We all are too familiar with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized set of questions randomly deployed to recently discharged patients. More recently, hospitalists have noticed the introduction of the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey, randomly deployed to recently evaluated ambulatory patients. HCAHPS has been publicly reported since 2008. CG-CAHPS will be in the near future. In addition to these, there are a variety of other types of CAHPS surveys, ranging from ambulatory surgery to patient-centered medical homes. For HCAHPS alone, there are more than 8,200 adult surveys completed every day from almost 4,000 different U.S. hospitals.1
In addition to these surveys being publicly reported and widely viewed online by patients, payors, and employers, the results now are tightly coupled to the reimbursement of hospitals and, in some cases, individual providers. As of October 2012, Medicare has relegated 30% of its hospital value-based purchasing (VBP) program to the results of hospitals’ HCAPHS survey results. For the foreseeable future, about one-third of the financial bonus—or penalty—of a hospital rests in the hands of how well our patients perceive their care. Many individual hospitals and practice groups have started coupling individual physicians’ compensation to their patients’ CAHPS scores. Within the (approximately) seven minutes it takes to complete the survey, our patients determine millions of dollars of physician and hospital reimbursement.1
With all of the financial and reputational emphasis on HCAHPS, it is vital that hospitalists understand what it is these surveys are actually measuring, and if they have any correlation with the quality of the care the patient receives. The questions currently address 11 different domains of hospital care:
- Communication with doctors;
- Communication with nurses;
- Responsiveness of hospital staff;
- Pain management;
- Communication about medicines;
- Discharge information;
- Cleanliness of hospital environment;
- Quietness of hospital environment;
- Transitions of care;
- Overall rating of the hospital; and
- Willingness to recommend the hospital.
As the domains of care are all very different, one can imagine a wide range of answers to the various questions; a patient can perceive that communication was excellent but the quietness and cleanliness was disgraceful. And, depending on what they consider the most important aspects of their stay, they therefore may rate their overall stay as excellent or disgraceful. Why? Because each of these rest in the eye of the beholder.
But to keep pace, hospitals and providers across the country have invested millions of hours dissecting the meaning of the results and trying to improve upon them. My hospital has struggled for years with the “cleanliness” question, trying to figure out what our patients are trying to tell us: that we need to sweep and mop more often, that hospital supplies are cluttering our patient rooms, that the trashcans are overflowing or within eyesight? When we ask focus groups, we often get all of the above—and then try to implement several solutions all at once.
The quietness question is much easier to interpret but certainly difficult to improve upon. We have implemented “yacker trackers,” “quiet time,” and soft-wheeled trash cans. And the results of the surveys take months to come back and get analyzed, so it is difficult to quickly know if your interventions are actually working. Given that so many hospitals and providers are back-flipping to “play to the test,” we really need some validation that care is truly improving based on this patient feedback.
A recent New York Times article calls to light a natural paradox in the medical field, in that patients who understand more about disease processes and medical information actually feel less, rather than more, informed. In other words, those who are actually the most well-informed may rate communication the lowest. The article also calls to light the natural paradox between providers being honest and providers being likable, especially considering they routinely have to deliver messages that patients do not want to hear:
- You need to quit smoking;
- Your weight is affecting your health; and
- Your disease is not curable.
Given these natural paradoxes, the article argues that it is difficult to reconcile why hospitals and providers should be held financially accountable for their patients’ perception of care, when that perception may not equate to “real” care quality.2
However, there is some evidence that patient satisfaction surveys may actually be good proxies for care quality. A large study found that hospitals with the highest quartile HCAHPS ratings also have about 2%-3% higher quality scores for acute MI, CHF, pneumonia, and surgery, compared to those in the lowest quartile. The highest scoring hospitals also have about 2%-3% lower readmission rates for acute MI, CHF, and pneumonia.3,4 And, similar to other quality metrics, there is evidence that the longer a hospital has been administering HCAHPS, the better are their scores. So maybe hospital systems and providers can improve not only the perception a patient has of the quality of the care they received, but improve the quality, as measured by the patient’s perception.
Although there are legitimate arguments on both sides as to whether a patient’s perception of care reflects “real” care quality, in the end these CAHPS surveys are, and have been publicly reported, and will be tightly coupled to reimbursement for hospitals and (likely) providers for the foreseeable future. So in the meantime, we should continue to focus on patient-centered care, take seriously any voiced concerns, and have a relentless pursuit of perfection for how patients perceive their care. Because in the end, you would do it for your family so we should do it for our patients.
- Centers for Medicare & Medicaid Services. Spring 2013 HCAHPS Executive Insight Letter. Available at: www.hcahpsonline.org/Executive_Insight. Accessed Aug. 15, 2013.
- Rosenbaum L. When doctors tell patients what they don’t want to hear. The New Yorker website. Available at: www.newyorker.com/online/blogs/elements/2013/07/when-doctors-tell-patients-what-they-dont-want-to-hear.html. Published July 23, 2013. Accessed Aug. 15, 2013.
- Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' perception of hospital care in the US. New Eng J Med. 2008;359(18):1921-1931.
- Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].