Better HCAHPS Scores Protect Revenue

Providing an excellent patient experience is tied more closely than ever to reimbursements.

This article first appeared in the July/August 2014 issue of HealthLeaders magazine.

It has always been a moral imperative for hospitals and health systems to provide a high-quality patient experience, but now that the Centers for Medicare & Medicaid Services is tying reimbursements to HCAHPS scores, it's becoming a financial priority, as well.

Through the Hospital Consumer Assessment of Healthcare Providers and Systems survey, patients rate their inpatient stay in 27 categories, ranging from communication with doctors and nurses to pain management to facility cleanliness and quietness. Based in part on these scores, hospitals can either lose or gain up to 1.5% of their Medicare payments in fiscal year 2015. CMS will up the ante over the next few years, with 2% of reimbursement dollars ultimately being at risk by fiscal year 2017.

With a growing amount of revenue at stake, hospital leaders are looking for strategies to improve the patient experience and boost their HCAHPS scores.

Focusing on culture

Oxnard, California-based St. John's Hospitals, a Dignity Health member with 330 licensed beds and a $350 million annual operating budget, has been intensely focused on improving patient satisfaction for the past three years.

In 2010 and 2011, St. John's HCAHPS scores ranked in the bottom quartile within Dignity Health. After seeing such disappointing results for two consecutive years, the leadership team set out to improve the patient experience—something CEO Laurie Harting says starts with the overall culture of the organization. Harting also serves as senior vice president of operations for Dignity Health's Southern California West service area.

"We've been really focused on developing a culture that lends itself to creating an excellent experience for patients," she says. "We also want it to be an excellent environment for our employees to work in every day and for our physicians to practice in."

In 2011, St. John's formed its Service Excellence Steering Committee and began doing daily leadership rounds where each clinical leadership member is assigned to visit specific patient rooms and report findings during daily leadership huddles. Rounding takes place between 9 a.m. and 11 a.m. every day, and no other meetings are allowed to be scheduled during that time.

"Bringing together the steering committee was the first step," Harting says. "We took specific steps to develop a culture where people knew they had the freedom to speak up, where they had the power to change things, and where leadership would listen."

Daily rounding leads to quick action to improve the patient experience and demonstrates to staff the level of importance St. John's leadership is placing on clinical quality, Harting says.

"After rounding, the team shares its findings and solves problems in real time. Then we go back to staff with immediate feedback on what is going to change. Employees are engaged because they know they can make a difference in the patient experience," she says. "Leadership has to model what we are emphasizing to the staff. I'm a nurse by background, and I know that anyone who goes through the educational requirements to become a clinical provider does so because they want to make a difference in patients' lives. We have to make sure we have the systems in place to support that."

Cathy Frontczak, St. John's chief nursing officer and vice president of patient services, says the leadership team also rounds on staff.

"When we started leadership rounds, we really primarily focused on the patient. One day, a nurse in the ICU asked me why I walked right past her every day and went directly to talk to the patient. That was an aha moment. Now we round not only on patients and families, but on staff as well," Frontczak says. "We can't expect them to be able to take exceptional care of our patients if we aren't taking care of them."

Keeping noise down

One area St. John's has zeroed in on to improve the patient experience is the noise level within its units. Harting says she saw firsthand what an impact noise can have on patients when her mother was recovering from emergency open-heart surgery 10 years ago.

"I spent hours with my mom and watched her get more and more depressed because of the noise. Because of that experience, noise has been my primary focus. I want to make sure our patients can go home faster and with less emotional distress than they would otherwise," she says.

St. John's recently began giving quiet kits to all its patients. Each kit includes earplugs, an eye mask, a "voices down, please" card, a notebook patients can use to jot down questions for their care team, lip balm, and Sudoku and crossword puzzles.

"These are things that can be used by the patient throughout the day," Frontczak says. "Patients may be bored or in pain, and these diversions can help alleviate pain or anxiety and can actually decrease pain and the need for pain medication. We have had such incredible feedback from patients and their families. Hospitals tend to be very busy places, and they are not always conducive to the patient getting a good night's sleep. Drowning out noise and light helps patients rest, which is important for healing."

Harting estimates that the quiet kits save St. John's about 8% compared to what it would cost to buy the items individually and deliver them separately when requested by patients. "We are really getting some bang for our buck," she says.

Measuring results

St. John's efforts to improve its HCAHPS scores have paid off significantly, Harting adds.

"We've made tremendous strides. The result is we have gone from the bottom quartile to the top quartile, and that doesn't just happen," she says. "It's been very rewarding. With any kind of change in culture, it takes years. The most impatient person in this whole organization is me, but I know to change a culture is a three- to five-year journey. We are now heavy into year three of this journey, and I can taste it. I can feel it. I can touch it."

While the financial benefits of improving the patient experience are harder to analyze than HCAHPS scores, Robert Wardwell, chief financial officer for Dignity Health Southern California West, says meaningful economic gains are also being made.

"It's not an easy calculation, but we certainly believe there is a return on investment," he says. "Our HCAHPS scores have soared, and from a value based purchasing aspect, we've done well. We have averted hundreds of thousands of dollars in losses by improving our value-based purchasing metrics."

Sharing data

One of the reasons St. John's has been able to make a noteworthy turnaround in its HCAHPS scores is that it regularly shares data with staff and patients, Frontczak says.

"We are very transparent with the data. That is very important for us," she says. "The results are posted in every department every month so staff can see how their unit is trending over time. Also, if you are a patient or a family member, you will see this patient experience information as well. Again, that lets staff know how important this is to us as an organization and how seriously we all need to take this."

David Hughes, chief financial officer at Greenville, North Carolina–based Vidant Health, a nine-hospital system with 1,488 beds and $1.6 billion in fiscal year 2013 operating revenue, agrees that when it comes to enhancing HCAHPS scores, being open with data is essential.

"You can't be afraid to share the data," he says. "Put it in an open place for patients and families to see. It will be a motivator for staff to say that if the scores are not what you want, then you are the folks with the ability to do something about it. … If we are embarrassed by the data, we are in control of it, and we can fix it."

Mark Rumans, MD, Vidant's chief medical officer, says receiving data from the HCAHPS survey as quickly as possible is another important factor in making patient care improvements.

"We switched to a phone survey instead of the mailed survey to get a faster response and a quicker turnaround," he says. "We now get the information back on a weekly refresh and are able to provide it in a more real-time fashion so the data is more operational and targets can be achieved more easily."

Incentivizing employees

To encourage its staff to focus on improving HCAHPS scores, Vidant has adjusted its incentive plan to include quality metrics.

"We are really trying to tie quality and finance together," Hughes says. "In the past, our employees had the ability to earn incentives strictly on meeting financial margins. We have split that in half so now half is based on HCAHPS scores and the other half is based on margins."

In total, employees can earn an extra $1,000 per year through the incentive program. "It isn't a percentage and it isn't a huge number, but it is enough to raise employees' eyebrows and get them to say, 'How can I help?' It also got us more disciplined about communicating with our employees on a regular basis. They use the information in their weekly huddles to ask how they can prevent problems from happening with the patients who are here today," Hughes says.

Listening to patients and board members

Learning from previous patient experiences and using that information to create better clinical methodologies is one of Vidant's biggest priorities. There are about 100 patient advisors throughout the system who participate in rounds and serve on process improvement teams, board committees, and quality committees.

"Having patient and family advisors on major committees has been pretty instrumental," Rumans says. "The patient stories are invaluable because they bring a personal perspective to the care we are delivering. Surveys are limited, and through the stories, the patients and families always bring aspects that are not measured on the survey."

Board support has also been key, Hughes says. "We've been led by the most engaged board I've seen related to patient experience and quality. We have patient advisors sitting on one of the board committees, and at every meeting we have a patient story. Every time, a board member will ask what we could have done better. Some stories are good, others are not good, and we have to ask where the gaps are in a patient hand-off or transition so we can make our processes the best possible. The board challenges us to deliver that."

Generating positive metrics

The work Vidant does to create a positive patient experience is evident in the metrics. All of the system's hospitals are in the top quartile on HCAHPS scores nationally, and several are in the top 10%. In addition to being a source of pride for the organization, these numbers help protect revenue, Hughes says. "We spend a lot of time on improving our processes to take care of patients throughout the whole continuum, and that has also helped us financially."

Regardless of its current success, Vidant will always strive to provide a better patient experience, Rumans adds.

"This is about constantly improving," he says. "There isn't a sense of satisfaction that we are in the top of the country so we can let it be. The patient experience is critically important, and we have to deliver high-quality medical care."

Reprint HLR0814-9