Patient Satisfaction Surveys: A Continuous NCODA Initiative for Improvement Within the Oncology Dispensing Practice

Patient satisfaction is an essential metric in the growing trend of value-based care within the oncology community. The National Community Oncology Dispensing Association (NCODA), in conjunction with Syracuse University’s Maxwell School of Citizenship and Public Affairs’ Community Link Program, has developed and distributed a patient satisfaction survey to its practice members. NCODA practices have held the high standard and goal of providing the best patient care to their respective communities, and surveys are one method by which NCODA has been able to provide its members a platform to display the benefits and value of their practice.

As of spring 2018, NCODA had collected over 700 patient responses from across the country, which were evaluated by Syracuse University’s Community Link Program. The satisfaction metric was separated into 4 core categories: time, convenience, staff interaction, and overall satisfaction. These data were subsequently stratified over multiple demographic groups for additional analysis such as gender, patient usage between mail order and in-office dispensing, financial assistance, and future patient use of dispensing. For NCODA practices, the overall satisfaction measured approximately 95% for patients who reported they were satisfied or very satisfied. From that subset, 92% reported being very satisfied overall. Moving forward, we aim to display this measure as an advance in value-based care within NCODA member practices. This aim is consistent with improvement of survey utilization and increased distribution. Reports such as these can be deemed beneficial for practices that are looking to exhibit and leverage these data to create a dialogue among various stakeholders for continued sustainability as well as to self-audit their own pursuit of excellence in oncology patient care.

Patient Satisfaction Surveys in the Medically Integrated Dispensing Practice: Issues and Observations

Data are a real and valuable commodity in most industries. We use data of all kinds, relevance, lot size, and accuracy as we try to proactively manage this historicly elusive wealth of information. Monetizing these data is quite another matter. In our business space, what specific data should we obtain, analyze, and operationalize?

Some say that improving the US healthcare system requires simultaneous pursuit of 3 aims: “improving the care experience, improving the health of populations, and reducing per capita costs of healthcare. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of a care provider organization that accepts responsibility for the 3 aims for that population. The healthcare organization’s role includes at least 5 components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.”²

When discussing patient satisfaction, 3 fundamental questions emerge: “Is it worth measuring? How can it best be measured? How are we to use the results? These 3 questions—1 philosophical, 1 empirical, and 1 practical—form a framework for evaluating the place of patient satisfaction within the patient outcomes movement.”^{3​​​​​​}

Patient satisfaction can carry strategic weight beyond the traditional objectives of other patient surveys for medically integrated dispensing (MID) practices. Under current circumstances, would it be more appropriate to address the patients as “consumers”? Today, patients are guided to see themselves as buyers of health services. “Once this concept is accepted, there is a need to recognize that every patient has certain rights, which puts emphasis on the delivery of quality healthcare.”⁴

Private MID practices are at the intersection of healthcare, technology, and human service We all have data dashboards, laws, regulations, and policies to guide our decisions on every aspect of the business. These data are usually timely and valid, and we can reasonably rely on them. What we do not have are data that are just as valid and reliable to help us better manage the business with the goal of an optimal, at least a favorable, patient experience.

Patient satisfaction surveys have evolved into a full-fledged data set and platform. From large health systems to the smallest private medical practice, obtaining, analyzing and responding (or not) to results can certainly provide benefits. They can also serve as a management tool to better align management’s goals, marketing messages, and process design based upon survey results. The practice of medicine has evolved over centuries. There are certain significant developments that have taken place in health systems in recent times, chief among them being:

1. Establishment of high-cost corporate-style hospital systems equipped with the latest facilities.
2. Strategic integration of third-party payers, insurance companies, specialty pharmacies (SPs), pharmacy benefit managers (PBMs), government entities, distributors, and companies on the periphery of the doctor—patient relationship.
3. Availability of information through the internet, and higher expectations of patient care.⁵
4. Increasing litigation methods from delay in diagnosis to breakdowns in communication6 and other consequences of unsatisfactory results such as financial distress/toxicity.⁷

All of these factors have resulted in a challenging environment for the healthcare industry, with a movement away from the traditional concept of a noble profession toward more of a service industry.

In a major report published in 2001, the Institute of Medicine, now the National Academy of Medicine, set forth 6 aims for quality and patient safety in a healthcare system¹:

1. Safe
2. Equitable
3. Evidence-based
4. Timely
5. Efficient
6. Patient-centered

Factors 4 through 6 directly influence patient satisfaction.

The NCODA Patient Satisfaction Survey

The NCODA Patient Satisfaction Survey was developed in conjunction with Syracuse University in 2016 with the purpose of measuring qualitative differences within the pharmacy-dispensing space. NCODA created a template that allows practices to add their own brand details that could be sent to a central location for aggregation. The Community Link Program has a process where the data can be coded and accounted for future analysis, which

is then presented to the membership in multiple channels such as at national conferences and webinars. Practices utilizing the surveys have the ability to account for areas of high satisfaction and possible improvement, which is paramount to the NCODA foundation and quality standards. The goal of the surveys is to create a quantitative narrative based on the positive influence that MID practices can provide by virtue of being at the cross-section of clinical and operational responsibilties. NCODA members strive to focus on creating better quality interventions within the continuity of care for the patient, and the surveys allow for that collective voice to be heard.

The MID Patient as a Consumer

Patients with cancer, as a population within the healthcare environment, present with certain issues and characteristics that can be well managed in the MID space, and at an overall lower cost than what is found in larger systems. Further exacerbating the higher costs and challenges to timeliness and quality of care are the payer/SP/PBM demands and constraints placed upon the MID practice. However, these issues are outside the scope of this article to develop more fully.

The NCODA survey is meant primarily as a tool to prove to legislators, regulators, insurance companies, SPs, PBMs, employers, and patients that the MID practice has real value in the cancer care continuum. The survey is intentionally brief. Most MID practices conduct other patient surveys besides the in-office dispensing (IOD) service line. Numerous surveys are available to obtain a picture of satisfaction and other metrics across all organizational aspects. The NCODA survey is given exclusively to IOD patients, usually at their second visit, the reason being that at the first visit, patients are bombarded with information about treatment decisions, drug interactions, studies, imaging, and other ancillary services. Survey fatigue can be a real issue for patients with cancer, over half of whom are over age 65 and suffer from comorbidities. Also, for MID practices that are in the Oncology Care Model or other government advanced payment models, those patients receive lengthy surveys already. The MID practice must be sensitive to this reality.

The NCODA Patient Satisfaction Survey is straightforward and easy to complete. No personally identifiable information, such as name, address, or social security number—is collected. The 1-page survey mainly includes check-box questions, and the hard copy surveys are collected, scanned, and sent to NCODA headquarters for coding and accounting. Summaries are available for either the individual practice submitting the data or the NCODA-wide summary data. When evaluating the data, NCODA believes that service excellence revolves around 3 factors: doctor, patient, and a medically integrated organization.

The Medical Oncologist/Hematologist

“Undoubtedly, physicians have the twin responsi- bilities of giving the best healthcare to the patient and leading the MID practice in attaining the goal of satisfying the patient,” Bhanu Prakash writes.⁴ Listed below are a few “house rules” to handle patients so as to have all satisfied:⁴

1. Break the ice: Make eye contact, smile, call patients by name, and express words of concern.
2. Show courtesy: Kind gestures and polite words make patients very comfortable.
3. Listen and understand: Encourage patients to narrate their problem. Invite and answer their questions.
4. Inform and explain: These promote compliance. People are less anxious when they know what’s happening.
5. See the whole person: Envision the whole person beyond the illness.
6. Share the responsibility: Risks and uncertainty are facts of life in medical practice. Acknowledging risks builds trust.
7. Pay undivided attention: This reduces distractions and interruptions as much as possible.
8. Secure confidentiality and privacy: Watch what you say, where you say it, and to whom you say it to.
9. Preserve dignity: Treat patients with respect. Respect modesty.
10. Remember patients’ families: Families feel protective, anxious, frightened, and insecure. Extend yourself, reassure, and inform.
11. Respond quickly: Keep appointments, return calls, and apologize for delays.

From a healthcare provider’s perspective, specifically a pharmacist, there are gaps and scenarios where patient satisfaction surveys are underutilized. For example, in one participating practice, surveys are considered beneficial primarily from a business and operations perspective. However, they should also be considered valuable for patient outcomes, because continuous quality improvement is a vital aspect of any dispensing service and healthcare practice. From a pharmacy and dispensing outlook, it is often difficult to distinguish and visualize the impact of the pharmacist and staff. At some practices, physicians and nurses are strained for time and often are unable to spend as much time with a patient as they would prefer. This gap, which in the past has gone unmeasured, could potentially be covered by pharmacists and the auxiliary staff (ie, pharmacy technicians, nurses, patient financial advocates, etc). The NCODA Patient Satisfaction surveys help to validate the continuity of care to help transverse the different disciplines involved.

There are also other opportunities where assessing patient satisfaction can be implemented at a practice, such as in an oral chemotherapy follow-up program, where a pharmacist can initiate education around a new oral chemotherapy drug with a patient. Patients who are part of an MID practice are also contacted at predetermine intervals, in addition to their office visits, to assess adherence and drug toxicity. Education and reinforcement are provided as needed.

Questions to always ask:

1. Does the patient walk away feeling more comfortable with the information they need to begin taking the medication?
2. Does the patient fully understand how to take their medication and why they are taking it?
3. Does the patient feel that their adverse effects are under control?
4. Does the patient feel they have the support they need if there is cognitive impairment or they face financial issues?

Anecdotal evidence suggests many patients are unaware of their diagnosis, why they are on a certain medication, or why their particular medication was discontinued, held, or switched. The MID is a service of the practice that can provide clarity and relieve fears about adverse effects.

When a patient understands and trusts the health- care providing team and their decisions, they can be much more satisfied knowing that they are being taken care of on a personal level.⁸ For example, in a scenario involving a personal exchange between a patient and pharmacist, a patient mentions that she does not trust the drug companies. The pharmacist then shows a study that found that adding a particular drug improved progression-free survival by 10.2 months. Through data and a friendly and understanding healthcare provider, the patient is able to visualize the effectiveness and see that the practice had her best interests in mind.

For drugs that are filled at SP, the MID practice’s responsibility as the patient’s healthcare provider is often mixed, given certain circumstances that disallow continued refills at the practice. Even in those situations, the burden may still be placed on the MID practice to ensure that the patient receives their medication on time. For certain restricted drugs in a practice, for example, prescriptions are not permitted to have refills. The physician must sign a new prescription every cycle and an authorization number must be obtained from the manufacturer.

MID practices can also help patients who cannot afford their medications by connecting them with charitable foundations that provide financial assistance. Without oversight, numerous patients may not get their medication on time especially during long events, such as holidays. For example, what if a patient needed an early refill/vacation override prior to embarking on a month-long vacation? A vacation override would be needed for the manufacturer, their specialty pharmacy, and their insurance provider. Patient satisfaction is readily apparent when they receive assistance in such scenarios. Patients are extremely grateful and happy that MID practices can provide this kind of service.

Utilizing Survey Data

How can these patient satisfaction survey results be utilized? Many satisfaction batteries can reliably distinguish between physicians who are great commu- nicators and those who are interpersonally challenged. Patient satisfaction is also related to a variety of possible downstream outcomes, such as the propensity to change health plans or to sue for malpractice. These results are clearly of interest to managers and marketers, but their relation to clinical quality improvement is tenuous. The important question is whether information on patient perceptions and values can stimulate genuine gains in patient-centered care. Providing physicians, payers, SPs, PBMs, employers, and staff with comparative quarterly satisfaction reports is likely to accomplish little except fuel resentment.

Accounting for all of these sources of variation, it is important to recognize that a satisfaction score is a perspective, not the truth, about a physician’s ability to deliver quality care. It is information that reflects a subset of daily interactions, and it is dependent on the number of variables involved.

NCODA plans to continue building an inventory of survey responses to help members better manage their IOD and other internal processes. We also hope to apply this data as one more piece of evidence that we are a better alternative to the current restrictions and barriers to cost avoidance, waste reduction, and more timely care.

Conclusion

Patient satisfaction is an attitude. Patient satis- faction is an indirect, or a proxy, indicator of the quality of care, the provider, or their MID practice overall. Delivery of patient-focused care requires that we provide care in a particular way, always. It must be the best care for every patient every time. Ideally what is needed is for the MID pratice to have the ability to manage the patient with cancer in totality, unencumbered by interference from specialty pharmacies; incomplete payer or PBM formularies; and the complicated system of authorizations and financial support, policy changes, inadequate beneficiary education on the part of policy purchasers and sellers, and regulations that frustrate the realization of lower cost, same or better quality of care, and a higher patient satisfaction score. AUTHOR INFORMATION

Joshua J. Nubla, PharmD, is a manager of the National Community Oncology Dispensing Association.

Robert D. Orzechowski, MBA, is chief operating officer of the Lancaster Cancer Center in Pennsylvania.

Aaron Budge, PharmD, was a clinical pharmacist of Tri-County Hematology & Oncology when this article was drafted and is currently a practicing pharmacist in Northeastern Ohio.

ACKNOWLEDGEMENTS

National Community Oncology Dispensing Association

ADDRESS FOR CORRESPONDENCE:

Joshua J. Nubla, PharmD

PO Box 468

Cazenovia, NY 13035

Email: joshua.nubla@ncoda.org

REFERENCES

1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The National Academies Press; 2001. nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/ Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20 report%20brief.pdf. Published March 2001. Accessed June 2018
2. Berwick, Donald & W Nolan, Thomas & Whittington, John. (2008). The triple aim: care, health, and cost. Health Affairs (Project Hope). 27. 759-69. 10.1377/hlthaff.27.3.759.
3. Kravitz R. Patient satisfaction with healthcare: critical outcome or trivial pursuit? J Gen Intern Med. 1998;13(4):280-282. doi:10.1046/j.1525- 1497.1998.00084.x.
4. Prakash B. Patient Satisfaction. J Cutan Aesthet Surg. 2010;3(3):151-155. doi:10.4103/0974-2077.74491.
5. Basch, Ethan & Thaler, Howard & Shi, Weiji & Yakren, Sofia & Schrag, Deborah. (2004). Use of information resources by patients with cancer and their companions. Cancer. 100. 2476-83. 10.1002/cncr.20261.
6. Legant P. Oncologists and medical malpractice. J Oncol Pract. 2006;2(4):164-169.
7. National Cancer Institute. Financial Toxicity and Cancer Treatment. https://www.cancer.gov/about-cancer/managing-care/track-care-costs/fi- nancial-toxicity-hp-pdq. Updated January 2018. Accessed September 2018.
8. Lis CG, Rodeghier M, Gupta D. Distribution and determinants of patient satisfaction in oncology: A review of the literature. Patient preference and adherence. 2009;3:287-304.

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