HCAHPS: Making a Difference While There's Still Time

Leaders must address organizational deficiencies before 2% of Medicare payments will be at risk in 2017.

This article appears in the October 2015 issue of HealthLeaders magazine.

Like it or not, HCAHPS scores are about to get a lot more attention from hospital and health system senior leadership.

It's not that they have ignored the scores in the past. Results from the Hospital Consumer Assessment of Healthcare Providers and Systems survey have been publicly reported since 2008, so hospitals have had plenty of time and some incentive to address their current and future impact on their reputation and on reimbursement and, more holistically, to use them to try to deliver a better customer experience to their patients.

The problem is one of priorities. Some leaders have placed HCAHPS improvement initiatives lower on their list, given that penalties for poor performance have ratcheted up slowly over time.

Crunch time
In 2015, time is essentially up. In fact, HCAHPS scores will determine up to 2% of a hospital or health system's Medicare payments by 2017, and it's already to 1.5% in 2015. That's a lot of potential money. So improving the patient experience is getting plenty of attention as time grows ever shorter.

"It doesn't make sense to leave money on the table that we could be investing back in patient care because we're not achieving the scores we could be achieving," says Lauraine Szekely, senior vice president of patient care services and chief nursing officer at Northern Westchester Hospital in Mount Kisco, New York. Northern Westchester has achieved the highest rating from CMS (five stars) for patient satisfaction, she notes. "The financial part of this is not our primary mission but it's certainly important."

The survey has been pilloried since its inception for what it is not. Results from patient responses to its 27 questions don't deliver a measure of quality, and were never meant to. It's also not comprehensive, and many criticize that the survey twists motivations among healthcare providers so that they "teach to the test." Its focus on the word always regarding a patient's interactions with staff is a continuing area of disagreement.

Many of these challenges can lead to cynicism about the measures, and to attempts to game the system. But regardless of HCAHPS' failings, it delivers a piece of information that patients may use to decide where to receive care; so, for that reason alone, how a hospital does on it is an increasingly important and direct factor in its level of reimbursement. Perhaps the best way to describe HCAHPS is that it measures a customer's satisfaction—and as such, it's a valuable, if sometimes annoyingly incomplete, measure of a service attribute that most agree healthcare has largely lacked historically.

Many organizations have prepared for the survey's impact by engaging their staff in initiatives designed specifically to improve areas the survey measures. Others have taken an approach that team-based care—where specific interactions are embedded in team-based training—is the best approach.

Communication and real-time intervention
Communication around a patient's plan of care, developed, when possible, before admission, has helped elevate HCAHPS performance over time at Northern Westchester, says Szekely.

The organization has spent a lot of time and effort on process redesign and on creating care teams responsible for upholding those processes once the redesign is finished, she says. Part of that accountability stems from color-coding progress on patient satisfaction goals. Red, yellow, or green color-coding helps with continuous improvement around goals and national averages. "We break HCAHPS scores down by unit, so there are overall and unit goals, color-coded for ease of navigation," she says.

Another philosophy that has helped improve patient satisfaction is the organization's shared governance management philosophy. Management and staff work together to cascade goals down to the unit level, which means leaders are working with frontline staff on process redesign teams, Szekely says. Process redesign is informed by data and patient focus groups to determine where the current process is breaking down.

"And once a process is designed, the redesign team turns into a process team," she says. That means the same people who designed a process are responsible for maintenance of and adherence to it.

Beyond that, she says, the staff and leadership have both adopted the idea that they should spend lots of time "proactively rounding, asking patients what they need from us," she says. "We round while we're doing everything— while administering medication, in interdisciplinary huddles, with rehab staff, nursing, case management, nutrition, pharmacy—and the hospitalists spend time huddling and looking at the plan of care and discharge plans, making sure we're progressing that plan of care."

Szekely says built into the service excellence program is real-time work to alleviate patient dissatisfaction before it's reflected in a poor survey response.

"We have the service recovery model posted right in the room, so if there's a problem that anyone on the staff can't immediately resolve, they can call the patient advocate who can get right on it. So instead of waiting for the patient to be discharged and maybe getting a letter from the patient, we can recover while the patient is with us so we can turn that around," she says.

Process redesign and patient feedback
Terrie Sterling is executive vice president and chief operating officer at Our Lady of the Lake Regional Medical Center, and has been working for more than 10 years on the patient experience at the 719-staffed-bed hospital in Baton Rouge, Louisiana.

A three-star organization as ranked by the HCAHPS rating system, Our Lady of the Lake has made dramatic improvement since 2008, when, as Sterling admits, the hospital ranked near the bottom. This was unexpected for the 2008 and 2010 recipient of the Performance Excellence Award from the Louisiana Quality Foundation and Hospital of the Year winner in both of those years as named by the Louisiana State Nurses Association.

Sterling says service was one of the organization's core values well before HCAHPS and patient experience became buzzwords of the industry, but that they weren't tying that aspiration to enough rigor and discipline in performance. At the time, the concept of team-based healthcare was foreign, largely. She says that, with the help of Press-Ganey, the organization began to hardwire team-based tools like the daily huddle and other evidence-based principles that are proven to improve patient experience.

"We really had to work on being more deliberate that patient satisfaction is the main goal," says Sterling, whose clinical background is in nursing. "Clinicians don't get excited about an HCAHPS score."

Much of the work started under the theme of "everyday excellence with the next patient," Sterling says. "That resonated with staff: The responsibility is to the patient in front of you, and that's where our mission is real."

Beyond tying patient experience to the organization's Catholic mission of healing, the nuts and bolts of receiving good feedback from patients stems from what the patient expects to accomplish. That's not always easy to distinguish from what the staff wants the patient to accomplish, Sterling says, because the two can be quite different.

Members of the care teams on the units use what Sterling calls an evidence-based approach to rounding, which happens whenever they are in contact with a patient. Members of the team ask a standard set of questions. One of them is: Is there something I can help you with today? One patient told an environmental services worker that he hadn't spoken with his granddaughter since he'd been in the hospital and really wanted to. Even though it was outside his area of expertise, that employee took responsibility for making sure that request was accomplished that day.

"We started with the golden rule, and we transitioned to the platinum rule, which is to treat the person not the way we would want to be treated, but the way they want to be treated," Sterling says.

As for focusing on the test—the HCAHPS scores—Sterling says they try to stay away from that.

"We try really hard to make sure nothing around patient experience is seen as 'the next initiative,' " she says. "This is a normal evolutionary journey."

Plenty of effort has also gone into process redesign, incorporating feedback not only from the staff but also from patient comments from the surveys. Our Lady of the Lake, says Sterling, invested in transcribing those comments for review by the care teams. Those are incorporated into Lean competencies around processes on which the hospital has partnered with General Electric, a pioneer of process improvement. "Our team members were demonstrating the spirit of healing—that's our tagline—but we partnered with GE to help us around accountability for outcomes and where we had process gaps," she says.

Data shows that as the ER and OR patient experience goes, so goes the rest of the downstream scoring, says Sterling, so they focused on eliminating time spent in these areas that was not "value added."

After nine months of redesigning the ER experience, the improvement team has identified four "wraparound" processes that feed into the ER, and they're working on reengineering those. Critical to the whole effort, not surprisingly, has been listening to patient feedback and acting upon it, she says.

"The first thing we had to do is see the feedback—just the education with the staff and getting them to make a binder of surveys and read them was invaluable. Then we added huddle and other structural pieces. The scores mean one thing, but to hear the voice of that patient is really powerful."

Setting goals, rewarding performance
Sterling says another positive development has been to strengthen Our Lady of the Lake's service line strategy by putting a person in charge of experience design for a multitude of common elective procedures: "Hips, knees, open-heart surgeries, those things we do large numbers of—even the harm measures, as you reduce those you're satisfying the patient. All of those are tied to patient experience and families feeling confident their trust is well placed."

Huddles incorporate teamwork and esprit de corps through regularly updated documents that guide the huddles. The documents come out each Friday, says Sterling. Huddle meetings start with a prayer, discussion of the service standard, and then someone on the team is designated to relate a success story. Organizational birthdays are also included, because employee satisfaction is second only to patient satisfaction, she says.

"When we started that, a neuro-surgeon told me he thought it was just goofy, but when it came to his, he later told me he was surprised at how special it made him feel," she says.

Northern Westchester has taken employee satisfaction and the motivation it engenders a step farther. There are team goals and individual goals on patient satisfaction, and individual goals based on duties. Both are part of employees' incentive compensation. For example, there's a hospital goal and an individual goal for patient experience. Incentive compensation is based on those two scores.

"Everyone on the team, for example, in food service—the nursing and food director and lead dietitian—all have the same goals in their incentive comp," says Szekely. "The success of one is dependent on the success of another, which makes it a true team and which focuses team members on what's good for the patient, not the department."

Northern Westchester's electronic medical record makes clinical documentation almost all automated.

"We use that to do reminders and cues for the staff," Szekely says. "Healthcare is a very person-dependent process, so we want to make sure alerts and reminders and documentation flow easily and assist communication."

Each patient room has what Szekely calls patient access tablets, which are really iPads that give the patient access to clinical information in a patient-friendly format. The same device controls entertainment for the room, ensuring they'll use it. Also very helpful for responsiveness, she says, is a hands-free Vocera communication device issued to both patients and staff.

"This is not only for staff-to-staff but staff-to-patient communication. It goes directly to their nurse."

What's really important in high achievement with HCAHPS is a little investigative reporting as to why scores are where they are, Szekely explains. "You don't want to fix the wrong problem, so that's why we spend time talking to physicians, staff, and patients, and look closely at comments and complaints.

"We even interview patients at the beginning of their stay, which sets up what we're going to work on to make sure we're really designing around what the patient wants and not what the staff wants," she says.

"If process isn't enabling staff to deliver care amid all those obstacles, culture alone won't improve those HCAHPS scores."

[Reprint HLR1015-4]