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HCAHPS Is All About Patient Satisfaction
by Charles F. Bombard, RN, MHA, CPHQ, FACHE and Catherine E. Jordan, RN, MSA, LNCC
CE559 | 1.00 contact hrs
Course Objectives
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For a moment, think of yourself not as a healthcare professional, but as a healthcare consumer. You want to find the best facility for yourself or your family. You want information on how quickly clinicians 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, nurses and other professionals who 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 into your role as a healthcare professional. 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 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 that need improvement. Hospitals view patient satisfaction as a key tool in their quality improvement armamentarium.1 In addition, the Hospital Value-Based Purchasing Program of the Centers for Medicare & Medicaid Services links part of a hospital’s payment from CMS to performance on a set of quality measures and provides 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 1% of their CMS reimbursement monies in 2013 and 0.25% in 2014 to 2017 and redistribute those monies to hospitals according to their performance in 12 clinical process of care domains. The process of care domains include core measure indicators associated with heart failure, acute myocardial infarction, pneumonia and the Surgical Care Improvement Project and eight patient satisfaction dimensions (HCAHPS). Hospital reimbursement is determined by the clinical process of care scores, which account for 70% of the formula, and the HCAHPS scores, which carry a 30% weight.2
The HCAHPS patient satisfaction program gives consumers an opportunity to provide CMS with information about the patient experience and how well the facility performed in regard to pain control, promptness of care delivery, communication, discharge instructions, room and facility cleanliness, and whether the patients felt they were treated with courtesy and respect.3
The HCAHPS survey allows for uniform measurement and public reporting of patients’ perspectives about their inpatient care. While many hospitals collect patient satisfaction data, no national standard existed for collecting the data that enabled 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 allows 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, such reporting increases transparency in regard to the quality of care delivered, which can enhance accountability.
CMS worked with the Agency for Healthcare Research and Quality, another agency within the Department of Health and Human Services, to develop a valid and reliable survey. AHRQ conducted a rigorous, scientific process — including literature reviews, customer focus groups and inviting public comment — as it wrote and tested the HCAHPS survey. National Quality Forum, the voluntary healthcare standard-setting organization, endorsed the survey in May 2005.2 CMS implemented the survey in early 2006.
The HCAHPS survey consists of 27 questions. It features 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
  • Discharge information.
The survey also asks for demographic information (race, education level, health status and language) which is used in the overall analysis.2
Ten HCAHPS measures (six summary measures, two individual items and two global items) are publicly reported on the Hospital Comparewebsitefor each participating hospital. Each of the six summary measures, or composites, is constructed from two or three survey questions. Combining related questions into composites allows consumers to quickly review patient experience of care data and increases the statistical reliability of these measures. The six composites summarize how well clinicians and other healthcare professionals communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicate with patients about medicines and whether key information is provided at discharge. The two individual items address the cleanliness and quietness of patients’ rooms while the two global items report patients’ overall rating of the hospital and whether they would recommend the hospital to family and friends. Survey response rate and the number of completed surveys, in broad ranges, are also publicly reported.
CMS and the HCAHPS Project Team aim to ensure that the scores are fair and offer accurate comparisons of hospitals. Therefore they adjust for factors, such as patient characteristics or survey mode used, that could offer an advantage or disadvantage to a facility.
In addition, the HCAHPS Project Team undertakes a series of quality oversight activities, including inspection of survey administration procedures, statistical analyses of submitted data and site visits of HCAHPS survey vendors, to assure that the HCAHPS survey is being administered according to protocols.
Hospital administration must make several decisions 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.)
Survey Results
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 must attend training sessions on how to conduct the survey.5
Mail or telephone surveys are conducted among randomly selected adult patients who have spent at least one night in the hospital. The surveys may take place from two days to six weeks post-hospitalization. The surveys are not designed to address the unique needs of pediatric or psychiatric patients, so those patients are not contacted.
To ensure a valid report, a hospital must obtain a minimum of 300 responses each year. Every month or quarter (it is 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.6
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, 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?”7
It is important to remember that access to a hospital’s satisfaction data is universal and that information obtained may be publicized by the media, funders or any interested party through any number of venues. Increased public scrutiny is an additional incentive for healthcare professionals of all disciplines to be aware of HCAHPS and work to improve patient satisfaction scores.
While at least initially some hospitals may have been hesitant to disclose patient satisfaction scores, many hospitals now promote scores that significantly exceed state and national values on their websites. This is an excellent marketing strategy for hospitals as it demonstrates to prospective patients a positive, consumer-focused image.
As mentioned, HCAHPS scores will influence the financial outcome of a hospital’s participation in the Hospital Value-Based Purchasing Program. The financial incentive for a hospital is to score well enough to be reimbursed for the funds it contributed to the CMS Value-Based Purchasing Program. A hospital that scores high will receive more than it contributed; a hospital that performs poorly on HCAHPS will receive less - or perhaps none - of the money it paid into the program. Depending on the size of a hospital’s budget, the potential cost to the institution may be significant. CMS redistributes all value-based purchasing funds collected to hospitals; CMS retains no funds it collected.8
Patient satisfaction surveys do not reflect a hospital’s morbidity or mortality rate, nor do they illustrate 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 into 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 does not understand the importance of clinicians taking steps aimed at decreasing the risk of bloodstream infections or ventilator-associated pneumonia.6 HCAHPS should be part of a broader quality improvement effort that includes other reviews, audits, studies and analyses.
Effect of Patient Satisfaction
In his book Patient Satisfaction: Understanding and Managing the Experience of Care, Irwin Press, an internationally recognized anthropologist, says, “When you take patient satisfaction very seriously, you will achieve higher quality of care; your staff will be more content with their jobs and turnover will be lower; you will be more likely to stay financially healthy; your competitive position will be strengthened; and you will be less likely to be sued.”9 These words provide an incentive for a hospitalwide effort to improve patient satisfaction scores.
Patients’ perceptions of care are affected by clinicians’ attitudes, the information and explanations they are given, how promptly care is delivered, how they are touched, and what they hear and see. Those perceptions and experiences become valid indicators of the quality of care when collected with a patient satisfaction tool. Patients will respond more positively to the care they receive when they have a positive belief about the clinicians’ motives, empathy, judgment and communication.
Moments of Truth
Imagine the hundreds of sights, sounds, impressions, events and interactions that every patient experiences in your hospital. Each of these interactions and experiences are potential “moments of truth.” A moment of truth is any experience that has an effect on the patient’s predisposition toward the caregiver. The experience can be mundane, positive or terrifying: a dirty floor, a rude unit clerk, a tasty meal, the healthcare professional who asked if the patient needed anything else before they left the room or a staff member who helped family members find the patient’s room. (The experiences of family members can also influence a patient’s evaluation of the institution and care provided.)9
Creating a list of all moments of truth would be impossible; so too would be developing suggestions to make positive experiences of each moment. Knowing that explanations, serious listening and empathy are key to patient satisfaction, Press developed the following generic hierarchy of satisfaction:9
  1. Good food counts more than lousy food.
  2. Friendliness counts more than good food.
  3. Communication counts more than friendliness when information exchange is necessary.
  4. Empathy enhances communication.
This hierarchy holds true across the healthcare spectrum of inpatient, outpatient and emergency care. Friendliness and communication are always important, and empathy makes communication more effective. Note that “technical” quality is not included because it’s assumed to be present. Patients are far more likely to understand and rate friendliness, communication and attitude than they would medication administration, surgical techniques or IV drip rates.

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