For a moment, think of yourself not as a nurse, but as a healthcare consumer. You want to find the best facility for yourself or your family. You want information on how quickly nurses respond to requests for pain medications, how well they listen when you try to tell them something, how well they explain things about your care, how clean the facility is and whether the facility has physicians and nurses that treat patients with courtesy and respect. Impossible task? A few years ago, perhaps. But now with the federal government’s addition of patient satisfaction data to its Hospital Compare website, all this information is available. Simply access the website and search for hospitals you want to compare. Now put yourself back in your nursing role. With all of this information available on a public website, you can appreciate the importance of patient satisfaction surveys.

 

This module will provide information on patient satisfaction, including its relationship to quality improvement; a brief history of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS); and finally, actions you can take to help your hospital achieve and maintain high patient satisfaction scores.

 

Patient satisfaction survey results can provide invaluable information about the overall hospital experience for the patient. They can also pinpoint areas of patient satisfaction success and those in need of improvement. Hospitals view patient satisfaction as a key tool in their quality improvement armamentarium.¹ In addition, , the new value based purchasing program of Centers for Medicare and Medicaid Service, or CMS, will provide significant financial incentives for hospitals to score well in the HCAHPS survey. The program, authorized under the Patient Protection and Accountable Care Act of 2010, allows CMS to collect from hospitals up to 2% of their CMS reimbursement monies (1% in 2013 and 0.25% in 2014 to 2017) and redistribute those monies back to hospitals according to how well the they perform on 12 process indicators (core measure indicators associated with heart failure, acute myocardial infarction, pneumonia and the Surgical Care Improvement Project) and eight patient satisfaction indicators (HCAHPS). The process measure scores will carry a 70% weight in determining hospital reimbursement while HCAHPS scores will be weighted at 30%.²

 

HCAHPS is CMS’s patient satisfaction program that provides consumers with an chance to provide feedback about a hospital’s performance in key areas of communication, pain control, timeliness of care, discharge instructions, hospital cleanliness and treatment with courtesy and respect.³

 

The government developed HCAHPS to uniformly measure and publicly report patients’ perspectives on their inpatient care. While many hospitals collect patient satisfaction data, no national standard existed for collecting the data that would enable valid comparisons across all hospitals. To make “apples to apples” comparisons to allow healthcare consumers to make a choice between hospitals, a standardized measurement of the data must be available. HCAHPS provides this standardization with its survey instrument and collection methodology.⁴

 

Three broad goals have shaped the HCAHPS survey. First, it was designed to produce comparable data on patient satisfaction that would allow objective and meaningful comparisons between hospitals on issues important to healthcare consumers. Second, public reporting of the survey results is intended to create incentives for hospitals to improve the quality of their care. Third, public reporting enhances accountability by increasing the transparency of the quality of hospital care.⁵

 

To ensure a valid, reliable survey, CMS partnered with the Agency for Healthcare Research and Quality, an agency in the Department of Health and Human Services. AHRQ carried out a rigorous, scientific process to develop and test the HCAHPS survey. After significant literature review, interviews, customer focus groups, stakeholder input, pilot testing and public comment, the survey was put into use in early 2006. Before that, the 27-item survey was endorsed by the National Quality Forum, a voluntary standard-setting organization for healthcare quality measurement and reporting.⁵

The HCAHPS survey is composed of two global questions that relate to patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends, plus questions that relate to seven key topics: communication with physicians, communication with nurses, responsiveness of the hospital staff, cleanliness and noise level of the physical environment, pain control, communication about medicines and discharge information. It also asks for demographic information (race, education level, health status and language) which is used in the overall analysis.⁵

 

Hospital administration must decide several things before conducting the HCAHPS survey. First, hospital administrators must choose whether they want to conduct the survey themselves if approved by CMS to do so or whether they want to hire a vendor to conduct the survey. Another consideration is whether the survey will be mailed to patients after discharge or conducted over the phone. (Telephone surveyors must follow a CMS script when conducting the survey.)

 

 

There are four different survey modes: mail, telephone, mail with telephone follow-up, and active interactive voice recognition, the telephone technology that allows a computer to detect a person’s voice or keypad responses to questions. Mailing the survey is standard. All vendors and hospital employees who plan to administer the survey are required to attend training sessions on how to conduct the survey.⁶

 

Adult patients who have spent at least one night in the hospital are randomly surveyed by mail or on the phone 48 hours to six weeks after discharge. (Pediatric and psychiatric patients aren’t included because the survey is not designed to address their unique hospitalizations.)

 

Each hospital must obtain at least 300 responses annually to ensure a valid report. Every month or quarter (it’s up to the hospital), each facility reports its results to CMS. Results are posted hospital by hospital on the CMS website which displays a rolling four quarters of data (as each new quarter is added, the oldest quarter is removed). To put the results in perspective, the CMS site includes state and national averages as well as other comparative information. Hospitals may add questions to the survey, but the CMS questions must appear first on the questionnaire.⁷

 

To ensure that HCAHPS data are collected correctly, CMS started a series of quality oversight activities that include inspection and approval of survey administrative procedures, an analysis of submitted data and detailed on-site reviews of approved HCAHPS vendors and hospitals that survey themselves.¹

 

HCAHPS provides healthcare consumers with information that is much easier to understand and relate to than clinical information and allows consumers to make an informed choice of an inpatient provider. It allows them to see patient satisfaction data from up to three hospitals that they choose to compare. It provides further comparisons with state and national data. For instance, the data show the percentage associated with nurses who “always,” “usually,” or “sometimes/never” communicated well. The communication composite is taken from these survey questions: “During this hospital stay, how often did nurses treat you with courtesy and respect?” “During this hospital stay, how often did nurses listen carefully to you?” and “During this hospital stay, how often did nurses explain things in a way you could understand?”⁸

 

In addition to healthcare consumers, there is a less obvious user: the media. It’s one thing for a relatively small number of people to see a hospital’s data and another to have the data in the local media. This wider audience is another incentive for nurses to be aware of HCAHPS and work to improve patient satisfaction scores.

 

While at least initially, patient satisfaction scores may not be something that some hospitals want to advertise, many hospitals have promoted their scores on their websites. Patient satisfaction scores that significantly exceed state and national values can’t help but give a visitor to the website (a prospective patient) a good feeling about the hospital.

 

As mentioned, the value based purchasing program will probably result in HCAHPS scores having a considerable impact on the hospital’s financial bottom line. The financial incentive for hospitals is to score at least well enough to be reimbursed for the money they contributed to the CMS “pot.” Hospitals scoring at a higher level would receive more than they contributed; those hospitals doing poorly would receive less - or perhaps none - of the money they paid into the “pot.” Depending on the size of a hospital’s budget, the possible cost to the institution is not insignificant. CMS will pay back to hospitals all the monies collected. None will stay in the CMS coffers.²

 

Patient satisfaction surveys do not show a hospital’s morbidity or mortality rate, nor will they show the advanced technology offered or the hospital’s high level of medical and surgical skill. These are some of the reasons that patient satisfaction has not been factored in to the rankings of U.S. News & World Report’s America’s Best Hospitals. To put it on a more personal level, a patient may certainly know when a physician is not communicating well, but the patient probably doesn’t understand the importance of reducing ventilator-associated pneumonia or bloodstream infections.⁷ While HCAHPS should be an important part of overall quality improvement efforts, it must be accompanied by a multitude of other measures, analyses, audits, reviews and studies.