Using any number from 0 to 10, Was Your Catheter Insertion Comfortable? How Reliable are the HCAHPS Survey Questions – Part Two

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The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) cquestionontinues to grow in importance.  This federally mandated measure of patient satisfaction is being used to determine hospital reimbursements and as a criterion for hospital awards.  It is the subject of training, and there are many consultants and businesses offering to help institutions get higher scores.  It has even been proposed that the government develop these into a star rating system so that prospective patients could choose hospitals in the way that diners use the Michelin guide to pick restaurants.  Ok, so this blogpost title is a little inflammatory, but doesn’t it make sense for us to check in with our expectations with respect to HCHAPS questions?

In an earlier post, we took a look at the actual HCAHPS survey questions on communication.  Almost half the score comes from these questions, which of course do cover a very important factor in hospital care.  Here we take a look at the other questions, which focus more on care, or as the survey itself puts it, “the hospital environment”.

“How often were your room and bathroom kept clean?”  Clearly important, and a fair question.  Still it might be difficult for patients to really know if the hospital is really doing what it necessary to prevent infections, given the very technical nature of the problem.

“How often was the area around your room quiet at night?” It has been shown that noise is a critical issue in how well patients do and one that requires changes in the organizational culture to improve.  So a good question, even if “quiet” is somewhat subjective.

If it was needed, how quickly did you get help getting to the bathroom or getting a bedpan?  Five minutes can seem like a question mark applifetime for patients and what is a reasonable response time for staff?  Important as this matter may be, it also is one in which patients may feel humiliated and thus perhaps not disposed to give a good judgment.  Too, “quickly” is also subjective.  That not all patients will have need such assistance may lessen the validity of the question.  And what about catheters?

If medicine was needed for pain, how well was the pain controlled?  Pain management is highly important, but subjectivity is an important concern here.  For example, patients might be wrong in thinking that medication is the only cure for pain and answer according to how their wishes for medication were answered.  Again, waiting when in pain can seem like forever.

“How often did the hospital staff do everything they could to relieve your pain?”  Now we are getting subjective to the point of absurdity.  “Everything they could”: How would a patient reasonably know what that means, and what kind of expectation does is suggest (all Oxcycontin I want)?  Overmedication might improve HCAHPS score, but also bring on lawsuits.

There are then two questions about “when you left the hospital,” a topic covered in other federal surveys.  These actually about communication:  Did the doctors and nurses ask if you would need help after discharge?  Did you get written information about possible symptoms or problems to look out for? Good points, but the subject is not well captured by simple “yes-no” answers.

All this leads up to the summary question:  “Using any number from 0 to 10 where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?”  Though using a common statistical measure, this may be the worst question in the set, amounting to an exercise in imagination rather than objective data.

After all, what kind of mental exercise is needed to conjure up the “worst possible” and the “best possible”? What standards of reference can patients accurately employ? Why would such a question be superior to asking “overall, how good was the care you received?”

When surveys are done, there can only be so many questions.   Question wording matters, but language can never be perfect.  And there are advantages to standardization.

So the HCAHPS will continue, patient input is very important, and these questions have validity.  But reducing healthcare to numbers is nonetheless questionable.  More it’s worth considering whether alternative questions might also be asked.   Readers are encouraged to give their own suggestions: is there a question you would like to see patients asked?

Here’s another thought:  In determining the quality of hospitals, are patients the only ones whose opinions should be sought.  What about asking the people who work there?

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3 Responses to Using any number from 0 to 10, Was Your Catheter Insertion Comfortable? How Reliable are the HCAHPS Survey Questions – Part Two

  1. Pingback: Supplementing HCAHPS? Ten Quality Improvement Questions for Everyone in Healthcare

  2. Sally O'Hara says:

    This is an important topic to raise. When patients ring for the nurse, it may be for anything from a request for help to change the TV channel because the current program is boring or a request for emergency help because the patient moved and an arterial bleed has started due to a combination of equipment malfunction and the patient not hearing the instructions not to pull out the equipment to use the rest room. It might help to have patients ring for the nurse in a manner that they can choose to say how long they could wait. This would have to be brought up routinely on admission, with reminders during admission. Also, the nursing staff may have multiple priorities such as responding to a code blue, a Joint Commission audit in progress, and coping with a staff shortage. If an intruder has entered the hospital, this might be considered a more pressing concern that should not wait too long, not knowing if other more vulnerable patients could be at risk.

  3. Hi Jim,

    In addition to seeking patient and family feedback, it also seems extremely important to be realistic about the continuum of patient expectations and availability of organizational resources.

    Spending time in a hospital seems very different from eating out at a restaurant or staying in a hotel. Most folks don’t want to be hospitalized and may be angry, fearful, powerless, or anxious for a variety of reasons. These strong emotions may inform patient experience and answers to questions making healthcare professionals great targets for projected anger and grief. Do you think this is considered in creating HCHAPS questions?

    The other question I have is about resources, like staffing. Are goals stated clearly and are the resources available to meet them? For instance, what is an appropriate amount of time for a patient to wait for someone to answer their calllight? One minute, five minutes, longer? This information plus some data on average frequency of calllights and time spent responding could help determine resources necessary to meet the goal.

    Maybe we could ask; “How long do you think patients should have to wait from the time you ring for help and help arrives?” or “Using a scale of 0-10 how high a priority is it for you to spend time in the hospital?” or “How much would you be willing to pay more for faster, better service?”

    Thanks for a provocative post on this important subject!

What are your thoughts?