NewYork-Presbyterian CXO Rick Evans: Updated patient experience measures are long overdue

Well over a decade ago, the way we measure patient experience was transformed when the HCAHPS survey was launched. 

Hospitals had been measuring patient experience using an array of tools with different vendors for decades. With the 2006 advent of HCAHPS, which is implemented by CMS, a standardized tool was used across the nation for the first time. Results were publicly reported for consumers to compare organizations against one another. Questions were asked in a new format, focusing on the consistency of the experience in key domains. Results were also used as part of CMS' Value-Based Purchasing Program.

HCAHPS was a game changer. It elevated patient experience as a core measure of quality for healthcare. Its standardized nature assured that results were integrated into payment structures and other quality programs ranging from U.S. News & World Report hospital rankings to American Nurses Credentialing Center Magnet designation. The pervasiveness of its use as a core measure also assured that organizations focused more strategically on understanding and improving the patient experience. All of these were big steps for the elevation of patient experience in healthcare. HCAHPS helped move PX improvement from "nice to do" to "must do."

Fifteen years later, we have seen improvements in the patient experience. HCAHPS measures continue to improve year over year in most categories. Studies have shown correlation between HCAHPS results and higher care quality and also better financial performance for hospitals. A body of knowledge about how to meaningfully improve patient experience has emerged. It's been a good run.

For many reasons, however, we are past due for updates in how we measure patient experience in our country. Here are a few of them.

First, HCAHPS is currently only administered by paper surveys. In 2021, this is anachronistic. 

Fewer and fewer of us live on paper. Surveys must be administered in multiple modes now — including via phone, email and text. Having only one option — paper — must be addressed as soon as possible, as response rates are dropping year over year. Paper surveys also make HCAHPS a lagging indicator at best. Real-time results are needed to assure that PX metrics keep pace with the rest of the quality metrics used by hospitals in this era. Thankfully, CMS is currently conducting tests of new survey modes. This must be accelerated.

Second, questions must be updated with patient input. The current HCAHPS questions still have value because they focus on the most essential element of patient experience — communication with providers and the team. But the patients and advisory councils I speak with say updates are needed. Some questions seem duplicative. Other key elements seem to be missing, especially related to the role of family members in the patient experience. It's time to review and refresh this important, standardized tool.

Events of the last year bring urgency to this issue. COVID-19 and an awakening to issues of health justice and equity are having a wide impact, including on how we measure and understand patient experience. Our measurement system must be updated at its foundation to ensure we are collecting data on race, ethnicity and other identity issues so that we can understand patient experience results more fully and deeply. This has to be done in concert with overhauling the tools themselves. And, it has to be done now.

Finally, HCAHPS only applies to adult inpatient experiences. Other CAHPS tools have been created to measure experiences in the emergency department, ambulatory surgery department, physician practice environments and for pediatric experiences. CMS has said for years that these tools would also be formally promulgated nationally — but this has not yet happened. The result has been confusion and churn in survey tools being used across the country. It's time to "land the plane" on these tools as well. Patient experience is the entire continuum of care, not just inpatient episodes. It's time for a true national system of PX measurement that builds on the legacy of HCAHPS.

There are many patient advocates and patient experience leaders across the country who are ready and willing to help drive this effort, both alongside CMS and also with our legislative and policy leaders whose involvement is needed to advance this agenda. We are here and ready to help. 

It's important to remember that patient experience surveys aren't just about questions and statistics. Properly structured and delivered, they can be a powerful voice of patients and families to help us make healthcare better. The events of the last year and a half have brought us to a number of moments where change is both necessary and possible. We should use this opportunity to further evolve patient experience measurement as well. 


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