Quality assurance leaders like the National Quality Forum (NQF), a
coalition that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations, maintain that health care outcomes are tied directly to patient perceptions of the care they receive. Press Ganey Associates, Inc., introducing its 2008 Hospital Pulse Report (Pulse Report), says that “The federal government has realized that listening to and acting upon patients’ feedback is critical to improving the qualify of health care in America. Hospitals that have focused on patient-centered care will have a business advantage as transparency and public reporting garner more attention.” The report, released by the company in March 2008, goes on to note that “The most successful hospitals are finding that patient-centered care complements other hospital goals, including clinical and financial outcomes.”
Does Patient Satisfaction Data Really Matter?
The Pulse Report, based on Press Ganey’s Inpatient Survey, is intended to give recently released hospitalized patients the opportunity to provide feedback about their stay. It is used by acute care hospitals across the United State to improve the quality of the service and care they deliver. The company has been working with health care client facilities for more than 20 years to provide measurement tools, consulting services, networking opportunities, and improvement solutions using patient, employee, and physician feedback to drive health care improvement initiatives. More than 11 million surveys are processed annually and more than 40% of U.S. inpatient hospitals currently contract with Press Ganey to measure patient satisfaction.
Avery Comarow, editor of the U.S. News and World Report’s America's Best Hospitals annual rankings, wrote on his “Comarow on Quality” blog the same month as the Pulse Report's release that patient satisfaction surveys have been on consumer advocates' wish lists for more than 10 years. Their wishes were granted when “the federal government’s Hospital Compare page added a massive amount of information about 2,521 hospitals that reveals how often and how well various patients needs were met: nurses listened to them, doctors treated them with courtesy and respect, their pain was kept in check, and in 19 other ways they were recognized as individuals.”
Comarow was referring to results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). He goes on to ask: “Do patient satisfaction surveys convey information that is medically relevant or even worth serious consideration? Should a patient choose a hospital based on its ability to be caring and attentive?” While explaining that he is still undecided about how or whether patients would benefit from the data, he notes that “there are major reasons patient satisfaction has never been factored into the annual rankings of ‘America’s Best Hospitals’ and asks if it’s fair to ask whether the chance of living or dying, of departing the hospital on schedule or having to stay because of a complication, truly depends on answers to questions like, “How often did the nurses listen carefully to you?”
Chasing the Money
For all intents and purposes, the question of the value of patient satisfaction perceptions has become a moot point. The Centers for Medicare and Medicaid Services (CMS) has announced that “beginning in July 2007, hospitals subject to IPPS payment provisions (“subsection (d) hospitals”) must collect and submit HCAHPS data in order to receive their full IPPS annual payment update (APU) for fiscal year 2008. IPPS hospitals that fail to report the required quality measures, which include the HCAHPS survey, may receive an APU that is reduced by 2.0 percentage points.
Deirdre Mylod, PhD, Vice President of the Acute Business Unit for Press Ganey, elaborates that “HCAHPS is a patient survey developed by the Agency for Healthcare Research and Quality (AHRQ) at the request of CMS. It is designed to reflect the care provided to adults in an inpatient setting. It is a short set of measures created to be a report card of how patients view their care so that consumers can compare hospitals on these and other publicly available quality measures”. She adds that “as a report card, the instrument provides a set of key indicators that are important to consumers, but does not include all of the major concept areas an organization would want to track as part of their quality improvement efforts.
“For example it does not include information about how patients evaluate privacy, emotional support, service recovery, shared decision making, or coordination of care. HCAHPS current public reporting, updated in September 2008, provides information about how hospitals performed for patients discharged January through December of 2007.”
According to Mylod, prior to July 2007 hospitals had the opportunity to voluntarily participate in data collection and public reporting. Beginning with July 2007 discharges; however, hospitals that choose not to participate will not receive their full IPPS payment update from CMS. Non IPPS hospitals, she adds, such as Critical Access Hospitals do not have their payment impacted by their choice to participate, but they are encouraged to voluntarily collect and share their HCAHPS performance.
She also notes that a Value-Based Purchasing plan has been proposed by CMS, that while not yet final, describes a scenario by which hospitals reimbursement could be reduced by 2-5% with the ability to earn back those funds based upon performance on clinical measures and HCAHPS measures.
HCAHPS is proposed to account for between 20-40% of the funds that could be earned back- or lost- based upon performance.
Outsource or Go it Alone?
According to CMS, the survey is shaped by three broad goals: the “First, the survey is to designed to produce comparable data on patients’ perspectives that allows objective and meaningful comparisons among hospitals on topics that are important to consumers. Second, public reporting of the survey results is designed to create an incentive for hospitals to improve quality of care. And third, public reporting will serve to enhance public accountability in health care by increasing the transparency of the quality of hospital care provided in return for the public investments.”
Hospitals can choose to administer HCAHPS internally or contract with an outside survey administer. However, to participate in HCAHPS data collection and public reporting, all hospitals self-administering the survey, as well as hospitals administering the survey for multiple sites, and survey vendors must meet certain program requirements and must be in accordance with the requirement in the HCAHPS Quality Assurance Guidelines, V. 3.0. They can use one of four approved modes of administration for the survey—mail only, telephone only, mail followed by telephone, and active interactive response (IVR).In addition, hospitals and survey vendors must submit a Participation from to the HCAHPS Project Team for approval prior to the administration of the survey. Moreover, at a minimum, the hospital’s or survey vendor’s project manager is required to participate in HCAHPS training. However, hospitals that have contracted with a survey vendor are not required to attend training.
Mylod explains that there are probably three main reasons to use an outside firm. “The first is that the guidelines and regulations for administrating HCAHPS are lengthy and complex. Most organizations do not want the burden of building and maintaining a system for data collection to meet the many requirements and then stay abreast of requirements as coding and rules change. Second, partnering with an organization that offers real time comparative data gives offers a completely different perspective on their performance than merely collecting the data and benchmarking yourself against the publicly available data that is between 9 and 18 months old.”
She goes on to note that Press Ganey clients are compared in real time against 1857 other hospitals currently conducting HCAHPS surveys with the firm so they know how they performed and are ranked in the current quarter. “Third, and most important, working with Press Ganey provides access to evidence-based best practices as well as consultative support to implement those best practices.”
Edward Hospital, located in suburban Naperville, Illinois, a Press-Ganey client, has been participating in the HCAHPS process for more than two years “In the beginning, we chose to use a third party provider for HCAHPS implementation because it was much simpler for us than going through the process of becoming a certified site,” says Jeff Sass, MBA, Manager, Market Research for Edward Hospital & Health Services. “We had already been using a third party for patient surveying; it was simply a matter of adding the HCAHPS questions to our existing questionnaire, and adjusting our sample size. Becoming a certified site, would have involved duplicating many of our existing surveying processes.” Sass adds that, “We’ve also realized the added benefit of being able to see how our HCAHPS data compares to a large number of hospitals nationwide. Our data is available several months before it is posted on the Hospital Compare web site. We can also see how we rank against other providers; as opposed to just how we compare to national and state averages.”
Getting Ready—The Medicare Payment and Beyond
Regardless of whether hospitals choose to self-administer the survey or go with an outside consultant, there are steps they can take to make sure the data is collected and reported accurately. Mylod from Press Ganey suggests that hospitals are already in the position of having their participation linked to payment, but “in the future their performance and improvement will also be linked to payment specifically under the proposed Value –Based Purchasing. Hospitals need to be transparent within their own halls by sharing their current performance and current external rankings with those who make the change happen, the unit managers.” She adds that hospitals who improve the fastest are those who allow nurse managers to track their own performance and see the results of their efforts for quality.
Beyond using the survey to qualify for the full Medicare payment, data collection and public reporting can also serve to enhance a hospital’s market position and reputation in the community.
Mylod notes that when Press Ganey analyzed proprietary patient satisfaction data—including HCAHPS measures—for hospitals that began reporting it in March 2008, following the first public release of HCAHPS data, a positive year-over-year increase in performance was seen in April. “This further widened to statistically significant year-over-year increases for the months of May and June. These trends were noted both for the percentage of patients rating their hospital as a 9 or 10, as well as the percentage of patients who said they would definitely recommend the facility, which directly impacts a hospital’s patient volumes and its revenue.”
She also mentions that there has always been a slow and steady improvement in patient-centered care over the years and many have enhanced their performance improvement initiatives in the months leading up to the HCAHPS release. “The HCAHPS measures show a dramatic increase timed following the public reporting which indicates that everyone really stepped up their efforts.”
Press Ganey also reported in September that data the company released showed an unprecedented improvement in patient satisfaction—a result that underscores the impact of public reporting of hospital-by-hospital satisfaction scores. “Press Ganey experts analyzed the company’s proprietary patient satisfaction data—including Hospital HCAHPS measures—for hospitals that began reporting the data in March 2008, and found a dramatic upturn in patient satisfaction, which strengthens the link between public disclosure and health care quality.”
The company also reports that these trends were noted both for the percentage of patients rating their hospital as a nine or 10, as well as the percentage of patients who said they would definitely recommend the facility, which has a direct impact on a hospital’s volume and revenue.
Sass notes that his hospital has been tracking and monitoring patient satisfaction for more than a decade, but that “Over the last two years, Edward has achieved its highest scores ever.”