team at Tickit Health played an active role in working with patients and patient advisory councils to use their feedback, focusing on improving readability, suitability with clinic processes, interface of the application, and workflow in refining the tablet-based survey adaptation at the clinic.
The year-long pilot study positively supported the use of a Digitally Empathetic version of CAHPS in capturing more complete and accurate responses from patients.
Findings on usability and acceptability of Tickit to administer CAHPS
72% of respondents preferred a Tickit based survey over a paper-based survey which had traditional wording.
Participants found Tickit was quick, easy, and convenient to use due to its novelty, color, interactivity, and “fun” factor.
Patients felt greater value in collecting feedback at the point of care to avoid mail delay and occupying time in the waiting room, itself an improvement in the patient experience.
Employing the Digitally Empathetic way of asking questions on Tickit led to participants reporting that it was faster to complete the survey using the tablet, citing the use of figures, survey interface, and adaptations to questions which improved readability.
Patients felt the data collected on Tickit would drive changes in quality of care and improve clinical processes.
“I liked [the tablet version] because everyone will fill it out when it’s this easy. If it’s difficult, then people like me who don’t have a lot of education will have trouble”
– Age 55–64, Female, Latina, Spanish speaker
Improved response rates from CG-CAHPS with Tickit
The year-long pilot resulted in a steady increase in responses month over month and higher representation from younger and Latino individuals. The real-time feedback from enhanced data collection displayed in graphical reports provided added information to clinic staff to initiate quality improvement measures and patient experience efforts with enhanced data collection. The positive feedback boosted the morale of staff and providers, while negative feedback drove changes towards improving the delivery of care. Based on these findings, researchers suggested that federal policy should support enhancing the CG_CAHPS based on Digital Empathy for collecting patient experience data from diverse populations.
Digital Empathy™ CAHPS survey was preferred to a paper-based version of the survey
Despite varying levels of education, literacy, and experience with tablets, it was found that both English-speaking and Spanish-speaking patients & staff at UCSF strongly preferred a digitally empathetic-based delivery of the CAHPS patient experience survey compared to traditional paper-based survey methods. It was also noted that requesting patients to complete a survey regarding their experience while using a survey that itself has a less than exceptional experience may be undermining CAHPS scores, and impeding reimbursement.
1. Anhang Price R, Elliott MN, Cleary PD, et al. Should health care providers be accountable for patients’ care experiences? J Gen Intern Med. 2015;30:253–256.
2. Elliott MN, Lehrman WG, Goldstein EH, et al. Hospital survey shows improvements in patient experience. Health Aff (Millwood). 2010;29:2061–2067.
3. Elliott MN, Edwards C, Angeles J, et al. Patterns of unit and item nonresponse in the CAHPS Hospital Survey. Health Serv Res. 2005;40 (pt 2):2096–2119.
5. Klein DJ, Elliott MN, Haviland AM, et al. Understanding nonresponse to the 2007 Medicare CAHPS survey. Gerontologist. 2011;51:843–855.
The CG-CAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems) survey is widely used to gauge patients experiences with healthcare providers and staff. The survey comes with a standardized, evidence-based set of questions for adults and children either in primary care or a specialized care setting. Survey results help to improve care provided by individual doctors, sites of care, medical groups, or provider networks. For patients, feedback is also used to equip consumers with information to aid in choosing physicians, medical groups, or other healthcare providers. To learn more about Tickit CG-CAHPS survey and how to improve your response numbers, contact us at firstname.lastname@example.org.
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