Patient experience: the quality of care according to the HAS and the transformation of the healthcare system

Patient experience has become an essential theme in the healthcare sector, gradually 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 people's lived experiences as a key indicator of quality, revealing opportunities for improvement and impacting all aspects of the organization, from architecture to information systems, including communication and the organization itself. The Haute Autorité de Santé (HAS) has significantly reinforced 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 lived experience throughout their care pathway. This perception encompasses what they see, think, hear, or understand. More broadly, it corresponds to the totality of interactions and situations experienced by a person or their entourage during their healthcare journey. It is specified that the term "patient" is understood in its broadest sense, designating any person benefiting from care within a pathway or a hospital, whether it is a health or medico-social setting. This includes patients in healthcare facilities and individuals receiving care in medico-social structures, often referred to as "supported individuals."

This concept goes far beyond the simple caregiver-patient relationship, integrating everything that surrounds the care and what the patient perceives. Patient experience is an approach centered on the patient's subjectivity, involving their experience, their life story, their expectations, and their emotions. It is an adaptation of the concept of "user experience" applied to care.

Several factors can influence this perception:

• All persons involved: healthcare professionals or not, caregivers, relatives, or other patients. The quality of human interactions with professionals is very important.
• The care environment: the configuration of the premises, noise, light, displays, devices with which the patient interacts, comfort, hygiene, available equipment.
• Emotional support and involvement of loved ones.
• The clarity and quality of the information received.
• Streamlining administrative procedures.
• Respect for the patient's choices and preferences.
• Coordination and continuity of care.
• The period before, during, and after a consultation or hospitalization.
• The history and culture of each person being cared for.

It is important to distinguish patient experience from simple satisfaction or perceived outcomes. Although satisfaction is recognized as essential in assessing the quality of care, it alone cannot cover all dimensions of the experience, as it remains subjective. The experience seeks to understand the lived experience, what happened (or did not happen), and what the patient went through emotionally, while satisfaction measures whether expectations have been met in relation to identified needs. The results perceived by the patient assess how the patient understands and feels the effects of care. It is by combining these complementary approaches that we obtain a fine and nuanced vision, useful for continuous improvement. The Haute Autorité de Santé (HAS) emphasizes that patient satisfaction alone cannot correspond to all dimensions of the patient experience, and that it is necessary to take objective elements into account in order to understand and measure it. To understand each other well, it is necessary to specify whether we are talking about lived facts, opinions and perceptions of lived facts, or actions taken.

Origins and development of the concept in France and abroad

The concept of patient experience, although increasingly used in France, has its origins and pioneers in English-speaking countries. The Beryl Institute, an American establishment, was the first to clearly lay the foundations. Canada, the United States, and the United Kingdom were the first to realize that patients held keys to improving their care pathway.

Major initiatives have been launched in these countries:

• The Cleveland Clinic in the United States, with its "Patient First" policy.
• The United Kingdom created its "Expert Patient Program" in 2002, based on studies from Stanford University in California.
• The Canadian healthcare system has promoted patient engagement at all levels for nearly 20 years, considering the patient as "a caregiver and a full partner", like the "Montreal Model" of the Faculty of Medicine of the University of Montreal for chronic diseases.

These Anglo-Saxon approaches are based on the premise that conventional care, characterized by a marked hierarchy between patient and professional, may neglect patient 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 System for Reporting Patient Experience (SDEPC)", 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 new. As early as 2009, the Pierre and Marie Curie University began training and graduating patients through the University of Patients, allowing patients to leverage the expertise acquired through their experience with the disease. In 2011, the Haute Autorité de Santé (HAS) published an initial report on patient experience, recognizing that patients' judgments on 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 grow in France with the creation of the French Patient Experience Institute (IFEP) in 2016. This institute advocates for a "more welcoming, more attentive, more human health system" and aims to develop the knowledge and mastery of patient experience by professionals, with the goal of a global improvement of the health system.

The HAS has fully embraced the subject, disseminating its concerns via surveys (notably e-Satis), recommendations for good practice and indicators for improving quality in medico-social and healthcare hospitals. The Haute Autorité de Santé has also significantly reinforced the priority on patient experience in its 6th certification cycle, introducing one mandatory criterion, one advanced criterion and four standard criteria. The strengthening of these requirements is seen as an opportunity for patients, professionals and hospitals.

Patient experience as a key indicator of the quality of care according to the HAS

Considering the patient's perspective significantly enriches the approach to improving the quality of care. According to the Haute Autorité de Santé (HAS), "measuring the quality of care is a prerequisite for defining the actions to be implemented and objectifying progress in order to improve the service provided to patients," and this approach is "enriched by the complementary vision of patients." There is a direct link between considering the patient's point of view and improving the quality of care provided. This concept clearly links patient experience to the continuous quality improvement process.

The HAS (Haute Autorité de Santé) has evolved its expectations and tools to give patients a central role, with patient experience indicators being essential for measuring the quality of healthcare and medico-social hospitals.

Within the framework of the new HAS v2020 certification for healthcare facilities, the patient experience is a major focus, aiming to place the patient back at the heart of the pathway and to promote the emergence of a patient-partner, an actor in their care to improve the effectiveness of care. 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, benevolent care).
• 1.3: Relatives and/or caregivers are involved in the implementation of the care plan with the patient's consent.
• 1.4: The patient's living conditions and social connections are taken into account as part of their care.

Chapter 3 ("the hospital") also integrates the patient experience into an objective and a criterion:

• 3.2: The hospital promotes patient engagement individually and collectively.
• 3.7-02: The hospital takes into account the patient's point of view in its quality improvement program. This criterion is even a mandatory criterion in the HAS's 6th certification cycle, where visiting experts will assess whether the governance supports the use of questionnaires targeting patient-assessed care outcomes. Hospitals are expected to demonstrate their ability to implement and ensure the traceability of projects and actions that take into account the information collected 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 ESSMS requires compliance with several criteria related to patient experience, including:

• Criterion 1.5.2: The individual receiving support is informed of the follow-up actions taken on their requests within collective bodies or other forms of participation.
• Criterion 1.6.1: The individual receiving support is encouraged to express themselves, share their experiences, and have their preferences taken into account.
• Criterion 1.7.1: The individual receiving support can express their informed consent through clear information and appropriate means.

The HAS emphasizes the central role of the supported person in the quality approach of the ESSMS (Établissements et Services Sociaux et Médico-Sociaux), in particular through the deployment of the Accompagné Traceur method, which evaluates the quality of support via the cross-referenced perspectives of the supported person and professionals.

Patient experience complements more conventional indicators such as satisfaction surveys or medico-administrative data. A positive care experience is correlated with a higher level of treatment adherence, better clinical outcomes, improved patient safety, and reduced service utilization.

The benefits of improving patient experience

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

For patients and their families:

• Strengthening the feeling of trust and consideration: Patients appreciate that we are interested in how they experienced their care.
• More active role in their own care: This includes vigilance and adherence to treatment, promoting autonomy and the ability to act.
• Sense of usefulness and appreciation: By expressing themselves, patients contribute to the improvement of the entire system, thus benefiting others.
• Relationship consolidation: Expressing the 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 legitimized.
• Improved clinical outcomes and patient safety: A positive experience is correlated with better adherence to treatment and greater safety.

For professionals and teams:

• Improved Quality of Work Life (QWL): The approach contributes to better working conditions by offering a "space for expression and participation", by restoring meaning to work and by putting care back at the center of concerns. There is a documented link between the quality of professionals' working conditions and the quality of their work.
• Enhanced human connection with patients: Teams feel more connected to patients by asking 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 makes it possible to learn things both on an individual level (what can be done better) and collectively (improvement of organization and coordination). The organizational weaknesses revealed by the patient experience may reflect the needs of professionals.
• Access to valuable information: The patient experience reveals "blind spots" in the organization and internal operations, particularly at interfaces and in 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 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 hospitals and organizations:

• Overall performance improvement: The patient experience approach makes it possible to "identify opportunities for improving care pathways", to "be part of a continuous improvement approach" and to "promote transversality". It can be a real lever for performance by revealing areas for improvement that were previously in the blind spot.
• Improved image and trust: Working on patient experience can improve the image of the hospital and patient confidence in the system.
• Staff mobilization and attractiveness: Managing teams focused on what matters to patients makes the hospital more attractive.
• Identification of weaknesses: Patient experience enables work on improving internal operations, internal coordination, and interfaces with the outside.
• A strategic and differentiating issue: Patients can choose their hospitals based on the patient experience offered.
• Restoring meaning and values to caregivers: This allows for re-examining the human aspect and the connection with the person behind the patient.
• Strengthening partnership: The patient becomes a stakeholder in the healthcare system.

In summary, the patient experience approach is an approach that uses people's experiences as a quality indicator and a revealer of opportunities for improvement. 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 lever for performance.

The four fundamental pillars of the patient experience

For the patient experience approach to fully fulfill its role as a lever for performance and improvement, it is crucial to respect four fundamental pillars. These pillars are presented by the ANAP (Agence Nationale de la Performance sanitaire et médico-sociale, National Agency for Health and Medico-Social Performance) in its guide "Patient and User Experience".

• Pillar 1: Adopt a posture of listening and not auditing to take an interest in the lived experience.
  • This involves focusing on patients' perceptions of the outcomes of care, while taking care not to judge the curative results of that care. 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 come together to work together. It is about bringing users and caregivers closer together and balancing their points of view.
• Pillar 2: Take into account the temporal dynamics of this lived experience by focusing on all the times that construct 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 that occur throughout the journey, such as "emotional bank accounts" (positive and negative moments).
  • The experience is cumulative because it allows exploring moments that occur throughout the journey, and it is integrative because the patient is often the only one to see the experience from start to finish, allowing to reconstruct what is fragmented and compartmentalized within different teams. Key moments include the first 24 hours after discharge or arrival, and the initial contact with staff.
• Pillar 3: Take into account all the elements that influence the experience.
  • The patient and their experience are influenced by the people involved (relatives or professionals) and by the care environment. These dimensions should therefore be considered.
• Pillar 4: Take into account, 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 capture and analyze the richness of the patient experience, enabling concrete and significant improvements.

Methods and tools for collecting and measuring patient experience

To improve the patient experience, it is essential to know how to listen to and measure it. It is necessary to organize to actively seek out this experience, as patients mainly share it within their private circle and not sufficiently with professionals. It is important to make patients understand that sharing their experience is a service they provide, which can advance care.

Three complementary dimensions are used to measure experience:

1. Satisfaction: Measures whether the patient's expectations have been met in relation to identified needs, often via satisfaction questionnaires.
2. The 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.
3. The result perceived by the patient: Evaluates how the patient understands and feels the effects of the care they received, via PROMs.

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

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

• National and international indicators :
  • e-Satis: The national system for continuous measurement of patient satisfaction and experience in healthcare facilities, deployed by the HAS since 2016. It includes questions about reception, care (information, waiting times, respect for privacy/confidentiality, pain management), room and meals, and discharge planning.
  • PREMs (Patient-Reported Experience Measures): Inquire about the patient's experience of care (satisfaction, information received, attention to pain, waiting times, relationships with providers).
  • PROMs (Patient-Reported Outcomes Measures): Assess the results of care from the patient's point of view. These two tools are promoted by the HAS because they encourage user participation in improving their care pathway.
• Qualitative and narrative methods :
  • Observation: Allows direct capture of lived experience.
  • Narrative method (experience story): Organizing opportunities to collect patients' stories about their experience of care is very important and informative for teams. Patients are grateful for this. It involves letting the patient tell their story, share their emotions and facts, for an exchange and dialogue. The "Experience Journal" can be a guide to accompany the patient.
  • Focus groups: Allow for the collection of qualitative information from groups of patients.
  • Shadowing Method: Consists of following a patient in their journey to observe their experience.
  • Mystery shopper: Involves the use of an "incognito" patient to assess 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) through their experience with the disease, transforming them into expertise. They can become care partners and shift the boundaries of knowledge sharing.
  • Peer support: Particularly in psychiatry, patients help other patients through their lived experience. "Patient partners" are already very active in hospitals, working with patient associations and participating in awareness-raising activities.
  • The tracer patient (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 relatives via 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 indicators to be tracked, action plans to be drawn up and the improvement process to be rolled out. A method structured in three stages is proposed: preparation (volunteer team, patient selection, support guide), meeting (group discussion), and assessment (thank-you letter, written summary, flash and targeted actions, feedback to the patient). The choice of the patient is crucial: he or she must be at ease, able to express him- or herself, "ordinary" (with no special ties to the team), with a generally positive experience to initiate the process, and 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 experience as a quality indicator and a revealer of opportunities for improvement. It can impact all areas of the organization: architecture, information systems, communication, and the organization itself. This implies a change of perspective in the relationship between the healthcare professional and the patient, moving from a hierarchical relationship where the professional is the bearer of knowledge and authority, to a relationship where patient and professional are considered equals, each bearing different and complementary knowledge. The goal is to build an effective and patient-centered care pathway, involving the patient in improving care.

The mobilization of all stakeholders is necessary for this dynamic. Patient experience involves all concerned parties:

• Healthcare professionals (medical and non-medical).
• Caregivers.
• Family members.
• Other patients.
• User representatives and members of the User Commissions (CDU).
• Patient partners.

The involvement of patients as actors in their care pathway and the transformation of the healthcare system is a key commitment. Care teams are encouraged to "do with people".

Governance plays an essential role in the success of this approach. Support from senior management is fundamental. Groups such as Vivalto Santé have placed the patient at the heart of their mission and governance. They have established a national strategic patient experience committee, integrating the CEO, the director of operations, patient partners (resources and peer supporters), practitioners (surgeon, anesthesiologist, geriatrician), operational profiles (nurse, stretcher-bearer, care manager, hospital experience referent, regional general manager) and functional directors (medical, care, quality, performance, HR, communication, patient experience). This committee meets four times a year to share measurement results, decide on actions, guide the strategic roadmap, monitor implementation, and promote actions. Operational committees are also deployed at the hospital level. The voice of patients is thus integrated as a "compass" in all decisions.

Symmetry of attention is an important principle: the patient experience is inseparable from the professional experience, because what caregivers experience directly influences what patients experience. Quality of work life programs are being pursued to ensure that employees and practitioners are respected and happy.

Training and awareness of teams are major levers for improvement. Patient experience is a concept that is still not well known in France, and the lack of training for teams is a barrier. Training all professionals (not just healthcare professionals) and liberal practitioners is essential, as all occupations around the patient are concerned. Training modules can be developed on existing tools (surveys, indicators, audits) and tailor-made programs can be co-constructed.

The deployment of a patient experience approach takes time, involves training and engaging professionals, and represents a change in culture and approach. It requires focusing on the needs and expectations of patients, their opinions, feelings and ideas for improvement, and the experience of the facts. The collection of the patient's voice must serve a strategy, translate into actions and serve a vision, an objective and clearly defined priorities.

Challenges and perspectives for patient experience

Despite the growing importance of the patient experience, challenges remain. Lack of training for teams is one of the main obstacles to improving patient experience, with 51% of healthcare establishments declaring that they are not committed to this approach, according to the IFEP 2021 barometer. Deploying such an approach is a lengthy process, involving a change of culture and a commitment of time and resources to training and involving all professionals. What's more, the experience of the people concerned is not always listened to or recognized, and is sometimes used without any real benefit to them, hence the need to clarify its relationship with user involvement.

However, the prospects for patient experience are promising and essential for the future of the healthcare system.

• Increased integration and recognition: Consideration of patient experience is progressing within hospitals. Organizations like IFEP strive to develop knowledge, train teams, and raise awareness among a broad audience about the importance of this topic to unite teams around improving patient experience.
• Strengthening patient partnership: The objective is to put the patient back at the heart of the healthcare system, their journey, and their care in all its uniqueness. The integration of the patient's voice in the governance of hospitals is a decisive turning point, as illustrated by the approach of Vivalto Santé. This integration makes it possible to make informed decisions and improve the quality and safety of care.
• Development of tools and methods: The construction and provision of tools for understanding and improving the patient experience continues. The use of PREMs and PROMs is encouraged for user participation. The narrative method and the structured collection of patients' experiences are developing practices.
• Continuous improvement: Patient experience is a driver of continuous improvement. The information collected from patients should serve a clearly defined strategy and translate into concrete actions.
• Awareness and sharing of best practices: Events such as the "Patient Experience Week" organized by the FHP aim to create a "dynamic training effect" around this theme, through the sharing of knowledge, methods, tools, and best practices from existing approaches.
• Clarification of concepts: The HAS guide "Patient experience and experiential knowledge" aims to clarify these notions and to recognize the voice they express (opinion, perception, knowledge, know-how) to encourage engagement and collaboration.

Patient experience is a progressive approach that requires "experiencing the Patient Experience." It is used to guide continuous improvement efforts, but also to restore meaning for professionals. Ultimately, the goal is for those who provide care to be supported by those who receive care, thereby reinforcing the principle of partnership. Recognition and partnership are important issues for innovation and improvement of the healthcare system, involving the sharing of decision-making power.

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