I've heard a lot lately from nurses railing against performance measures. Such complaints have been escalating since July 2007, when the Centers for Medicare and Medicaid Services (CMS) began requiring hospitals to publicly report scores from a standardized survey, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, or face eventual reductions in cost reimbursements. The survey assesses patients' perspectives of hospital care on items such as communication with physicians and nurses, responsiveness of staff, pain management, discharge information, and cleanliness and quietness of the environment. In short, the HCAHPS scores are a measure of those aspects of care known to matter to most hospitalized patients.
Last July I posted a question on AJN's Facebook page, asking nurses if they felt that HCAHPS measures were helping hospitals increase the quality of care by focusing on the patient experience. We received a slew of responses. While a few said that these measures help "keep us mindful of the person in the patient," the great majority of responses were negative. Here is a sampling.
* "I am spending so much time on trying to improve performance scores... I have less time to focus on the status of the patient, diagnosis and treatment plan."
* "The scores reflect the patients' perception and their satisfaction. Quality [care] does not always equal satisfaction."
* "I'm honestly sick of hearing about HCAHPS scores!... Things happen that you can't quite help and I just don't think patients understand that.... If only someone explained to patients what to expect during their stay."
Reading these, I wondered whether people who'd recently had a loved one hospitalized or been patients themselves would feel differently. And I thought about the comment that "someone" should explain to patients what to expect-shouldn't that "someone" be the admitting nurse? When I practiced, the admitting nurse oriented the patient to the hospital environment and explained likely aspects of care (such as diagnostic and laboratory tests, therapies, medications, diet, and activity level). Isn't that the practice now?
I spoke with Christy Dempsey, the chief nursing officer of Press Ganey, a consulting firm that works with U.S. hospitals to improve patients' experiences. I told her about the negative responses on Facebook, and she said she's heard such comments before, adding, "The focus shouldn't be about the scores but what they reflect-the overall patient experience. If we do what we know we should be doing, the scores will take care of themselves."
There's no getting around the importance of nurse-patient interaction and communication to patients' hospital experience. Nurses are critical to how well the hospital performs on these aspects of care, just as they're critical to protecting patients from medication errors, falls, and complications such as ventilator-associated pneumonia and catheter-associated bloodstream infections. In a recent analysis of HCAHPS data from over 3,000 acute care hospitals, Press Ganey found that communication with nurses was the linchpin-improving this measure was the key to improving the other measures. The report also noted that the literature "points to strong associations between levels of performance on these dimensions and clinical areas of interest... evaluated in CMS's other payment programs," areas such as improved treatment compliance, reduced 30-day readmission rates for cardiac and pneumonia patients, and lower inpatient mortality rates for patients who've had an acute myocardial infarction.
I also spoke with MaryAnn Hozak, the director of innovative nursing practice and quality management at St. Joseph's Regional Medical Center in Paterson, New Jersey, and a member of AJN's editorial board. She told me that when the number of critical care beds was increased at her facility, some performance measures showed a worsening trend. Nurse administrators used this data as evidence to make a case for adding new staff, and they got the staff they needed.
Smart nurses will use performance measures to show the value of nursing-and smart hospitals will invest in nursing, or they'll pay later in reduced reimbursements. And in the end, HCAHPS together with other clinical performance measures reflect whether patients have had a safe passage and a positive experience in a healing environment. Isn't that the point?