Patient Experience of Care Surveys

Revised February 2023, June 2016 with current title

Originally approved September 2010 titled "Patient Satisfaction Surveys"

The American College of Emergency Physicians (ACEP) recognizes that patient experience of care surveys that are methodologically and statistically sound can be reflective of the patient’s perception of their health care experience, and that patient outcomes can be related to perceived patient experience of care.

However, neither institutions nor survey vendors have established widespread standardization of survey tools, populations, or methodologies. Inclusion and exclusion criteria have not been consistently applied, resulting in inconsistent survey results. Hospitals and survey vendors may sample or receive responses from a small percentage of the patients seen in the emergency department (ED) potentially leading to results with poor validity. Importantly, acutely ill or injured patients who are admitted to the hospital are typically excluded, the very patients to whom emergency physicians appropriately devote disproportionate amounts of time and attention. Moreover, factors leading to poor patient experience scores, including wait times, are often related to factors extrinsic to ED operations and outside of the control of the staff working in the ED.

Consumer Assessment of Healthcare Providers & Systems (CAHPS) was a program introduced by the Centers for Medicare & Medicaid Services (CMS) in the mid-2000s as part of the overall shift of healthcare from a fee-for-service to a pay-for-performance model. The program was designed to assess the experiences of adult ED patients who were subsequently discharged home. An early version of a care quality survey for EDs, based on outpatient tools, was initially conceived as ED PEC (Patient Experience of Care); however, despite a prolonged trial of ED PEC and its offspring instrument, labeled ED CAHPS, CMS has still not validated nor issued standard ED surveys.

ACEP holds that patient experience of care survey tools should be:

• Standardized and validated for the average education level of those being
• Administered and tabulated as close to the date of service as
• Based on a statistically valid sample size free from selection bias.
• Administered to all categories of ED patients regardless of location seen or admission/discharge/ observation/transfer status to create a broad representation of patient experiences without marginalizing certain populations.
• Structured with methods to exclude patients who:
  • Leave without being seen/elope
  • Leave against medical advice
  • Require security intervention or restraint
  • Have altered mental status or lack capacity due to medical or psychiatry illness
  • Are held under involuntary behavioral health holds
  • Are evaluated in the custody of law enforcement
  • Have been surveyed within the last 30 days
  • Expired in the course of the ED/hospital stay
• Transparent in the administration and analysis
• Explicit in the intended purpose and use.
• Designed to address clinically meaningful aspects of the patient’s perception of care in the ED.

Due to the difficulty in refining whether patient experience of care scores are the result of physician performance or due to demands and restrictions on the current health care system, implicit bias, or other factors out of the control of the physician, patient experience of care metrics should not be used in isolation for purposes such as credentialing, contract renewal, or incentive bonus programs. Instead, they should be viewed as one data point among many when assessing perception of ED care.

Using patient experience of care scores for credentialing, contract renewal, or incentive bonus programs could have potential negative impacts on quality patient care including safe prescribing of controlled substances, use of antibiotics, and utilization of imaging. Patient experience surveys are best utilized in a collaborative fashion between physicians and healthcare organizations to assess the patient experience of care in the ED.

ACEP believes that:

• Patient experience scores whether attributed to an individual physician, other elements of the department, or the entire ED must be criterion-referenced. The standard to which it is compared must be previously determined and applicable to similar institutions in similar settings. The use of rank ordered percentiles must be abandoned, given irrelevant meaning of such comparative positioning.
• CMS should provide emergency physicians the opportunity to provide input into the ED CAHPS survey and methodology.
• Methodologies should be based on national standards.
• Patient experience of care measurement and methods to assess the validity of individual survey tools be incorporated into the training of residents in emergency medicine.