Filling in the gaps: What else should HCAHPS be measuring? 4 questions with quality expert Dr. William Maples

In the era of value-based care, the HCAHPS survey is the most influential measure of the patient experience, as hospitals can be financially penalized when they record low patient experience scores. However, there is conflicting evidence as to whether or not excellent HCAHPS scores actually translate into high-quality care and better outcomes.

In April 2015, CMS began rating hospitals on a five-star scale based entirely on HCAHPS scores. In April 2016, research published in JAMA Internal Medicine determined hospitals with high CMS star ratings do in fact have lower mortality and readmission rates than lower rated hospitals. That evidence was contradicted this August in a study released by the healthcare software company Quantros. The Quantros study found some one-star hospitals outperformed five-star hospitals based on a composite score assessing for mortality, complication rates and patient safety indicators from the Agency for Healthcare Research & Quality.

To accurately measure the true patient experience and understand the impact of creating a culture of excellence on care quality, HCAHPS would require some additions to capture key elements driving the experience, according to William Maples, MD, CMO of Professional Research Consultants and leader of PRC's The Institute for Healthcare Excellence. Before joining PRC, Dr. Maples led quality and safety efforts across Asheville, N.C.-based Mission Health System. Prior to joining Mission Health, Dr. Maples was a quality leader and practicing oncologist at Mayo Clinic in Jacksonville, Florida, for more than two decades.

Recently, Dr. Maples spoke with Becker's about HCAHPS, the survey's shortcomings and the role teamwork plays in improving patient experience and care quality.

Note: Responses have been lightly edited for length and clarity.

Question: How has HCAHPS changed since it was first created in 2002?

Dr. William Maples: HCAHPS were tested with rigor and validated when they were first launched in 2002 with the intent to understand the patient's perception of care, drive accountability, improve quality and safety of care by creating a patient-centered culture. In the last few years they've added questions regarding population health and transition of care. There have been a few questions added that have contributed some richness to the survey, but for the most part the basis of the survey has stayed intact.

Q: What do the HCAHPS surveys get right? Where are they lacking?

WM: I think the HCAHPS were really designed to produce data about the patient's perspective of care and to improve quality and safety in healthcare. The core survey addresses aspects of physician and nursing care such as listening, explaining, and treating individuals with courtesy and respect. In addition, the survey also addresses aspects of the hospital environment.
That's what they get right. As they are an important piece of accurately assessing the patient experience I would not recommend replacing the HCAHPS.

There are some gaps in the survey because of the financial award and penalties that are a part of value-based care. The connection between penalties and care value is not synonymous. Often times it can lead to efforts to improve the scores rather than working on things to improve the difference in the patient experience.

There are some critical elements that are necessary to create an excellent experience which are not addressed in the current HCAHPS survey, including teamwork across all elements of the healthcare team, confidence in the provider, and empathy. For the past 20 years, patients have said the things they care most about when seeking care that the HCAHP survey doesn't really address are things like "does my provider team really care about me and my health? Does my care team give me the perception that they have time for me? Does my team respect me and my beliefs as an individual?" Because of the financial rewards, providers focus on improving the scores measured by the HCAHPS, they tend to not focus on solutions that drive the patient experience. We've made our own definition of what the patient experience is, but it doesn't address the questions that are truly necessary to define a quality patient experience.

Q: What is the value of understanding and measuring the patient experience?

WM: The patient experience really derives from the workplace culture. If we really accurately measure and implement solutions which work to improve teamwork, trust, listening, valuing others, we will create an exceptional experience for the caregivers and create a highly functional team. When we create that team, we can drive outcomes and safety in positive directions for both employees and patients. The work of Michael Leonard, MD, [author of Collaborative Caring: Stories and Reflections on Teamwork in Health Care] has shown high levels of teamwork are associated with reduced healthcare-associated-infections, reduced medical errors and an increase in employee safety. Nowhere in the HCAHPS is teamwork assessed. By tackling the ingredients, like teamwork, which create an optimal patient experience, we subsequently create an optimal caregiver experience. Above and beyond that is the whole issue of burnout. When we truly connect with our patients and put the patient at the center of the team and truly connect with each other, when we truly connect, we allow ourselves to connect to our purpose and allow the possibility of experiencing joy in the practice of medicine. That's the benefit of focusing on the patient experience. As far as finances go, when we do the work to benefit the patient experience, the return on the investment is 5 to 1. That makes this work a no brainer.

Q: In your opinion, how can providers increase the accuracy of their patient experience measures and use what they know to improve care quality?

WM: We need to measure the correct things and the measurements have to be reliable. As a provider I would want to understand the answer to the following questions: What is being measured and are we assessing the key elements which drive an exceptional experience? Are the measurements reliable? Do the measurements accurately reflect my care delivery—that is do the measurements reflect the breadth of my practice? Do the measurements help me implement solutions to create a culture embracing excellence?

The second thing that's important is that we really do need to understand what that experience is if we're going to make interventions to close gaps. We need to be certain that the measurements reflect the experience of the entire population of patients served and not segments of that population. Most people don't fill out surveys that come in the mail. So you either get responses from people who are really upset or you get the small percentage that are incredibly happy, but you miss the 85 percent of those you serve in the middle. So often times you're making decisions based on data from a skewed population set. One of the things we've done in America to solve this issue is send out more surveys. And we still end up with same spectrum of individuals. I think if I was a provider, I would be asking, what are the measures? Are all the measures being questioned? And what's the response rate? If it's lower than 20 percent, I'm skeptical. I would want to be certain to capture the voice of the broad spectrum of patients I serve as I design and implement solutions.

Once we have metrics that capture the key elements of the patient experience and capture the breadth of the patients we serve, we can transparently share the data across the system to drive accountability and improve care quality as initially intended by the HCAHPS process. We need to avoid tactical solutions and invest in culture changes that truly change the way we show up to work and interact with one another. I would focus on building those core cultural skills to help facilitate teamwork. I would then add tactical measures on top of culture changes. The most essential piece is the cultural work. Focusing on nurturing the core cultural skills to develop high functioning teams will be essential in this cultural journey as we create moment-to-moment exceptional care for our patients and caregivers.

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