Hospitals In Focus

Reexamining How We Measure Patient Experience


A patient’s health care experience at a hospital is considered one indicator of quality of care. Since 2008, those experiences have been captured and publicly reported at a national level via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. However, it hasn’t been reviewed since its creation more than a decade ago. We were hearing anecdotally that response rates were falling and some of the questions weren’t as relevant as they used to be. So we joined with several other major hospital organizations to investigate. In the episode, Chip and Dr. Claudia Salzberg, FAH’s VP of Quality, discuss our just-released study examining the HCAHPS survey from the perspective of Patient Experience Leaders.

Chip Kahn (00:11):
Hello and welcome to another edition of Hospitals in Focus. I’m your host Chip Kahn. Today we’re going to focus on something of great importance to the patient care our hospitals provide. Quality and performance measurement. This is a special edition because it focuses on an initiative undertaken by the Federation and our colleagues in the hospital community and for the first time we will be speaking with one of our Federation staff experts, Dr. Claudia Salzburg.

Claudia conducted, and we are now releasing, a major study on the hospital consumer assessment of healthcare providers and systems survey, commonly referred to as HCAHPS. This survey is the primary way that government and hospitals obtain feedback from patients on their hospital experience. Our project assessed the usefulness of HCAHPS through the work of hospital experienced leaders to improve the patient experience in their facilities. It was made possible by the cooperative effort of key provider organizations including the American Hospital Association, America’s essential hospitals, the Association of American Medical Colleges and the Catholic Health Association.

We will talk with Claudia in a few moments, but first let me set the stage for our conversation by providing context for why we undertook this study. Over the past few years, the Federation has focused on the future of hospital quality and performance measurement and led an effort to start a conversation about the best direction forward for the all-important Medicare pay for performance programs.

We started by assessing the programs in terms of three primary missions and themes. Care improvement, provider accountability, and quality and performance transparency. We discussed these missions and themes and publications and hosted conferences with the well known journal Health Affairs to foster expert discussions on pathways to improve the utility of these programs. We work to raise the consciousness to foster a new generation of development of quality and performance measurement as well as pay for performance. All to serve the patient. We decided through this process that we would make a real tangible difference by focusing on the HCAHPS survey.

As I mentioned, the survey is a key measurement tool of the critically important patient experience in the hospital. A measure essential to the themes, care improvement, care and provider accountability, and transparency to enable consumer choice. The HCAHPS questionnaire is given to a sample of patients after they leave the hospital. The survey has a great track record, but it has not been thoroughly reviewed in more
than a decade. That is until now.

The Federation joined with our hospital colleagues to take the deep dive. We will be discussing today with Claudia. But I’ve gone on long enough with this background. Let’s bring in Claudia to take that deeper dive into her project, its findings and its recommendations. Welcome Claudia.

Claudia Salzburg (03:29):
Thanks for having me, Chip.

Chip Kahn (03:31):
Let’s start by talking about you. You are uniquely qualified to conduct the research we are going to be discussing today. Let’s hear a bit about your background and the work you do every day here at the Federation.

Claudia Salzburg (03:43):
Well, I’m a health services researcher by training. I got a PhD in public health from the Johns Hopkins Bloomberg School of Public Health. At the Federation I’m largely responsible for managing issues related to quality and performance, and I also have a background in computer science.

Chip Kahn (04:00):
Now to the project. Let’s start with the basics. Tell us what the HCAHPS survey is and how it’s conducted.

Claudia Salzburg (04:07):
So HCAHPS is a 32-question survey that asks about different aspects of the patient experience of an inpatient. It has two modes of delivery, by phone and by mail. And what that means is that if you’re selected to fill the survey, you either receive a mail survey that you fill out or you get a phone call. Not every patient is surveyed. It’s a representative sample of the hospital patients that get selected. And it was first publicly reported on hospital compare beginning in 2008. It is overseen by CMS but deployed by hospitals usually through survey vendors.

Chip Kahn (04:50):
Now, before we talk about how it’s used by hospitals, let’s establish how HCAHPS is used by CMS in terms of some of the themes I mentioned earlier with the emphasis here on provider accountability and transparency through this website you described that CMS has a hospital compare.

Claudia Salzburg (05:12):
Well, CMS has three main goals that it’s trying to fulfill through the use of the survey. The first is to produce comparable data on the patient’s perspective on care that will allow for objective and meaningful comparisons between hospitals across the nation on topics that are important to patients. The second goal is to create incentives for hospitals to improve their quality of care and the third is to enhance public accountability in health care by increasing the transparency of the quality of care provided by hospitals.

Chip Kahn (05:44):
Claudia, from what you said it is clear hospitals are being graded by CMS and those grades affect everything from publicly published ratings to payment for government programs. Hospitals not only have to focus on that, but they do want to use the data for their own improvement as you described. I believe that great hospital care will always be patient-centered, meeting the need of patients and understanding the perception patients have with that experience is vital. But this goes beyond just giving us data. Let’s talk about where the rubber meets the road. How do the results of HCAHPS affect hospitals directly?

Claudia Salzburg (06:25):
Well, the HCAHPS survey results are playing an increasingly important role. First and foremost it’s available to patients and it affects patient choice of hospitals. So second, as you alluded to in your question, it’s increasingly tied to payment. In 2008 it was tied to the annual payment update. This means that hospitals have to collect and report HCAHPS data to receive their full annual payment update from Medicare. Then in 2013 it became incorporated into the value based purchasing program. In 2015 the HCAHPS star ratings were added to hospital compare and in 2016 parts of the HCAHPS were incorporated in the overall star system that is used by CMS to summarize hospital performance.

Chip Kahn (07:10):
So Claudia, who at hospitals is on the front lines of the HCAHPS survey. Who takes the lead?

Claudia Salzburg (07:17):
Well, it’s a very important person who works behind the scenes and patients generally have never heard of them. They’re broadly referred to as patient experience leaders. I will refer to them as PELs and their roles vary from CMOs to CNOs to directors of patient experience. It varies widely by hospital. But they all have the same role. Generally they’re responsible for overseeing patient experience strategy in their organization.

They work with vendors and or deploy the survey themselves. They identify root causes for poor ratings. They develop alternative questions or surveys to aid with the analytics so that they can further dig into what the issues are that challenge their improvement in their ratings and they liaise with clinicians, with patients, with leadership and with survey vendors to achieve these goals. Some of them also have informal ties to social media and customer service department because the patient experience is tied to these departments.

Chip Kahn (08:23):
It really sounds like an important position. And you interviewed patient experience leaders for this project?

Claudia Salzburg (08:30):
Yes. They’re the ones who are in the front line. They’re the ones who know the HCAHPS inside out and have to work with it in their organizations and see how it works for their patients. You know, Chip, while everyone from the hospital CEO to the physicians and nurses look at their facility’s HCAHPS scores, it’s PELs who are in charge of compiling the scores and leading efforts to improve the patient experience.

Chip Kahn (08:53):
Claudia, now let’s get into the specifics of our study. Can you describe the survey and the methodology you used?

Claudia Salzburg (09:00):
We decided to collect perspectives from the patient experience leaders in a systematic way and ensure that we had our presentations from all types of hospitals. So the way that we collected these perspectives was by using qualitative methods. Where quantitative methods use numeric data to uncover trends, qualitative methods are used to uncover trends in individual’s thoughts and opinions. It offers insights into why things work or fail to work and is employed across many academic disciplines.

It was also really important to have representation from all types of hospitals, so we pulled our interviewees from across our membership, the Federation’s, but also each partner organizations, the American Hospital Association, the Catholic Health Association, the Association of American Medical Colleges, and America’s essential hospitals. What we did was we developed a semi-structured interview instrument that focused on different aspects of the HCAHPS and capture a patient experience in a hospital setting.

What works, what are the challenges and what needs improvement is what we focused on. We ended up interviewing 27 patient experience leaders from across the spectrum of all hospital types and this allowed us to reach what’s called saturation. This is where we started seeing repeated instances of the same themes. Each interview lasted between 30 minutes to an hour. Each interaction was recorded, transcribed, and then analyzed to identify these emerging themes.

Chip Kahn (10:27):
The approach is interesting. Using experts to do the qualitative assessment and then ultimately analysis. As you examined the answers and the content, what did you learn? What were the primary findings of this study of representatives from 27 different types of hospital systems?

Claudia Salzburg (10:49):
Well, it was truly eye opening, but there were a few things that really stood out. Let me elaborate on a few of them.

The first is that response rates are falling. Patient experience leaders mentioned that with each year they were finding it increasingly difficult to meet minimum response rates that ensure the validity of their data. When we did a further analysis by looking at actual data that’s reported by CMS, we found that response rates are falling. Since 2008 where they were at a rate of 33% to only a rate of 26% in 2017.

The second is that there is consensus among patient experience leaders that the HCAHPS survey needs updating. While most respondents thought that the HCAHPS surveys ability to provide patients with comparable data on patient experience was a good one, they all felt the survey needed improvement. What’s behind this is that the model for medical treatment, particularly in hospitals now, is vastly different than it was when HCAHPS was created over 15 years ago and it’s crying out for reexamination. Starting from the teamwork based approach to care to the higher acuity of patients in the hospital to the increasing dependence and habit of using technology. A lot has changed in the past decade.

The third is that the topics covered in the HCAHPS are important but incomplete. So respondents found that eight of the 27 core questions were important to keep. Additionally, however, they identified five topics, questions, that they would like to see added to the survey.

The fourth is that research is needed on additional factors that influence patient experience. You know, CMS does a terrific job adjusting for survey mode deployment and for individual patient factors, but our respondents identified that there are community level factors that they feel also influenced the scores and that should be considered as part of the adjustment.

And finally, the literacy levels need to be reevaluated. There’s two aspects to this that were identified by PELs. The first is the health literacy level of the English survey and the second is the literacy level of the Non-English version surveys. So CMS makes available multiple non-English translations of the survey and PELs found that the translations do not have an appropriate literacy level to match that patient population. What this ends up doing is generating the feeling that these segments of the population are being under surveyed or not appropriately captured in the HCAHPS results.

Chip Kahn (13:25):
Claudia, let’s follow up on a couple of the findings where I’d like a further elaboration. You mentioned one of the areas: topics covered that are important but incomplete. And you mentioned numbers of questions that need to be reconsidered. Can you give us an example just so our audience can get a sense for what kinds of questions we need to move to?

Claudia Salzburg (13:53):
Sure. So one of the topics that was identified as missing was teamwork and the efficiency of team based care. So patients experience leaders felt that the presence of a good teamwork leads to higher quality care. The second item that was identified, not as missing, but as potentially not capturing the information in the best possible way, was cure transitions. So this is considered a very important part of the inpatient experience. But patient experience leaders were hearing back from their patient advisory groups and patient focus groups that they didn’t really understand what these questions were asking. So patient experience leaders understandably are concerned about whether or not they’re capturing the right information.

Chip Kahn (14:49):
And talking about the right information and particularly patients’ understanding, let’s go to the last finding. And can you elaborate here on what we mean by health literacy and what are the experience officers, our PELs, sensing from their analysis of the returns on the survey from their patients?

Claudia Salzburg (15:14):
Sure. So health literacy refers to the understanding of health-based related vocabulary or concepts. So if I, for example, refer to a discharge plan, some people are going to understand what that means and some people are not going to understand what that means. And so it’s important if we’re asking about specific health based topics that we either refer to them in a way that patients understand or ensure that the way that we’re describing them is captured by the literacy level of the patients we’re serving.

Chip Kahn (15:51):
What I like about the approach you took to the project, Claudia, was that you didn’t end with the survey findings themselves, the ones we just reviewed. You went on to conduct with our hospital colleagues a round table to review and elaborate on those findings. That took place late last year here on our offices in Washington at the Federation. And it was an all encompassing group. Not only did we have representatives from the major hospital organizations, several of the PELs that you interviewed, but we also were fortunate to bring in staff and officials from CMS, the agency for healthcare research and quality, which are the two agencies that oversee the HCAHPS survey. What areas received the most attention at this round table?

Claudia Salzburg (16:41):
So Chip, that was a great experience. We were truly honored to have around the table such capable experts as well as CMS and HRQ who came to listen and provide a bit of feedback when certain issues came up. There were a few areas that received more attention than others. In particular, the area around enabling a digital mode. Many of the challenges and opportunities around creating a digital modality of the HCAHPS survey were discussed, including the risk of not capturing certain patient populations or of in fact capturing patient populations that are currently not being captured.

So for instance, the PELs are very concerned that millennials are not responding to the current survey modes. But there was a feeling that the 65 and older population might not be as responsive to an electronic survey mode. And so there was a lot of discussion about the perception of that versus the experience of hospitals have in their own efforts and deploying electronic surveys. We also discussed at length the issue I brought up earlier related to literacy levels of the HCAHPS survey, as well as the need to consider adjusting for community level factors and as these relate to social demographic and social determinants of health.

Chip Kahn (18:11):
I know there’ve been further discussions since the round table, Claudia, so there’s been an effort by the Federation and our hospital colleagues to build on the survey findings themselves, the discussion at the round table. And we have concluded that process with a set of recommendations. Would you outline those recommendations for the audience?

Claudia Salzburg (18:35):
Sure. The recommendations from the patient experience leaders were many. But a few once again stand out. The first is the addition of a digital based alternative to existing modalities. The second is shortening the survey. The third is revising the survey in light of today’s shift to value based care, changes in healthcare delivery, improvements in technology, and evolving patient priorities. The fourth is the reframing of care transitions and discharge planning sections to capture what they intend to capture, and finally to implement a process for periodically reevaluating the HCAHPS so that we can stay ahead of changes in patient priorities and expectations as we move forward.

Chip Kahn (19:23):
Claudia, lets dwell a moment on one of the key recommendations you outlined above, which asked CMS to institute an online or digital option for the HCAHPS survey. I know it’s being discussed by the agency right now, so this recommendation is particularly relevant. Can you talk a little bit about the implications of this change moving from, not just mail and phone in terms of the modalities for the survey, but adding an online or digital based option?

Claudia Salzburg (19:58):
So CMS is beginning to study this and some of the issues around this are related to the fact that different modes capture different demographics. There is a concern, as I mentioned earlier, that for instance, millennials are not being captured because they would fill an online survey, but they will not necessarily fill a paper survey. Another implication of adding the digital modality is that it would bring down costs of deploying surveys and it would simplify data submission.

Chip Kahn (20:29):
Claudia, thanks so much for joining us today. I believe the work you and the rest of our hospital colleagues did on this research is going to have a real impact on the patient experience and improving care generally. For more information, please go FAH.org to find the link to the research we have been discussing today.

Thanks so much for listening to our podcast today. We hope you found this conversation interesting and will join us every other week as we talk with leaders on a broad spectrum of health care issues. Don’t forget to subscribe to Hospitals in Focus. We can be found on Apple podcasts, Google Play, and now Spotify. Be sure to rate and review us and tell a friend. Thanks for listening.

Dr. Claudia Salzberg, VP, Health Services Research and Policy, FAH

Claudia Salzberg is vice president of health services research and policy at the Federation of American Hospitals (FAH). A mixed-methods health services researcher, Claudia designs, implements and supports research and policy analysis pertaining to value based care, health system reform and performance, quality and safety, coverage and access, and drugs.

In addition, Claudia provides support for policy and legislative initiatives at the Federation, liaises with the Medicare Payment Advisory Commission (MedPAC) and staffs the Quality Committee and the Pharmacy Task Force.

Prior to joining the Federation, Claudia was a research scientist at the Children’s Hospital of Philadelphia (CHOP), University of Pennsylvania School of Medicine and a Research Fellow at the Johns Hopkins School of Medicine, Division of General Internal Medicine, where she conducted research and evaluation on health care delivery models, quality, health information technology and population health. She has authored numerous papers pertaining to health care evaluations.

Earlier in her career she conducted research and pilot initiatives at Brigham and Women’s Hospitals and Mass General Brigham (previously Partners Healthcare) and was a computer scientist at IBM.

Claudia received a Ph.D. in health policy and management from the Johns Hopkins School of Public Health and a Master of Science in Engineering degree from the University of Pennsylvania, School of Engineering and Applied Sciences (SEAS). She received her Bachelor of Science degree from Brown University.