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.