Hospitals are finding that it is no longer sufficient to take a narrow view of patient and physician satisfaction. As the payment system transitions to rewarding—and penalizing—performance across the continuum, hospitals are starting to assess perception of the entire delivery system.

In New Jersey, AtlantiCare has added to many of its 2011 surveys a question concerning how well it coordinates patient care, says Bush Bell, the health system's director of customer service.

AtlantiCare is working with Professional Research Consultants on a set of continuum of care questions for high-risk patients who participate in the health system's accountable care organization, a collaborative effort with Premier Inc.

Those questions, says Janna Binder, PRC's director of marketing and public relations, try to get at how well ACO providers are educating patients about their conditions, how well the ACO coordinates care between specialists and general practitioners, whether the patients get appointments as needed, and if they are even aware that they have an individualized care plan.

Bell says a key challenge has been tracking patients through their many different providers. AtlantiCare's approach is to survey patients at different points in the continuum and tie the surveys to demographic and clinical data extracted from their medical records.

"That will allow us to slice and dice the data and say, 'Patients who live in this area or with this diagnosis or seeing this individual provider, what kind of experience are they getting?' " Bell says.

AtlantiCare also surveys specialists and other network providers to determine their understanding of and degree of participation in the ACO, and whether the hospital needs to support them better with services like administration, nursing care, anesthesia and radiology.

Physician surveys are crucial, Binder says, because AtlantiCare "can't fully implement an ACO without the physicians being on board. They need to know 'Where are our physicians in our referral network in terms of being ready to be an ACO, and what can we do to get them there? Do we need to put money into these practices? Do we need to build better relationships with them?' "

Saint Francis Hospital in Tulsa, Okla., is tracking the continuum of care for the general patient population in its ACO by adding questions to its existing surveys "that help us focus on each step as well as on the transition between steps," says quality director Bill Nole. For instance, a home health care survey might go beyond asking about the helpfulness of staff who gave an at-home tutorial on medical equipment, to also zero in on whether the equipment was delivered promptly.

"We're trying to get the whole picture," Nole says. "If we're getting the medical equipment set up, but it took three days to get it there, we're not doing a good job."

Or if a patient visits the emergency department, it's important to go beyond asking whether the patient was satisfied with his medical treatment, and ask whether he left the ED with a follow-up appointment and how he was prepared for the next step, Nole says. "We want to ask that in a way that is good survey science, but also get as many puzzle pieces as we can."