How Reliable are the HCAHPS Survey Questions? Can We Do Better? What Would You Ask?

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The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) has been discussed here on several occasions.  This survey of patient satisfaction is crucial for hospitals as their scores will strongly impact their federal reimbursements.question

There has been considerable criticism as to how valid the instrument actually is.  Some reviewers have noted, however, the same can be said for all ratings systems, such as those for restaurants and hotels, yet these remain popular and useful.

Now it is true that hospitals are in the business of meeting the needs of and satisfying patients, just as restaurants are in the business of meeting the needs of and satisfying diners.  But to some people the use of stars  to choose which hospital to go to may seem more questionable than the analogous case of selecting a place to eat.

Fakery in restaurant ratings is hardly unknown.  Once you see ads inviting hospitals to get help in raising their HCAHPS scores, you have to wonder about a similar trend in healthcare.  Certainly there has a serious problem of cheating in the interest of getting high scores in school testing, and education is probably a closer case to healthcare than restaurants or hotels.

How reliable are the HCAHPS questions themselves as indicators of hospital quality?  Beth has pointed out one problem:  Some communication can by its nature hardly be satisfying.

Recently the Gallup organization experimented with supplementing the HCAHPS questions with additional ones (developed in conjunction with the Cancer Treatment Centers of America), such as whether “even during stressful times, hospital staff equipped you with all the information, resources, and motivation that you needed to maintain proper diet and exercise”.  It found that patients with positive scores on these questions had significantly lower readmission rates.  This raises interesting questions about interpreting feedback and strategizing changes based on patient lifestyle and possibly many other factors.

Of course it’s hardly surprising that effective communication is important in determining whether discharged patients will follow their indicated regimen, but one could say that this Gallup study gives some credence to the validity and usefulness of such survey instruments.  Still, they did not use just the HCAHPS questions themselves but expanded on them.

If one looks at the actual questions, they seem appropriate and meaningful.  But there is generally an arbitrary side to any such set.  Likewise there are always nuances left out in a finite number of questions.  The number in the HCAHPS survey is fairly high (thirty-two, with eleven not about the hospital itself but rather “demographic” or “directional”); the more questions, the lower survey compliance usually is.

Of the twenty-one questions pertaining to hospital stay, ten are about communication, a rather high percentage, though of course that is a critical issue.  Let’s take a look at these.

Three ask about nurses and three about doctors whether they showed “courtesy and respect,”  “listened carefully,” and “explained things”.  Those are good questions, but as Beth pointed out, the standard is not too high:  one could do what was asked about and still not be caring and compassionate.

Also asked is whether hospital staff communicated what any new medicine was for and described any possible side effects.  I think the questions should have emphasized that oral communication was being meant, since such information is commonly given in written form and respondents could interpret that to mean communication “from” staff.  But again those are reasonable queries but not indicative of very high goals.  Why was this medicine chosen, what do you know about it, did you have a chance to discuss it, were there alternatives, what should you do if side effects occur – stronger questions could have been put.

True, you can’t ask everything, standardization serves a purpose, and patient experience is absolutely vital.  Still, considering and experimenting with alternatives (as in the Gallup study) would seem to be a useful exercise. What questions do you think patients should be asked?   As a patient what questions do you think would provide helpful feedback?     

Jim murphyJim Murphy has a solo consulting practice called Management 3000, focusing on organizational development and change management. Formerly he led the Massachusetts Bay Organizational Development Learning Group, was Human Resources Director for the City of Boston Assessing Department, and served as a consultant with the Boston Management Consortium.  His consulting practice includes management coaching as well as research and writing on employee relationships, leadership, healthcare and collaborative practices.  Having produced newsletters for several organizations  and being a frequent content writer for the”Confident Voices in Healthcare” blog, he is interested in writing and research opportunities, as we all consulting and coaching.





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4 Responses to How Reliable are the HCAHPS Survey Questions? Can We Do Better? What Would You Ask?

  1. Pingback: Seven Questions About Seven Ways to Increase Patient Satisfaction

  2. Beth, you bring up a good point. It is often a case of “don’t shoot the messenger” when caregivers must deliver news that a patient cannot get the pain medication (s)he wants, because, e.g., the MD has changed the order, the pharmacy hasn’t sent it yet, the allotted time has not passed, etc.

    In keeping with this fact is the HUGE difference in how nurses and other caregivers deliver care.

    The HCAHPS survey asks patients/families (it is not always the patient who completes the survey) general questions, requiring a distillation of emotions. As we all know, the way one finishes the encounter determines the emotional “taste in your mouth.” As such, these measures are filled with variability and ungeneralizable. However, such scores, summarized by a capable statistician, may be useful in determining general areas for needed improvement.

    Through all this, interprofessional and patient effective communication is key. As I tell my students, every word you say acts to either build a bridge or a wall .

    We must chose our words and our intentions emphatically and well.

    • Jim Murphy says:

      I second your remarks about the importance of communication!

      You also raise a good point about how the circumstances in which the HCAHPS survey is completed potentially jeopardizing the accuracy of the data. In particular, someone other than the patient doing the form would seem to be a red flag. I am wondering how well this has been looked into by the statistical experts.

  3. Thanks for keeping the spotlight on this topic, Jim. I so believe in the power of consumer feedback and support in efforts towards positive change in healthcare. Yet as this and related posts indicate, there are flaws in our current process and questions. Sometimes, in my direct care role as an RN, I feel trapped. I can not possibly do all of the things I am supposed in a way that I feel good about and suspect my patients and families would consider a high standard of care. Keeping the conversation going seems vital to me. The more consumers and healthcare professionals are talking and listening the more we can seek informed and helpful feedback. We must be care not to punish healthcare professionals who are trying to do their best and don’t have all the resources they need to be successful.

What are your thoughts?