In what ways is this a myth? First, whereas the Press Ganey tools ask consumers to rate aspects of care on a continuum of satisfaction, HCAHPS only asks about frequency. The words “how often” precede all but two questions on the survey. “How often did nurses explain things in a way you could understand.” The fact that Nurse Smith is an awesome communicator and cared for the patient during much of his stay has essentially no bearing on deciding whether the best answer is “Sometimes, Usually, or Always.” (In HCAHPS scoring, only “always” is scored in the numerator).
Where have we seen this kind of scoring before? The answer is in the Joint Commission’s Core Measures, where top decile performance requires that the healthcare team accomplishes specific actions 100% of the time. That might be the frequency with which influenza vaccine is administered to eligible patients, or aspirin to patients experiencing symptoms of AMI. Providing exemplary service to cardiovascular patients is one thing; building process reliability to do one simple thing without fail requires another approach.
Is this analogy really valid? Yes. First, the same philosophy of quality improvement that underlies the Core Measures was at work in designing HCAHPS. The goal was to encourage organizations to build reliable processes that ensure that they do what they intend to do for the patient, every time (or nearly so). If there is going to be variation in care, let that variation be planned - around the needs of the patient - rather than as the accidental byproduct of inconsistency.Additionally, almost all of the HCAHPS measures were designed to improve aspects of care that drive clinical outcomes of interest. “Before giving you any new medicine, how often did staff explain side effects in a way you could understand” is not the kind of question that would ever be included in a patient satisfaction survey. Performance in the domains of Nurse Communication, Physician Communication, Medications, Care Transitions and Discharge all align with important outcomes, including medication adherence, medication errors, readmission, markers of disease management (such as hemoglobin A1C in diabetic patients), 30-day readmission and, in the case of AMI, 1-year mortality.
Some have argued that “exceeding expectations” by emphasizing customer service could improve the “hospital rating” questions (there are two). There may be some truth to this…but with caveats. The first is that not every such effort drives this metric to the degree that we might guess. Focusing strategically on what actually matters to patients is key. Another is that CMS doesn’t treat these "hospital rating" metrics as special. Together, they comprise just 18% of the Patient Experience measure set (which itself comprises 22% of the CMS Stars Rating report card). So lets focus on helping patients by improving those aspects of hospital quality that are targeted by HCAHPS. Some such efforts are well underway in our hospital.
In my next post: more about those efforts, and how the Relationship-Centered Communication course brings to the bedside evidence-based “micro-skills” that improve patient outcomes even as they help physicians to be more efficient, relieve our workplace stress and bring us greater joy in practice.
