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 driver for the continuous improvement of the quality of care and the transformation of healthcare organizations. This approach highlights individuals’ lived experiences 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 patients have of their experience throughout their care pathway. This perception encompasses what they see, think, hear, or understand. More broadly, it refers to 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 in 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 experienced, what happened (or did not 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, has its origins and pioneers in Anglo-Saxon countries. The Beryl Institute, an American organization, 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 key to improving their healthcare journey. Major initiatives emerged in these countries: the 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, viewing 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 participation is sought (information, consent, advance directives).
• 1.2: The patient is treated with respect (respect for dignity, compassionate 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 in their care.

Chapter 3 ("The Facility") also incorporates the patient experience into a single objective and a single criterion:

• 3.2: The institution promotes patient engagement both individually and collectively.
• 3.7-02: The institution takes the patient’s perspective into account in its quality improvement program. This criterion is mandatory in the sixth cycle of HAS certification, during which visiting experts will assess whether institutional governance supports the use of questionnaires designed to capture patient-reported outcomes. Institutions are expected to demonstrate their ability to implement and ensure the traceability of projects and actions that incorporate 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 encouraged to express themselves, to share their experiences, and their preferences are taken into account.
• Criterion 1.7.1: The person receiving support is able to give informed consent through clear information and appropriate means.

The HAS emphasizes the central role of the person receiving support in the quality assurance process for ESSMS, particularly through the implementation of the Tracer Support Method, which assesses the quality of support from the combined perspectives of the person being supported and the professionals. Patient experience complements more conventional indicators such as satisfaction surveys or medical and administrative data. A positive care experience is associated 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 significant benefits, not only for the patients themselves, but also for healthcare professionals and the institution as a whole.

For Patients and Their Families:

• A Greater Sense of Trust and Consideration: Patients appreciate being asked about their care experience.
• A more active role in their own care: This includes staying vigilant and adhering to treatment, as well as promoting autonomy and empowerment.
• Sense of usefulness and value: By expressing themselves, patients help improve the entire system, thereby benefiting others.
• Strengthening relationships: Sharing their experiences helps build stronger bonds with care teams and caregivers.
• Improved quality of care and support: Patients feel that their concerns are taken more seriously and that they receive better care, as their voices are heard.
• Better clinical outcomes and patient safety: A positive experience is associated 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 providing a "space for expression and participation," restoring meaning to work, and putting care back at the center of attention. 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 provides valuable insights 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 experiences reveal "blind spots" in the organization and its internal operations, particularly at the points where different functions meet and in the coordination between teams.
• Job satisfaction: The opportunity to help improve the experience of future patients is a source of satisfaction.
• Building trust: A report published by the IFEP revealed a 20-point gap between the perceptions of healthcare professionals (71%) and patients (51%) regarding how their experiences are taken into account, underscoring the importance of improving this dialogue.

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 process," and to "promote cross-functional collaboration." It can be a real driver of performance by revealing areas for improvement that were previously overlooked.
• Improved image and trust: Improving the patient experience can enhance the institution's image and patients' trust in the system.
• Staff motivation and attractiveness: Managing teams that focus on what matters to patients makes the institution more attractive.
• Identifying weaknesses: The patient experience provides an opportunity to work on improving internal operations, internal coordination, and interactions with external partners.
• A strategic and differentiating factor: Patients can choose their healthcare providers based on the patient experience they offer.
• 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 essential to adhere to four fundamental pillars. These pillars are outlined 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 behind the project is to foster a sense of trust, to be a trusted partner, to avoid criticism, and to work together.
    The goal is to bring users and caregivers closer together and foster 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, taking into account all the stages they have gone through. This involves examining moments that occur 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 start to finish, making it possible to piece together what is fragmented and compartmentalized among different teams. Key moments include the first 24 hours after discharge or arrival, and the first interaction with staff.
  • Pillar 3: Consider all factors that influence the experience.
    • The patient and their experience are influenced by the people involved (family members or healthcare professionals) and by the care environment. It is therefore important to take these factors into account.
  • Pillar 4: Consider, beyond satisfaction alone, all the aspects that make up the experience.
    • These aspects 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 full scope of the patient experience, enabling concrete and meaningful 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. We must organize ourselves to actively seek out this experience, as patients mostly share it within their private circles and not enough with healthcare professionals. It is important to help 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-Reported Outcomes: Assesses how patients understand and experience the effects of the care they receive, using PROMs.
  
  • National and International Indicators:
    • e-Satis: The national system for the ongoing measurement of patient satisfaction and experience in healthcare facilities, implemented by the HAS since 2016. It includes questions on reception, care (information, wait times, respect, privacy/confidentiality, pain management), the room and meals, and discharge planning.
    • Patient-Reported Experience Measures (PREMs): Assess the patient's experience of care (satisfaction, information received, attention to pain, wait times, relationships with providers).
    • Patient-Reported Outcome 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 patient involvement in improving their care pathway.
  • Qualitative and narrative methods:
    • Note: Allows for capturing lived experience directly.
    • Narrative method (experience narrative): Creating opportunities to gather patients’ accounts of their care experiences is very important and informative for the teams. Patients appreciate this approach. It involves allowing patients to tell their stories, share their emotions and facts, and engage in discussion and dialogue. The “Experience Journal” can serve as a guide to support patients.
    • Focus groups: Enable the collection of qualitative information from groups of patients.
    • Shadowing method: This involves following a patient throughout their care journey to observe their experience.
    • Mystery shopper: Involves the use of an "undercover" shopper 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) through their experience with the illness, transforming them into expertise. They can become partners in care and expand the boundaries of knowledge sharing.
    • Peer support: Particularly in psychiatry, patients help other patients based on their personal experiences. "Patient partners" are already very active in healthcare facilities, working with patient organizations 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 lasting 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 using a comprehensive quality management solution that enables 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 selection 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. Organizations like Vivalto Santé have placed the patient at the heart of their mission and governance. They have established a national strategic patient experience committee, including the CEO, the COO, patient partners (resource 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 assessment results, decide on actions, guide the strategic roadmap, monitor implementation, and promote initiatives. Operational committees are also established at the facility level. The patients’ voice is thus integrated as a “compass” in all decisions. reciprocity of attention is an important principle: the patient experience is inextricably linked to the experience of healthcare professionals, because what caregivers go through directly influences what patients go through. Workplace well-being programs are being implemented to ensure that employees and practitioners are respected and happy.The training and awareness-raising Teams are key drivers of improvement. The patient experience is still a relatively unfamiliar concept in France, and the lack of training for teams is a major obstacle. Training all professionals (not just healthcare workers) and private practitioners is essential, as all roles that interact with patients are involved. Training modules can be developed using existing tools (surveys, indicators, audits), and customized programs can be co-designed. Implementing a patient experience initiative takes time, requires training and engaging professionals, and represents a shift in culture and approach. It requires paying attention to patients’ needs and expectations, their opinions, feelings, and ideas for improvement, and their lived experiences. Gathering the patient’s voice must serve a strategy, translate into action, and support a clearly defined vision, objective, and priorities. Challenges and Prospects for the Patient Experience Despite the growing importance of the patient experience, challenges remain. The lack of training team engagement is one of the main obstacles to its improvement, with 51% of healthcare facilities reporting that they are not currently implementing such an initiative, according to the IFEP’s 2021 survey. The implementation of such an initiative is a lengthy process which requires a cultural shift and a commitment of time and resources to training and engaging all professionals. In addition, there is a a lack of willingness to listen to and acknowledge the experiences of those affected, and sometimes the use of patient experience data without any real benefit to patients, hence the need to clarify how it relates to patient engagement. However, the outlook for the patient experience is promising and essential to 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.
      The patient experience is a step-by-step approach which requires "experiencing the Patient Experience." It is used to guide continuous improvement efforts, but also to restore a sense of purpose among healthcare professionals. Ultimately, the goal is for those who provide care to be supported by those receiving care, thereby reinforcing the principle of partnership. Recognition and partnership are key to innovation and improvement in the healthcare system, involving the sharing of decision-making power.

By combining these approaches, we gain a detailed and nuanced understanding that is useful for the continuous improvement of practices.

There are several tools and methods available for measuring and collecting patient experience: