Patient Experience: Quality of Care According to the HAS and the Transformation of the Healthcare System

Patient experience has become a crucial topic in the healthcare sector, steadily gaining importance in recent years. It is recognized as a fundamental lever for the continuous improvement of the quality of care and the transformation of healthcare organizations. This approach highlights the lived experience of individuals as a key indicator of quality, revealing opportunities for improvement and impacting all aspects of the organization, from architecture and information systems to communication and the organization itself. The French National Authority for Health (HAS) has significantly strengthened the priority given to patient experience in its 6th certification cycle.

Definition and Scope of Patient Experience

Patient experience can be defined as the perception that patients have of their experience throughout their care pathway. This perception encompasses what they see, think, hear, or understand. More broadly, it corresponds to the all the interactions and situations experienced by a person or their family during their healthcare journey. It should be noted that the term "patient" is understood in its broadest sense, referring to any person receiving care within a healthcare pathway or facility, whether it be a health or social care setting. This includes patients in healthcare facilities and individuals receiving care in social and medical care settings, often referred to as "supported individuals." This concept goes far beyond the simple caregiver-patient relationship, encompassing everything surrounding care and the patient's perception. Patient experience is an approach centered on the patient's subjectivity, involving their lived experience, life story, expectations, and emotions. It is an adaptation of the concept of "user experience" applied to healthcare. Several factors can influence this perception: All individuals involved: healthcare professionals and others, caregivers, family members, and other patients. The quality of human interactions with professionals is very important.

It is important to distinguish patient experience from simple satisfaction or perceived outcomes. While satisfaction is recognized as essential in assessing the quality of care, it cannot alone encompass all dimensions of the experience, as it remains subjective. Experience seeks to understand what was lived, what happened (or didn't happen), and what the patient went through emotionally, while satisfaction measures whether expectations were met in relation to identified needs. Patient-perceived outcomes assess how the patient understands and feels the effects of care. It is by combining these complementary approaches that we obtain a nuanced and insightful view, useful for continuous improvement. The French National Authority for Health (HAS) emphasizes that patient satisfaction alone cannot encompass all dimensions of the patient experience, and that it is necessary to consider objective elements to understand and measure it. To ensure we understand each other, we need to clarify whether we are talking about lived experiences, opinions and perceptions of lived experiences, or steps taken.

Origins and evolution of the concept in France and internationally

The concept of patient experience, although increasingly used in France, finds its origins and pioneers in Anglo-Saxon countries. The Beryl Institute, an American institution, was the first to clearly lay its foundations. Canada, the United States, and the United Kingdom were among the first to recognize that patients held the keys to improving their healthcare journey. Major initiatives emerged in these countries: Cleveland Clinic in the United States, with its "Patient First" policy; the United Kingdom, which created its Expert Patient Program in 2002, based on studies from Stanford University in California; and the Canadian healthcare system, which has been promoting patient engagement at all levels for nearly 20 years, considering the patient as "a caregiver and a full partner," similar to the "Montreal Model" of the University of Montreal's Faculty of Medicine for chronic diseases. These Anglo-Saxon approaches are based on the premise that traditional healthcare, characterized by a strong hierarchy between patient and professional, can neglect patients' expectations. Programs such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) in the United States, the NHS Patient Survey Program in the United Kingdom, the Canadian Patient Experience Reporting System (CPERS), the Consumer Quality Index in the Netherlands, and the Patient Experiences Questionnaire in Norway are also pioneers in this field. In France, the emergence of this concept is more recent, but not entirely new. As early as 2009, Pierre and Marie Curie University began training and awarding degrees to patients through the Patients' University, allowing patients to recognize and value the expertise they have acquired through their lived experience with illness. In 2011, the Haute Autorité de Santé (HAS) published its first report on patient experience, recognizing that patients' judgment of the quality of their care is "essential in assessing the quality of healthcare". However, the HAS also emphasized that satisfaction alone is not enough and that objective elements must be integrated. The concept continued to gain traction in France with the creation of the French Institute for Patient Experience (IFEP) in 2016. This institute advocates for a "more welcoming, more attentive, more humane healthcare system" and aims to develop professionals' knowledge and mastery of patient experience, with the goal of overall improvement of the healthcare system. The HAS has fully embraced the subject, disseminating its concerns through surveys (notably e-Satis), best practice recommendations, and quality improvement indicators in healthcare and social care facilities. The French National Authority for Health (HAS) has also significantly strengthened the priority placed on patient experience in its 6th certification cycle, introducing one mandatory criterion, one advanced criterion, and four standard criteria. Strengthening these requirements is seen as an opportunity for patients, professionals, and institutions. Patient experience as a key indicator of quality of care according to the HAS. Taking the patient's perspective into account significantly enriches the approach to improving the quality of care. According to the French National Authority for Health (HAS), "measuring the quality of care is a prerequisite for defining the actions to be implemented and objectively assessing progress in order to improve the service provided to patients," and this approach is "enriched by the complementary perspective of patients." There is a direct link between taking the patient's perspective into account and improving the quality of care provided. This concept clearly links patient experience to the continuous quality improvement process. The HAS (French National Authority for Health) has adapted its expectations and tools to place the patient at the center, with patient experience indicators being essential for measuring the quality of healthcare and social care facilities. Within the framework of the new HAS v2020 certification for healthcare facilities, patient experience is a major focus, aiming to put the patient back at the heart of the care pathway and to foster the emergence of a patient-partner, an active participant in their care to improve the effectiveness of treatment. Chapter 1 ("The Patient") of this certification integrates the patient experience into four objectives:

• 1.1: The patient is informed and their involvement is sought (information, consent, advance directives).
• 1.2: The patient is respected (respect for dignity, compassionate treatment).
• 1.3: Relatives and/or caregivers are involved in the implementation of the care plan with the patient's agreement.
• 1.4: The patient's living conditions and social connections are taken into account in their care.

Chapter 3 ("The Facility") also integrates the patient experience into one objective and one criterion:

• 3.2: The institution promotes the engagement of patients individually and collectively.
• 3.7-02: The institution takes the patient's perspective into account in its quality improvement program. This criterion is even mandatory in the 6th cycle of HAS certification, where visiting experts will assess whether governance supports the use of questionnaires aimed at patient-reported care outcomes. Institutions are expected to demonstrate their ability to implement and ensure the traceability of projects and actions that take into account information gathered from patients.

In social and medico-social establishments and services (ESSMS), patient experience is also a tool for improving the quality of care. The new HAS assessment of social and medico-social establishments and services (ESSMS) requires compliance with several criteria related to patient experience, including:

• Criterion 1.5.2: The person receiving support is informed of the follow-up given to their requests within the framework of collective bodies or other forms of participation.
• Criterion 1.6.1: The person receiving support is supported in their expression, the sharing of their experience is encouraged, and the expression of their preferences is taken into account.
• Criterion 1.7.1: The person receiving support can express their informed consent through clear information and appropriate means.

The HAS emphasizes the central role of the person receiving support in the quality assurance process of ESSMS, particularly through the deployment of the Tracer Support Method, which assesses the The quality of support is assessed through the combined perspectives of the person being supported and the professionals. Patient experience complements more conventional indicators such as satisfaction surveys or medico-administrative data. A positive care experience is correlated with higher treatment adherence, better clinical outcomes, improved patient safety, and lower service utilization.

Benefits of Improving the Patient Experience

Improving the patient experience offers considerable benefits, not only for the patient themselves, but also for healthcare professionals and the institution as a whole.

For Patients and Their Families:

• Increased Sense of Trust and Consideration: Patients appreciate being asked about their care experience.
• More Active Role in Their Own Care: This includes vigilance and adherence to treatment, promoting autonomy and empowerment.
• Sense of usefulness and value: By expressing themselves, patients contribute to improving the entire system, thus benefiting others.
• Strengthening relationships: Expressing their experience strengthens ties with care teams and caregivers.
• Improved quality of care and support: Patients feel better listened to and better cared for, as their voices are validated.
• Better clinical outcomes and patient safety: A positive experience is correlated with better treatment adherence and greater safety.

For professionals and teams:

• Improved Quality of Working Life (QWL): This approach contributes to better working conditions by offering a "space for expression and participation," restoring meaning to work, and putting care back at the heart of concerns. There is a documented link between the quality of professionals' working conditions and the quality of their work. Strengthened human connection with patients: Teams feel more connected to patients by asking them about their experiences, which is extremely informative on a human level. Recognition and motivation: Patients spontaneously express many positive things, which is very motivating for caregivers. Improved professional practices: Patient feedback allows for learning both individually (what can be done better) and collectively (improved organization and coordination). Organizational weaknesses revealed by patient experience can reflect the needs of professionals.
• Access to valuable information: Patient experience reveals "blind spots" in the organization and internal functioning, particularly at interfaces and in the coordination between teams.
• Job satisfaction: The opportunity to contribute to improving the experience of future patients is a source of satisfaction.
• Building trust: A report published by the IFEP showed a 20-point gap between the perception of professionals (71%) and that of patients (51%) regarding the consideration of their experiences, highlighting the importance of strengthening this listening.

For institutions and organizations:

• Overall performance improvement: The patient experience approach makes it possible to "identify opportunities for improvement in care pathways", to "be part of a continuous improvement approach" and to "promote cross-functionality". It can be a real driver of performance by revealing areas for improvement that were previously overlooked.
• Improved image and trust: Working on the patient experience can improve the institution's image and patients' trust in the system.
• Staff motivation and attractiveness: Managing teams focused on what matters to patients makes the institution more attractive.
• Identifying weaknesses: The patient experience allows for work on improving internal operations, internal coordination, and interfaces with external partners.
• A strategic and differentiating factor: Patients can choose their institutions based on the patient experience offered.
• Restoring meaning and values ​​to Healthcare professionals: This allows us to re-examine the human element and the connection with the person behind the patient. Strengthening partnerships: The patient becomes an active participant in the healthcare system. In summary, the patient experience approach uses people's lived experiences as a quality indicator and a catalyst for improvement opportunities. It can impact all areas of the organization, such as architecture, information systems, communication, and the organization itself, making it a cross-functional approach and a driver of performance. The four fundamental pillars of patient experience: For the patient experience approach to fully fulfill its role as a driver of performance and improvement, it is key to respect four fundamental pillars. These pillars are presented by the ANAP (National Agency for Health and Social Care Performance) in its guide "Patient and User Experience":
  • Pillar 1: Adopt a listening, not an auditing, approach to focus on lived experience.
    • This involves focusing on patients' perceptions of care outcomes, while being careful not to judge the curative results of these treatments. This implies taking a non-judgmental approach and valuing the teams.
    • The philosophy of the project is to create a state of trust, to be a trusted partner, without denouncing, and to work together.
    The aim is to bring users and caregivers closer together and create a balance of perspectives.
  • Pillar 2: Consider the temporal dynamics of this experience by focusing on all the moments that make up the journey.
    • It is recommended to consider the patient's experience over time, through the lens of all the stages experienced. This means exploring moments occurring throughout the journey, such as the "emotional bank account" (positive and negative moments).
    • The experience is cumulative because it allows us to explore moments that occur throughout the journey, and it is integrative because the patient is often the only one to see the experience from beginning to end, making it possible to reconstruct what is fragmented and compartmentalized among different teams. Key moments include the first 24 hours after discharge or arrival, and the first contact with staff.
  • Pillar 3: Consider all elements that influence the experience.
    • The patient and their experience are influenced by the people involved (family or professionals) and by the care environment. It is therefore important to consider these dimensions.
  • Pillar 4: Consider, beyond satisfaction alone, all the facets that constitute the experience.
    • These facets can be subjective (subject to personal interpretation, such as waiting time or pain) or objective (measurable or observable, such as the presence of equipment or a timestamp).
  These pillars guide the approach to capturing and analyzing the richness of the patient experience, enabling concrete and significant improvements.

• Methods and Tools for Collecting and Measuring Patient ExperienceTo improve the patient experience, it is essential to know how to listen to and measure it. It is necessary to organize ourselves to actively seek out this experience, as patients mostly share it within their private circle and not enough with healthcare professionals. It is important to make patients understand that sharing their experience is a service they are providing, which can improve care. Three complementary dimensions are used to measure the experience: Satisfaction: Measures whether the patient's expectations were met in relation to identified needs, often through satisfaction questionnaires. The lived experience: What the patient perceived or felt, what happened or did not happen, and what they went through emotionally. This is measured by PREMs, observations, and interviews.
• Patient Perceived Outcome: Evaluates how the patient understands and experiences the effects of the care provided, via PROMs.
  
  • National and International Indicators:
    • e-Satis: The national system for the continuous measurement of patient satisfaction and experience in healthcare facilities, deployed by the HAS since 2016. It includes questions on reception, care (information, waiting times, respect) privacy/confidentiality, pain management), the room and meals, and discharge planning.
    • Patient-Reported Experience Measures (PREMs): Examine the patient's experience of care (satisfaction, information received, attention to pain, waiting times, relationships with providers).
    • Patient-Reported Outcomes Measures (PROMs): Evaluate the outcomes of care from the patient's perspective. These two tools are promoted by the HAS (French National Authority for Health) because they encourage user participation in improving their care pathway.
  • Qualitative and narrative methods:
    • Observation: Allows for capturing lived experience directly.
    • Narrative method (experience narrative): Organizing opportunities to collect patients' accounts of their care experiences is very important and informative for the teams. Patients appreciate it. It involves letting the patient tell their story, share their emotions and facts, for exchange and dialogue. The "Experience Journal" can be a guide to support the patient.
    • Focus groups: Allow for the collection of qualitative information from groups of patients.
    • Shadowing method: Consists of following a patient throughout their journey to observe their experience.
    • Mystery patient: Involves the use of an "incognito" patient to evaluate the quality of services.
  • Other approaches based on patient involvement:
    • The resource patient / expert patient: Patients who, since 2009, have developed skills (knowledge, know-how, interpersonal skills) during their experience with the illness, transforming them into expertise. They can become partners in care and shift the boundaries of knowledge sharing.
    • Peer support: Particularly in psychiatry, patients help other patients based on their lived experience. "Patient partners" are already very active in healthcare facilities, working with patient associations and participating in awareness-raising activities.
    • Patient tracer (HAS method, Nov. 2014): Retrospectively analyzes the quality and safety of a patient's care throughout their journey, the interfaces and interprofessional collaboration, and takes into account the experience of the patient and their family through an interview of approximately 30 minutes. This method aims to identify and implement improvement actions. For effective implementation, it is essential to manage the improvement of the patient experience with a comprehensive quality management solution, enabling the monitoring of indicators, the development of action plans, and the deployment of the improvement process. A structured three-step method is proposed: preparation (volunteer team, patient selection, support guide), the meeting (group discussion), and the evaluation (thank-you letter, written summary, targeted and immediate actions, feedback to the patient). The choice of the patient representative is crucial: they must be comfortable, able to express themselves, "ordinary" (without a privileged connection to the team), have a generally positive experience to initiate the process, and be eager to improve and share. The Patient Experience Approach: A Cross-Functional and Co-Constructed Approach. The Patient Experience Approach is a cross-functional approach that uses people's lived experiences as a quality indicator and a catalyst for identifying opportunities for improvement. It can impact all areas of the organization: architecture, information systems, communication, and the organization itself. This implies a shift in perspective in the relationship between healthcare professionals and patients, moving from a hierarchical relationship where the professional holds the knowledge and authority, to a relationship where the patient and professional are considered equals, each possessing different and complementary knowledge. The goal is to build an effective, patient-centered care pathway, involving the patient in improving care. The mobilization of all stakeholders is necessary for this dynamic. The patient experience involves all those concerned: Healthcare professionals (medical and non-medical), caregivers, family members, other patients, patient representatives and members of Patient Committees, and patient partners. Patient involvement as active participants in their care pathway and the transformation of the healthcare system is a key commitment. Care teams are encouraged to "work with people." Governance plays a crucial role in the success of this approach. Support from senior management is fundamental. Groups like Vivalto Santé have placed the patient at the heart of their purpose and governance. They have established a national strategic patient experience committee, including the CEO, the COO, patient partners (resources and peer supporters), practitioners (surgeon, anesthesiologist, geriatrician), operational staff (nurse, porter, care manager, facility experience coordinator, regional CEO), and functional directors (medical, nursing, quality, performance, HR, communications, patient experience). This committee meets four times a year to share the results of assessments, decide on actions, guide the strategic roadmap, monitor implementation, and promote the initiatives. Des comités opérationnels sont également déployés au niveau des établissements. La voix des patients est ainsi intégrée comme une "boussole" dans toutes les décisions.La symétrie des attentions est un principe important : l'expérience patient est indissociable de l'expérience des professionnels, car ce que vivent les soignants influence directement ce que vivent les patients. Des programmes de qualité de vie au travail sont poursuivis pour assurer que les collaborateurs et praticiens soient respectés et heureux.La formation et la sensibilisation des équipes sont des leviers majeurs pour l'amélioration. L'expérience patient est un concept encore peu connu en France, et le manque de formation des équipes est un frein. Former tous les professionnels (pas seulement de santé) et les praticiens libéraux est essentiel, car tous les métiers autour du patient sont concernés. Des modules de formation peuvent être développés sur les outils existants (enquêtes, indicateurs, audits) et des programmes sur-mesure peuvent être co-construits.Le déploiement d'une démarche d'expérience patient prend du temps, implique de former et d'impliquer les professionnels, et représente un changement de culture et d'approche. Elle nécessite de s'intéresser aux besoins et attentes des patients, à leurs avis, ressentis et idées d'amélioration, et au vécu des faits. La collecte de la voix du patient doit servir une stratégie, se traduire en actions et servir une vision, un objectif et des priorités clairement définies.Défis et perspectives pour l'expérience patientMalgré l'importance croissante de l'expérience patient, des défis subsistent. Le manque de formation des équipes est l'un des principaux freins à son amélioration, avec 51% des établissements de santé déclarant ne pas être engagés dans cette démarche selon le baromètre 2021 de l'IFEP. Le déploiement d'une telle démarche est un processus long qui implique un changement de culture et l'engagement de temps et de ressources pour la formation et l'implication de tous les professionnels. De plus, il existe un manque d'écoute et de reconnaissance de l'expérience des personnes concernées, et parfois une utilisation de l'expérience sans bénéfice réel pour elles, d'où la nécessité de clarifier son articulation avec l'engagement des usagers.Cependant, les perspectives pour l'expérience patient sont prometteuses et essentielles pour l'avenir du système de santé.
      • Intégration et reconnaissance accrue : La prise en compte de l'expérience patient progresse au sein des établissements. Les organisations comme l'IFEP s'efforcent de développer les connaissances, de former les équipes et de sensibiliser un large public à l'intérêt de ce sujet pour fédérer les équipes autour de l'amélioration du vécu des patients.
      • Renforcement du partenariat patient : L'objectif est de replacer le patient au cœur du système de santé, de son parcours et de sa prise en charge dans toute sa singularité. L'intégration de la voix du patient dans la gouvernance des établissements est un tournant décisif, comme l'illustre la démarche de Vivalto Santé. Cette intégration permet de prendre des décisions éclairées et d'améliorer la qualité et la sécurité de la prise en charge.
      • Développement d'outils et de méthodes : La construction et la mise à disposition d'outils de compréhension et d'amélioration de l'expérience patient se poursuivent. L'utilisation des PREMs et PROMs est encouragée pour la participation des usagers. La méthode narrative et le recueil structuré du vécu des patients sont des pratiques qui se développent.
      • Amélioration continue : L'expérience patient est un levier d'amélioration continue. Les informations recueillies auprès des patients doivent servir une stratégie clairement définie et se traduire en actions concrètes.
      • Sensibilisation et partage des bonnes pratiques : Des événements comme la "semaine de l'expérience patient" organisée par la FHP visent à créer un "effet d'entraînement dynamique" autour de cette thématique, par le partage de connaissances, de méthodes, d'outils et de bonnes pratiques issues des démarches existantes.
      • Clarification des concepts : Le guide de la HAS "Expérience patient et savoir expérientiel" vise à clarifier ces notions et à reconnaître la parole qu'elles expriment (avis, perception, connaissance, savoir) pour susciter l'engagement et la collaboration.
      L'expérience patient est une démarche progressive qui nécessite de "faire l'expérience de l'Expérience Patient". Elle est utilisée pour guider les efforts d'amélioration continue, mais aussi pour redonner du sens aux professionnels. En fin de compte, l'objectif est que ceux qui soignent soient soutenus par ceux qui sont soignés, renforçant ainsi le principe du partenariat. La reconnaissance et le partenariat sont des enjeux importants pour l'innovation et l'amélioration du système de santé, impliquant le partage du pouvoir de décision.

By combining these approaches, we obtain a detailed and nuanced view, useful for the continuous improvement of practices.

Several tools and methods are available to measure and collect patient experience: