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Measuring Patient Experience of Oral Health Care: A Call to Action

Nadeem Karimbux , Mike T John , Amy Stern ,

Morgan T Mazanec , Andrew D’Amour , Jim Courtemanche ,
Barbra Rabson

PII: S1532-3382(22)00114-2
DOI: https://doi.org/10.1016/j.jebdp.2022.101788
Reference: YMED 101788

To appear in: The Journal of Evidence-Based Dental Practice

Received date: 11 July 2022

Revised date: 30 August 2022
Accepted date: 14 September 2022

Please cite this article as: Nadeem Karimbux , Mike T John , Amy Stern , Morgan T Mazanec ,
Andrew D’Amour , Jim Courtemanche , Barbra Rabson , Measuring Patient Experience of Oral
Health Care: A Call to Action, The Journal of Evidence-Based Dental Practice (2022), doi:
https://doi.org/10.1016/j.jebdp.2022.101788

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Measuring Patient Experience of Oral Health Care: A Call to Action

Nadeem Karimbux, DMD, MMSc, Dean and Professor of Periodontology, Tufts University School of
Dental Medicine, One Kneeland St, Boston, MA 02111 (Nadeem.karimbux@tufts.edu)

Mike T John, DDS, PhD, MPH, PhD, Associate Professor, University of Minnesota School of
Dentistry, Department of Diagnostic and Biological Sciences, 7-536 Moos Tower 515 Delaware Street
SE, Minneapolis, MN 55455 (johnx055@umn.edu)

Amy Stern, PhD, Director of Operations and Commercial Surveys, Massachusetts Health Quality
Partners, 1380 Soldiers Field Road, Floor 3, Brighton, Massachusetts 02135 (astern@mhqp.org)

Morgan T Mazanec, MPH, Project Manager, Massachusetts Health Quality Partners, 1380 Soldiers
Field Road, Floor 3, Brighton, Massachusetts 02135 (mmazanec@mhqp.org)

Andrew D‟Amour, Director of Business Development, Massachusetts Health Quality Partners, 1380
Soldiers Field Road, Floor 3, Brighton, Massachusetts 02135 (adamour@mhqp.org)

Jim Courtemanche, SM, Vice President of Programs and Analytics, Massachusetts Health Quality
Partners, 1380 Soldiers Field Road, Floor 3, Brighton, Massachusetts 02135
(jcourtemanche@mhqp.org)

*Barbra Rabson, MPH, President and CEO, Massachusetts Health Quality Partners, 1380 Soldiers
Field Road, Floor 3, Brighton, Massachusetts 02135 (brabson@mhqp.org)

*corresponding author

Key words: patient experience, experience measurement, quality

Abstract

Surveys to measure patients‟ experience of health care have become a common practice in general
medical care to improve patient centered care. However, such questionnaires are not consistently
used to capture the patient‟s experience of oral health care. Because patient experience is an
important component of high-quality care, there is an urgent need to measure it in the oral health care
setting. This article aims to illustrate the need for patient experience measurement in oral health care,
highlight the challenges such measurement in this setting faces, and provide a set of next steps.

There is a critical need for patient experience measurement in oral health care. The authors propose
the following course of action:

1. Convening and stakeholder buy in.

2. Framework and theory development.
3. Survey tool development.
4. Survey tool implementation.

Introduction

Dental patients expect to have their oral health care needs (diagnosis and treatment) met. However,
they also expect to get timely appointments, have easy access to information, have informative

1
communication with and feel known by their oral health care providers, and have good interactions
with office staff. In short, dental patients expect a good experience of care.

The Quadruple Aim of health care (Figure 1) lays the foundation for value-based care, building on the
Triple Aim of "improving the health of populations, improving patient experience with care, and
1,2
reducing costs” through the inclusion of the provider experience. In the field of value-based oral
health care, attention has focused mainly on the health of population characterized by outcomes of
3,4
care. When it comes to oral health care performance, current measurement generally focuses on
5
the process of care. While a next generation of multi-item tools to assess outcomes is in the process
6–8 9
of being developed, some outcome measurement systems are already globally available today.
10
While progress is being made, implementing data collection systems and infrastructure to aggregate
11 12
patient encounter data remains a challenge, with low resource settings affected the most. There
has been very little progress to date in the measurement of patient experience in oral health care.

Measurement of the patient experience has become a common practice in general medical care and
is often quantified using surveys that enable comparisons among practices and providers. However,
such questionnaires are not consistently used to capture the patient‟s experience of oral health care.
The tools available for practitioners to understand their dental patients‟ experiences of care are also
not well developed. Implementation is challenging due to the nature of dental practices (solo practice,
single owner) and there are no incentives for implementation. While the application of questionnaires
in clinical and research settings does not pose substantial difficulties, such assessment is often
neglected, which may limit the quality of oral health care.

In this article, we will:

 define patient experience and explain how and why to measure it,
 provide a critical assessment of the current state of dental patient experience measurement,
and
 provide a call to action and recommended steps to move forward with lessons learned from
medical care and oral health outcomes assessment.

Definition of Patient Experience

Several leading health care agencies and stakeholders emphasize that centering the patient voice in
understanding their experience of care is fundamental to both clinical outcomes and quality
improvement. For example, the Agency for Healthcare Research and Quality (AHRQ) defines patient
experience as follows:

Patient experience encompasses the range of interactions that patients have with the health care
system, including their care from health plans, and from doctors, nurses, and staff in hospitals,
physician practices, and other health care facilities. As an integral component of health care
quality, patient experience includes several aspects of health care delivery that patients value
highly when they seek and receive care, such as getting timely appointments, easy access to
13
information, and good communication with health care providers.

While the terms “patient experience” and “patient satisfaction” are sometimes used interchangeably,
there is a distinct difference between the two. Patient experience reflects what patients say happened
during encounters they have with their provider, practice, and health system. Measures of patient
experience ask about whether and how often certain care was received. Patient satisfaction is
formulated on patients‟ evaluation of the care provided relative to their expectations. Patient
experience questions ask patients to provide a direct report of what actually happened and therefore
are less subjective than questions that ask patients to rate their satisfaction which is based on
expectations and not necessarily an actual care encounter.

The Importance of Measuring Patient Experience

Reforms to achieve a patient-centric system were conveyed over two decades ago in the landmark
2001 Institute of Medicine (now National Academies of Science, Engineering and Medicine) report
14
Crossing the Quality Chasm. The report envisioned a system that is "respectful of and responsive to

2
individual patient preferences, needs, and values, and ensuring that patient values guide all clinical
15
decisions." Patient experience is a fundamental component of health care quality. Patient
experience measurement focuses on the aspects of care that patients tell us matter most to them and
what actually happens when they receive care. Therefore, patient experience surveys are designed to
ask questions about aspects of care where the patient is the best (and sometimes only) source of
information.

Patient experience is an important concept in clinical care and is related to other key concepts such
as quality and health outcomes. Measuring patient experience provides significant advantages to
providers, payers, patients, and regulators.

There are numerous reasons documented in the literature that underscore the importance of
capturing the patient‟s voice and experience. First, research gathered over more than three decades
documents the connection between patient experience and improved care outcomes, the relationship
16–19
to clinical quality processes and to patient adherence to treatment.

Second, evidence demonstrates that patients value patient-centered care. For example, a 2014 study
found that 59 percent of patients rated doctor-patient relationships and physician characteristics as
20
the most important aspects of high-quality care. Patients ranked how well their physician listens to
them as the number one factor that makes a high-quality doctor. That same study found that failure to
20
listen or be attentive was the highest-ranking factor in a poor-quality doctor.

Third, patient experience survey results have significant value and utility in quality improvement
efforts, recognition awards, and consumer transparency through public reporting. In medicine, the
growth of value-based reimbursement models has brought increasing importance to quality metrics.
Specifically, patient experience scores may be tied to high-stakes endeavors including physician
compensation structures, board certification and licensing, and physician/practice recognition
21
programs.

Fourth, the business case for measuring and reporting patient experience is well documented and
positive patient experiences are associated with increased patient loyalty, enhanced reputation in the
22–25
community, reduced malpractice claims, and greater efficiency.

Finally, there is a fundamental need for reliable and representative patient experience data. Since the
implementation of the Affordable Care Act, there has been an increased focus on public reporting and
transparency of health care quality data. More consumers have access to health care and need to
make choices which often have a cost impact and they seek out information to support their
decisions. While there are a myriad of sources of information available on the internet, many have
unknown reliability, small numbers of respondents, and non-transparent methodologies. Patients
need trustworthy and standardized sources of information and metrics that use psychometrically
sound instruments with sufficient precision. Such resources are already available for patients seeking
information about primary care providers (e.g.,MHQP‟s website, https://www.healthcarecompassma.org/).

These fundamental principles are behind the ongoing efforts to design and advance the Consumer
Assessment of Healthcare Providers and Systems (CAHPS) family of surveys, widely recognized as
26
the national standard for patient experience measurement tools in a variety of healthcare settings.
These survey instruments have been psychometrically validated and used throughout the United
States healthcare system. There are similar programs globally, such as the GP Patient Survey in the
27,28
United Kingdom, or the Australian Bureau of Statistics‟ Patient Experience Survey.

Patient Experience in the Context of Oral Health Care

Oral health is an important component of general health and the interactions between oral and
general health are numerous and complex; oral health influences general health and vice versa.
Consequently, the patient experience of oral health care and care for other diseases is also similar.
General oral health care as provided by a typical dental practice bears significant similarities with
primary care in medicine. The general dentist is the primary connection through which patients access
care for most oral health problems, preventative care, care coordination and referrals to specialists as
appropriate, as well as needed screenings.

3
In the measurement of health care patient-reported outcomes, general health patient-reported
29 30,31
outcome measures (PROMs), such as the SF-36, or dPROMs, such as the OHIP-5, exist as
conceptually similar assessment options. Given the similarities, one might consider whether tools
utilized for measuring the patient experience of general medical care might be sufficient in measuring
the patient experience of oral health care. However, there is research which demonstrates differences
in applying these instruments to oral health care and provide insight into whether PROMs or dPROMs
should be used. For example, when tooth loss was treated with dental implants, generic health-
related quality of life measures could not distinguish between the benefits of different forms of dental
32
treatment, whereas oral health related measures could. Therefore, there seems to be a fundamental
difference in the measurement of general medical care and oral health care. While similarities
between such patient experiences may exist, the differences are substantial enough to justify using
separate instruments.

Patient experiences with oral health care is an important component of oral health care quality,
33
though it is not the only one. Measurement for some of the other components has advanced more
than for others. For example, dental patient-reported outcome measures (dPROMs), which examine
the impacts of dental interventions on the patient, are well-researched and have been shown to be
34 35
necessary for evidence-based dentistry, identification of research waste in dentistry, dentist-patient
36 37
communication, and value-based oral health care. Several dental fields such as prosthodontics
(including dental implants), endodontics, care for craniofacial disorders such as cleft lip/palate, or
TMD/orofacial pain management have acknowledged the importance of dPROs and dPROMs for
34,38–42
patient care and research. Not only dentists but also allied oral health professionals such as
dental hygienists and dental therapists emphasized the significance of these concepts and their
43,44
measurement tools. Therefore, lessons learned from measuring other quality metrics in oral health
care in these various settings can provide valuable insight for the measurement of the oral health care
experience.

Challenge 1: Oral health care experience measurement lacks an agreed upon framework and
stakeholder investment

Creating a measurement initiative requires significant buy-in from stakeholders. A sense of urgency
and understanding of the critical importance of measuring patient experience is needed in oral health
care. And yet, despite the advantages of targeted patient experience measurement, there has been
no remarkable effort to garner support. This is not surprising: in many clinical practice settings,
adoption has been slow for promising new initiatives to improve care quality such as new dental
diagnostic codes and clinical practice guidelines. Therefore, a serious push towards measuring
patient experience in this setting must begin with a stark call-to-action and onboarding of patient
experience measurement champions. Having large organizations that have a vested interest in the
state of oral health care (e.g., American Dental Association, Academy of General Dentistry, National
Institute of Dental and Craniofacial Research) acting as key supporters of the measurement of patient
experience is necessary to move forward. Therefore, a compelling case for patient experience survey
programs must be made to drive awareness and buy-in from relevant stakeholders before
measurement is pursued.

Scientifically sound and clinically useful measurement programs allow for aggregate results,
comparative benchmarking, and historical tracking. A cornerstone to successful programs is
stakeholder engagement which is needed early and often to ensure measurement programs are
appropriately aligned with patient, provider, payor, employer, and regulator goals.

The oral health care field does not currently have the patient experience survey programs that general
medical care does. Limited research exists in the area of oral health care patient experience
measurement and such work typically occurs in a silo with little comparability across networks,
45
practices, and providers.

Lessons learned from current measurement

Successful survey programs incorporate early and substantive stakeholder input. In the planning
phases of a measurement initiative, it is critically important to solicit input from all stakeholders. For
patient experience measurement, this includes providers, patients, and payers, as well as employers

4
and regulators, who will have a vested interest in the program and its findings. Patient experience
survey results may be used for a variety of purposes, including clinical quality improvement programs,
public reporting, and financial accountability. To the extent that stakeholders can have a common
understanding of and be aligned across these purposes will strengthen the program. Developing a
common understanding of the goals, operational approach, and use of the results builds trust among
stakeholders. Further, survey programs must be aligned with incentives across stakeholders and
include scientifically robust processes.

A high premium must be placed on scientifically robust processes throughout the survey development
process. For a patient experience survey, this includes development of survey concepts and
psychometrically valid tools, criteria for determining who could receive the survey, a comprehensive
algorithm to select patients to be surveyed, and a robust plan to analyze results and provide
meaningful data-driven feedback to help oral health providers identify successes and areas for
improvement and deliver a positive experience for their patients. While a rigorous survey development
process will result in an instrument and analytical process which yields the most accurate results and
has the best chance of being accepted by stakeholders, it will also require significant resources to
accomplish. As has been seen in general medical care, the long-term benefits of this investment in a
valid and reliable tool will pay dividends for many years into the future.

With limited resources available at the provider and practice level, programs of this kind also allow
organizations without their own measurement infrastructure to still have robust patient experience
data and thereby effective improvement efforts. As the type of practices shift from solo practice to
group practices and dental support organizations (DSOs), the opportunities to implement patient
46
experience tools for improving the quality of oral health should be prioritized.

Conclusion for Challenge 1.

Oral health care patient experience measurement programs must be designed using substantial
stakeholder feedback to ensure alignment of incentives across stakeholders and a scientifically-driven
approach to survey development. Dedicated time and financial investments in such a program have
ultimately yielded the most successful programs and survey infrastructures.

Challenge 2: Lack of standard oral health care patient experience measurement tool.

For the limited number of dental care settings who survey their patients about their experiences of
care, they tend to use short surveys fielded to all of their patients using a visit-based convenience
sample to capture limited information about their patient‟s satisfaction with care. These efforts are
typically small scale and utilized by individual practices to track performance and identify potential
quality improvement targets. While this approach may provide limited feedback and insights, the data
is often not psychometrically valid, not comparable across practices or dental groups, and lacks the
scientific rigor needed for accountability purposes.

There are also independent rating sites which enable patients to provide reviews of their care, such
45
as Healthgrades or Yelp. This approach similarly draws information from a convenience sample and
does not have the methodological rigor needed to benchmark and compare practices‟ performance.
Further, because these sites allow users to review businesses without customer verification, there is
no guarantee that a patient review reflects an actual visit with the provider being reviewed.

There is little published quantitative research that has examined patient experiences with oral health
47,48
care. Traditionally, research has focused on subjective, attitudinal measures of patient satisfaction
and in the recent literature, many studies are limited to qualitative data. A qualitative study conducted
in Australia examined patients‟ experiences of preventive dental care, with a particular focus on
49
understanding what patients value. Findings reveal that patients valued the dentist-patient
relationship, including communication, respect, knowledge of patient, education, and help with self-
managed care. While these studies are necessary to develop quantitative instruments, these studies
50
are not adequate to measure and compare patient experiences on a large scale.

Lessons learned from current measurement

5
In general medical care, some key domains of patient experience, as developed by the CAHPS
consortium, include: communication, organizational access, integration of care, knowledge of patient,
self-management, office staff, pediatric preventive care, and patients‟ overall rating. Table 1 contains
a list of example questions within these domains. Many of these domains and questions can be
utilized in the context of oral health care with little or no modification.

A number of survey questionnaires have been developed to assess the quality of dental care from the
patient‟s perspective, albeit most instruments have largely been utilized in the UK and Australian
51,52
marketplace for regulatory and accreditation purposes. In the U.S., use of standardized measures
is far rarer in oral health care than other types of providers and settings. In fact, the Institute of
Medicine noted in 2011 that “few quality measures are used in oral health, and there are no standards
in practice to determine the overall quality of oral health care in the United States. Because quality
measures do not exist, patients cannot find information to help them make decisions about their oral
53
health care, and best practices are limited.” However, little progress has been made in oral health
care in the 11 years since this report.
54
Two somewhat widely known instruments, the Dental Satisfaction Questionnaire and the Dental
55
Visit Satisfaction Scale both assess patient satisfaction. These instruments differ from patient
experience measures such that high satisfaction ratings may not indicate that people have had good
or even average experiences in relation to the service; rather, expressions of satisfaction may often
47
reflect attitudes such as „they are doing the best they can.” There is also a very clear distinction
between measuring satisfaction versus experience as noted previously in this article. Thus, results
from these satisfaction surveys are not inherently useful or actionable for quality improvement efforts.

Two more recent surveys that measure patients‟ actual experiences rather than their expectations or
56
attitudes include the Dental Practice Questionnaire and the CAHPS Dental Plan Survey from
57
AHRQ; both are valid and reliable instruments that can be utilized to examine important aspects of
the quality of dental care from the patient‟s perspective. Because these measures are not subjective
in nature and are methodologically sound, they can yield meaningful, actionable information that is
feasible for implementation to improve quality. While the Dental Practice Questionnaire has merit, it is
designed specifically for the Practice Accreditation Scheme as part of the Australian National Safety
and Quality Health Service. The CAHPS Dental Plan Survey is a standardized survey that asks adult
enrollees in dental plans about their care and service experiences with their dental plan, dentist, and
staff. The survey includes 39 questions which encompass three composite measures and four rating
measures as well as some single-item measures (Table 2). As compared to other CAHPS instruments
and domains within, this survey only includes the communication and access composites/domains.
Other domains that are central to understanding patients‟ experiences are not included such as
knowledge of patient, care coordination, self-management, to name a few.

While the CAHPS measures are of interest, and come from the leading patient experience
measurement organization, this instrument is intended to be used by dental plans rather than
providers. Rather than focusing exclusively on the experiences with the provider, the tool asks health
plan members to reflect on their experiences with their dental plan, dentists, and office staff.

Delta Dental, a leading oral health plan provider, has adopted the use of the CAHPS Dental Plan
58
Survey nationwide. There may be a temptation for oral health care providers to rely on this
instrument to understand the experiences of their patients, or for oral health care plan providers to
rely on results from this tool to measure their members experiences of care. As noted, this tool is
specifically oriented to measuring the experience of members with their oral health care plan and
does not include a number of domains and questions which are central to understanding the patient
experience of care, such as coordination of care, office staff, knowledge of patient, self-management
(including pain). Furthermore, there is no CAHPS Dental Survey Instrument for the pediatric dental
population.

Conclusion for Challenge 2.

The oral health care experience needs to be rigorously measured to provide providers, patients, and
stakeholders with a quantitative and qualitative assessment of how well patient needs are addressed.
Patient experience improvement efforts rely on an accurate and precise measurement. Findings to
47
date suggests that what matters to patients is a complex, multidimensional set of concepts.
However, we currently do not have a way of capturing the complex construct of the patient‟s oral

6
health experience in a scientifically valid, psychometrically sound, and fundamentally actionable
59
way. Oral health stakeholders should come together to collaboratively develop the needed
constructs and a single instrument to measure experiences of oral health care. This instrument will
need to undergo the series of confirmation and validation steps.

The process to develop a scientifically valid measure begins with identifying the concepts to be
measured. Often, we use qualitative research methodology to collect feedback directly from
stakeholders, including patients themselves, to understand the needs and/or challenges that are most
important to them. Once identified, a literature review is done to inventory validated and unvalidated
measures for the concept. From this information, a draft instrument is created, with input from experts
about the validity of the scale. Items within the survey instrument undergo iterative cognitive
testing/revision with the populations to be measured by the instrument. The survey is then piloted,
and the results psychometrically tested for validity and refined, as needed. Figure 2 outlines this
process.

This process also applies to the measurement of the health outcomes of oral diseases. Substantial
progress has been made in recent years with the identification of the dimensions of health-related
61
quality of life being the cornerstone of capturing this complex multidimensional construct. The
lessons learned while identifying the dental care outcomes dimensions Oral Function, Orofacial Pain,
Orofacial Appearance, and Psychosocial Impact should be transferred to the identification of oral
health care experience dimensions.

Challenge 3: Practical challenges hamper widespread use of dental patient experience

assessment – the need for a pragmatic tool

Respondent burden is a common problem in survey research, and involves survey length, complexity,
60
required effort, and frequency of contact. Survey response rates have generally declined over time,
61
necessitating larger sample sizes. The way patients are contacted to take the survey is a critical
aspect to consider in addressing. Based on current digital times as well as the efficiency, affordability,
and better response rates, electronically surveying enables a far more effectual survey mode of
administration than traditionally historic mailed surveys. In fact, it is one way to address the final
challenge of survey burden.

Patients may not always be aware of the value of their feedback on their care experiences.
Additionally, increased stress and provider burnout and staff shortages have impacted the oral health
care space, particularly in recent years, and can impact practices‟ ability to measure and respond to
62,63
the measurement of their own work. Critical consideration of what efforts are possible in the
context of patient experience measurement is essential for both patients and providers. The migration
from a high cost mailed survey to more convenient electronically fielded surveys, through email or
text, could partly offset respondent burden while improving affordability.

The length of survey instruments is a balancing act between benefit and burden, for both patients and
64
providers. The CAHPs Dental Plan Survey contains a total of 39 questions. It is clear that a
questionnaire of this length is only feasible in some dental settings. For routine general dental
practice, the length seems to be prohibitive as learned from dental patient-reported outcome
measures (dPROMs). While the 49-item Oral Health Impact Profile is widely used in research
settings, application for routine dental patients is rare. The Dental Plan Survey composite measures,
which include 5 or 6 items each, do offer an opportunity to abbreviate them, thereby including fewer
items while still addressing the target concept. However, this must be approached with caution, as
this can affect the psychometric properties of oral health care experience scores. Still, feasibility
concerns may warrant a minor reduction in validity and reliability for in order to become a pragmatic
assessment tool, i.e., to minimize burden and maximize responses.

Lessons learned from current measurement

The Oral Health Impact Profile – the most widely used multi-item oral health patient-reported outcome
65
measure – started as a 49-item questionnaire. Later, 14- and 5-item versions were developed
30,31,66
allowing a very flexible measurement in all dental patient and community settings. The shorter
instruments have gained more popularity than the original instrument in practical settings with large
organizations such as the University of Minnesota School of Dentistry now including short dPROMs

7
such as the OHIP-5 in their routine assessment of dental patients. The 5-item OHIP is now also being
67,68
recommended for most research settings.
Therefore, prior instrument development demonstrates in oral health that there is the potential to
reduce survey burden through shorter surveys and to improve acceptability of pragmatic
measurement tools.

Conclusion for Challenge 3.

Because dental patients‟ care experience needs to be feasible, minimizing the burden of patient
experience measurement is important for both patients and providers. While the dimensions that
make up oral health care experience are currently not known and need to be addressed before
creating pragmatic measurement tools, findings from the area of dental patient-reported outcomes
indicate a substantial potential for the development of concise oral health care instruments to ensure
measurement efforts to not unduly increase patient survey burden.

Discussion
15
The patient experience of oral health care is an essential component of oral health care quality. To
advance oral health care, the health outcomes, the experience, and the costs of the care need to be
optimized. This article attests to the needs of the dental community to measure oral health care
patient experience. Still, major obstacles are present:
1. Oral health care patient experience is underappreciated as an essential component of oral
health care quality in dental practice, education, and research. Satisfaction with treatment is
often assessed, which is not the same as assessing the experience of care.
2. Oral health care settings do not tend to employ valid and reliable oral health care experience
measures for a variety of reasons (types of practices, incentives for implementation, lack of
tools/validated surveys for oral health).
3. When oral health care experience is measured, it faces technical problems: assessment is
typically short, subjective, and isolated. Further, we have limited knowledge on what items
and composites are necessary to measure oral health care patient experience.
4. Oral health care patients are subject to heavy survey burden.

Call To Action
There are substantial opportunities to drive improvement in oral health care through the measurement
of patient experience. To begin its evolution, we call to action the salient need to measure dental
patients‟ experiences with oral health care. Patient experience is the urgently needed but currently
missing element of the Quadruple Aim applied to oral health. The following course of action is
recommended to advance this work (see also Figure 3):
 Convening and stakeholder buy in. Convene a national multi-stakeholder steering
committee to create buy-in with key players. Elicitation and understanding of the perspectives
of oral health care educators, providers, payers, regulatory bodies at the state and federal
level, advocacy organizations, professional societies, measurement organizations, and, most
importantly, patients are essential to the success of any measure development and
implementation.
 Framework and theory development. Build off the current concept of oral health care
patient experience and its measurement tools and determine the direction for measurement
by conducting qualitative research among patients, providers, payers, and regulators to
understand the needs and perspectives of diverse stakeholders.
 Survey tool development. Develop, validate, and test a tool for the measurement of oral
health care experience. Successful measurement requires oral health care experience
assessment to follow the rigorous survey development process used in other settings and
instruments in general, dental patient-reported outcome measures in particular.
 Survey tool implementation. The survey tool must be implemented as broadly as possible
in real clinical care settings in order to begin to understand the oral health patient experience.
A suitable infrastructure to administer, aggregate, and report the results of an oral health
patient experience survey must be leveraged.

8
These concrete action items can help address the complex landscape of measuring oral health care
experience and chart a course to valid, reliable and comparable measurement of the patient
experience in oral health care. Only in capturing the dental patient‟s care experience, together with
dental patient-reported outcomes assessment, will the oral health community be able to pursue the
Quadruple Aim in dentistry.

CRediT author statement

Nadeem Karimbux: Conceptualization, Writing – Original draft preparation

Mike John: Conceptualization, Writing – Original draft preparation

Amy Stern: Conceptualization, Writing – Original draft preparation, Writing – Review &

Editing

Morgan Mazanec: Conceptualization, Writing – Review & Editing, Visualization, Project

administration

Andrew D’Amour: Conceptualization, Writing – Original draft preparation

Jim Courtemanche: Conceptualization, Writing – Review & Editing

Barbra Rabson: Conceptualization, Writing – Review & Editing, Supervision

Term definitions: https://www.elsevier.com/authors/policies-and-guidelines/credit-author-

statement

Figure 1. The Quadruple Aim.

Figure 2. Survey development process
Figure 3. Call to action.
Table 1. Commonly used domains and survey items for the measurement of patient experience in
26
general medical care.
Domain Example survey items
Communication During your most recent visit, did the provider listen carefully to you?
Organizational Access When you contacted this provider‟s office to get an appointment for care
you needed right away, how often did you get an appointment as soon
as you needed?
Integration of Care During your most recent visit, did this provider seem informed and up-to-
date about the care you got from other providers?
Knowledge of Patient How would you rate this provider‟s knowledge of you as a person,
including values and beliefs that are important to you?
Self-Management During your most recent visit, did anyone in this provider‟s office ask you
if there are things that make it hard for you to take care of your health?
Office Staff Thinking about your most recent visit, was the staff from this provider‟s
office as helpful as you thought they should be?

9
Pediatric Preventive Care During your child‟s most recent visit, did you and anyone in this
provider‟s office talk about specific goals for your child‟s health?
Overall Rating How likely is it that you would recommend this provider to your family
and friends, using a number from 0 to 10 where 0 is not at all likely and
10 is very likely?

57
Table 2. Summary of CAHPS Dental Plan Survey measures.
Composite Measures
Care from Dentists and Staff 6 items
Access to Dental Care 5 items
Dental Plan Information and Services 6 items
Rating Measures
Overall Rating of the Dentist 1 item
Overall Rating of Dental Care 1 item
Overall Rating of Ease of Finding a Dentist 1 item
Overall Rating of the Dental Plan 1 item

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