Hospital Consumer Assessment of Healthcare Providers and Systems

HCAHPS Implements Consumer-Friendly Star Rating System

In April, the Centers for Medicare & Medicaid Services (CMS) rolled out a new star-rating system on Hospital Compare, the agency’s public information website. The star ratings are calculated from data compiled through the Hospital Consumer Assessment of Healthcare Providers and Systems, which you probably know as HCAHPS (and pronounce as H-Caps). The idea behind the survey itself hasn’t changed – it still aims to collect information that makes it easier for consumers to choose a hospital, while encouraging hospitals to improve quality of care by linking reimbursement incentives to patient satisfaction scores.

In a press statement, CMS explained that it implemented the star ratings because it is a quick-summary format that is increasingly familiar to consumers – and therefore allows them to more easily compare hospitals. If you shop for products on Amazon or browse movies on Netflix, you’re already familiar with this type of rating system, which measures user satisfaction on a scale of one to five stars. However, applying this five-star system to healthcare facilities has been met with some criticism.

It’s perception that matters

To begin with, many healthcare professionals, including nurses, have expressed concern that HCAHPS measures the patient perception of things like effective communication, nurse response times, pain levels, and hospital cleanliness – as opposed to objectively measuring the reality of the situation. A nurse might respond to a patient’s call as quickly as possible, but we all know that time can seem to pass slowly when you’re hungry, uncomfortable or waiting to use the bathroom.

On top of this objection to being rated so subjectively, hospital administrators are now worried that the star system may serve to confuse consumers, or to over-simplify very complex care issues. For one thing, each hospital now has 12 star ratings in total. Eleven of them correspond to individual HCAHPS survey questions about communication, responsiveness, pain management, discharge planning, cleanliness, noise levels and more. The final star is a summary rating that averages all the measures included in the HCAHPS survey, and this is the rating that most concerns healthcare professionals, because it encompasses so many complex factors. One healthcare management consultant blogged about the CMS star ratings, wondering if they are a more valid assessment than the hospital ratings on Yelp. (The star ratings do not replace the current percentage ratings, which remain online and available to the public, along with the state and national averages that consumers can use for comparison purposes.)

Weighing the pros and cons

Nurses make up the largest group of health care workers, and they are the “face” of the daily care that patients receive. So it’s no surprise that the HCAHPS survey section on nurses’ communication has been found to have the single greatest impact on overall patient satisfaction and likelihood to recommend the hospital to family and friends. To some nurses, this can seem like a lot of pressure; they are uneasy about being held accountable for overall patient satisfaction.

An entire consulting industry has already arisen around improving HCAHPS scores. Some hospitals are asking their nurses to use techniques known as “scripting” and “teach-back” in order to improve patient communication. Scripting aims to influence patient perception in positive ways, through your dialogue. For example, since patients will be surveyed about how often you provided information about the medication you administered, you might say something like, “This is a new medicine for you, so I want to explain to you in detail how it works and what it is being prescribed for, and then to listen to any concerns you might have.” The hope is that patients will more readily remember that they were given adequate information when they get to that question on the HCAHPS survey. On the other hand, this technique has sometimes been criticized as a form of “teaching to the test,” meaning it’s more about improving a score than improving the actual care that we deliver.

Still, we can view the HCAHPS initiative overall as a positive and unexpected opportunity to advance nursing interests. For example, studies have shown that patient satisfaction is higher when nurses have a better work environment, greater collaboration with physicians and more favorable staffing ratios. Hospitals haven’t always taken note of this data or acted on it to improve the nursing work environment, but that may change, now that patient satisfaction is linked to reimbursement – and nurses are poised to benefit when they do.


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