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  • Practice Perfect

    Use Patient Surveys to Boost Practice Performance

    By Linda Roach, Contributing Writer, interviewing Pamela Ballou-Nelson, RN, MSHP, PhD, Ricky Bass, MBA, MHA, Ron D. Hays, PhD, and Robert E. Wiggins Jr., MD, MHA

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    How do you know if your practice is meeting patients’ needs? Ask them—with a patient survey.

    Improvement Is the Goal

    “The first reason to do patient surveys is to improve quality in your practice. It shows patients that you’re interested in quality from their standpoint, and it shows staff that you’re interested in im­proving quality,” said Robert E. Wiggins Jr., MD, MHA, the Academy’s senior secretary for Ophthalmic Practice.

    “The second reason is that this is really what the marketplace demands,” he said. “When appointments are made these days, patients frequently will look up the practice online before they come in. So, if you’re going to be competitive in the future, that’s a good reason to improve quality by doing surveys and acting on the results.”

    Nomenclature matters: Patient experience or patient satisfaction? “What I encourage practices to do is to call them patient experience surveys, not satisfaction surveys,” said Pamela Ballou-Nelson, RN, MSHP, PhD, a senior consultant in the Medical Group Management Association’s Health Care Consulting Group.

    “After all, everybody has an experi­ence but not everybody is satisfied,” she said. “Satisfaction can be very sub­jective, and there are some things that you cannot do anything about.”

    Which Aspects of the Patient Experience Should You Assess?

    Topics to cover. Experts advise focusing patient experience surveys on 4 aspects of the patient visit:

    • the office experience,
    • physician communication,
    • shared decision-making, and
    • access to care.

    “You don’t need to cover a ton of things,” said Dr. Ballou-Nelson. “You can ask about friendliness at the front desk and helpfulness of the staff. And it’s important to find out how well the patients feel the procedures were explained to them and whether the information was in a style and format that was usable to them.

    “You also want to find out what their experience is with access [to care]. That is, if I call the doctor’s office, can I get an appointment when I feel I need it or when it’s convenient for me? That’s another biggie—absolutely huge—with patients.”

    Topics to avoid. “Don’t ask questions about things that you can’t do anything about, such as billing, because the whole goal is to be able to ask questions about patient experiences that you can improve on,” said Dr. Ballou-Nelson. Patient experience surveys also aren’t the right tool for assessing clinical outcomes, said Dr. Wiggins.

    Borrow from CG-CAHPS. Take advantage of the CG-CAHPS survey1 (“Consumer Assessment of Healthcare Providers and Systems” for clinicians and groups), which was developed with support from the U.S. Agency for Healthcare Research and Quality (AHRQ). Because the CAHPS items have been extensively evaluated and are freely available at the AHRQ website,2 they should serve as a starting point for ophthalmic practices that want a brief survey for internal use, said Ron D. Hays, PhD, a member of the RAND team that helped to develop the CAHPS surveys.

    “We’ve found that when providers want to make quality improvements, they identify a subset of CAHPS survey items that they want to focus on,” said Dr. Hays, at the University of Califor­nia, Los Angeles.

    “For example, some users may be most interested in the CAHPS com­munication items and the items about office staff courtesy and respect.”

    However, outcomes of the truncated survey will not carry the same statisti­cal rigor as the full CAHPS would, said Ricky Bass, MBA, MHA, an executive consultant to the American Academy of Ophthalmic Executives. “This type of survey is useful for internal evaluation but does not meet federal reporting requirements,” Mr. Bass said.

    9 Tips for Using Surveys Effectively

    Keep it short. Response rates improve with a maximum of 10 questions and are even better with just 5, said Dr. Ballou-Nelson.

    Gather a small “patient council.” Your patients can help you identify new topics for the survey.

    Avoid compound questions. One idea per survey item yields unambiguous results.

    Don’t ask about things you can’t change. This frustrates everyone.

    Make the last query open-ended. Comments here might identify unex­pected issues for the practice. (Check out the CAHPS researchers’ guidance on wording open-ended queries.)

    Watch the response rates. At least 30% of surveyed patients should re­spond, and higher is better. Consider revising your survey if the response rate is less than 30%.

    Post the survey results. Posting the results on an office wall or the patient portal, tells staff—and patients—that quality improvement matters.

    Respond by making changes. Later surveys will show if the changes worked.

    Do surveys quarterly or biannually. Periodic surveys let you track perfor­mance over time.

    How to Perform Your Survey

    The advantages of software-based methods. Because conducting a survey by postal mail is expensive and time-consuming, electronic survey tools are becoming increasingly attrac­tive, said Dr. Ballou-Nelson. “I don’t see a lot of practices that still do it with paper.”

    Dr. Wiggins said that his 20-provider practice in Asheville, North Carolina, found it most cost-effective to conduct patient surveys online. “We’ve transi­tioned over the past 2 years away from handing out comment cards in the office to surveying our patients online through a vendor that interfaces with our practice management system,” he said. “After a visit, patients will see a survey that they can fill out online. Our success rate has improved dramatically—we’ve gone from getting just a handful of comment cards to, on the last survey, several thousand responses.” Patient surveys also can be posted on the practice’s Internet patient portal.

    In the waiting room. Some practices ask patients to complete a survey in the waiting room after the visit, either on paper or using a handheld computer. “But you have to be mindful with written surveys that patients who have had their eyes dilated during the visit aren’t going to be able to read it,” said Dr. Ballou-Nelson.

    Low-cost, web-based tools. For smaller groups and solo practitioners, several Internet sites might have every­thing needed for cost-effective patient surveys, with automatically tabulated results. The sites include,,, and They charge $12 to $25 per month for basic survey capabilities, which vary from one site to another. Two of these sites, SurveyLegend and SurveyMonkey, have health care survey templates that consist of questions that are in CAHPS. For a higher monthly fee ($85), SurveyMonkey also will provide a HIPAA-compliant template.

    External Versus Internal Benchmarking

    Surveys that allow you to measure your performance against external benchmarks are valuable but can be burdensome. Some medical coverage plans, including Medicare, require clinical practices to administer specific surveys to patients and submit the results for evaluation against external bench­marks. One widely recognized tool is the CAHPS survey. But such a lengthy survey may be too cumbersome for routine monitoring of the quality of patients’ experiences in the opthalmology practice, Dr. Wiggins said.

    Use your own past performance as a benchmark. “If you’re comparing yourself with other groups, you really have to have something that’s truly validated, like the complete CAHPS survey. But most ophthalmology practices can ben­efit by tracking progress toward their own internal bench­marks, without having to do a comparison to other groups,” Dr. Wiggins said.

    Do You Need Outside Help?

    Hiring a consulting firm to design and perform your surveys would be the easiest option—but this is too expensive for most ophthalmic prac­tices, said Mr. Bass, who added that the AAOE will help fill this gap in November (see the “More at the Meet­ing” box).

    Survey expert Dr. Hays suggested that physicians would do well to at least seek basic advice from someone familiar with survey procedures before embarking on a do-it-yourself project. He said that users can get some support through the CAHPS User Network. The CAHPS team also has created a guide for quality improvement, as well as other resources.


    1 CAHPS Clinician & Group Survey 3.0. Rockville, Maryland: Agency for Healthcare Research and Quality. Accessed April 13, 2017.

    2 Get the Clinician & Group Survey and Instruc­tions. Rockville, Maryland: Agency for Healthcare Research and Quality. Accessed April 13, 2017.


    Dr. Ballou-Nelson is a senior consultant with the Medical Group Management Association’s Health Care Consulting Group. Relevant financial disclosures: MGMA Consulting Group: E.

    Mr. Bass is an executive consultant to the Ameri­can Academy of Ophthalmic Executives. Relevant financial disclosures: None.

    Dr. Hays is a professor of medicine at the Uni­versity of California, Los Angeles, and an adjunct researcher for RAND in Santa Monica, Calif. Relevant financial disclosures: RAND: C.

    Dr. Wiggins is the senior secretary for Ophthal­mic Practice at the Academy; pediatric ophthal­mologist and physician administrator at Asheville Eye Associates in Asheville, N.C. Relevant finan­cial disclosures: None.

    See the disclosure key at

    More at the Meeting

    “Measuring Your Most Critical KPI: Patient Satisfaction.” This 1-hour instruction course will teach you how to efficiently assess patients’ perceptions, and how to use that information to boost pa­tient referrals and inoculate your practice against critical reviews.

    For further details, check the AAO 2017 Program Search, which will launch on June 28.