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Improving HCAHPS Scores and The Patient Experience

Gerald Taylor MBA

Managing Director, TPMG Global

Patient satisfaction is an important and commonly used indicator to measure the value of health care. Across the United States, shifts in health-care policy have tied hospital and physician compensation to patient experience measures that focus on patient engagement.  As of late, understanding and improving the patient experience has become almost a burning platform for U.S. healthcare executives.  The patient experience survey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), serves as a remarkably effective guide for the success of doctors and hospitals.

Res Ipsa Loquitur – Facts About the Patient Satisfaction

According to McKinsey & Company, many health systems make large investments in initiatives to improve the patient experience but fail to achieve their desired objectives. 

Here are some interesting facts about patient satisfaction:

  1. Performance on the HCAHPS survey can affect up to 33% of a physician’s reimbursement.
  2. 25% of value-based purchasing reimbursements are tied directly to HCAHPS scores.
  3. In fiscal year 2020, 55% of the approximately 2,800 participating hospitals received approximately $1.9 billion in CMS value-based purchasing program incentive payouts – roughly $1.3 million per hospital.
  4. Health system executives find that roughly 70 percent of their patient experience initiatives fail.

McKinsey also concludes that hospital in-depth data analysis and research can be better at pinpointing which factors most strongly influence patient satisfaction levels.  Moreover, TPMG Global® research has discovered more than half of healthcare facilities across the United States find the most difficult barrier to improving HCAHPS scores is focusing on the right drivers of “Would Recommend Hospital.”  And that is what this article is about.

In this piece we will discuss how to pinpoint the drivers that most strongly influence “Would Recommend Hospital,” and how to overcome common flaws which wreak havoc in patient experience initiatives. 

Improving HCAHPS Scores and The Patient Experience

Many in the healthcare industry believe there are few financial rewards for improving and sustaining respectable HCAHPs scores.  However, according to a study by the Deloitte Center for Health Solutions:  Hospitals with excellent HCAHPS patient ratings between 2008 and 2014 realized an average net margin of 4.7%, as compared to just 1.8% for those with low ratings.   

At TPMG Global, we believe improving patient satisfaction is not about making patients happy – par se’, but about improving the patient’s entire experience across the continuum of care.   The patient experience encompasses not just the clinical aspects of care delivery, but also the administrative, operational, cultural and behavioral characteristics of the entire care delivery system.   The object of improving the patient experience is to yield greater value by not only producing higher HCAHPS scores, but to also maximizing a facility’s reimbursements and sustaining meaningful improvements in real patient satisfaction.

To that end, we offer a simple 5 step method for improving the patient experience.

  1. Put the HCHAPS survey into the field
  2. Conduct the appropriate data analysis
  3. Pinpoint the drivers that most strongly influence “Willingness to Recommend Hospital”
  4. Conduct the appropriate qualitative analysis
  5. Implement a plan, do, check, act test of change

This article will provide you with two easy step-by step data analysis methods that will pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital.

An HCAHPS Case Study – Hospitals in the Same System are Not Alike

A large hospital, part of an even larger system:  HCAHPs Survey Analysis 2014 – 2018

Case Study Problem Statement:  This healthcare facility is part of a larger healthcare system on the eastern cost of the United States.  For more than 4 years they have not been able to improve their stagnant patient satisfaction scores.  The head of the facility’s patient experience team instinctively knew the patient satisfaction driver report they received from their system’s central office was not focusing on the right factors.  They needed a change.

Baseline Analysis:  Since 2014, their HCHAPS “Willingness to Recommend” score has averaged 77.32 – ranking the facility between the 50th and 75th percentiles.  Though their scores are better than both the state (69) and national (72) results, the baseline analysis covers a serious weakness.  The facility’s scores fall below the national ratings almost 17% of the time and its performance misses the 90th percentile mark of 84 (their goal) 94% of the time. 

Interpreting HCAHPS: Pinpointing the Determinants of Patient Satisfaction

To pinpoint the right drivers that most strongly influence willingness to recommend, there are 2 kinds of analysis you must perform.  The first type establishes linear cause and effect relationships between the drivers of patient satisfaction and their willingness to recommend a hospital. The other proves dependencies between those drivers and the same outcome.  Most importantly, the data analysis must be “statistically significant” to have the predictive power and confidence needed to ensure an initiative will generate a strong return on the time, hard work, and capital invested.

The Results:  Drivers of Patient Satisfaction – Linear Relationships

Drivers of Willingness to RecommendRelative Strength
Governing StrengthR – Square:  .74
Drs Explained Things UnderstandablyImpact  -0.40
Treated w/ C&R by DrsImpact  0.35
RNs Listened Carefully to YouImpact  0.50
Told What Medicine Was ForImpact  0.30
Treated w/ C&R by RNsImpact  0.42
Received Phone Call at HomeImpact  0.14
P-Value0.000000021

The table above identifies 6 statistically significant drivers of the patient experience that best determines Willingness to Recommend Hospital.  The key performance indicators suggest the following:

  1. R-Square:  the subset of characteristics, outlined here, are a 74% driver of patient satisfaction.  Other variables (26%) may also drive Patient Satisfaction but may not be captured by the survey.
  2. P-Value:  we can be 99.9999979% confident these are the appropriate drivers of patient satisfaction for this facility.

Critical to Satisfaction Characteristics

The model indicates, a one-point improvement in “Treated with Courtesy and Respect by Doctors” drives Willingness by 0.35 points; a one-point improvement in “RNs Listened Carefully” drives Willingness by 0.50 points etc…  (Linear Relationships)

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Drivers of Patient Satisfaction – Dependent Relationships

Now that we have determined the fundamental drivers of patient satisfaction, we move forward to discover the extent to which patient satisfaction is dependent upon them.  Here, we evaluate the relationship between the attribute “Treated w/ C&R by RNs” and “Willingness to Recommend.”  The approach tells us the extent to which Willingness to Recommend is dependent on Treated w/C&R by RNs.

The basic idea of the method is to compare the observed performance of the driver with its expected performance.  If there is no dependent relationship between the potential driver and outcome, the actual frequencies at which willingness to recommend is observed will be close to their expected frequencies (in the norm).

Conclusions 

All other things remaining equal – the analysis indicates that we can be 99.995% confident – patients punish Very Good performance but reward Excellent performance in this category.  It appears performing very good in this category is not good enough. The hospital must be excellent to be rewarded with a willingness to recommend rating. For Very Good performance, patients are 59% less likely to “Definitely Recommend Hospital”.  For Excellent Performance in this category, patients are 89% more likely to “Definitely Recommend Hospital”.  Only 23% of patients give an excellent rating for this category!  

At the end of the day, we can safely conclude Willingness to Recommend Hospital is not only strongly driven by Treated with Courtesy and Respect by RNs, but it is also dependent on the driver for improvement.   In addition, the opportunity for improvement (OFI) is substantial!    The charter for the patient experience initiative should include an objective and key result (OKR) for this driver, like:  Improve the percentage of respondents for “Treated w/ C&R by RNs” with an excellent rating by 77% (predicted target date – here). 

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at:  TPMG Global® – Improving HCAHPS Scores and The Patient Experience

Gerald Taylor is the Managing Director at TPMG Global®

Cleveland Clinic’s Patient Satisfaction Strategy: A Millennial-Friendly Experience Overhaul

Micah Solomon

If you want to improve the patient experience — and your patient satisfaction and HCAHPS scores — here’s a good place to start: Reconsider how your hospital or practice thinks about time. And get to work swapping a patient-centered approach to time for your provider-centered viewpoint.

To see this in action, try a quick phone call to Cleveland Clinic. Here’s precisely what you’ll hear, after just a bit of voice jail navigation:

“Thank you for calling Cleveland Clinic. Would you like to be seen today?”

And they mean it.  They do “about a million” same-day appointments a year, according to James Merlino, MD, Cleveland Clinic’s Chief Experience Officer (CXO). 

Now, doing a good job in healthcare does take time. Scans take time to read properly. Cultures take time to grow. Thoughtful diagnoses and effective discharges absolutely take time.

The last thing I want to do is turn your hospital or practice into the healthcare equivalent of a fast food joint.

But some of the wait times your patients suffer through don’t add anything to successful clinical outcomes. And the reason you’re making patients wait? Probably it’s partly because you’ve always done things this way, and everyone else in healthcare is making patients wait as well.

Well, you can’t use that last rationalization anymore. Not if you’ve been watching what Cleveland Clinic has been doing on the timeliness front.

Let’s go back to listening to Cleveland Clinic, and that mind-blowing greeting:

“Thank you for calling Cleveland Clinic. Would you like to be seen today?” (After 4PM the greeting rolls over to”Would you like to be seen tomorrow?”)

This is for real. According to Dr. Merlino,

“Anybody calling [Cleveland Clinic] for an appointment for any specialty can be seen today.”

Getting people in to see a doctor the same day they call is an extreme and extraordinary move by Cleveland Clinic to take patient satisfaction to a new level.

Which is something that’s come a long way since the bad old days, when their incoming CEO, Toby Cosgrove, would joke, “Patients come to us for high quality care– but they don’t like us very much. ” (Which wasn’t much of a joke, really.  When Cosgrove took the reins at Cleveland Clinic in 2004, patient satisfaction was in the lowest 10 percent of the nation.)

An eye on the millennial generation of patients

While nobody of any age likes to wait, this commitment to speed comes partly from Cleveland Clinic’s eyes being trained specifically on the incoming millennial generation of patients. (Millennials are a crucial generation of customers for any business—including healthcare—to consider. They are 80 million strong in the U.S., making them larger than the baby boom, and much larger than Generation X, the generation that immediately preceded them. And their expectations are quite different, being the first generation to take the internet, and smartphones, entirely for granted. A historical reality which changes their perception of time, convenience, and more.)

A million same-day appointments

They pull this off… how? Well, the same-day appointment commitment required Cleveland Clinic to get through some operational hurdles. Actually, Dr. Merlino corrects me on this: “‘operational hurdles’ is an understatement.”  An extraordinary amount of work has had to be put into “managing the flow and ensuring we have the capacity.”

The same-day appointment promise is also dependent on a sophisticated triage process.

In other words: I can’t just call up and say

“I have a headache. I want to see a neurosurgeon.”

Well, actually, I can call in and say that—and they’ll be ready to deal with it. Here’s what happens: I’m taken through a series of questions on the phone; depending on how I answer those questions, the Cleveland Clinic telephone agent will be able to determine whom I should see, and will ensure I get that appointment today.

Dr. Merlino:

“So, Micah, [in the example above] you may not see a neurosurgeon for your headache, but you may see somebody who is a headache specialist or you may need to talk to a nurse who can better triage what you need. But we will get you to the right provider at the right time.

“If you call and say, ‘Look, I was in the emergency department last night with a headache and they did a CAT scan and they say I have a brain tumor. I need to be seen by a neurosurgeon today,’ you will see that neurosurgeon today.  If you call in with a headache [and] you say certain things which are warning signs—answering yes to ‘is this the worst headache you ever have in your life?’ is one — you will immediately be transferred to a nurse who will do a more assessment and then guide you to an emergency department.

If it’s just a garden variety headache, as determined by the agent’s triage questions, they’ll still “get you an appointment with somebody today who can help you with the headache.”

Speak the patients’ language, use the patients’ channels

The same-day appointment commitment isn’t the only time-bending patient satisfaction change Cleveland Clinic has introduced.   Another one that struck me is their understanding that patients these days, especially but not only millennial patients, want to communicate with their healthcare providers through the same communication channels they use to run their social lives. Which is a theme I am seeing in every arena of business. Appointments via mobile, information via mobile, chat online, doctors (after HIPAA waivers) corresponding with patients via email. Using telepresence for followup care with homebound patients. and more.

All of which, if you think about it, are ways to stretch, bend, mitigate the effect of time on the patient experience. Emails are asynchronous: they don’t have to be read at the time the doctor wrote them, a fact that can make things more convenient for both parties. Online chat is immediate when you need it to be immediate, again reducing wait. Information on mobile apps (Mayo is another leader in this) is another time — and potentially life— saver as well.

—–

So what’s next on the speed front? Chief Experience Officer Merlino, who is also a practicing colorectal surgeon, jokes it might be, “Thank you for calling Cleveland Clinic. We’ve already solved your medical issue; is there anything else we can help with?”

Micah Solomon is a customer experience and patient satisfaction consultant, customer service keynote speaker, and author.

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at:  TPMG Global® – Improving HCAHPS Scores and The Patient Experience

Building A Culture of Nurse Excellence to Drive Patient Satisfaction

Driving nurse excellence and engagement will be essential to delivering on patient satisfaction and experience.

  By Sara Heath

– When it comes to nurse engagement, efforts must go a lot further than just driving good job satisfaction. In fact, nurse excellence isn’t entirely about the nurses at all, although they are important. Instead, nurse engagement is an essential means to yield an overall positive patient experience, connecting all of the key elements of healthcare into one cohesive picture.

The call for good patient experiences is not something new. Healthcare has long valued the patient, striving for excellent bedside manner and good clinical quality outcomes. But in an age where healthcare consumerism reigns supreme and CMS reimbursements hinge on good satisfaction scores, driving that positive hospital experience has become even more crucial.

But building that experience is extremely nuanced, most industry experts can appreciate. A good patient experience requires a balance of certain hospitality elements, patient safety, and meaningful interactions between patients and staff.

And that’s hard, experts say. Hospitals only have so many resources to dedicate to facility amenities and clinicians are strapped for time, seriously hindering their ability to connect with patients on a personal level. Patient safety, although essential to clinical quality outcomes, can falter to human error in the most unfortunate cases, despite best efforts. Communicating those lapses then present a whole new challenge.

But those challenges aren’t insurmountable, especially when nurses are engaged. These clinicians are on the frontlines of everything ranging from patient interactions to medical care. So, when nurses thrive, everything else thrives, too, according to Christy Dempsey, DNP, MSN, MBA, CNOR, CENP, FAAN, the chief nursing officer at healthcare consulting firm, Press Ganey.

READ MORE: Pushing for Nurse Engagement to Drive Better Patient Experience

“A culture of nursing excellence really does impact everything,” Dempsey said in a recent interview with PatientEngagementHIT. “If you have a good culture of nursing excellence, then you’re more likely to have better physician engagement. You’re more likely to see that patient experience of their physicians, not just of the nurses, is better. Clinical quality is better. It’s the rising tide that lifts all boats in healthcare.”

As noted above, nursing excellence looks like a lot more than just good job perks and satisfaction, although those factors can be important. Instead, nursing excellence is about developing and advancing strong nurse leaders, who are then able to advocate for their patients and nurse peers.

“Nursing excellence requires a structure within the organization that supports shared governance so that nurses at every level are helping and involved in making decisions, measuring transparency of data, and establishing performance benchmarks and promoting autonomy for nurses inside that shared governance framework,” Dempsey explained.

Nurturing a culture of provider teamwork and implementing care frameworks that emphasize not just clinical quality, but safety and patient experience as well, is another key hallmark of nursing excellence.

But although the industry has a good model of what nursing excellence is – strong team-based care that gives all stakeholders the tools to succeed – it isn’t always happening.

READ MORE: Supporting Nurses to Address the Social Determinants of Health

“We are in an environment that is constantly changing. It’s complex in terms of the patients and the venues, the continuum of care,” Dempsey said. “There are a lot of pressures within healthcare today.”

But it’s those very factors that hamper efforts for nurse excellence that nurse engagement and empowerment can solve. When nurses are empowered, Dempsey maintained, the patient can thrive because the team can thrive.

“Even in today’s complex, constantly changing healthcare environment, that culture of nursing excellence can be fostered, promoted, and then impact everything else that happens in healthcare,” Dempsey asserted.

Healthcare organizations on a journey to nurse excellence need to start where they are today. Understanding their current competency in patient safety, nurse experience, and clinical quality and experience will be important for understanding the root causes of any underperformance they see in their facility, Dempsey instructed.

From there, organizations can design a path forward.

READ MORE: Nurse-Led Education Program Boosts Older Patient Experience

“Define what the nursing professional practice model in your practice is,” Dempsey said. “Once you have determined that, you’ve got to make sure that you have CEO and board support for that model and that the chief nursing officers and nursing leadership are involved in executive level decision making at the C suite and the board level.”

A nursing shared governance that included nurse managers and engages bedside nurses will help organizations build their accountability structure, leading nurses and other stakeholders to take ownership of the process. Stakeholders should also play a hand in writing out job descriptions, performance reviews, and standards for clinical practice.

After that, teams must scale that plan organization-wide.

“You need to establish a communication plan so that you are able to disseminate information and initiatives that help you drive towards nursing excellence,” Dempsey said. “You must have an organizational strategy for data transparency in how you talk about the data. You can’t just post it on the wall. How do you talk about the data and wrap stories around that data to make it come to life? Then, look at the specific work unit information and communication strategies.”

All of this must lead to an optimized work environment, Dempsey continued. Work environment, or the factors that make a job doable and even enjoyable, is even more important that staffing levels, Dempsey reported.

“Optimizing that nursing work environment is so important,” she said. “That includes the leadership development plan, how you are engaging nurses and fostering their development, and how you are providing incentives for professional development.”

Organizations must also assess how they are assuring they have the appropriate resources – both human and material – and emotional support for nurses. This will allow nurses to continue efforts for patient-centered care.

“Make sure that you’re optimizing staffing so that you have the right people taking care of the right patients in the right place at the right time,” Dempsey stated.

“Then, finally, track integrated metrics, so reducing silos both in terms of operations, but also in terms of the way we look at data,” she continued. “Integrate that data so that you can see things and how things move together — or don’t. This will help you draw insights from that integrated data and then build improvement plans, and accountability and ownership plans based on that integrated data.”

All of this will hinge on a culture of team-based care. The organizations that Dempsey sees fully committed to a culture of excellence are already deploying strong team-based care strategies, fostering collaboration, communication, and support across the team. This is a symbiotic relationship, she said, because the culture of excellence also draws on the whole hospital team.

And at the end of the day, that is what will help organizations push to the next level in value-based and patient-centered care.

“Driving nursing excellence is not just a good idea, it makes good fiscal sense,” Dempsey concluded. “It makes good sense to recruit and retain the best and the brightest. It is the rising tide that will help health care. We need to really promote that.”

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at:  TPMG Global® – Improving HCAHPS Scores and The Patient Experience

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