Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system

BMC Health Services Research Unannounced standardized patients: a promising method of assessing patient-centered care in your health care system Sondra Zabar 0 Kathleen Hanley 0 David Stevens 2 Jessica Murphy 2 Angela Burgess 0 Adina Kalet 0 Colleen Gillespie 0 0 Division of General Internal Medicine, Department of Medicine, New York University School of Medicine , 550 First Avenue, New York, NY 10016 , USA 1 5 , New York, NY 10013 , USA 2 NYC Health & Hospitals Corporation , 346 Broadway Background: While unannounced standardized patients (USPs) have been used to assess physicians' clinical skills in the ambulatory setting, they can also provide valuable information on patients' experience of the health care setting beyond the physician encounter. This paper explores the use of USPs as a methodology for evaluating patient-centered care in the health care system. Methods: USPs were trained to complete a behaviorally-anchored assessment of core dimensions of patient-centered care delivered within the clinical microsystem, including: 1) Medical assistants' safe practices, quality of care, and responsiveness to patients; 2) ease of clinic navigation; and 3) the patient-centeredness of care provided by the physician. Descriptive data is provided on these three levels of patient-centeredness within the targeted clinical microsystem. Chi-square analyses were used to signal whether variations by teams within the clinical microsystem were likely to be due to chance or might reflect true differences in patient-centeredness of specific teams. Results: Sixty USP visits to 11 Primary Care teams were performed over an eight-month period (mean 5 visits/team; range 2-8). No medical assistants reported detecting an USP during the study period. USPs found the clinic easy to navigate and that teams were functioning well in 60% of visits. In 30% to 47% of visits, the physicians could have been more patient-centered. Medical assistants' patient safety measures were poor: patient identity was confirmed in only 5% of visits and no USPs observed medical assistants wash their hands. Quality of care was relatively high for vital signs (e.g. blood pressure, weight and height), but low for depression screening, occurring in only 15% of visits. In most visits, medical assistants greeted the patient in a timely fashion but took time to fully explain matters in less than half of the visits and rarely introduced themselves. Physicians tried to help patients navigate the system in 62% of visits. Conclusions: USP assessment captured actionable, critical, behaviorally-specific information on team and system performance in an urban community clinic. This methodology provides unique insight into the patient-centeredness and quality of care in medical settings. Quality improvement; Unannounced standardized patients; Patient-centered care; Assessment; Quality of care - Background Newly developed models of health care delivery such as Patient-Centered Medical Homes (PCMH), Accountable Care Organizations (ACO) and explorations of the features of a clinical unit or microsystem that are associated with high quality care [1] are based on an appreciation of the impact of the entire care system on patients health. A central principle of these models is that care should be oriented around the needs of patients. Ensuring such patient-centered care requires understanding how patients experience care from the moment they walk in the door until they walk back out, including the range of health care professionals with whom they interact, the functioning of health care teams, the ease with which they can find their way and or get help navigating through the system, and the quality and safety of the services and care they receive throughout that process. Maximizing health outcomes and patient safety requires a well-designed patient-centered health care system which includes everyone the patient encountersphysicians, nurses, clerks and paraprofessionals. High quality care performed by an individual cannot overcome a poorly run system or team [2]. Poor functioning teams contribute to errors such as increased nosocomial infections or patients not following through on recommended tests [3-5]. Unfortunately, efforts to address dysfunctional teams or clinical units are often driven by isolated incidents or complaints and conducted as post hoc evaluation that does not capture the real time, routine behavior of a clinical system. Proactive initiatives to continuously monitor the quality of the care provided in a clinical system or unit, from the perspective of patients, are critical for improving quality. Current methods for measuring the functioning of the clinical health system have significant limitations as well as strengths. Direct observation is intrusive and therefore may not reflect every-day, actual functioning; in most contexts, care measured through direct observation is generally assumed to be of much higher quality because providers are aware they are being assessed. However, direct observations use of a highly trained observer contributes to its status as one of the most reliable methods for assessing the care that is actually provided [6-9]. Data collected through patient exit interviews have often been shown to be biased in multiple ways, ranging from patients reluctance to judge their care negatively [10] to the influence of patients prior experience, expectations, health care status/needs, and personality [11]. Patient satisfaction surveys suffer from similar limitations [6,12-14]. However, what both methods may lack in internal validity can be balanced by the generalizability benefits associated with understanding how individuals representative of the targeted patient population respond to and experience health care. This trade-off is especially important when the goal is to understand the impact of health care on patients. When the focus of the assessment is on the practices and processes of the health care system, patient characteristics, on the other hand, can contribute uncontrolled noise to the equation, making it difficult to identify how much of health care system responses are due to specific patient variables and how much are truly attributes of the system. We believe that unannounced standardized patient (USP) visits provide a unique perspective on the functioning of health care systems because they combine a number of methodological strengths: 1) they avoid the Hawthorne effect by capturing the practices of health care professionals when they are not aware of being assessed; 2) they involve a highly trained observer/assessor (the USP); 3) they focus on the vantage point of the patient; 4) they control not only for the influence of patient characteristics on recall and evaluation of care through the use of a highly trained professional but also, because they are standardized in terms of the clinical features of the case and the demeanor and personality of the patient, for the effects of su (...truncated)