Much discussion about pay-for-performance has focused on how hospitals measure up against one another clinically, and how the dollars may be divvied up accordingly. So far there has been less emphasis on how patients perceive their hospital care and how the public reporting of that data may drive quality improvement and eventually hospital revenue.
That's about to change.
Beginning this month, hospitals subject to the inpatient prospective-payment-system provisions are required to submit data from a standardized survey of their adult patients to receive their full annual payment update from the CMS for fiscal 2008. Beginning in March 2008, the data culled from these patient surveys will be posted publicly on the
Hospital Compare Web site. Hospitals that choose not to submit and publicly report the data may receive an update that is 2 percentage points lower than their peers.
The Consumer Assessment of Healthcare Providers and Systems hospital survey, known as HCAHPS, is the standardized survey hospitals must use to report their patient-experience data to the CMS. The first national standardized survey of hospital patient experiences, HCAHPS has been a joint project of the CMS and the Agency for Healthcare Research and Quality.
"We went into this really with the idea that (patient experience) is a measure of quality," said Chuck Darby, social science administrator for AHRQ's Center for Quality Improvement and Patient Safety. "It's not what someone might call an objective measure, but at the same time it is a measure, and it's an important perception."
Darby has led the AHRQ team that designed the survey with recommendations from various industry stakeholders. The National Quality Forum endorsed the survey in May 2005.
In the short term, hospitals need to be aware that consumers, employers, insurers and legislators may use this comparative data to decide where to seek care or where to steer patients. In the longer term, they should also be mulling how their payments might be affected by what patients are saying about them. In some regions, this is already beginning as private insurers incorporate patient perceptions into their pay-for-performance initiatives. And the CMS may not be far behind.
Up and running
The possibility of rolling HCAHPS data into pay-for-performance measures was floated in an April "options paper" in which the CMS discussed how to design a so-called
value-based purchasing program for Medicare.
Much agonizing and debate has gone into the exact format of the HCAHPS survey instrument, and the CMS has taken pains to educate hospitals and their survey vendors about it through training sessions and voluntary "dry runs."
Even before the July 13 deadline for hospitals to begin submitting data if they want their full payment update, nearly 3,000 hospitals were voluntarily using the HCAHPS survey, said Nancy Foster, the American Hospital Association's vice president for quality and patient-safety policy.
Hospitals may use survey vendors and add additional questions at the end of the HCAHPS survey, and are allowed to conduct it by mail, phone or interactive voice recognition. While the voluntary information is not yet publicly available for individual hospitals, it has been gathered into "chartbooks" available on the
AHRQ Web site, that show how the hospitals have done as a group on the various survey questions.
"I guess our hope in terms of implementation is just getting all the hospitals onboard, getting them to do HCAHPS, making sure everyone's following the administration protocol," said Elizabeth Goldstein, director of the CMS' division of consumer assessment of healthcare surveys. "Our hope is that hospitals use this information for quality improvement and that consumers use this information when choosing a hospital with their physician."
The survey consists of 27 questions grouped into seven categories: communication about medications; responsiveness of hospital staff; cleanliness and quiet of hospital environment; pain management; communication with doctors; communication with nurses; and discharge information. It also asks whether the patient would recommend the hospital to others.
Patients at hospitals that have voluntarily submitted surveys seem to be relatively pleased with the experience. Some 60% of 190,690 respondents from 927 hospitals that submitted HCAHPS data in 2006 rated their hospitals either a 9 or a 10 on a 10-point scale where a 10 was the highest score, according to the
2007 CAHPS Hospital Survey Chartbook.
The highest scores on specific questions in the survey were for communication with doctors and nurses, with 84% of respondents reporting that doctors always treated them with courtesy and respect. The lowest scores were for communication about medications and discharge information, with 26% of respondents reporting that hospital staff never described possible side effects of medications in a way they could understand.
The cost to hospitals of fulfilling the HCAHPS requirements is not expected to be excessive. A cost-benefit analysis of the program prepared for the CMS by Abt Associates in October 2005 concluded that administering HCAHPS as a separate survey would cost an average of $11 to $15.25 per complete survey. Incorporating its 27 questions into a hospital's existing patient-satisfaction surveys would cost $3.26 per completed survey, the firm said in the report.
Some hospitals got into the game early, with the idea that they might get a leg up on the latecomers. Tenet Healthcare Corp. piloted the HCAHPS survey with eight of its hospitals in late 2004 and then replaced its own patient-satisfaction survey at all of its hospitals in January 2005 with the HCAHPS instrument plus a few extra questions.
In response to the HCAHPS focus on patient experience, Tenet has made several changes. To help boost medication safety and improve communication with patients about their medicines, Tenet created a color-coded how-to kit for nurses using medication dispensing machines. The chain has also encouraged its hospitals' administrative teams and department heads to participate in patient rounds to provide patients with more opportunities to express any concerns and provide feedback.
Kupietzky
|
In addition, Tenet is in the process of putting white boards in patient rooms in all of its hospitals with key information for patients and their families about their treatment, phone numbers they can call for help and departure dates. HCAHPS can provide hospitals with an opportunity to demonstrate their strengths, said Jacob Kupietzky, Tenet's vice president of operations excellence. "It's a way to showcase all the wonderful services they provide to patients," he said.
Griffin Hospital in Derby, Conn., is another facility that got an early start. Connecticut was one of four states that participated in a pilot program for the survey in 2004, when it consisted of more than 60 questions. Patrick Charmel, president and chief executive officer of 111-bed Griffin, said being involved so early enabled the hospital to provide recommendations for the survey developers at AHRQ. He said he believes "absolutely" that HCAHPS will be incorporated into the CMS' value-based purchasing initiative, and that commercial payers will use the data to make payment decisions as well.
This could work to the advantage of hospitals that have paid attention to HCAHPS all along, he said. "I could see myself in a conversation with a payer saying, 'You're paying our competitor significantly more than us. Our clinical outcomes are better and our patient-satisfaction scores are higher, so why are you doing that?' "
California hospitals are already getting a taste of HCAHPS accountability. Some 209 hospitals representing about 70% of the states' admissions have volunteered to submit data on quality, safety and patient experience that incorporate the HCAHPS survey with other clinical quality measures.
The Web site offering the data on the hospitals, called
CalHospitalCompare.org, went live on March 6. Maribeth Shannon, director of the market and policy monitor program at the California HealthCare Foundation, said it's too early to tell whether the public disclosures have led to any quality improvements because the hospitals have only reported data representing a few months of responses. Even so, the comparative information can be helpful to hospitals, Shannon said.
A number of the state's private insurers also helped develop the CalHospitalCompare Web site, and some—including Blue Cross of California—have announced they plan to use it as the basis of upcoming pay-for-performance programs, Shannon said.
The new wave of transparency is likely to be an incentive for hospitals to put more resources into patient satisfaction, Griffin's Charmel said.
"More hospitals are reallocating resources realizing that now they're going to be held accountable publicly for their patient experience," he said. "Hospital reputations are at stake."
Patient-satisfaction survey vendors did not initially jump up and down with excitement about the advent of HCAHPS. At first, there were those who saw a standardized national survey as potential competition for their own established products. But most have since come around and are working with their hospital clients to make the most of HCAHPS by providing additional survey questions and guidance. Vendors and consultants have begun tailoring their services to the growing importance of HCAHPS by offering strategies on how to improve scores, how to interpret rankings and how to add value to the data.
"Our inpatient offering is in assisting hospitals with measurement, benchmarking, telling them what to focus on," said Deirdre Mylod, vice president of public policy at healthcare survey company Press Ganey Associates. "HCAHPS is part of that measurement." The company has about 1,600 clients using HCAHPS, she said.
Inguanzo
|
Joe Inguanzo, president and CEO of Professional Research Consultants, a research firm based in Omaha, Neb., has about 250 hospital and system clients and has been involved in the development of the HCAHPS survey. He said that HCAHPS is weaker at measuring patients' loyalty than their perspectives on clinical care. His firm offers clients an additional 20 questions focused on loyalty to add to the HCAHPS survey. "HCAHPS is operational; loyalty is more service delivery," he said. HCAHPS is "not asking how you feel about what was done, but just asking you whether they did these things."
Some consultants say HCAHPS data, when they are released early next year, may provide more media buzz than the 20 measures of clinical quality of care hospitals have been providing to receive their full Medicare updates already. The smart hospitals will try to get out in front of the HCAHPS data release, said Mary Malone, who worked at Press Ganey for 14 years before becoming an independent patient-experience consultant to hospitals.
"I don't think they're (hospitals) strategically releasing information about what a great experience patients have," she said. "They should build a communications strategy around getting as many of those positive stories out there as possible in advance of that public data release."
While most within the industry agree that HCAHPS will shine a much-needed spotlight on patient perceptions of hospital care, there are still some concerns. The AHA's Foster said she wonders whether hospitals with large groups of illegal immigrants might have trouble collecting enough patient data.
And the CMS has approved only Chinese, English and Spanish translations of the survey. That means hospitals with large groups of patients who speak other languages may have a hard time collecting data from sizable segments of their patient base. The CMS is soliciting information on its Web site about languages that hospitals think should be targeted for translation, Goldstein said.
Hospitals are required to survey all patients eligible for HCAHPS, and the CMS is asking that they aim for at least 300 surveys completed per year.
Barbara Kirchheimer, a former news editor and reporter at Modern Healthcare,
is a freelance writer based in Highland Park, Ill. Reach her at bkirchh@sbcglobal.net.
An expanded version of this story initially appeared in this week's edition of Modern Healthcare
magazine.
What do you think? Write us with your comments at hitsdaily@crain.com. Please include your name, title and hometown.
