NewYork-Presbyterian CXO Rick Evans: An HCAHPS update is needed urgently

Virtually every adult inpatient hospital in America administers the HCAHPS survey to patients. The data from these surveys are publicly reported for all to see, and star ratings are assigned to hospitals based on this patient feedback. In addition, results of these surveys are a driver of the government’s Value-Based Purchasing program, which rewards or penalizes hospitals based on performance. HCAHPS and other CMS-mandated quality measures are ingrained into most hospitals’ goal setting and operations. The stakes on performance are high.

When HCAHPS came into being in 2006, followed by the first public reporting of results in 2008, it was a game changer. The survey shined a bright light onto the importance of patient experience and elevated improvement work to a new level. There were great benefits from this change. Patient experience improved across the country with survey measures rising year over year until the pandemic. The advent of HCAHPS moved many hospitals from an ad hoc approach to improving patient experience to a much more strategic stance. This was good for everyone — patients, families and our care teams.

That was nearly 15 years ago. The survey tool and process has barely been adjusted since. At the same time, healthcare and our society have changed. Patient expectations and priorities have evolved dramatically, especially informed by their experiences in other parts of their lives. Technology has transformed many elements of the care experience that the HCAHPS survey measures. Healthcare has become an ecosystem of both in-person and virtual interactions.  It’s a whole different world.

The survey that changed the landscape in 2006 is now outdated. It is only allowed to be administered on paper. Additional survey modes — especially digital modes such as email and texting — must be deployed. The questions asked also need to be re-evaluated to evolve with patient expectations. An update is way past due and needs to happen now. If updates are not implemented soon, I fear that we risk losing some of what we have gained in recent years. 

A looming concern is that response rates for the paper HCAHPS survey are declining year over year. More paper surveys than ever land in the junk mail pile and eventually the trash. Lower response rates mean we are getting less and less feedback from our patients. This is noticed by our care teams - and especially our physicians and other clinicians. They have been great partners in the work of improving patient experience. The relevancy of the data is paramount to them. The credibility of our work is at stake. Make no mistake, if we lose that hard won buy-in from clinicians, our efforts will be in jeopardy.  

There are also concerns about the range of perspectives that are collected with a paper survey. Generational differences and concerns about healthcare equity need to be factored into the survey tool and the modes for survey administration. Patient advocates around the country have been very vocal about these issues. An updated tool and process is needed to harness all voices. 

There is also the risk to the work of patient experience itself. The visibility that HCAHPS gave to the importance of patient experience as a quality and business imperative has been critical to harnessing precious resources — especially hospital budgets — to support improvement. This investment helped us improve the critical interactions that are essential for patients and the care team to achieve the outcomes we all desire. Advances have also been made in related areas such as patient engagement, diversity and inclusion and the caregiver experience. A body of knowledge has grown around these and other key issues and areas of focus. As I have said, all these advances were hard won. The credibility of data from surveys such as HCAHPS is foundational to all of the above and must be preserved.

In recent months, I’ve seen several articles in the literature that are questioning HCAHPS, and, to some degree, the importance of patient experience work itself. There is a danger of conflating the importance of the work with the survey tool itself. We must be clear about the distinctions here, and we must update the source data that drives so much of the work. 

CMS has already undertaken an effort to evaluate and update the HCAHPS survey tool and modes. In fact, testing of these items is underway. I laud CMS for doing this. But the pace must be accelerated. The factors I have already mentioned threaten to overtake what has been accomplished in recent years. We need a more relevant survey in multiple modes, and we need it as soon as possible. 

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