What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement

Abstract

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement.

Context: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement.

Methods: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders.

Findings: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements.

Conclusions: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Keywords: narratives; patient experience; patient surveys; patient-centered; quality improvement.

Figure 1

Mapping the Potential Value of Narrative Content for Quality Improvement in Health Care Abbreviations: CAHPS, Consumer Assessment of Healthcare Providers and Systems; QI, quality improvement. “Composite” refers to the quantitative metrics constructed from the aggregation of survey responses to several different questions that are all in a particular domain of practice, such as provider‐patient communication or coordination of care. “Composite score” refers to the performance rating for a clinician or clinicians using that composite. “Overall ratings” refers to the quantitative assessment of the complete patient care experience, reported on CAHPS using a 1‐10 scale.

Figure 2

Question Wording for the CG‐CAHPS Narrative Elicitation Protocol

Figure 3

Frequency of Domains of Patient Experience Reported in Narrative Accounts [Color figure can be viewed at wileyonlinelibrary.com]

Figure 4

Illustrative Examples of Concrete Narrative Feedback for the Communication Composite

Figure 5

Illustrative Examples of Concrete Narrative Feedback for the Office Staff, Access, and Care Coordination Composites

Figure 6

Illustrative Examples of Concrete Narrative Feedback for the New Domains Not in CG‐CAHPS

Figure 7

Illustrating Extent of Actionability

Figure 8

Prevalence of Actionable Passages in Patient Narratives [Color figure can be viewed at wileyonlinelibrary.com]

Figure 9

Prevalence of Identified Actors in Actionable Elements of Narratives [Color figure can be viewed at wileyonlinelibrary.com]

Figure 10

Intersection of Axial and Actionability From Domains Related to Communication (by Type of Actor) Abbreviation: QI, quality improvement. ^a “Composite scores” refers to the quantitative metrics constructed from the aggregation of survey responses in a particular domain of practice, for example, provider‐patient communication, coordination of care, and so on.