HCAHPS: Ways to Improve on the Environment Question

By Carl Solomon, Sr., MBA, CHESP

June 19, 2013 | Formats: Article | Content Areas: Administration | Tags: Environmental hygiene and sanitation, Evidence-Based Practice Solutions, HCAHPS, Management

Since 2008, the HCAHPS—Hospital Consumer Assessment of Healthcare Providers and Systems—survey has allowed valid comparisons across hospitals locally, regionally, and nationally. Starting last October, HCAHPS scores resulting from patient discharge surveys are being used in the calculation of value-based incentive payments in the Hospital Value-Based Purchasing (VBP) program. The HCAHPS survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 18 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with the care. The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports. (1)

Inpatient Prospective Payment System: funds at risk

Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions must collect and submit HCAHPS data in order to receive their full annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS Survey, may receive an annual payment update that is reduced by 2 percent. (1)

HCAHPS & hospital Value-Based Purchasing (VBP) Scoring

The Hospital VBP program links a portion of IPPS hospitals’ payment from the Centers for Medicare & Medicaid Services (CMS) to performance on a set of quality measures. The hospital’s total performance score (TPS) for FY 2013 has two components: the clinical process of care domain (70 percent of TPS), and the patient experience of care domain (30 percent of TPS). The HCAHPS survey is the basis of the patient experience of care domain. (1)

Eight HCAHPS measures are employed in the hospital VBP: the six HCAHPS composites (communication with nurses, communication with doctors, staff responsiveness, pain management, communication and medicines, and discharge information); one new composite that combines the hospital cleanliness and quietness survey items; and one global item (overall rating of hospital).

The percentage of a hospital’s patients who chose the most positive, or “Top-Box,” survey response in these HCAHPS dimensions is used to calculate the patient experience of care domain score. Below are details about what hospitals are doing to improve their Top-Box score1 on the cleanliness and quietness survey item.

Cleanliness

For cleanliness, the patient is asked the following question: “During this hospital stay, how often were your room and bathroom kept clean?” Departments that are responsible for cleaning patients’ rooms are having their staff perform the following duties:

  • Having a supervisor or manager check in on every newly admitted patient the same day they are admitted, if possible.
  • Retraining their cleaning staff on how to properly clean an occupied patient room and bathroom.
  • Using bleach-based germicidal cleaners or alcohol-free germicidal cleaners to help the room smell clean.
  • Removing trash and soiled linen at the start of the day, and making a second round in the evening after dinner is served.
  • Conducting a sample of daily room inspections before and after the room has been cleaned.
  • Rotating the order of occupied room cleaning (e.g., the first room cleaned on a given day is not the first room cleaned the next day).
  • Interviewing a few patients and family members on each patient care unit each day and leaving a business card.
  • Providing AIDET Training (Announce, Introduce, Duration, Explanation, Thank You) to all newly hired staff, quarterly at staff meetings, and annually when giving performance evaluations. In applying AIDET to cleaning staff, these steps are followed: cleaning staff knocks on the door, asks if they may enter to empty trash/linen and/or clean the room, uses alcohol gel when entering and exiting the room (ensuring that the patient sees them rubbing their hands), makes eye contact with the patient and family, says their name and job title, explains what they will do and how much time it will take, asks if there is anything the patient needs, and thanks the patient and family for their time.
  • Having generic department business cards available for cleaning staff to offer to the patient and family. If the patient is asleep, a business card may be left in the restroom. If the patient is out of the room when it is being cleaned, a business card should be left to let the patient/family know that the room and restroom have been cleaned.
  • Placing a tent card on the over-bed table and toilet seat bands on the toilet when the room is discharge cleaned to let the patient know that the room was cleaned, and where to call if they have a cleaning need.
  • Using a VIP (Very Important Patient) log to identify patients who communicated a cleaning concern, and following up with patients at least daily to ensure that their rooms and bathrooms are cleaned to their satisfaction.
  • Designating an existing EVS supervisor as a quality assurance supervisor and trainer, or hiring one. The focus would be on inspecting an agreed number of patient rooms and following up with cleaning staff to correct deficiencies.
  • Participating on conference calls, or attending seminars or conferences where there is an opportunity to learn what others are doing to improve their HCAHPS scores, and sharing best practices.
  • Raising the bar on the caliber of the cleaning staff hired, to include being customer focused, pleasant, and knowledgeable about cleaning techniques.

Quietness

For quietness, the patient is asked the following question: “During this hospital stay, how often was the area around your room kept quiet at night?”

Departments are doing the following to make the patient environment quieter:

  • Using “Quiet Zone” signs in the corridors.
  • Using noise meters
  • Installing white noise machines that muffle the noise in the environment.
  • Offering patients headphones and CDs with relaxing music.
  • Offering patients ear plugs, which can be placed in the patient admit kit.
  • Providing patients with a notice of construction or repair work that may create noise or vibrations.
  • Having set quiet times each day when the lights are dimmed.
  • Asking patients if they want their doors closed. 
  • Evaluating all transport carts and replacing noisy wheels/casters. This may include carts used by nursing, environmental services, material services and linen, facilities, nutritional services, and construction services.
  • Turning down the alarm sound level on monitoring equipment if feasible. Some hospitals also have telemetry equipment monitoring away from the patient (e.g., in the nurses’ station).
  • Having EVS departments perform work using heavy equipment only during the daytime. This includes using battery powered scrubbers, buffers, and other equipment.
  • Using a portable lantern in multi-bed patient rooms to illuminate only the area where the employee is working during evening and overnight hours.

This is just a sample of the creative ways hospitals are striving to improve their patients’ perception of whether their room and bathroom is always clean, and whether noise is minimized near their room. I also recommend identifying hospitals in your region that have the highest Top Box scores and visiting them to learn how they are achieving excellence in HCAHPS. Also, hospital systems should freely share best practices information within their system to uncover new and creative ideas.

HCAHPS is here to stay, so we must be ready, willing, and excited to meet its challenges.

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