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Improving HCAHPS, Patient Mortality and Readmission

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Overview

Using data from 1,879 healthcare organizations across the United States, we examined the relationship between overall Hospital Consumer Assessment of Health Providers Survey HCAHPS ratings, clinical care processes, and mortality and readmission rates. A statistical methodology known as Structural Equation Modeling (SEM) was used to analyze the way in which HCAHPS behaviors drive clinical care processes and mortality/readmission rates. SEM is a statistical technique that, when combined with strong theory and logical assumptions, allows researchers to estimate causal relationships between sets of variables.

The results of Phase 1 of our study indicated that HCAHPS ratings and clinical quality processes are cause-and effect drivers of patient mortality and readmission. Together, HCAHPS ratings and clinical care processes account for eight percent of the variance in readmission rates and one percent of the variance in mortality rates. The bottom line is that improving HCAHPS ratings and clinical process of care scores directly impacts life or death outcomes for patients. The results of Phase 1 are depicted in the figure below.

In Phase 2 of our study we examined the relationship between care providers’ behaviors and clinical processes of care. The results indicate that HCAHPS Overall Ratings are a statistically significant, cause-and-effect driver of clinical care processes. Within U.S. healthcare organizations, higher levels of behavioral consistency, as measured by the overall HCAHPS rating, lead to higher rates at which recommended clinical care processes are delivered to patients. HCAHPS Overall Ratings are driven, in turn, by the critical dimension-level HCAHPS behaviors. Specifically, Nurse Communication has the greatest impact on Overall HCAHPS Ratings, followed closely by Discharge Information, Cleanliness/Quietness, and Pain Management. All four of these behaviors are significant, cause- and-effect drivers of HCAHPS Overall Ratings, which in turn drive the frequency with which care providers deliver treatment consistent with recommended clinical care processes.

The results indicate that consistency in care providers’ behaviors causally impacts clinical care processes and clinical outcomes (i.e., readmissions and mortality). Specifically, improving consistency in nurse communication, discharge information, cleanliness/quietness, and pain management will have the greatest impact on overall HCAHPS ratings and clinical care processes, in turn reducing readmission and mortality rates. In summary, this study reinforces the need for healthcare organizations to focus on building and sustaining patient-centered cultures. Establishing an organizational culture that is focused on the entire continuum of the patient experience – from registration to discharge – not only improves patient satisfaction and clinical quality, but also reduces readmission and mortality rates.

Introduction

The provision of high quality care is an enduring focus of the healthcare industry. As defined by the Institute of Medicine (IOM), quality of care refers to “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Several quality measures are available to help healthcare organizations quantify the quality of particular aspects of care. Of particular interest are clinical quality measures, or the quality of the preventative, diagnostic, therapeutic, and rehabilitative measures taken to maintain, restore, or improve patients’ health outcomes.

Clinical quality has been found to be highly variable across healthcare organizations in the U.S. Such variation is problematic for healthcare providers and the patients they serve, as lapses in the quality of clinical care delivered to patients often result in higher levels of readmission and mortality. Additionally, under the Centers for Medicare and Medicaid Services’ (CMS) “value-based purchasing” proposal, hospitals’ clinical quality (70 percent) and patient satisfaction performance (30 percent) will be directly linked to Medicare reimbursement rates. As the proposal currently stands, Medicare will begin withholding one percent of its payments to hospitals beginning in October 2012. The withheld money – approximately $850 million in the first year of value-based purchasing – will be distributed in a ‘pay for performance’ manner to hospitals scoring above the average on several clinical quality and patient satisfaction measures. Faced with increasing financial pressures, healthcare leaders are therefore looking for novel solutions to reduce variability and improve clinical care processes.

A common misperception is that clinical quality improvement efforts fall solely on the shoulders of clinical care providers. The truth, however, is that all members of healthcare organizations, from direct care providers to housekeeping and maintenance staff, play an integral role in improving the quality and consistency of the clinical services delivered to patients. Specifically, the behaviors in which all members of the healthcare organization engage – from communicating with patients to maintaining a clean, safe environment – contribute to improvements in clinical quality processes and corresponding reductions in readmission and mortality rates.

CMS has identified a core set of healthcare provider behaviors that are associated with high quality care and a satisfying patient experience. These behaviors, which are measured using the HCAHPS, include nurse communication, physician communication, staff responsiveness, pain control, medication communication, discharge information, cleanliness, and quietness. HCAHPS asks patients to rate the frequency with which members of the healthcare organization engage in each of these behaviors. The consistent enactment of these behaviors, in turn, is expected to result in higher patient satisfaction, enhanced quality of care for patients, and lower readmission and mortality rates. To evaluate this assumption, we conducted a nationwide study of healthcare organizations. As we describe below, the purpose of this study was to identify the relationships between HCAHPS behaviors, clinical care processes, and mortality/readmission rates.

Using Analytics To Link HCAHPS Behaviors To Key Healthcare Outcomes

We used SEM to analyze the way in which HCAHPS behaviors drive clinical care processes and mortality/readmission rates. SEM is a statistical technique that, when combined with strong theory and logical assumptions, allows researchers to estimate causal relationships between sets of variables. SEM is a more robust tool and provides more actionable results than traditional statistical methods (e.g., correlation, regression). Particular advantages of SEM are that it:

  • Implies cause-and-effect relationships,
  • Lends itself to ROI calculation,
  • Allows multiple independent and dependent measures to be assessed concurrently, and corrects for measurement error.

In the nationwide study presented below, we used SEM to (1) examine the relationship between overall HCAHPS ratings, clinical care processes, and mortality/readmission rates, and (2) identify the specific behaviors that drive overall HCAHPS ratings and clinical care processes.

Nationwide Study Phase 1: Drivers Of Mortality And Readmission Rates

Using data from 1,879 healthcare organizations across the United States, we examined the relationship between overall HCAHPS ratings, clinical care processes, and mortality and readmission rates. The overall HCAHPS rating assesses patients’ perceptions of the hospital on a scale from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible. For the purposes of the present study, this measure was interpreted as an evaluation of the consistency with which the HCAHPS behaviors (e.g., nurse communication, doctor communication, cleanliness, etc.) were enacted.

The clinical process of care measures assess the frequency with which recommended clinical treatments were provided to patients with certain medical conditions or surgical procedures. See Table 1 for a description of the specific clinical care processes assessed in this study.


Figure 1 – Drivers of Mortality and Readmission *Higher values indicate a stronger impact based on a 0.0 to |1.0| scale


Table 1

We used SEM to link HCAHPS ratings and clinical process of care scores at the organizational level directly to organizational-level mortality and readmission rates. Our findings are presented in Figure 1.

As shown in Figure 1, HCAHPS ratings and clinical quality processes are cause-and effect drivers of patient mortality and readmission. The values in the figure (referred to as beta weights in SEM) specify the strength of the relationships based on a 0.0 to |1.0| scale where values closer to 1.0 or -1.0 denote a stronger relationship.

The beta weight of .17 between HCAHPS ratings and clinical care processes indicates that higher overall HCAHPS ratings lead to higher rates of delivery of clinical care processes to patients. In contrast, the negative beta weights in the model (labeled “Decreases”) indicate that higher overall HCAHPS ratings and clinical care processes contribute to lower mortality and readmission rates.

Together, HCAHPS ratings and clinical care processes account for eight percent of the variance in Readmission rates and one percent of the variance in mortality rates. The bottom line is that improving HCAHPS ratings and clinical process of care scores directly impacts life or death outcomes for patients. The level of impact that improvements in HCAHPS ratings and clinical quality scores has on mortality and readmission rates is depicted in Table 2.


Table 2 - *Assuming all else is held equal

The results of this study reinforce the need for healthcare organizations to focus on improving HCAHPS ratings as a means of enhancing consistency in the delivery of clinical quality processes and reducing patient readmission and mortality rates. There are a wide range of interventions that healthcare leaders might consider in an effort to improve their organization’s HCAHPS ratings. Many interventions focus on changing physician and employee behaviors.

The purpose of the second phase of this study was to identify the specific behaviors on which healthcare leaders should focus to produce the greatest improvements in clinical care processes and corresponding reductions in patient readmission and mortality rates.

Nationwide Study Phase 2: Drivers Of Clinical Care Processes

Using data from 2,273 U.S. healthcare organizations, we examined the relationship between care providers’ behaviors and clinical processes of care. Dimension-level HCAHPS ratings were used to measure care provider behaviors in each of the following categories: nurse communication, physician communication, staff responsiveness, pain control, medication communication, discharge information, cleanliness, and quietness. As in the first phase of our study, the overall HCAHPS rating was interpreted as the overall consistency with which the behaviors were enacted. We lined up dimension-level HCAHPS ratings for each healthcare organization with their clinical process of care frequencies to assess which of the HCAHPS behaviors were driving clinical care processes. The results are depicted in Figure 2.

As shown in Figure 2, HCAHPS Overall Ratings are a statistically significant, cause-and-effect driver of clinical care processes. The results indicate that, within U.S. healthcare organizations, higher levels of behavioral consistency, as measured by the overall HCAHPS rating, lead to higher rates at which recommended clinical care processes are delivered to patients.


Figure 2 - *Denotes statistically significant relationship. Higher numbers indicate a stronger impact based on a 0.0-1.0 scale.

Key HCAHPS Focus Area

  • Nurse Communication
  • Discharge Information
  • Cleanliness/Quietness
  • Pain Management

HCAHPS Overall Ratings are driven, in turn, by the critical dimension-level HCAHPS behaviors depicted in Figure 2. Specifically, Nurse Communication has the greatest impact on Overall HCAHPS Ratings, followed closely by Discharge Information, Cleanliness/Quietness, and Pain Management. All four of these behaviors are significant, cause-and-effect drivers of HCAHPS Overall Ratings, which in turn drive the frequency with which care providers deliver treatment consistent with recommended clinical care processes. This model was validated across multiple clinical care measures (e.g., SCIP, PN, AMI, and HF).

The results of this study reveal several key HCAHPS behaviors on which healthcare leaders can focus to improve behavioral consistency and clinical care processes, which in turn will help to reduce patient readmission and mortality rates. The key HCAHPS behavioral focus areas are presented in order of importance. By investing in initiatives that target these key behaviors, healthcare leaders can play a significant role in improving clinical care processes and reducing readmission and mortality rates.

Summary of Results

The results of this study indicate that overall HCAHPS ratings and clinical care processes are critical, cause-and-effect drivers of patient readmission and mortality rates. By identifying the key behavioral drivers of overall HCAHPS ratings and clinical care processes, this study allows healthcare organizations to make evidence-based investment decisions that drive reductions in readmission and mortality rates and maximize the return on investment for human resource initiatives. The results of this study suggest that investing in initiatives and systems that target nurse communication, discharge information, cleanliness/quietness, and pain management will produce the greatest return in the form of improved clinical care processes and lower rates of readmission and mortality. Similar analyses can and should be replicated using organization or department-specific data, thus allowing healthcare leaders to identify the key drivers of clinical quality within their unique culture.

Recommendations For Taking Action In Healthcare Organizations

Within the healthcare industry, it is not uncommon to encounter skeptics of the patient- centered approach, many of whom prioritize high quality clinical care but question the validity of HCAHPS and the importance of prioritizing the patient experience. The findings of this nationwide study speak directly to the skeptics and validate many of the assumptions made by CMS when designing the value-based purchasing framework; patients’ experiences in healthcare facilities impact the quality and effectiveness of the clinical treatment they receive. Specifically, the results indicate that the degree of consistency with which healthcare providers engage in specific, patient-centered behaviors (as measured by HCAHPS) directly and causally impact clinical quality processes and, in turn, readmission and mortality rates. This study reinforces the need for healthcare organizations to focus on building and sustaining patient-centered cultures. The bottom line is that doing so can ‘save lives’. Establishing an organizational culture that is focused on the entire continuum of the patient experience – from registration to discharge – not only improves patient satisfaction and clinical quality, but also reduces readmission and mortality rates.

The need to focus on building a patient-centered culture does not replace the importance of delivering high quality clinical care to patients; indeed, the best and most sustainable results will be achieved when high quality care becomes embedded within a culture focused on the patient experience.

The findings of this study reinforce the need to undertake the hard work required to build and sustain a patient-centered culture. The results indicate that consistency in care providers’ behaviors causally impacts clinical care processes and clinical outcomes (i.e., readmissions and mortality). Specifically, improving consistency in nurse communication, discharge information, cleanliness/quietness, and pain management will have the greatest impact on overall HCAHPS ratings and clinical care processes, in turn reducing readmission and mortality rates. In addition to being the right thing to do, prioritizing the patient experience improves clinical outcomes for patients and bottom line financial outcomes for healthcare organizations.


IRI Consultants partnered with SMD, the leader in predictive analytics for employee assessments, to form IRI Analytics. IRI Analytics is the only provider of patented analytics technology for healthcare organizations
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