The Best HCAHPS Score: A Rodeo Invitation

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Continue to adhere to the basics of our profession, and patient satisfaction will not be far behind. And it should not be a surprise if the HCAHPS scores also go up!
— Chandrakanth Are, MBBS, MBA, FRCS, FACS

An otherwise healthy, actively working, independent 60-year-old patient came to us with a several months’ history of abdominal pain. He had been seen by other physicians prior to coming to us for a second opinion. Our workup revealed a large cystic lesion emanating from the pancreas but involving several adjacent organs including the stomach. Multiple tests were inconclusive for obtaining a conclusive benign or malignant diagnosis, although the radiographic features were ominous. After extensive discussions on multiple occasions with the patient and numerous family members, it was decided we would proceed to the operating room for biopsies with or without resection.

Intraoperatively, we were no better, with not much help from frozen sections. I scrubbed out to have a family meeting in the consultation room, which included more than 15 family members from 3 generations. We went over the options of proceeding with a major multivisceral resection for an inconclusive diagnosis or not doing anything, with the risk of leaving the lesion behind. The family wanted us to proceed with resection, and the patient tolerated it.

Intent of the Survey

This patient may have already received the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. As noted by the Centers for Medicare & Medicaid Services (CMS), the intent of the HCAHPS survey follows:

The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspectives of care information that would enable valid comparisons to be made across all hospitals. To make “apples to apples” comparisons to support consumer choice, it was necessary to introduce a standard measurement approach: the HCAHPS survey, which is also known as the CAHPS Hospital Survey or Hospital CAHPS.

Three broad goals have been established for the HCAHPS survey: (1) producing comparable data to enable comparisons between hospitals; (2) public reporting of these data to stimulate hospitals to improve patient care; and (3) enhancing public accountability through transparency of public reporting and increasing the value of public investment in health care. The survey encompasses nine key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. The survey contains 21 patient perspectives on care and includes 32 questions.

The HCAHPS score is gaining importance due to its link to reimbursements. The website further states how the HCAHPS score will be used to influence reimbursement for health-care services provided. It appears that some part of the reimbursement for inpatient services can be affected by how the hospitals and providers are graded on the HCAHPS surveys by patients and families.

A Laudable Effort

This survey is a laudable effort by the CMS and the Agency for Healthcare Research and Quality (AHRQ). These agencies need to be commended for the rigorous work that started in 2002, which led to its endorsement in 2005, implementation in October 2006, and first public reporting in March 2008. This is no mean feat, considering these two agencies had to come up with a survey instrument for a population of more than 317 million with varying levels of literacy/education and who receive their health care at institutions equally variable in patterns and settings. The vast troves of data that will be collected will hopefully be of use in improving the quality of health care in the United States.

Surveys are an often-used research instrument with numerous inherent advantages and disadvantages. Although the advantages serve the cause of the survey, the disadvantages are rarely addressed. The quality of survey results depends on various factors, such as correctly interpreting the questions, assessing the educational and socioeconomic backgrounds of the respondents, assigning accurate weight to the questions, and correlating the questions to the actual activity that is being rated. In addition, respondents sometimes base their responses on their subjective feelings rather than objective metrics.

For instance, a patient with a medically optimal intraoperative and postoperative course may rate us unfavorably due to delays during the discharge process. Patients and family members may also provide unfavorable ratings based on the presence or absence of ancillary services, such as valet parking or the quality of food provided. These points need to be noted when taking into account the data that will emanate from the HCAHPS survey.

For our patient, the postoperative course was uneventful, and he was eventually discharged in stable condition. (The ultimate diagnosis was poorly differentiated carcinoma likely arising in the pancreas.) During his inpatient stay, the family had the magnanimity to place a Father’s Day card in my hand on Father’s Day and wished me well. As he was being discharged, the patient invited me to his town to watch the rodeo and celebrate the 50th anniversary of their family business. In case I forgot, at his postoperative clinic visit, the patient reminded me with a firm handshake that I owed him a visit to his town, which I was honored to accept.

Unmeasured Metrics

These are the best HCAHPS scores we as physicians can get, and I hope we are able to practice our profession in an environment where we can continue to place value on this type of unmeasured metrics of patient satisfaction. Although these gestures by patients are purely subjective and may never reach a survey instrument or a list of documented metrics, they are the truest measures of patient satisfaction. What could be a more accurate measure of patient satisfaction than a patient inviting a hitherto unrelated physician into the walls of his home?

Our efforts to improve patient satisfaction always start and end with what the vast majority of physicians have being doing well for decades—focus on the physician-patient relationship. Let not anyone tell us otherwise. Treat patients with respect, communicate with them with honestly, interact with them compassionately, and show them we genuinely care. Be the island of strength and compassion for patients as they meander their way through the complexities of their sickness, hospital, and health-care system. These are the most basic tenets of our profession, which have been in practice for centuries, and the introduction of new administrative scoring systems should not alter our core tenets. Although we should strive to aim for the best objective HCHAPS scores, it should not fundamentally change the basic and well-established principles of a physician-patient relationship.

Continue to adhere to the basics of our profession, and patient satisfaction will not be far behind. And it should not be a surprise if the HCAHPS scores also go up! ■