Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.
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Objective & Validation Documentation
Objective: Improve patients’ experience of and satisfaction with care by gathering and applying learnings from relevant data to make care more patient-centered.
Validation Documentation: Evidence that patient experience and satisfaction data are collected, and that follow-up occurs through an improvement plan. Include at least two of the following elements:
1) Report of patient experience and satisfaction – Report including collected data on patient experience and satisfaction (e.g., survey results). Report may include description of effort to implement patient surveys in multiple languages based on the needs of the patient population. The eligible clinician or practice may use a third-party administrator; AND/OR
2) Follow-up on patient experience and satisfaction – Documentation that the eligible clinician’s practice has implemented changes based on the results of the patient experience and satisfaction data gathered and analyzed (e.g., specific improvements made to practices/processes in response to survey results); AND/OR
3) Patient experience and satisfaction improvement plan – Documentation of a patient experience and satisfaction improvement plan.
Example(s): A practice offers patients the option to fill out a questionnaire after their visit. A) The practice finds that a consistent complaint is the long wait times and that the practice is losing patients as a result. The practice develops a plan to address wait times. B) The practice finds that there are multiple complaints about a single eligible clinician that include poor listening skills and a tendency to rush in and out of the room so fast that questions are not answered. The practice creates an education plan for the eligible clinician and also identifies and addresses environmental issues, or provides support to address personal issues, that lead the eligible clinician to feel pressure to rush through patient visits.
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for Healthcare Research and Quality: https://www.ahrq.gov/cahps/surveys-guidance/cg/index.htmlcy and https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/MIPS
• Tools and advisory councils: https://www.ahrq.gov/topics/patient-and-family-engagement.html
• Patient experience surveys: https://www.ahrq.gov/cahps/surveys-guidance/index.html
• Other available surveys: https://www.rand.org/health-care/surveys_tools/psq.html