Monitoring Hospital Care Through HCAHPS

If a doctor has opened with a bronze lancet an abscess of the eye of a gentleman and has caused the loss of the eye, the doctor’s hand shall be cut off.” Luckily for today’s physicians, Hammurabi (circ 1820-1750 BC) did not live long enough to impose his version of paying for performance. However, while physicians have thus far escaped this eyefor- an-eye concept of justice, the theory lingers on. In fact, it has gained momentum in the last decade; there is increasing emphasis on holding physicians, hospitals, and other healthcare providers monetarily accountable for the quality of care they provide. The National Association for Healthcare Quality (NAHQ), the Agency for Healthcare Research and Quality (AHRQ), the Leapfrog Group, the Joint Commission, the Institute for Healthcare Improvement (IHI), and the Centers for Medicare and Medicaid Services (CMS) are just a few of the many national and local payers and regulatory agencies that have developed indicators to monitor quality of care and link it to the fee providers receive for their services. Monitoring patient satisfaction The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a tool developed by the AHRQ and adopted by CMS to measure patient satisfaction with the care they receive. While CAHPS has been around for a decade, CMS has recently asked the hospitals participating in a prospective payment system (PPS) to monitor the satisfaction of patients with overnight stays using HCAHPS, the hospital version of CAHPS. Although Congress voted to override the most recent proposed cut in payments under the Medicare physician fee schedule, it is still important for care providers to be able to earn every single penny on the table. Th us, hospitalists must learn what HCAHPS is and how it can aff ect hospital reimbursement.

Hospitals, like any other business, are likely to pass any fi nancial losses on to their vendors. Although HCAHPS on the surface will appear to aff ect the hospitals’ earnings, it is likely this will be passed on to hospitalists.

As a hospitalist team leader, Harjot Kahlon, MD, monitors his team’s performance with the eye of a hawk. He sifts through the data and then provides feedback to his physician colleagues. Similarly, the Society of Hospital Medicine (SHM) advocated the use of 10 indicators to monitor a hospitalist team’s performance: Mortality rate Readmission rate JCAHO core measure Provider satisfaction Productivity Hospital cost Patient satisfaction Length of stay Volume Case mix."

We monitor all of those closely,” Kahlon announces proudly. One measure that has troubled him, however, is the patient satisfaction survey. Kahlon’s team uses their own phone-conducted survey to assess the satisfaction of every patient leaving the hospital, and their results thus far have been very good. “When I go into my CEO’s office, he will show me the hospital conducted patient satisfaction survey, which uses the vendor Press Ganey, where we seem to score in a lower percentile,” he says. But Press Ganey uses a mail-based survey, and an entirely diff erent questionnaire.

“So how can we compare the results between two surveys?” asks Kahlon, also hospitalist program leader at Florida Hospital, Palm Coast. CMS has considered the same question for a decade. Hospitals have monitored patient satisfaction for decades, using phone and mail surveys, and even some hybrid models. They have asked different sets of questions, used different vendors, and applied different inclusion criteria. So how can any benchmarks be developed?

Making strides

The answer to Kahlon’s woes is provided by HCAHPS. It is designed to produce comparable data, fi nancial incentives are added to improve quality of care, and public reporting will ensure transparency. Now Kahlon can compare “apples to apples.”

In July 2002, AHRQ, solicited instruments designed to measure patients’ perspectives of in-patient care. After researching literature, holding public hearings, and conducting interviews with experts, AHRQ submitted to CMS a draft of “CAHPS.” In 2005, CAHPS was endorsed by the National Quality Forum. It was first tested as a pilot in three states. HCAHPS provided for standardized methodology and comparable data and allowed researchers to adjust for confounding variables. Surveys could be conducted by mail, by telephone, by a hybrid of the two, and even used in interactive voice recognition. The surveys conducted by phone are adjusted downwards when compared with surveys conducted by mail, as surveys conducted by phone usually get a better response rate and also a higher satisfaction rate. The mail survey, on the other hand, is often completed by unsatisfi ed and angry patients only. The hospitals can do it themselves or outsource it to diff erent vendors.

Since most hospitals already measure patient satisfaction, mostly using vendors (eg, Press Ganey, Gallup), they do not need to start from scratch, but can instead incorporate HCAHPS in their present methodology. All hospitals that opt for PPS (voluntary) are mandated to put HCAHPS in use and report the findings. Failure to report will result in a 2% reduction in the payment. The HCAHPS is composed of 27 questions, and covers the following topics:

Patient perspective on care Communication with doctors, nurses Responsiveness of hospital staff Cleanliness and quietness Pain management Communication about medication Discharge information

The results are posted by CMS on a website; CMS has started a major public awareness campaign to publicize the website called Hospital Compare and encourage the general public to use it.

The data on the website can be used to compare diff erent hospitals. Prospective patients are encouraged to use the website and compare neighboring hospitals in their catchment area. The website posts not only the results of the patient satisfaction survey, but also process-of-care measures and the outcomes-of-care indicators. The results are aggregated into 10 categories:

Six composite topics Nursing communication Physician communication Pain control Explaining medication Staff responsiveness Discharge instructions Two individual topics Clean environment Quiet environment

At any one time, consumers can compare up to three diff erent hospitals; the hospitals could be chosen by distance from a city, by name, or by zip code. The results are user-friendly, easy to interpret, and presented in bold yellow color. Results can be viewed as graphs or numbers.

“My hospital is participating in the PPS and has implemented the HCAHPS,” says Kahlon. “I am excited; this gives us a method that is comparable and benchmarkable. I will like to know how our patient satisfaction compares with other hospitalist teams in our county and state.” As Jerod Loeb, executive vice president of The Joint Commission, said, “When grades are posted on the classroom door, and your name is up there, you want to do well.” HCAHPS is the fi rst standardized, publicly reported survey instrument that measures patient satisfaction with hospital stay. CMS has succeeded in attaching part of the hospital payments to HCAHPS score, and will allow the public to learn about their local hospital care in comparison with competing hospitals drawing from the same catchment area.

Saeed A. Syed, MD, FRCP, FACP, is the National Medical Director for Emcare Inc.’s Hospitalist Division, the nation’s leading provider of emergency care, which provides services to more than 300 client hospitals, including many of the top 100 hospitals in the United States. Dr. Syed also writes the weekly blog Vital Signs for MDNG.