The Patient Experience

Do you remember your last overnight stay at a hospital?

You probably had some pain. Did the physicians and nurses do everything in their power to keep it tolerable? Did a caregiver always, usually, sometimes or never show up immediately after you pressed your call button?

Were the nurses and physicians courteous and respectful to you? All of them? All the time?

Did the nurses check on you frequently? Did they listen patiently to your questions and explain things in ways you understood? Did they make sure you knew what medicines you were taking and why, and what side effects you could experience every time they gave you medicine?

Were your room and bathroom kept spotless? Were the hallways quiet throughout the night?

When it was time to go home, did the hospital staff make sure you had all the outside help you would need to avoid a relapse and readmission? Did they give you written instructions to consult about symptoms or problems you might experience, and how you should care for yourself?

Now think over your entire experience. Using a scale of zero to 10 — where zero represents the most awful hospital conceivable and 10 rewards human perfection in medical care, attentiveness and quality — which score would you give to that hospital? Would you recommend it? Will you choose to be treated there again given an alternative?

Okay, end of exercise. You've just completed an abbreviated version of the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS survey, a set of 21 questions the Centers for Medicare & Medicaid Services requires that you (or a sample of patients older than 18 like you) be asked after a hospital stay.

And if you're a hospital trustee, consider it a thumbnail guide to the eight basic dimensions — nurse-patient communication, doctor-patient communication, prompt responsiveness of hospital staff, pain control, communication about medication, cleanliness and quietness of the hospital environment, discharge information and overall rating — your organization has to focus on to give patients what they expect and deserve when they're in your hands.

Note that there are no questions about flat-screen TVs, atriums with waterfalls, valet parking or coq au vin. Just skill, bedside professionalism, caring attention, plain talk, good housekeeping and calm. And not just sometimes, not just usually, certainly not never, but always.

Link to Quality

For nearly 40 years, U.S. hospitals have followed the example of other industries in trying to gauge and improve customer response to their services. They've looked to the hospitality sector for tips on room design and amenities. They've followed culinary trends to offer more appealing meals. They've devised a panoply of measurements to figure out just what patients value most when circumstances bring them across a hospital's threshold.

Initially, says Hope Brown, senior consultant at Professional Research Consultants Inc., hospitals were motivated to pay structured attention to the perspective of their bed occupants by a desire to reduce complaints and earn high marks they could trumpet in their advertising. "Ninety-nine percent patient satisfaction" emblazoned next to the institution's name on a billboard might give it a leg up on the competition.

By the 1990s, she says, hospitals had come to recognize that embellishing the patient experience can be more than a marketing tool. There is a strategic dimension. "If patients feel their care is excellent, they're four times as likely to recommend you," Brown says. "That's been shown in every industry."

Beyond that, she notes, making sure patients feel comfortable and well cared for is congruent with a hospital's compassionate mission.

In fact, patient experience actually correlates directly with hospital quality, Brown says. Press Ganey, an analytics and strategic consultancy firm that pioneered patient satisfaction measurement, recently summarized a growing body of research that links how patients feel about their experience in the hospital with how well they recover from their illness. In one study of 2,500 hospitals, for example, 30-day readmission rates for heart attack, heart failure and pneumonia were lowest at the facilities that had the highest patient satisfaction scores. A good experience was even more important, the researchers found, than clinical performance.

At least 55 separate studies have backed up that conclusion, according to a systematic review published in BMJ Open earlier this year. Greater patient satisfaction is accompanied by better patient adherence to treatment guidelines and lower inpatient mortality rates; patients who rank hospitals high on their HCAHPS surveys have fewer complications; organizations that score high on HCAHPS provide a higher quality of care across all measures of clinical performance than those beneath them. The authors summarized: "Patient experience is positively associated with clinical effectiveness and patient safety … . [Data] support the case for the inclusion of patient experience as one of the central pillars of quality in health care."

Link to Reimbursement

In 2005, CMS gave hospitals another compelling reason to ensure that their patients are happy campers: value-based purchasing. Providers are now being paid not just for how many things they've done to their Medicare and Medicaid clientele, but instead, at least in part, for how well they've done them. One of the key measures by which that performance is judged is the patients' own assessments of their inpatient experience via uniformly comparable HCAHPS scores.

Starting this fiscal year, hospitals with low scores will see their federal reimbursements docked. Those with high scores will receive bonuses. A percentage of Medicare and Medicaid payments — 1 percent this year, rising to 2 percent in 2017 — will be withheld by the government each year under a value-based purchasing formula in which HCAHPS accounts for 30 percent. Do well by VBP standards and a hospital will get back the entire percentage withheld — plus a reward, pegged to how high the organization ranks among all hospitals nationally that year. The bonuses will come at the expense of the hospitals that fare poorly. Because Medicare and Medicaid patients consume almost 60 percent of the average hospital's services, performance as measured by the VBP indicators can make a difference of hundreds of thousands if not millions of dollars to an organization's bottom line.

The VBP calculus is too complex for easy summary. In addition to patient experience, it also factors in a dozen clinical processes, mortality and per-case spending as a gauge of efficiency in changing ratios from year to year. What's more, under the Affordable Care Act, hospitals are now at risk of federal reimbursement being withheld up to 2 percent in 2013 (3 percent next year) based on the rate at which heart attack, heart failure and pneumonia patients are readmitted within 30 days of initial discharge.

In fiscal 2013, according to CMS, some 2,217 U.S. hospitals will be penalized for excessive readmissions. More than 300 will incur the full reduction. But if the knee-jerk reaction of an organization that loses revenue under VBP is to slash costs to compensate, it's making a potentially fatal mistake, warns PRC CEO Joe Inguanzo. Quality of care will suffer, the decline will be registered in patients' experiences as reported on the HCAHPS survey, outcomes will suffer and more penalties will accrue in a vicious downward spiral.

Instead, Inguanzo argues — and his Press Ganey counterpart, CEO Patrick Ryan, concurs — these hospitals especially should focus on improving the inpatient experience. Nothing but good will result.

Looking for Love

"Executives ask, 'What is our biggest problem?' " says PRC's Brown. Her usual answer: "You have too many patients who like you." Then she continues: "You don't have enough who love you."

Very few hospitals — about 3 percent — get zero or 1 as an overall grade, Inguanzo explains. Even the worst hospitals get a 9 or a 10 from as many as half their patients.

"Anybody can do okay care," he says. "Excellence is what counts." And hospitals that are loved merit a 9 or a 10 from at least 70 percent of those who've experienced their care.

Nor is it enough to rely on HCAHPS ratings alone, cautions Press Ganey's Ryan. Those numbers are stale by the time they're published. "You're looking in the rearview mirror," he says. "If you're happy with last year's data, you're already behind because the rest of the country is moving forward."

For real improvement, he says, hospitals need to go beyond the government mandate, query every single patient and mine the data constantly for real-time insights. Press Ganey emails queries to all its clients' patients immediately after discharge and processes the responses within a day or two.

"Today we can drill down and find exactly what's happening — by floor, by unit, by provider," he declares. "That's how you learn your strengths and your opportunities." For example, he notes, "We had one system that had a problem with its ob-gyn unit. In the past, using only the aggregate score, we would have gone in and retrained everyone in that unit. But now we could see it was the Saturday shift and the evening shift that were getting bad scores from a particular segment of the patient population."

Problem identified, remedial action targeted, issue efficiently corrected.

Both Ryan and his chief medical officer, Thomas Lee, M.D., are seasoned hospital trustees who currently sit on the boards, respectively, of Lahey Clinic and Geisinger Health System. "The boards I've been on know that the game is changing," Lee says. "In the old world, the focus was on fund-raising, margin and fee-for-service volume. Now the big concern is market share. My colleagues and partners look at [patients'] likelihood of recommending as hugely important. We talk about it at every meeting."

Ryan agrees. "It's a best practice to review patient experience data as the first priority at every meeting," he emphasizes. "I could name a thousand CEOs who'd tell you the same thing. Patient experience is the first, the second and the third priority because in totality that's what drives clinical and safety and financial performance.

"The proof is in the marketplace," he adds. "Look at the HCAHPS scores over the last three or four years nationwide. The improvement has been dramatic. And the curve continues to go up."

David Ollier Weber is a principal of the Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.