“We have to be careful about how we hold hospitals responsible,” says Dr. James Merlino, chief experience officer at the Cleveland Clinic, which has conducted research on patient-satisfaction surveys. “We should be holding hospitals responsible for things that they can actually improve.”
The few published analyses of HCAHPS surveys have found their respondents generally disfavor organizations such as large, academic hospitals in northern regions of the country that treat large numbers of patients with either depression or complex and serious illnesses. Those poor patient scores come regardless of the high quality of the clinical care that other measures have found those institutions provide.
Among the practical impacts of such perceived biases is that no hospital in the nation with 500 or more beds has scored in the 90th percentile for such basic measures as physician communication or nurse communication, one Cleveland Clinic study found.
The cumulative impact of the HCAHPS biases, according to hospital advocates, indicates that small community-based hospitals in the Southeast perform best on the surveys, based on their current design. The regional disparities consistently result in hospitals in the South and Midwest ranking higher and those in Northeastern states lower, according to Medicare's Hospital Compare website.
Differing expectations of hospital care in various regions of the country produce patient-satisfaction results that sometimes run counter to reports on the quality of the hospitals' clinical care, according to patient-satisfaction researchers.
However, some hospital officials say ongoing discussions with the CMS and the Agency for Healthcare Research and Quality, which designs the survey, could produce some changes in the methodology of the surveys in an attempt to account for the perceived biases.
Among the changes reportedly under discussion are modifications to the methodology of the survey to add risk adjustments and population adjustments.
Officials at the CMS did not confirm or deny whether discussions of changes to HCAHPS are under way.
Another complicating factor on the impact of the patient-satisfaction surveys are some indications that their biases may be offset by other components of the value-based purchasing program.
Nancy Foster, vice president of quality and patient safety with the American Hospital Association, says that earlier reviews of such data found teaching hospitals that perform poorly on patient satisfaction tend to receive higher scores on process-of-care measures than nonteaching hospitals. She says that is one of the many issues the AHA plans to track as the value-based purchasing program rolls out, which also will include identifying the hospitals that are struggling or exceeding expectations under the program and why that is happening.
“For the ones that are succeeding, our hope is to find that secret sauce and make sure everybody knows how to better serve their patient population,” Foster says.