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HCAHPS: Update for Trustees Mary Therriault RN MS Senior Director, Quality and Research Initiatives Healthcare Association of New York State July, 2012. HRET Curriculum: A New Way of Thinking about HCAHPS. H ospital C onsumer A ssessment of H ealthcare P roviders and S ystems.

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HCAHPS: Update for TrusteesMary Therriault RN MSSenior Director, Quality and Research Initiatives Healthcare Association of New York State July, 2012

hret curriculum a new way of thinking about hcahps

HRET Curriculum: A New Way of Thinking about HCAHPS



Assessment of


Providers and


what hcahps means
What HCAHPS Means


Can you



Patients/ Providers


ahrq hret patient safety learning network psln project
AHRQ/HRET Patient Safety Learning Network (PSLN) Project
  • HANYS, HRET and AHRQ are partners in bringing you this free program of technical assistance for 6 months.
  • AHRQ has retained HRET to partner with health care leaders in creating Patient Safety Learning Networks to support hospitals that wish to use AHRQ’s patient safety improvement tools.
  • HRET will support learning network members in using HCAHPS, as well other AHRQ patient safety tools in 25 States during 2012.
  • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET).
  • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education.
  • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.
  • Faculty: Carrie Brady, MA, JD
    • Primary HCAHPS trainer
    • Former Connecticut Hospital Association staffer
    • Previous V.P. at Planetree
hcahps and hen priority challenges care transitions and adverse drug events
HCAHPS and HEN Priority Challenges: Care Transitions and Adverse Drug Events

Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs:

  • RN Communication
  • Responsiveness
  • Medication Communication*
  • Discharge Information*

* HCAHPS domains addressed by a patient-centered discharge process

our goal
Our Goal

To support hospital teams in effectively using HCAHPS as a tool for improving quality, safety, and the patient experience.

our strategies
Our Strategies
  • Provide expertise, research, and practical tools
  • Harness participants’ institutional wisdom
  • Build internal teams and external communities for ongoing improvement work
pop quiz
Pop Quiz!

In the United States,

how many HCAHPS surveys:

Will be administered today?

Will be completed today?

hcahps today

More than 25,000 surveys administered

More than 7,500 surveys completed

More than 7% of all hospitalized patients

complete the survey

Source: HCAHPS Executive Insight, October 2011. Centers for Medicare & Medicaid Services, Baltimore, MD.

hcahps in a nutshell
HCAHPS In a Nutshell
  • HCAHPS is a national standardized survey of hospital inpatients
  • 27 questions
    • 18 substantive questions
    • 4 screening questions
    • 5 demographic questions
hcahps topics
  • CMS reports individual scores for:
    • Cleanliness
    • Quiet at night
    • Overall rating
    • Willingness to recommend
  • CMS reports composite scores for 6 topics:
    • Nurse Communication
    • Doctor Communication
    • Medication Communication
    • Responsiveness
    • Pain Management
    • Discharge Information
patients see things differently than providers
Patients See Things Differently Than Providers

Source: Weingart SN et al. “Patient-Reported Safety and Quality of Care in Outpatient Oncology” Joint Commission Journal on Quality and Patient Safety; 33:2, 2007

22% of 193 patients reported a “recent unsafe episode”

More than 80% of the reported experiences were classified by reviewers as “service quality incidents”

  • 33% related to waits and delays
  • 21% related to poor communication and information for patients
  • 13% related to poor coordination of care among staff
the evidence is mounting
The Evidence is Mounting

HCAHPS Matters


why hcahps matters

Why HCAHPS Matters:

Value-Based Purchasing Implications

vbp overview
VBP Overview
  • DRG payments initially reduced by 1% in FY2013
    • reduction rises by 0.25% each year, ending with 2% reduction in FY2017
  • Payments adjusted based on performance on HCAHPS (30%) and clinical process measures (70%)
  • Hospitals may earn VBP points in two ways:
    • By achieving a certain level of performance or
    • By improving their performance
    • More points available for achievement than improvement
essential elements to consider
Essential Elements to Consider
  • Leadership Strategies
  • Strategies for Partnering with Patients and Families
  • Workforce Strategies
  • Data Use Strategies
  • Performance Improvement Strategies
ideal scenario
Ideal Scenario

HCAHPS is viewed as a valuable tool to help organizations achieve multiple objectives

HCAHPS is part of a coordinated, comprehensive approach to partnering with patients and families

Everyone works together as a team to identify opportunities for improvement, innovate and implement strategies, and celebrate success

improving communication through team training
Improving Communication through Team Training


  • A comprehensive evidence-based system to enhance teamwork and communication among healthcare professionals
  • HRET is the national training contractor
  • Free curriculum and tools available at