Patient Satisfaction - The Nursing Implications
Background Patient satisfactionor the patient experience is a very difficult item to rate.
There are seemingly endless variables that must be considered.
Once that is done, how can you compare your hospital to any other hospital who measures the patient experience in their own way.
And if hospitals are obtaining this information, how can the general public view the results? You end up comparing apples to grapefruit to bananas if you can find the information at all! The Agency Healthcare Research and Quality was tasked in the mid-1990's to develop a method to have an apples-to-apples comparison of various health related activities.
The original survey was titled the Consumer Assessment of Healthcare Providers and Systems (CAHPS®).
The CAHPS survey eventually was utilized to measure patient's experiences in several different areas.
A survey for hospitals, HCAHPS, was developed to focus on the hospital experiences of adult inpatients.
They input of many different national groups was used to develop a 27 question survey for all hospitals to use.
In May of 2005, the National Quality Forum formally endorsed the HCAHPS.
Thus, the playing field was leveled and meaningful comparisons could be made.
In October 2006, the Centers for Medicare & Medicaid Services (CMS) implemented the HCAHPS survey with its first public reporting of results in March 2008.
Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS)must collect and submit HCAHPS data to receive their fullIPPS annual payment update.
Failure to collect and submit this data results in an annual payment update that is reduced by 2%.
The reported information, once collected, is placed online at the Hospital Compare Website for viewing by the general public.
The online format allows comparison of up to three hospitals.
Links to graphs and tables are available that provide the national and state average for each quality topic as well as the information for the selected hospitals.
Survey Questions The survey questions are divided into seven areas.
The first six areas concern the care received while the last contains demographic questions.
The summary measures are derived from two or three questions in the survey.
The summary questions address:
The two global measures concern the overall hospital rating and whether the patient would recommend the hospital to others.
While the summary may have a heading of "Communications with Nurses" the individual survey questions are: "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?" "During this hospital stay, how often did nurses explain things in a way you could understand?" (Underlining is present in the survey instrument.
) Correlation to Nursing CMS performs statistical analysis of the information it receives.
One analysis of this informationseeks to provide insight into key drivers of patient satisfaction.
One such analysis is a section titled "HCAHPS Patient-Level Correlations.
" This information contains patient-level Pearson Correlations of linear means of HCAHPS measures.
Over two million completed surveys were utilized for this review.
The very obvious item that jumps out is that nursing has the highest positive correlation in seven out of nine measures.
The information basically shows that how a patient views nursing usually impacts most all of the areas on the survey.
The highest positive correlation (0.
65) is with the measure "Overall Hospital Rating.
" It actually should not come as any big surprise when you think of the role that nursing plays within the hospital setting.
Physicians may see the patient for a few minutes several times a day, dietary interacts with the patient three times a day and laboratory personnel may encounter the patient once or twice a day.
But the nursing staff (CNA, LPN, RN) is present 24 hours each day and is the main conduit of interaction between the patient and the rest of the hospital.
The impact of the nursing staff is tremendous since they are the "face" of the hospital.
This puts the spotlight on the nursing staff to provide a positive experience for the patient.
Looking back at the survey questions, one of the questions ask if the nursing staff listened to the patient.
All too often, we may think that we are listening but our non-verbal communications (looking away from the patient or typing on a computer keyboard) may suggest otherwise.
Sending mixed messages like this does not encourage a positive patient experience.
Another question inquires about the nurse explaining things in a way the patient could understand.
How many times are we guilty of spouting off medical terminology that is technically correct but not understood by the patient? We tend to use what the military refers to as a TLA (Three Letter Acronym).
We must make the effort to have our verbal and non-verbal communications in line and complimentary.
We need to use the language of the patient.
We also need to ascertain that the information that we give to the patient is accurately received.
This may require asking to the patient to tell us, in their own words, what we just told them.
Future Use of HCAHPS HCAHPS scores were designed with three goals in mind.
The first is to allow a meaningful comparison between hospitals on items that are meaningful to the patient.
The second goal is to create an incentive for hospitals to improve the quality of care.
Accountability in healthcare through transparency of the quality of healthcare provided in return for the public investment is the third goal.
Passage of the Patient Protection and Affordable Care Act (PPACA - also known as healthcare reform) in March of 2010 has placed much higher emphasis on the second and third goals of HCAHPS.
Starting in fiscal year 2013, hospitals will be eligible for incentive payments in a program called the value-based purchasing (VBP) program.
This program will look at specific patient conditions or procedures (heart failure, pneumonia, hospital acquired infections, etc.
), increased hospital efficiency and measure selected from HCAHPS.
From these three areas a composite score will be determined.
Hospitals that score in the lowest quartile will probably not receive any VBP incentive payment.
Some experts are predicting that the HCAHPS will account for 20 - 40% of the scoring for VBP payments.
It doesn't take a great deal of thought to see that nursing will have a huge impact on the future of healthcare and hospitals.
Nursing can already modify market share and revenue.
Now we can add incentive payments.
Unfortunately that modification can go both ways.
If the nursing staff is well versed in communications skills, critical thinking, leadership and similar soft skills (which produce hard results), the effect can be a big positive.
Unfortunately the reverse is also true.
A nursing staff that shows up for work and only performs to a minimal level will have a negative impact on all three areas of VBP.
All hospitals face cutbacks in funding from CMS.
These reductions will start at 1% (FY 2013) and increase to 2% (FY 2017).
The big question that healthcare organizations have to answer is, will they recoup those funds (and possibly more) through VBP payments? While the fine points of the program are yet to be released, the writing is on the wall for all to see.
Will hospitals in general, and nursing in particular, take the necessary steps to secure their financial future? For reprints, please include the author signature information listed below at the end of the article.
There are seemingly endless variables that must be considered.
Once that is done, how can you compare your hospital to any other hospital who measures the patient experience in their own way.
And if hospitals are obtaining this information, how can the general public view the results? You end up comparing apples to grapefruit to bananas if you can find the information at all! The Agency Healthcare Research and Quality was tasked in the mid-1990's to develop a method to have an apples-to-apples comparison of various health related activities.
The original survey was titled the Consumer Assessment of Healthcare Providers and Systems (CAHPS®).
The CAHPS survey eventually was utilized to measure patient's experiences in several different areas.
A survey for hospitals, HCAHPS, was developed to focus on the hospital experiences of adult inpatients.
They input of many different national groups was used to develop a 27 question survey for all hospitals to use.
In May of 2005, the National Quality Forum formally endorsed the HCAHPS.
Thus, the playing field was leveled and meaningful comparisons could be made.
In October 2006, the Centers for Medicare & Medicaid Services (CMS) implemented the HCAHPS survey with its first public reporting of results in March 2008.
Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS)must collect and submit HCAHPS data to receive their fullIPPS annual payment update.
Failure to collect and submit this data results in an annual payment update that is reduced by 2%.
The reported information, once collected, is placed online at the Hospital Compare Website for viewing by the general public.
The online format allows comparison of up to three hospitals.
Links to graphs and tables are available that provide the national and state average for each quality topic as well as the information for the selected hospitals.
Survey Questions The survey questions are divided into seven areas.
The first six areas concern the care received while the last contains demographic questions.
- Your care from nurses (4 questions)
- Your care from doctors (3 questions)
- The hospital environment (2 questions)
- Your experiences in this hospital (8 questions, 3 are qualifiers)
- When you left the hospital (3 questions, 1 is a qualifier)
- Overall rating of hospital (2 questions)
- About you (5 questions)
The summary measures are derived from two or three questions in the survey.
The summary questions address:
- Communications with nurses
- Communications with doctors
- Responsiveness of hospital staff
- Pain management
- Communication about medicines
- Discharge information
The two global measures concern the overall hospital rating and whether the patient would recommend the hospital to others.
While the summary may have a heading of "Communications with Nurses" the individual survey questions are: "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?" "During this hospital stay, how often did nurses explain things in a way you could understand?" (Underlining is present in the survey instrument.
) Correlation to Nursing CMS performs statistical analysis of the information it receives.
One analysis of this informationseeks to provide insight into key drivers of patient satisfaction.
One such analysis is a section titled "HCAHPS Patient-Level Correlations.
" This information contains patient-level Pearson Correlations of linear means of HCAHPS measures.
Over two million completed surveys were utilized for this review.
The very obvious item that jumps out is that nursing has the highest positive correlation in seven out of nine measures.
The information basically shows that how a patient views nursing usually impacts most all of the areas on the survey.
The highest positive correlation (0.
65) is with the measure "Overall Hospital Rating.
" It actually should not come as any big surprise when you think of the role that nursing plays within the hospital setting.
Physicians may see the patient for a few minutes several times a day, dietary interacts with the patient three times a day and laboratory personnel may encounter the patient once or twice a day.
But the nursing staff (CNA, LPN, RN) is present 24 hours each day and is the main conduit of interaction between the patient and the rest of the hospital.
The impact of the nursing staff is tremendous since they are the "face" of the hospital.
This puts the spotlight on the nursing staff to provide a positive experience for the patient.
Looking back at the survey questions, one of the questions ask if the nursing staff listened to the patient.
All too often, we may think that we are listening but our non-verbal communications (looking away from the patient or typing on a computer keyboard) may suggest otherwise.
Sending mixed messages like this does not encourage a positive patient experience.
Another question inquires about the nurse explaining things in a way the patient could understand.
How many times are we guilty of spouting off medical terminology that is technically correct but not understood by the patient? We tend to use what the military refers to as a TLA (Three Letter Acronym).
We must make the effort to have our verbal and non-verbal communications in line and complimentary.
We need to use the language of the patient.
We also need to ascertain that the information that we give to the patient is accurately received.
This may require asking to the patient to tell us, in their own words, what we just told them.
Future Use of HCAHPS HCAHPS scores were designed with three goals in mind.
The first is to allow a meaningful comparison between hospitals on items that are meaningful to the patient.
The second goal is to create an incentive for hospitals to improve the quality of care.
Accountability in healthcare through transparency of the quality of healthcare provided in return for the public investment is the third goal.
Passage of the Patient Protection and Affordable Care Act (PPACA - also known as healthcare reform) in March of 2010 has placed much higher emphasis on the second and third goals of HCAHPS.
Starting in fiscal year 2013, hospitals will be eligible for incentive payments in a program called the value-based purchasing (VBP) program.
This program will look at specific patient conditions or procedures (heart failure, pneumonia, hospital acquired infections, etc.
), increased hospital efficiency and measure selected from HCAHPS.
From these three areas a composite score will be determined.
Hospitals that score in the lowest quartile will probably not receive any VBP incentive payment.
Some experts are predicting that the HCAHPS will account for 20 - 40% of the scoring for VBP payments.
It doesn't take a great deal of thought to see that nursing will have a huge impact on the future of healthcare and hospitals.
Nursing can already modify market share and revenue.
Now we can add incentive payments.
Unfortunately that modification can go both ways.
If the nursing staff is well versed in communications skills, critical thinking, leadership and similar soft skills (which produce hard results), the effect can be a big positive.
Unfortunately the reverse is also true.
A nursing staff that shows up for work and only performs to a minimal level will have a negative impact on all three areas of VBP.
All hospitals face cutbacks in funding from CMS.
These reductions will start at 1% (FY 2013) and increase to 2% (FY 2017).
The big question that healthcare organizations have to answer is, will they recoup those funds (and possibly more) through VBP payments? While the fine points of the program are yet to be released, the writing is on the wall for all to see.
Will hospitals in general, and nursing in particular, take the necessary steps to secure their financial future? For reprints, please include the author signature information listed below at the end of the article.