Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Medical Home - Consumer Assessment of Health Care Provider and Systems
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In April, 2014, SETMA will formally receive the NCQA Distinction in Patient Experience Reporting.  The National Committee for Quality Assurance (NCQA developed the optional Distinction in Patient Experience Reporting to help practices capture patient and family feedback through the newly developed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient-Centered Medical Home (PCMH) Survey. Because consumer experience is a critical component of quality of care, giving more prominence to patient engagement is a crucial change to the PCMH program. The CAHPS PCMH Survey assesses several domains of care:

  • Access
  • Information
  • Communication
  • Coordination of care
  • Comprehensiveness
  • Self-management support and shared decision making.

Since 2010, SETMA has been an NCQA PCMH-Recognized practice and in September, 2013 began using the CAHPS PCMH survey tool to obtain the new NCQA Distinction in Patient Experience Reporting.  The survey is completed by an NCQA recognized vendor who sends out letters to a statistically significant sample of SETMA patients.  The letters are then followed up with telephone calls.  The completion of this survey involves more than 100 questions.   This represents a significant commitment of time by SETMA’s patients and we are grateful to those who take the time to participate in this process.  It gives SETMA providers critically important information on how they can improve the care patients receive.

At the next reporting period, April, 2014, SETMA will receive the NCQA’s Distinction in Patient Experience Reporting.  This will help the healthcare community as submitted data will be used to develop a benchmarking database that will allow comparison across practices.   As SETMA and other healthcare providers work to improve the quality of care everyone receives, these benchmarks are critical. 

The Completed CAPHS Survey for the 4Th Quarter of 2013

This graph is the Expanded Executive Summary of SETMA’s first quarter of our gathering of the Consumer Assessment Healthcare Providers and Services measurement of patient satisfaction.  The first column is the CAHPS PCMH Benchmark from 2012 CAHPS Data.  The other five columns are the results of the CAHPS survey for each of SETMA’s five clinics:  SETMA 1 on Calder; SETMA 2 on College; the Mark Wilson Clinic on Dowlen; and our Mid County and Orange Clinics. 

The “Noteworthy Findings” of the Expanded Executive Summary of the CAHPS survey are that SETMA’s “results are not significantly different in any of the categories“ from the Benchmarks.   This means that SETMA is doing well, however, not as well as we would like.  In our January 21st Provider Training Session, we will review each of the below “composite ratings” and discussion ways in which we can improve.  We expect that while we are doing “OK,” that in coming quarters, we will see significant improvement. That is the goal.


As more of SETMA’s pateints participate in the CAHPS surveys and as SETMA’s providers and staff study the resutls, we will improve the care we deliver.  Patient satisfaction is a key part of the transformation of healthcare. 

This is also true in the care patients receive in the hospital.  The pateint satisfcation survey tool in the hospital is the Hospital Consumer Assessment of Helalthcare Providers and Systems (HCAPHS).  Since July, 2013, SETMA has been working on and has seen dramatic improvement in our providers HCAHPS scores.  That would can be reviewed at | Letters | SETMA's approach to fulfilling the HCAHPS: Steps of action and SETMA's Video of our Care Transitions Process.

These aer exciting new days in healthcare. SETMA believes that our transparency of publishing this information will motivate us to improve and will give our pateints confidence that we genuinely care about them personally and about their health professionally.