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Can You Hear Us Now?

Wednesday, October 09, 2019
Barbara Lewis, MBA

Three ICU nurses revealed their bewilderment about the actions of my sister’s doctors:

“I don’ know why the doctor ordered that.”
“I don’t know why the doctor took so much fluid.”
“I don’t know why the doctor prescribed that medication.”
I finally asked the third nurse why she didn’t question the doctor. Her response, “We don’t do that at this hospital.” I was stunned!
It was 2012, and a program was emerging that would substantially impact those nurses’ attitudes. Ten years earlier, the Centers for Medicare and Medicaid Services (CMS), an agency within the federal Department of Health and Human Services (HHS), teamed up with the Agency for Healthcare Research and Quality (AHRQ), also part of HHS. Their mandate was to develop and test the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is also known as the hospital CAHPS® survey. (CAHPS now includes 11 patient surveys in healthcare settings.)
The HCAHPS survey had a three-prong goal: First, provide a standardized survey instrument, data collection methodology and implementation protocol, so that hospitals could be compared on topics that interest patients and consumers. Although hospitals had collected patient satisfaction data, until HCAHPS there was no method to compare hospitals. Second, publicly report survey results that incentivize hospitals to improve the quality of care. Third, enhance hospital accountability through the transparency that the HCAHPS survey would promote. AHRQ and CMS engaged in a rigorous and multi-faceted scientific process, which included “a public call for measures, literature review, cognitive interviews, consumer focus groups, stakeholder input, a three-state pilot test, extensive psychometric analyses, consumer testing and numerous small-scale field tests.” During three opportunities for the public to comment on the survey, CMS responded to over a thousand comments.
Ultimately, the HCAHPS survey debuted with 27 questions, known as dimensions, which covered a wide range of patients’ care experiences, including communication with doctors and nurses, responsiveness, pain management, communication about medicines, discharge information, cleanliness, quietness and the transition of care. The survey includes four screener and seven demographic questions to adjust the mix of patients across hospitals and for analytical purposes. In 2005 the National Quality Forum endorsed the survey and the federal Office of Management and Budget approved the survey implementation for public reporting purposes.
The following year, CMS launched the voluntary survey with four modalities – mail, telephone, mail followed by telephone and active interactive voice response. However, CMS discovered that the mode of survey delivery affected the patient responses. “Respondents typically give somewhat more positive responses when surveyed by telephone, as compared to mail.”[i] So in 2006, CMS conducted a four-month study to evaluate the effects of the modality and, subsequently, adjusted the calculation of the survey scores to remove the impact of patient responses based on the survey mode. Currently, CMS is reviewing public comments to add email as a modality. Originally, launched in three languages, today the HCAHPS survey is available in seven languages, including English, Chinese, German, Portuguese, Russian, Spanish and Vietnamese, although not available in every mode of delivery.
In 2008, CMS posted the first survey results on their website, which, at the time, was still a voluntary program. But that was about to change. The Inpatient Prospective Payment System (IPPS), which was defined under the Social Security Act, mandated that hospitals, “must collect, submit and publicly report HCAHPS data in order to receive their full IPPS annual payment update.”[ii] The same section in the Social Security Act established the Hospital Value-Based Purchasing (VBP) program, which rewards acute-care hospitals for quality care, plus performance on HCAHPS. The VBP program introduced the “top-box” score where the patient response is the highest choice on the survey. To make consumer analysis easier, CMS implanted a star rating system of one to five stars. In October 2012 money was tied to the HCAHPS scores. I’ve spoken to two hospitals that lost about one million dollars each in one year due to their low HCAHPS scores.
A 500+ page document, the HCAHPS Quality Assurance Guidelines, outlines the rules surrounding HCAHPS. Surveys must be distributed between 48 hours to six weeks after patients have been discharged from the hospital. A specific number of patients must be surveyed over a discrete amount of time, although certain hospitals survey all their patients.
Continuing their partnership mindset, which set the tone nearly 18 years ago when they embarked on this journey, CMS is all ears. They continue to routinely meet with stakeholders, listen to feedback, host public comment periods and thoughtfully propose revisions, which are then carefully tested and vetted. In 2013, CMS added new dimensions: transition to post-hospital care, emergency room admission, and mental and emotional health. The Agency replaced pain management questions with ones on communication about pain “to address any perceived conflict between appropriate management of opioid use and patient satisfaction by relieving any potential pressure physicians may feel to overprescribe opioids.”[iii]
Evidently, there are no public statistics on the number of consumers who have accessed the Hospital Compare website to view patient satisfaction survey results – one of the main purposes of HCAHPS. Anecdotally, when I speak to patient groups, almost all audience members are unaware of this robust resource. I wonder when CMS will marshal their many assets, the way they did when they created and tested the survey, to alert the public, so Hospital Compare is as popular as Yelp.
The survey can only be distributed by CMS-approved vendors, which is 20 with four conditionally approved. The vendors then submit the hospitals’ data to CMS. Press-Ganey is the largest of the vendors and contracts with hospitals to distribute the HCAHPS survey, analyze the results and offer recommendations to improve scores. The HCAHPS data is available to everyone for analysis. CMS’ analytics supported by Press Ganey and other institutions, reveal the importance of doctors and nurses communicating with patients and with each other.
For my sister, Joan, improvement in clinician communication skills doesn’t matter. She passed away in the ICU in 2012. But for millions of other patients, physicians and nurses communicating compassionately with patients and families and with each other, can enhance the patient experience, improve patient satisfaction scores and increase monies the hospital receives through VBP. HCAHPS ushered in a new era for the patient: You can hear us now!
Barbara Lewis, MBA, is the Managing Editor of DocCom, an online communication skills learning program for hospitals, residency programs and medical schools, and the founder of Joan’s Family Bill of Rights in memory of her sister. She can be reached at
[i] The HCAHPS Survey – Frequently Asked Questions, retrieved 9/30/19
[ii] The HCAHPS Survey – Frequently Asked Questions, retrieved 9/30/19
[iii] Industry Edge, A Press Ganey Publication, November 2018, retrieved 9/30/19

Tags: nursing, quality improvement, education, healthcare transformation
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