Earlier this year, nurses at Aurora Medical Center in Hartford, Wis., started an hourly rounding program that includes protocols for pain management, checking to see if patients are comfortably positioned within easy reach of their personal possessions and making sure their intravenous plugs are plugged in. Around the same time, all of the hospital's nurses made a service commitment to be "kind, respectful and courteous" to both patients and colleagues.

"We want them to be nice, kind and respectful not only to patients, but also to each other," says Karen Bialas, R.N., the hospital's nurse manager. "We're holding people accountable to that behavior."

Though vastly different in scope and purpose, both initiatives are part of a broader patient experience action plan under way throughout Milwaukee-based Aurora Health Care's 15-hospital system. Some of the new programs, like hourly, or "purposeful" rounding, are designed to improve specific aspects of patient care — for instance, how long patients wait for responses to their calls or how well they believe their pain is being managed. Other new initiatives, including the service commitment, are part of a broader organizational strategy to transform the system's culture, with the aim of improving both patient and employee satisfaction.

"We have strategies and tactics for the whole organization," says Kathy Leonhardt, M.D., patient safety officer and medical director of care management for Aurora Health Care. "We want to create a standardized, excellent patient experience."

The efforts come as hospitals and health systems work to improve performance on the 27-question Hospital Consumer Assessment of Healthcare Providers and Systems survey, given after discharge to selected patients. Starting in 2013, HCAHPS scores will be one of 13 measures used by the Centers for Medicare & Medicaid Services to calculate $850 million in payments from its new Hospital Value-Based Purchasing Program. Thirty percent of the VBP score will be based on HCAHPS and 70 percent on the 12 clinical measures. The survey includes 18 core questions about a patient's hospital experience, with topics that include communication with doctors and nurses, pain management, the quality of information given at discharge, cleanliness and noise in patient rooms.

Many hospitals and health systems are embracing a two-pronged HCAHPS strategy, with an emphasis on improving competencies around each of the 18 core questions alongside global efforts to improve the overall patient experience. The big-picture initiatives, which vary by hospital, range from comprehensive leadership training and employee satisfaction strategies to initiatives that identify potential new hires who possess both strong clinical and people skills.

The combined efforts are designed simultaneously to improve scores on individual HCAHPS questions and protect Medicare reimbursements at a time of financial uncertainty, while also building the foundation for lasting patient loyalty.

"The [hospitals] doing well are doing HCAHPS, but they're really focused on the patient experience," says Janna Binder, director of marketing and public relations at the health care consulting group PRC.

Measure for Measure

In October, CMS will begin using scores from HCAHPS surveys to help calculate value-based purchasing payments for 2013. In the meantime, many hospitals are launching educational efforts to prepare their employees for the changes and keep them apprised of how their units are performing on individual HCAHPS measures.

Leaders at Carolinas HealthCare System, a 28-hospital system based in Charlotte, N.C., are currently training employees on tactics to improve performance for all 18 core HCAHPS measures. Carolinas is also building an online HCAHPS scorecard that employees will be able to use to track their performance in real time, says Bonnie Felts, the system's data management coordinator.

"In 2012, we're planning education for our administration and staff in terms of what
HCAHPS and value-based purchasing mean to us," Felts says. " … But our ultimate goal is to create a scorecard for staff on what they need to know."

Throughout the Cleveland Clinic's network of eight hospitals in northeast Ohio, all managers have access to HCAHPS scores that are broken down for different work groups and individuals, says James Merlino, M.D., the system's chief patient experience officer. Individual physicians are given data on their own HCAHPS ratings, as well as information on how their perfomance rates against other Cleveland Clinic doctors.

"We let physicians know how patients score them on their skills," Merlino says. "Physicians are highly competitive, so it's important to let them know how they compare against their peers and where they rank."

'I Want To Make Sure I Understood You'

Patient communication represents the largest single chunk of the HCAHPS survey; half of the 18 core questions directly relate to how patients perceive their interactions with nurses, doctors and other hospital staff. These questions ask patients how closely clinicians listened to their concerns and whether they clearly understood the explanations or directions they received.

To standardize the way clinicians interact with patients and their families, an increasing number of hospitals are training their employees to use scripted communication tools and keywords. The tactics, which some liken to the attention a diner might get from a waiter at a high-end restaurant, are believed to improve patient perspectives of the care they receive — and also may relax tense patients during times of anxiety.

Nurses and physicians at Henry County Hospital in Napoleon, Ohio, employ the AIDET communication model developed by the Studer Group. AIDET — acknowledge, introduce, duration, explanation, thank you — requires clinicians to describe their educational background, listen carefully to patients and thank them after their consultation.

"Using AIDET effectively decreases anxieties, and decreasing anxiety decreases the patient perception of pain," hospital CEO Kimberly Bordenkircher says.

At Carolinas HealthCare System, employees are trained on tactics that include listening to patients for two minutes without interruption and regularly using expressions like "I want to make sure I understood you correctly."

"They're building that relationship through careful listening," says Patrick Ratchford, the system's human resources manager.

Even a clinician's body language can play a role; doctors who sit during consultations are perceived by patients to have spent twice as much time with them as those who stand during visits, the Cleveland Clinic's Merlino says.

However, some hospital leaders are wary of scripting and conversational tactics. Greg Johnson, D.O., chief medical officer at Parkview Health System in Fort Wayne, Ind., believes improvements in patient satisfaction from scripted questions and conversational tactics "are not sustainable. … [Scripting] is … really in a box by itself."

Leading by Example

Instead, Parkview focuses its patient satisfaction strategy on leadership training; selected physicians take up to 30 hours of class time on leadership principles that emphasize such values as curiosity, accountability and authenticity. Johnson believes the principles teach the hospital's physician leaders to model the behaviors the organization wishes to spread to the rest of the staff.

"It's difficult to hold the physician or nurse accountable, but it's our culture that's holding them accountable," he says.

At Mount Sinai Hospital in Chicago, that point is driven home during Sinai Service: Simply the Best, a daylong training course all incoming staff are required to take. Using techniques first developed by the Broadmoor ski resort in Colorado, Sinai's top executives meet with new hires to drive home the importance of patient service as a clinical and business imperative. Regardless of their job titles, the new hires work together in teams as they learn Sinai's approach to customer service.

"Everybody's hearing the same thing," says Karen Teitelbaum, chief operating officer. "Whether you're a security guard or a neurosurgeon, you're going through this together."

Engaged Employees, Satisfied Patients

Many hospitals also are focusing on improving the way their employees talk and interact with their peers, in the hope that the benefits of a friendly workplace will trickle down to patients. At Henry County Hospital, employees now are being asked to identify colleagues who have recently performed well, and are encouraged to send each other thank-you notes. Bordenkircher says the recognition from peers is part of an effort to reverse a longstanding tendency in health care to undervalue the importance of employee satisfaction.

"We're in the business of fixing people when they're broken," she says. "We're really trained to look for what's wrong. … But someone who feels supported by a team of other co-workers is going to be in a better position to provide exceptional care for patients."

Heightened employee morale and engagement can reap dividends beyond harnessing employee goodwill and passing it on to patients. Mickey Parsons, R.N., a professor for excellence in patient care with the University of Texas Health Science Center at San Antonio, argues that front-line staffers have a realm of expertise about the day-to-day life of a hospital that's hard to find elsewhere. If staff feel engaged and respected, Parsons argues, they are more likely to share their observations on patient care.

"There's an HCAHPS question about quiet at night," Parsons notes. "Who knows best about noise at night than the staff?"

Many hospitals traditionally operate within a model "where the doctor is king," argues Richard Corder, vice president of the patient safety strategies division of CRICO/RMF, a firm that provides malpractice insurance and risk management services to Harvard-affiliated medical institutions. But a framework in which all employees play a role in decision-making may lead to breakthroughs around patient satisfaction. "It might be the front-line member of your housekeeping staff who has the answer," he says.

Financial incentives that nudge clinicians in the right direction can help, Corder says. When he previously served as senior director of service excellence at Massachusetts General Hospital, the hospital offered incentives to physicians who attended communication training, which led to 92 percent attendance for the course and a temporary increase in HCAHPS scores for physician communication.

"Anything we've done to make the life of a front-line care provider easier to care for patients has shown an uptick," he says. "This is what good businesses do. You hire the right people, train them well, educate them to standards you've committed to and unleash them on your product or service."

Leadership is a key part of the patient satisfaction strategy at Aurora Health Care, where all of the system's 1,700 leaders receive specialized training on how to support caregivers to deliver care with "kindness, empathy and respect."

Lasting cultural change takes time and a consistent emphasis from leadership, Aurora Health Care's Leonhardt says. "Changing behavior is one of the biggest challenges for all human beings, and the culture in health care developed over centuries."

Hiring the Right People

Building a patient-friendly environment takes more than simply engaging existing employees, says Theresa Mazzaro, R.N., a nurse recruiter at PeaceHealth Southwest Washington Medical Center in Vancouver. A few years ago, the hospital reengineered its hiring process to assess potential hires for behavioral aptitudes. Previously, recruiters had focused primarily on a potential hire's clinical experience.

"We didn't really have a good process as far as establishing a quality hire," Mazzaro says. "If you had a pulse, you had experience and you hadn't hurt anyone in your career, essentially we were hiring you."

Today, the hiring process for nurses begins with a phone interview designed to see how applicants would resolve interpersonal conflicts and juggle multiple priorities. If applicants make it beyond that point, they proceed to a round of interviews with a council of nurses, who ask them to offer their views on various aspects of patient care.

"They need to be able to adequately define the patient experience and their expectations," Mazzaro says. "It's no longer: 'You're a nurse with critical care experience and you get the job.'"

For nurses fresh out of school who don't have prior clinical experience, PeaceHealth Southwest recruiters often ask about their customer service background — for instance, if they worked as a Starbucks barista while they were in nursing school.

Ultimately, Mazzaro says, the changes are designed to build a collegial, customer-oriented workforce, with the aim of improving both HCAHPS scores and patient loyalty.

"What's going to make patients return to us is the fact we took the extra time and we did the very smallest of things," she says. "Did somebody talk to them about their pain? When you start hiring people who understand those are the expectations, you're automatically changing that culture."



For Some Hospitals, HCAHPS Poses Added Challenges

Many hospitals looking to improve their HCAHPS scores must also overcome specific challenges posed by their patient base, facility or location. For instance, there's concern among administrators at older hospitals about how they'll stack up on the survey when patients compare them with competitors that offer more modern amenities.

"From a facilities perspective, we have unique challenges," says Karen Teitelbaum, chief operating officer of Mount Sinai Hospital in Chicago. "We're more than 90 years old, and some of our buildings are 90 years old. We still struggle with some facilities amenities. We have double rooms."

James Merlino, M.D., chief experience officer at the Cleveland Clinic, argues that academic medical centers often serve patients with higher comorbidities and rates of depression than other hospitals — both of which are associated with lower HCAHPS scores. While HCAHPS?includes a severity adjustment for patient conditions, Merlino says it doesn't do enough to reflect how patients at different stages of illnesses perceive their care.

"There's no robust risk adjustment process," Merlino says. "In the eyes of CMS, a 1,200-bed tertiary hospital in the middle of urban America is no different than a 200-bed community hospital in a rural setting."

For large, integrated systems like Aurora Health Care System in Wisconsin, whose care settings spread well beyond its 15 hospitals, it's imperative to sustain HCAHPS performance not just in the acute care setting but throughout its system, notes Kathy Leonhardt, M.D., vice president of patient experience and patient safety. That includes medical offices, home health settings and even retail clinics, Leonhardt says.

And for hospitals in areas with large populations that speak neither English nor Spanish — the two languages included on the HCAHPS survey — it may be difficult to get a representative sample of patients to take the survey, notes Nancy Foster, the American Hospital Association's vice president for quality and patient safety policy.

"It's great that HCAHPS is available in English and Spanish, but we know in certain communities there is a much broader representation of languages," Foster says. "To be able to understand how effective we're being for all of our patients, we need to have a broader range of translations available to collect that information."