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All over the world, governments and healthcare systems are struggling to improve “value based care”. In the US, the Centers for Medicare and Medicare Services (CMS) has developed a set of metrics to better evaluate how well hospitals are doing, including Hospital Consumer Assessment of Healthcare Providers and Systems, or “HCAPHS” and other comparative performance measures (

The validity and relevance of the HCAPHS survey in today’s diverse American population are notable challenges. HCAPHS metrics are based upon mailed surveys distributed to patients who have visited a hospital in the last 6 months or so. Response rates are remarkably low – any decent survey company or direct mail house would be ashamed at their response rates (we are talking 1 – 2% on average). Resultant ratings also significantly under-represent patients who are non-Caucasian Americans. So the question of how diverse patients value and how well they are being served by these hospitals cannot be known from CMS data. There are also high-risk disease challenges among specific ethnic populations that are not able to be evaluated in terms of benefit (outcomes). COPD, cardiovascular disease, diabetes, and hepatitis B and C viruses are prime examples of this.

PCCQ: Patient-centered Cultural Intelligence is a comprehensive means for hospitals to evaluate how well their ethnically diverse patients (and other affinities or cultural groups, including gender, religious, social, et al) are being served. First, we look at the HCAPHS and other ACO metrics that may be positively impacted by a focus on PCCQ. More specifically, we’ve identified 32 specific metrics that make up a PCCQ Center of Excellence.

Next, we conduct a PCCQ Executive Survey, interviewing all or most of the leadership of the hospital, to assess their motivate to serve their diverse patient base. Using methods established by Johns Hopkins Bloomberg School of Public Health (which we were involved in developing and validating. and which is published), we test for current perception of PCCQ performance, valence, expectancy, and instrumentality. These allow us quantify the level of motivation and thus likelihood of a hospital to be successful with PCCQ related transformation. If likely to fail, we walk away (or leaders need to make a major mindshift). If the leaders’ motivation ratings are sufficiently high, then we evaluate each hospital for 4 PCCQ Impact Areas:

1) Patient Experience

2) Hospital Performance

3) [Provider] Network Performance

4) Community Health

Next, we model the 5 PCCQ Touchpoints for the hospital – points at which the patient is impacted in some way by their engagement with the hospital, and evaluate how well the hospital is doing in each of these.

With hospital IRB (Institutional Review Board) approval of PCCQ Protocols, we also conduct a cross-cultural communications survey, in collaboration with U. of Colorado Institute for Bioethics (formerly AMA’s survey tool) to benchmark how well leaders vs staff vs patient perceive the hospital is doing with its diverse patient needs. Results always have a major surprises – positive and negative! (Some of these elements shed important light on underlying reasons for HCAHPS scores, but the surveys are not duplicative.)

Most importantly, we work with the CEO and other leaders of the hospital, to appoint the PCCQ Council. This council should be made up of future leaders across all areas of the hospital, who are responsible for proposing, developing, implementing and monitoring PCCQ Initiatives. Using principles of Lean Six Sigma, each initiative has a PCCQ Project Charter that limits the project to 6 months at a time, and progress is reviewed at each bimonthly or monthly PCCQ meeting. Others may be invited to join the Council Meetings from time to time, including physicians in the network, and patients and community leaders.

What have we learned?

  1. Based upon HospitalCompare data, no one hospital stands out as being ‘best’ at PCCQ. The closest one we could find that might serve as a current benchmark was Cleveland Clinic, but they also have much room for improvement.
  2. Without a focus on PCCQ, hospitals will continue to define their efforts and value improvements based upon feedback from highly motivated, highly literate Caucasian/English speaking patients.
  3. Non-English, semi-literate and immigrant patients are fearful of and will not respond to HCAPHS surveys and even require a great deal of encouragement to respond to ANY survey.
  4. It’s a long term process and commitment. It requires highly motivated leaders and some level of resources to make it happen, and to be maintained.
  5. The biggest PCCQ fall-outs that ultimately impact all 4 areas of performance happen at and after discharge. One of the reasons: There is inadequate follow up by the referring PCP, which is partially a result of misaligned ACO metrics that are driving care practices. (More on that to come in the future.)

The Office of Minority Health has issued 15 standards for Culturally and Linguistically Appropriate Services (CLAS), but there are no “teeth” to them, nor any requirement to report on or measure compliance (and thus no penalties for non-compliance). They and the Joint Commission claim that these Standards have been cross-walked with the JC inspection. However they may say this, they are not sufficient, nor obvious to anyone, and basically any JC-approved hospital is considered compliant. What is needed is a carve out of inspection elements to form basis for a PCCQ Center of Excellence that becomes a specific subset of the Joint Commission inspection that CAN impact a hospital’s certification. Then, we need to do the same at the primary care and clinic level, as well as hold insurers accountable to ensuring their diverse patients meet these standards.

Until and unless America values the health of its diverse population, “value based care” will only serve a future minority of Americans. With PCCQ, it may serve all.

NB: We’d like to acknowledge and thank Holy Name Medical Center (Teaneck, NJ), CEO Mike Maron, its PCCQ Council and all the staff and patients, and especially Ms. Kyung Hee Choi, VP, Asian Patient Services, for taking the PCCQ journey. This large, independent community hospital in a lower socioeconomic suburb of New York City with an ethnically highly diverse patient and community population (approx. 40% of whom are immigrants), aims to become the nation’s best practice community hospital leader in PCCQ in 2017.