What Are HCAHPS Scores, Why Are They Important to Patient Satisfaction?

What Is Patient Satisfaction?

Patient satisfaction is a challenging concept for healthcare professionals, considering a stay in the hospital hardly sparks the same delight a stay at a vacation resort or a good dining experience might. Nevertheless, patient satisfaction is important as the medical industry continues its pursuit to reimburse providers not for the volume of services rendered but rather for the quality of those services.

Patient satisfaction­ and experience—although distinct concepts—are integral parts of that quality equation.

According to the Agency for Healthcare Research and Quality (AHRQ), patient satisfaction “is about whether a patient’s expectations about a health encounter were met.”

That is different from patient experience, which “encompasses the range of interactions that patients have with the healthcare system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities,” AHRQ says on its website. “As an integral component of healthcare quality, patient experience includes several aspects of healthcare delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with health care providers.”

Patient satisfaction plays a role in some value-based care reimbursement models, such as the Inpatient Prospective Payment System (IPPS). Providers get paid for hitting a certain quality threshold, and patient satisfaction is a part of that quality equation.

In order to quantify that patient satisfaction and factor it into value-based care, payers and providers need a system for measurement. That’s where CAHPS surveys come in.

What Are HCAHPS Scores?

HCAHPS scores are the first national standard for patient satisfaction measurement, according to the Centers for Medicare and Medicaid Services (CMS). As of September 2022, the survey asks a random sample of discharged patients 29 questions about their hospital stay.

The survey particularly comprises:

• Four questions about care and communication from nurses
• Three questions about care and communication from doctors
• Two questions about hospital environment
• Five questions about experiences when in the hospital, like communication about medications or help using the bathroom
• Three questions about care after discharge, like receiving discharge instructions and communication about care transitions
• Two top-box questions about the overall experience and likelihood to recommend the hospital
• Three questions about patient education and communication

The survey also asks respondents for some demographic information.

Hospitals may use a CMS-verified vendor for issuing their HCAHPS surveys, or they may conduct their own HCAHPS surveying if approved by CMS. Other HCAHPS survey recommendations and requirements include:

• Issuing the survey across various medication conditions between 48 hours and six weeks after discharge
• Issuing the survey to both Medicare and non-Medicare adults
• Issuing the survey via mail, telephone, mail with telephone follow-up, or interactive voice recognition (IVR) software
• Offering the survey in English, Spanish, Chinese, Russian, Vietnamese, Portuguese, and German

CAHPS surveys are not unique to hospitals. CMS has developed surveys for specialties across the healthcare continuum, including home healthcare, pediatric hospitals, outpatient and ambulatory surgery, and even the emergency department.

As noted above, HCAHPS scores are often used for some value-based reimbursement models. However, CMS also uses the score as an accountability measure. The agency publicly reports the scores on Hospital Compare on a quarterly basis, asserting that it adjusts scores based on some demographic information that may skew results in such a way that is beyond the control of the hospital.

Hospitals, and providers filling out specialty-specific CAHPS surveys, can also use scores to better their own organizations.

Using HCAHPS Scores for Quality Improvement

HCAHPS scores are common tools for healthcare organizations nationwide, with CMS saying around 4,000 hospitals participate in HCAHPS and some 3 million patients complete the questionnaires.

That is in addition to the internal surveying many healthcare organizations conduct to measure patient satisfaction and experience.

Ultimately, this survey information is a critical tool for informing practice improvement.

At Sutter Independent Physicians (SIP), using patient satisfaction surveys is integral to its practice improvement efforts.

“Our aim really is to work on improving the clinical quality of care and then the service quality of care,” Jose Arevalo, MD, the chief medical officer for SIP, told PatientEngagementHIT in a previous interview. “And this effort is related to the service quality of care, identifying the voice of the patient, and using that information to identify opportunities for improvement in providing service to the patients we serve.”

Patient satisfaction surveying, whether after-the-fact like HCAHPS or real-time, like the system SIP uses, outlines the key pain points for patients.

Healthcare organizations should first look at longitudinal trends in their patient satisfaction scores. If the hospital usually performs poorly in physician care and communication domains, it may be helpful to offer continuing medical education seminars reviewing patient-provider communication.

The surveys may also guide organizations in making better health IT investments. Low scores in care transitions from hospital to long-term care facility could mark poor health IT interoperability. Consistently scoring low here could indicate that a healthcare organization needs to reconfigure the EHR or other supporting health IT systems.

It would be prudent for organizations to think critically about which investments—time, financial, and material—will actually move the needle on patient satisfaction. While hotel-like amenities are a bonus to a hospital stay, investing more deeply in communication and patient education is more likely to yield improvements.

According to Press Ganey, a CMS-approved HCAHPS vendor, organizations that have better reports of nurse teamwork and communication tend to see better HCAHPS improvements. Patient satisfaction is about making the patient feel safe and cared for during the hospital stay, the organization contended, signaling why nurse communication is of such high value.

How Can HCAHPS Surveys Improve?

Although HCAHPS is a national standard for patient satisfaction measurement, some experts say it is still an imperfect measure.

For one thing, non-response bias could lead to survey samples that are not representative of a hospital’s full patient population. Between 2008 and 2017, the HCAHPS response rate dropped from around 33 percent to about 26 percent, a report in 2019 found. As response rates went down, so did patient satisfaction scores.

“Typically, if a surveyed sample is representative of the population, a correlation does not exist between response rate and survey results,” the researchers explained. “The moderate correlations observed suggest that, at a national level, the HCAHPS data being collected are not capturing a representative sample of the patient population for these hospitals.”

Healthcare professionals may overcome this problem by mailing or telephoning more people to complete the HCAHPS surveys, but that’s only part of the issue. The researchers suggested that new survey modalities, like emailing the surveys, could make for a more representative respondent pool.

But even if a hospital has a perfectly representative sample, the actual content of the survey might not actually reflect clinical quality. HCAHPS is a relatively old survey developed years before value-based care and patient-centered care could truly take hold in the medical industry. Although it’s had some makeovers, experts asserted in 2019 that the survey needs a complete overhaul.

“Great hospital care needs to be patient-centered. Providing the best care, meeting patient expectations and keeping them comfortable and well informed is key,” the Federation of American Hospitals President and CEO Chip Kahn said in a 2019 statement. “Updating and improving the HCAHPS survey could have a major impact on improving care.”

FAH joined a handful of other industry leaders, including the American Hospital Association (AHA), American’s Essential Hospitals, the Association of American Medical Colleges (AAMC), and the Catholic Health Association of the United States (CHA), in publishing a report recommending some changes to modernize HCAHPS.

The group outlined important topics that the HCAHPS survey already reviews, including:

• Care transitions and discharge
• Level of provider teamwork
• Fulfillment and understanding of the patient care plan
• Open-ended response sections
• Sense of emotional and physician or patient safety

The areas to which patient experience leaders say the survey must expand include:

• Patient experience with billing
• Provider compassion and courtesy
• Food and nutrition
• Ancillary labs and tests
• Quality and safety
• Patient intake or registration process
• Family or caregiver support and engagement
• Traffic and parking around the facility

The group also noted HCAHPS should consider social determinants of health and health equity.

Separate studies have indicated that CAHPS surveys need to be mindful of the end-user. In pediatrics, for example, CAHPS surveys are completed by parents or guardians, not the child who is experiencing healthcare.

There is some validity to that approach; young kids aren’t always able to remember the small details from a hospital encounter. But according to a 2020 literature review about pediatric CAHPS surveys and child-facing surveys, kids can handle some questions.

These satisfaction questions should focus on what is important to a child, not an adult, the researchers advised. Questions about how well clinicians ameliorated fears, explained complex ideas, and how well the hospital environment made the child feel comfortable are all relevant to a younger audience, the researchers said.

If nothing else, the subject warrants further study, they added.

Measuring patient satisfaction is always going to be a challenging area. Satisfaction is subjective, after all. As noted by AHRQ, patient satisfaction is about whether an encounter met patient expectations. Being that everyone has different expectations, it will be hard to deliver a perfect encounter every time.

But as healthcare continues to emphasize healthcare quality, it must continue asking the patient about the healthcare journey. By assessing the patient perspective, organizations can make critical adjustments that help them achieve clinical quality and a good experience.