CMS looks to revise HCAHPS survey amid complaints from hospitals

The CMS wants to revise its mandatory and long-standing patient experience survey for hospitals. Health system leaders say it’s about time. 

The CMS recently asked for approval from the White House Office of Management and Budget to collect public feedback from stakeholders on possible changes to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, commonly referred to as HCAHPS. Comments to the OMB closed May 16 and at deadline the CMS was still awaiting approval before moving forward. Assuming the CMS gets the green light, “survey content may change as a result” of public feedback, an agency spokeswoman wrote in an email.

Hospital quality and patient-experience leaders agree it’s time for the CMS to take a fresh look at the survey. 

“Something that serves an important purpose should be reconsidered for updates periodically as practice changes,” said Chip Kahn, CEO of the Federation of American Hospitals, who wrote a Health Affairs blog post calling for HCAHPS revisions in March, before the CMS issued its notice for public input. 

Since 2007, the CMS has required hospitals to give patients the HCAHPS survey as part of Medicare participation. At the time, the tool created a national standard by which hospitals could understand their patients’ experience and consumers could use the findings to make care decisions. Hospital leaders say the survey provided valuable, nationally comparable information about patient experience unavailable until then. Now, years later, the survey is outdated.

“It’s almost 15 years old. If you think about medicine today and how it’s delivered, it really doesn’t approach the consumerism era we are in today,” said Dr. Shannon Connor Phillips, chief patient safety and experience officer at Intermountain Healthcare based in Salt Lake City.

A common complaint from hospitals is the way the survey is administered. It is 29 questions long and patients fill out a paper questionnaire, answer questions over the phone, or a mix of both. 

Hospital leaders argue that an electronic version would increase response rates and the timeliness of results. It’s harder now to get consumers to complete a survey and using mail and telephone survey modes doesn’t help, said Akin Demehin, director of policy at the American Hospital Association. 

“It isn’t only the younger patients who would prefer the electronic survey, it’s true for all ages,” said Nancy Foster, vice president for quality and patient safety policy at the AHA.

Indeed, data show that the overall response rate for the HCAHPS survey has been steadily declining. The response rate for patients discharged from October 2006 to June 2007 was 34% but dropped to 27% from July 2017 to June 2018, the most recent time period for which data is available.

According to the CMS notice, it will seek input on the feasibility of an electronic HCAHPS survey. 

Press Ganey, the largest vendor of the HCAHPS survey, offers separate email and text questionnaires to its hospital customers. Hospitals using those electronic surveys experience three to four times more responses compared with HCAHPS, said Deirdre Mylod, the company’s senior vice president for research and analytics.

Electronic surveys may also be less costly to deploy than mail and phone surveys, Phillips said. It would require fewer resources like paper, but hospitals would need to make initial investments in technology.

The low response rates for HCAHPS likely mean hospitals are only getting a limited understanding of their patient experience. Providers are also missing information from patients with social risks like homelessness.

Intermountain has a response rate of about 20%. “Are we reaching all the demographics we serve? I think not,” Phillips said. 

And because the surveys are conducted via phone and mail, the responses take longer to collect and analyze and are therefore less helpful for improvement work, said Deborah Larkin-Carney, vice president of quality at RWJBarnabas Health. 

It takes four to eight weeks before the New Jersey-based system receives completed survey responses from its vendor Press Ganey.

“There is such a huge lag time …and your recollection of things can change,” Larkin-Carney said. 

Phillips said she’s even received emails from patients who have complained about the length of the surveys and the questions, claiming some are redundant or confusing. “Most of the time they are frustrated with me, and say ‘Why are you sending me such a badly written survey?’ ” she said. 

The way questions are phrased also makes the information less actionable, said Chao Wu, assistant vice president of patient experience at the Hospital for Special Surgery in New York City. 

For instance, the mailed version of the survey asks patients how many times an action was done by selecting among “never,” “sometimes,” “usually” and “always.” One question is: “During this hospital stay, how often did doctors treat you with courtesy and respect?”

That doesn’t correlate to how clinical staff think about providing care, Wu argued, adding, “We talk about the quality of healthcare, not how many times we provide the service.” 

Frustration with HCAHPS is high in large part because results are tied to reimbursement. It is part of the inpatient prospective payment system and the Hospital Value-Based Purchasing Program. Some commercial insurers use it to calculate payment rates.

The results are also publicly available to patients through Hospital Compare and factor into overall star ratings as well as in a separate rating for patient experience. But there are doubts about how much patients pay attention to it. 

“I don’t think a lot of patients go to Hospital Compare,” Phillips said. “In fact, when patients look up a health system, they probably find Yelp more than they find Hospital Compare.”

Even with the strong incentives tied to the survey, it’s hard to rely on it completely because of the low response rates and the fact that hospitals are limited to those 29 questions, Phillips said. 

“The numbers that come out of HCAHPS are second to us. It’s the comments, the voice of the patient” Intermountain wants to know, she said. But HCAHPS doesn’t currently have a comments option available in its mail survey. 

Hospitals have increasingly relied on other avenues to get a sense of what the patient’s experience was like. Focus groups, advisory councils, separate electronic surveys, interviews during the patient stay and after discharge are all tactics that have been used. 

For instance, at Intermountain, the system is currently working on rolling out by next quarter an electronic survey that asks questions not addressed in the HCAHPS survey.

Upon discharge, Intermountain will ask patients to complete a survey seeking information about how the team worked together, the trust and confidence the patient had in the team, and how involved the patient was in care decisions. The survey can be completed via email and text, depending on their preference. 

“We are really focused on being an effective team, so we want to know from our patients how that is going and that isn’t really covered” in the HCAHPS survey, Phillips said. 

In addition to an electronic survey, RWJBarnabas monitors comments made on social media and has a patient family advisory council. “The HCAHPS survey isn’t able to capture what we are finding” from these other avenues, Larkin-Carney said. 

In addition to input from stakeholders, the CMS also plans to ask patients “about what aspects of hospital quality are important to them,” an agency spokeswoman said. 

Phillips at Intermountain said the inclusion of patients is critical. “Making sure that the questions don’t have bias in them, making sure they are asking something that matters to patients,” is important, she said.