Are Hospitals Prepared for the HCAHPS?

By Scott Wetzel

How many of you have bought a car, ate at a new restaurant, or invited a cleaning service into your house without first researching its cost and quality? From Yelp to Kelly’s Bluebook to Angie’s List, most of us seek out consumer reviews before making the big purchases in our lives. We reward companies with positive reviews and ignore those listed as providing lousy service or subpar products.

Now, how many of you have reviewed (or written) a consumer review of physicians and hospitals before a checkup or operation? I would venture that this number drops significantly. However, such reviews are about to become a major part of how hospitals are paid.  In October of this year, under a new Affordable Care Act program known as Value-Based Purchasing (VBP), hospitals will be paid based on their performance on a series of quality metrics. In addition to traditional quality measures, the VBP program will now include the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) — a patient’s experience of care survey — as a major part of the program’s scoring methodology.

HCAHPS is a 27-question survey mailed to recently discharged hospital in-patients, asking questions about such things as the cleanliness of the room, noise levels, and doctor and nurse communication. Tying consumer reviews to payment is controversial. On March 15, Theresa Brown, an oncology nurse at    UPMC Shadyside Hospital wrote a New York Times op-ed titled “Hospitals aren’t Hotels,” and argued that hospitals shouldn’t necessarily be assessed on patient satisfaction.  Dr. Ken Bottles responded in this blog that hospitals in fact have much to learn from how hotels operate and treat customers.

While teaching hospitals lead in providing first-rate innovative care, they have traditionally struggled with these surveys. The reasons for this are numerous and complex and to some degree are driven by factors outside the control of the hospital.  In addition, teaching hospitals treat more complex and vulnerable patients who, based on current research, tend to provide lower HCAHPS scores. There is also no doubt that teaching hospitals have significant room for improvement. In the end, poorly performing hospitals that don’t take steps to improve their scores will see their reimbursements decline.

The AAMC is working to ensure that teaching hospitals are prepared to address these challenges, and has started the conversation with members on potential strategies for improvement. In March, the AAMC hosted a webinar with representatives from the Cleveland Clinic, the Medical University of South Carolina (MUSC), and the University of California San Francisco (UCSF) Medical Center: three institutions that have implemented initiatives and programs to address low HCAHPS scores. All three have seen improvements in their scores based on their HCAHPS interventions.

Dr. James Merlino, the Cleveland Clinic’s Chief Experience Officer, presented the steps his institution implemented to improve such metrics as quiet at night and nurse and doctor communication. The Cleveland Clinic uses HUSH (“Help Us Support Healing”) champions to implement specific tactics. Patients receive fliers upon being admitted, describing noise expectations in a hospital; posters encouraging quiet are posted throughout the floor; hallway lights are dimmed at night; and staff are instructed to lower their voices during this time period. The hospital then performs internal audits and provides feedback to nurse and unit managers. The Cleveland Clinic also took time to inform the nursing staff on how the HCAHPS scores work (many didn’t know). Hourly nurse rounds are mandated, which increased nurse communication scores. Regarding physician communication, the hospital spends significant time identifying physician leaders to encourage accountability among the staff.

Traci Hoiting, Associate Director of Patient Care and Nursing at UCSF, discussed the innovative approaches her institution has taken to reduce noise.  One step was to install a “yacker-tracker,” a stoplight-like device that warns floor staff when noise levels exceed set decimal levels during quiet hours.  UCSF also works closely with  material services, hospitality, and facility departments to limit construction, delivery times, fire door closings, and so forth during set hours. ICU patients are offered earplugs, eye covers, headphones, and white noise machines to block out unavoidable sounds in the unit.

Joan Herbert, Director of Organizational Performance at MUSC, shared the strategies that her institution has implemented to improve doctor communication. MUSC instituted a broad excellence program that focused on close collaboration between the hospital and the college of medicine/faculty process plan. The program emphasized transparency: sharing quarterly reports of patient satisfaction and patient comments with physicians, and also included this information in physician dashboard reports. At departmental faculty and resident meetings, the Dean and CMO emphasize the importance of the patient experience and physician communication. Team leaders also internally share experiences and best practices among departments. Perhaps most important, MUSC leadership recognizes and rewards clinics and units with high performance scores.

A recurring theme of the presentations is that there is no “silver bullet” to improve HCAHPS scores. Improvements come through a process of trial and error, and it takes time to see significant results. Hospitals that are successful typically have dedicated leaders who are able to create a culture committed to quality improvements. Quality leaders must also overcome numerous challenges, not least being bureaucratic inertia, in implementing these changes. But perseverance pays off.

Scott Wetzel is a Health Care Affairs Program Specialist at the AAMC. He specializes in regulatory policy and hospital quality measurement issues and can be reached at