As the Affordable Care Act has concluded its first Open Enrollment Period, many individuals associate the Affordable Care Act with individual private healthcare coverage, failing to realize that there are many other important reforms that came along with this act. These reforms not only impact individuals, but also hospitals and health systems.
One of the reforms from the Affordable Care Act of 2010 was the establishment of Value Based Purchasing, which became effective after October 1, 2012. This reform impacts nearly 3,000 hospitals within the United States, and for many of these there is a significant financial impact not being realized and revenue being “left on the table” by not maximizing their Value Based Purchasing Scores. Not having the correct tools, visibility, and specifications hinders their capability to improve their score value and receive revenues they would otherwise leave behind.
The Hospital Value Based Purchasing Programs were created by the Centers for Medicare and Medicaid Services (CMS), and were designed to provide incentive payments to hospitals ranking in the top quartile for the quality of care they provide to their patients. These payments are based upon:
- How well they perform on each measure
- How much they improve their performance measured against their baseline performance
Value Based Purchasing payments for 2014 are determined by three categories:
- 13 measures of timely and effective care
- Patient Satisfaction and Experience - HCAHPS Survey
- Mortality rates among Medicare patients admitted for heart attack, heart failure, or pneumonia
For today, I would like to focus attention on the second category, Patient Satisfaction and Patient Experience, because of the incremental gains a hospital can make by focusing on fundamental patient/clinician communications thus beginning to recapture some of the “lost revenue” mentioned above.
The Value Based Purchasing assessment of Patient Satisfaction and Experience is an in-patient survey that is conducted through The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) appraisal tool. It is a standardized, publicly reported survey of recently discharged patients' perspectives of the consistency with which the hospital met their needs during their time of admittance.
The survey questions are broken down into nine topics:
- Communication with Doctors
- Communication with Nurses
- Responsiveness of Hospital Staff
- Pain Management
- Communication about Medicines
- Discharge Information
- Cleanliness of the Hospital Environment
- Quietness of the Hospital Environment
- Transition of Care
What are notable and predominant in these categories are the themes of communication and personal interaction. Another thematic element is consistency of the care experience. Most questions in the survey contain the phrasing “how often..?” For example, “How often did nurses treat you with courtesy and respect?” or “How often did nurses explain things in a way you could understand?” Even the non-communication related questions ask “How often was the area around you kept quiet at night?”
So, hospitals are faced with the challenge of approximately 60% of the appraisal questions centering on “consistent, effective communications”, with patients and families determining the hospital’s ranking. But how do we improve scoring centered on the inherently vague term communication? What I may define as great communication may be what another individual defines as poor and unacceptable communication. Thus, the burden is placed on the hospital to ensure that it has properly defined this ambiguous term, and is then able to assess its application over time.
One could write a book on this “communication” challenge, but today I would like to review the one building block upon which all success in this arena rests, and that is the concept of specifications. In the case of communication, the fundamental building block must be a definition and specification around what good communication is... if I can’t define it, I sure can’t manage it.
For example, one core HCAHPS question asks the patient: “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.” Does the patient agree, disagree, strongly or otherwise. Yikes! “A good understanding...”
This survey question begs for a definition (specification) for:
- What(specifically) should the patient know about their post-discharge responsibilities
- How do we assure that they understand
Thus our challenge to assure positive responses to this question (and the significant reimbursement dollars attached to those positive response), is to document the specific key knowledge points required, and define and document the training and communication techniques that will maximize understanding.
I had an interesting conversation on this topic recently with a very experienced med/surge nurse whom I highly respect. Her comment on whether she had been supplied with any specs on the post-discharge communication was, “No, that’s not really necessary, any good nurse knows how to cover that.”
Well, I believe she would be shocked if she were to list the specific knowledge-set required at discharge, and were to then observe a cross section of nurses in their pre-discharge discussions with patients and families. This is not a critique of nurses’ knowledge or diligence, it is simply an unavoidable outcome if specifications are not defined and documented.
The second challenge is the patient’s understanding. The key to this challenge is a specific (tactful) repeatable, question/response process with the patient and family, along with take-home documentation that is appropriate for the education and language capability of the patient cross-section. If the hospital administration truly wants to excel in this arena, it must test the effectiveness of their process by working with patients and families to fashion a specific pre-discharge protocol, and then videotaping real (with patient permission of course) or staged pre-discharge dialogues incorporating the defined “best practices” to use as a training and measurement tool. Heavy emphasis should be placed on the word “dialogue” in planning a pre-discharge specification. The saying “all effective communication is a dialogue” has never been more relevant, and the spec must include a prescribed question/response interaction to gauge level of understanding.
The beauty of the video and the spec (a list of “ingredients”) is the ability to easily gauge the “quality” of the communication. A “good quality” pre-discharge communication contains the list of “ingredients,” a “bad” one does not. To carry the analogy further, the spec lists not only what to say, but how to say it (i.e., sit, not stand beside the patient, look them in the eye, nod your head when they respond, etc.).
The point is not that all nurses will “follow the script” exactly, but they will have a much better chance of having a dialogue that leaves the patient and their family feeling like they have been effectively and respectfully communicated with. And you will see your HCAHPS scores improve nicely.
The improvement of HCAHPS scores all starts with being able to put a specification and definition around communication. This will then lead to the ability to measure your results. Having the correct business intelligence and visibility will allow you to move the scores in the correct direction.