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December 2012 Nursing Management

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Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Impressing
patients
while improving

HCAHPS
By Laura Long, PhD, RN

he healthcare system has

traditionally focused on
clinical outcomes, paying
less attention to feedback
on the patient experience. That
focus is shifting with the advent
of the Hospital Consumer Assessment of Healthcare Providers and
Systems (hcahps) as the first publicly reported survey of patients
perceptions of their hospital care.
hcahps is a data collection tool
measuring patients perceptions of
their hospital experience. Although
many hospitals collect patient satisfaction information for internal
use, hcahps provides a national
standard for collecting and publicly
reporting information that allows
comparisons to be made locally,
regionally, and nationally.
Not only does hcahps report information about patients experiences,
beginning in October 2012, hospital

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reimbursement from the Centers

for Medicare and Medicaid Services
(CMS) started linking to hcahps data
as part of the value-based purchasing
(VBP) system. This marks the first
time perceptions regarding the quality of nursing care will be directly
linked to hospital reimbursement.
The impact of nursing care on patient
satisfaction has long been established,
but never before linked to financial
rewards.1

Ranking performance
The hcahps survey asks discharged
patients 27 questions about their
recent hospital stay. The survey is
administered to a random sample of
adult patients between 48 hours and
6 weeks of discharge. Patients admitted to medical, surgical, and maternity care services may be selected
for the survey, and the survey isnt
limited to Medicare beneficiaries.

Nursing Management December 2012 33

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Impressing patients while improving HCAHPS

The October 2012 public report

scores are based on over 2.8 million
surveys from 3,867 hospitals. On
average, every day more than 26,000
patients are surveyed about their
hospital experience and more than
7,700 patients complete the hcahps
survey.2
The hcahps survey contains 18
core questions that ask how often
or whether patients experienced a
critical aspect of hospital care, rather
than whether they were satisfied
with the care. Ten measures are
reported on the Hospital Compare
website for each participating hospital.3 Rather than report responses
to each question, there are six summary measures constructed from
two or three survey questions. The
six composites summarize how well
nurses and physicians communicate
with patients, how responsive hospital staff members are to patients
needs, how well hospital staff help
patients manage pain, how well the
staff communicates with patients
about medications, and whether
key information is provided at
discharge. Two individual items
address the cleanliness and quietness of patients rooms, while two
global items report patients overall
rating of the hospital, and whether
theyd recommend the hospital to
family and friends.

Patients perceptions
Although patient surveys are often
referred to as satisfaction measures,
hcahps makes an important distinction between experience and
satisfaction. This difference was
recently articulated by the Robert
Wood Johnson Foundation. Surveys
that use rating scales (for example,
from excellent to poor) tend to reflect
expectations. Surveys designed to
measure experience focus on the
critical interactions patients would
ideally experience during healthcare

encounters. Because they ask patients

whether or not certain events or
behaviors actually occurred, or how
often they occurred, patient experience surveys highlight areas providers can focus on for improvement.4
(See HCAHPS goals.)

Monetary incentives
In October 2012, the CMS started
basing 1% of payments to hospitals
on hcahps as part of the hospital
VPB program. In fiscal year 2013,
the VBP will establish a total performance score (TPS) that will have
two components: the clinical process
of care domain, which will account
for 70% of the TPS, and the patient
experience of care domain, which
will be 30% of the TPS. The hcahps
survey is the basis of the patient
experience of care domain. Private
insurers are also likely to consider
hcahps data as factors in calculating
providers fees.
In fiscal year 2014, the CMS will
reduce base operating DiagnosisRelated Group (DRG) payment
to all hospitals reimbursed under
the IPPS model by 1.25% (up from
1% in fiscal year 2013). In future
years, the CMS is likely to withhold higher percentages of DRG
payments while increasing expectations in pursuit of greater value
and quality. The money withheld
will be used to create an incentive
fund to pay hospitals based on their
performance.

Providing advice
The new era of hospital VBP has
created growing interest in how hospitals can improve hcahps scores.
Vendors have responded with the
development of websites, consulting
services, and education programs to
help clinicians improve the patient
experience. Typing in improve
hcahps scores quickly yielded 95,000
responses on one search engine.

34 December 2012 Nursing Management

Among the companies providing hcahps improvement advice

is the Disney Institute, famous for
referring to employees as cast members. Disney recently began offering a 3-day program at its resorts in
Orlando called Building a Culture
of Healthcare Excellence.5
At several Massachusetts hospitals, nurses have been given laminated cards with scripted wording,
such as Is there anything else I can
do for you before I leave? I have
the time while Im here in your
room. These particular words,
consultants say, are important
because research shows patients
are more satisfied with their care
when they believe nurses made
time for them.6
Patient satisfaction has been
associated with a variety of nursing factors. Nurses ratings of their
work environment have been linked
to hcahps patient satisfaction measures.7 Specifically, lower patient-tonurse ratios and higher proportions
of RN staff have been linked with
higher job satisfaction, positively
associated with patients higher
ratings and recommendations of the
hospital to others, and with patient
satisfaction in receiving discharge
information.7,8

Making the grade

In a strategy for success with hcahps
data, its imperative that all employees understand the importance of
hcahps scores to the institution, and
the potential impact each employee
has on impacting the patient experience. For many institutions, this
may involve orienting all employees
to hcahps, providing newsletter
updates, and department meetings
tailored to staff needs at multiple
levels.
If hospitals want to improve performance, theyll benefit most from
focusing on interpersonal aspects of
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care.9 Hospitals need to focus on an

organizational culture that provides
an excellent experience at all levels
of patient interaction.10 This means
creating patient-/customer-focused
behaviors from all staff beginning
with the ED or admissions area
right through follow-up with phone
calls after discharge.
In order for hospital staff to
become more aware of hcahps
data, a means of reporting hcahps
results to all staff members should
be identified and should highlight
strengths, areas for improvement, and comparisons with local,
regional, and national facilities.

Its all about the patients

Hospital administrators focused
on maximizing reimbursement
will realize the greatest impact by
improving patient satisfaction with
nursing care.11 The following items
comprise the patient experience
domain, six of which are dramatically impacted by nurses:
communication with physicians
communication with nurses
pain management
cleanliness and quietness of the
hospital environment
responsiveness of hospital staff
communication about medications
discharge information
overall rating of the hospital.

should be sure to at least mention to

patients when they call physicians,
hear back from physicians, or document any communication. Statements
such as Ive paged the physician to
talk about your pain medication, or
Ive written in my notes that youre
still rating your pain as 6 let patients
know nurses are initiating physician
communication.
Whenever possible, nurses
should make an effort to round
with physicians, and physicians
should be encouraged to seek
out nurses. Creating a culture of
collaborative practice in the presence of patients can enhance positive
communication ratings.10 In teaching
hospitals, collaboration is important
to model for residents and medical
students because theyll also have
a significant impact on the patient
experience.
Physicians should be informed
about hcahps data on communication scores for the hospital. As a
top-down strategy, medical directors and department heads should
ask physicians to identify what can
make the hospital a better place
for them to practice and for their
patients to receive care. Like all
other healthcare personnel, physicians need to feel a part of the organizational culture, with problem
identification, improvement strategies, follow-up, and feedback.

Physician communication
Educating physicians about hcahps
is critical because physician communication during the patient
experience is a specific survey item.
Information from the medical director can highlight the importance of
hcahps, but a top-down, bottomup, and peer-to-peer approach is
important to get physicians focused
on communication.
Although patients may overestimate communication between hospital physicians and nurses, nurses
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Increasing nurse communication

To encourage direct care nurses to
buy into a customer-focused culture, nurse administrators should
be visible. They should focus on
making rounds in patient-care
areas; interfacing with patients and
staff to assess whats working well;
identifying barriers to providing
quality, efficient care; and providing input and feedback to staff.
Nurse managers should be rounding every day to follow up on care

HCAHPS

goals

1. Provide standardized data about

patients perspectives of care that allow
objective and meaningful comparisons
of hospitals on topics important to
consumers.
2. Create new incentives for hospitals
to improve quality of care by publicly
reporting results.
3. Enhance accountability in healthcare by
increasing transparency of the quality of
hospital care provided in return for the
public investment.2

needs and feedback regarding staff

and the unit. Most hospitals have
taken measures to be sure patients
know who their assigned nurse is by
using a white board. Nurse managers may want to make themselves
accessible to patients as well by providing their name and extension.
Hourly rounding by nurses is the
proactive strategy that may make
the biggest impact on improving
the patient experience.12 Hourly
rounding by nurses has been shown
to reduce patient falls by as much
as 50%, reduce pressure ulcer incidence by 14%, and reduce patient
use of call lights by 38%.12 Another
study revealed that on one orthopedic unit, 166 hours of nursing
time was gained back in 1 month
by performing hourly patient
rounding, which helped address
patients needs before using the
call light.13
There are specific priorities
nurses should address during
hourly rounds, which include:
address the three Ps (potty,
position, pain)
perform an environmental assessment (telephone, tissue, trash can,
TV controls)
ensure the patient is covered and
comfortable
tell the patient they were
rounded on so comfort levels
could be checked

Nursing Management December 2012 35

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Impressing patients while improving HCAHPS

ask the patient if theres anything

else the nurse can do before leaving
inform the patient that nursing
staff will return in an hour to round
again.14
In certain circumstances, such as
patient teaching, nurses are encouraged to sit rather than stand over
patients, establishing bedside eyelevel communication with patients.
Individualizing patient care is
another strategy to help achieve
patient-care excellence. Nurses are
encouraged to ask patients whats
most important to them, focusing
on short-term goals, and writing
them on a white board so other care
providers know what to focus on.14
Conducting shift report at the bedside also offers the opportunity to
introduce the oncoming caregiver,
update the white board, and highlight short-term goals. Nurses are
also encouraged to discuss patientcare progress with the patient so the
latter can verify accuracy.

Addressing pain management

Pain has frequently been referred to
as the fifth vital sign, and is perhaps

are to rate staff as providing attention to pain management.15

Cleanliness and quietness of the

hospital environment
Housekeeping staff should be
informed that patients will be asked
for feedback regarding the cleanliness of the hospital environment.
Like other members of the patientcare team, housekeeping staff members should be informed about
hcahps ratings and how their hospital ratings compare with regional
and national data.
In addition to routine housekeeping staff rounds, nurses should seek
housekeeping assistance when the
need arises, such as overflowing
trash or linen hampers after dressing
or linen changes. Housekeeping staff
members should also be encouraged
to seek assistance from nursing staff
when they become aware of patient
needs during their rounds as part of
the patient-care team.
Hospital staff members are often
poorly attuned to noise levels in
patient-care areas. Although the
pace and volume may be difficult

units. Housekeeping and facilities staff should be made aware of

wheels on all carts and equipment
that are unnecessarily squeaking
or rattling. On some units, shutting
patient doors for privacy to reduce
the noise level may be an option.
Managers should make it a point to
ask staff for ideas about improving
quietness on the unit.

Responsiveness of hospital staff

Patients use call lights when they
need something, and long waits will
negatively impact the perceptions
of staff responsiveness. A strategy
to answer call lights and respond in
a timely manner is essential. Staff
members should respond even if they
cant meet the patients need because
they can seek out the appropriate
person. When patients have to wait
for specific staff or equipment, such
as assistance with a lift, its important
to communicate a realistic time frame
to meet their need.

Discussing medication
Medication reconciliation needs
to be an ongoing process. While

The nurse communication section of the HCAHPS has the highest impact
on patients overall hospital satisfaction and likeliness to recommend
the hospital to others.

the one patients are most aware of.

Improving pain management should
be a daily goal. Nurses should ask
about pain, have patients rate their
pain, administer medications on a
timely basis, and ask patients about
relief. The more pain management
is discussed, the more likely patients

to monitor and manage during the

day shift, managing noise levels
should be a priority during evening and night shifts. Answering
call lights promptly, responding
to monitor and infusion alarms,
and minimizing overhead paging
are important on all patient-care

36 December 2012 Nursing Management

administering medications, nurses

should provide education regarding
the purpose of key medications and
information for patients and family
members about common adverse
reactions. Medication teaching during the hospital stay is an important
part of earlier discharge teaching.
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Discharge details

Other care providers

Discharge teaching should be a

focus throughout the hospital experience. Because various disciplines
often provide written information to patients, there should be a
uniform folder at each bedside for
these papers. In addition to providing written and verbal information,
its essential to validate patient
understanding by asking openended questions and involving
patients and caregivers in return
demonstration. Where there are
concerns about complex teaching
needs, case managers should be
involved in evaluating patients for
home-care services. Patients who
are referred for home care should
be provided with information
regarding providers, contact information, and a visit plan.
Research has revealed that phone
calls to patients following discharge
provide an important opportunity
to review discharge information,
assess compliance with information, answer questions, and improve
patient impressions of their hospital experience.12 Phone calls are
optimally made within 48 hours of
discharge.

The patient experience primarily

involves interactions with hospital
employees, but provider interactions shouldnt be overlooked.
Faculty members from programs
placing students in the clinical area
need to be informed about hcahps,
and students in these programs
need to be aware of hcahps as part
of their learning experience. Liaisons from vendor organizations,
such as home healthcare, infusion
vendors, and durable medical
equipment companies, who interface with patients also need to be
informed about the importance
of their influence on the patient
experience.

Recommending the hospital

The strongest predictors of
inpatients willingness to recommend a hospital are items that
reflect interpersonal aspects of
care such as nursing and physician
behaviors. The October 2012 report
of hcahps survey results revealed
70% of recently discharged patients
would recommend the hospital,
implying 30% may not.16 These findings are consistent with hcahps
data from 2008, when only 67.9% of
patients responded they definitely
would recommend the hospital.17
They highlight the importance of
hospitals focusing on patient satisfaction.
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Putting it all together

Based on hcahps test data, the
nurse communication section of the
hcahps has the highest impact on
patients overall hospital satisfaction
and likeliness to recommend the
hospital to others.18 Specific nursing
actions, including hourly rounds,
patient-focused communication,
bedside report, a focus on pain management, and discharge teaching
can make a measurable impact on
the patient experience. As hospitals
are focusing on improving the inpatient care experience, nursing has
an opportunity to demonstrate that
what we do makes a measurable difference, recognized by patients and
the public. NM
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Laura Long is a liaison RN at VNA Care Network
and Hospice in Worcester, Mass.

The author has disclosed that she has no

financial relationships related to this article.

DOI-10.1097/01.NUMA.0000422891.99334.68

Nursing Management December 2012 37

Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.