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Improving HCAHPS Scores and The Patient Experience

Gerald Taylor, MBA

Patient satisfaction is an important and commonly used indicator to measure the value of health care. Across the United States, shifts in health-care policy have tied hospital and physician compensation to patient experience measures that focus on patient engagement.  As of late, understanding and improving the patient experience has become almost a burning platform for U.S. healthcare executives.  The patient experience survey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), serves as a remarkably effective guide for the success of doctors and hospitals.

Res Ipsa Loquitur – Facts About the Patient Satisfaction

According to McKinsey & Company, many health systems make large investments in initiatives to improve the patient experience but fail to achieve their desired objectives. 

Here are some interesting facts about patient satisfaction:

  1. Performance on the HCAHPS survey can affect up to 33% of a physician’s reimbursement.
  2. 25% of value-based purchasing reimbursements are tied directly to HCAHPS scores.
  3. In fiscal year 2020, 55% of the approximately 2,800 participating hospitals received approximately $1.9 billion in CMS value-based purchasing program incentive payouts – roughly $1.3 million per hospital.
  4. Health system executives find that roughly 70 percent of their patient experience initiatives fail.

McKinsey also concludes that hospital in-depth data analysis and research can be better at pinpointing which factors most strongly influence patient satisfaction levels.  Moreover, TPMG Global® research has discovered more than half of healthcare facilities across the United States find the most difficult barrier to improving HCAHPS scores is focusing on the right drivers of “Would Recommend Hospital.”  And that is what this article is about.

In this piece we will discuss how to pinpoint the drivers that most strongly influence “Would Recommend Hospital,” and how to overcome common flaws which wreak havoc in patient experience initiatives. 

Improving HCAHPS Scores and The Patient Experience

Many in the healthcare industry believe there are few financial rewards for improving and sustaining respectable HCAHPs scores.  However, according to a study by the Deloitte Center for Health Solutions:  Hospitals with excellent HCAHPS patient ratings between 2008 and 2014 realized an average net margin of 4.7%, as compared to just 1.8% for those with low ratings.   

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At TPMG Global, we believe improving patient satisfaction is not about making patients happy – par se’, but about improving the patient’s entire experience across the continuum of care.   The patient experience encompasses not just the clinical aspects of care delivery, but also the administrative, operational, cultural and behavioral characteristics of the entire care delivery system.   The object of improving the patient experience is to yield greater value by not only producing higher HCAHPS scores, but to also maximizing a facility’s reimbursements and sustaining meaningful improvements in real patient satisfaction.

To that end, we offer a simple 5 step method for improving the patient experience.

  1. Put the HCHAPS survey into the field
  2. Conduct the appropriate data analysis
  3. Pinpoint the drivers that most strongly influence “Willingness to Recommend Hospital”
  4. Conduct the appropriate qualitative analysis
  5. Implement a plan, do, check, act test of change

This article will provide you with two easy step-by step data analysis methods that will pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital.

An HCAHPS Case Study – Hospitals in the Same System are Not Alike

A large hospital, part of an even larger system:  HCAHPs Survey Analysis 2014 – 2018

Case Study Problem Statement:  This healthcare facility is part of a larger healthcare system on the eastern cost of the United States.  For more than 4 years they have not been able to improve their stagnant patient satisfaction scores.  The head of the facility’s patient experience team instinctively knew the patient satisfaction driver report they received from their system’s central office was not focusing on the right factors.  They needed a change.

Baseline Analysis:  Since 2014, their HCHAPS “Willingness to Recommend” score has averaged 77.32 – ranking the facility between the 50th and 75th percentiles.  Though their scores are better than both the state (69) and national (72) results, the baseline analysis covers a serious weakness.  The facility’s scores fall below the national ratings almost 17% of the time and its performance misses the 90th percentile mark of 84 (their goal) 94% of the time. 

Interpreting HCAHPS: Pinpointing the Determinants of Patient Satisfaction

To pinpoint the right drivers that most strongly influence willingness to recommend, there are 2 kinds of analysis you must perform.  The first type establishes linear cause and effect relationships between the drivers of patient satisfaction and their willingness to recommend a hospital. The other proves dependencies between those drivers and the same outcome.  Most importantly, the data analysis must be “statistically significant” to have the predictive power and confidence needed to ensure an initiative will generate a strong return on the time, hard work, and capital invested.

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The Results:  Drivers of Patient Satisfaction – Linear Relationships

Drivers of Willingness to RecommendRelative Strength
Governing StrengthR – Square:  .74
Drs Explained Things UnderstandablyImpact  -0.40
Treated w/ C&R by DrsImpact  0.35
RNs Listened Carefully to YouImpact  0.50
Told What Medicine Was ForImpact  0.30
Treated w/ C&R by RNsImpact  0.42
Received Phone Call at HomeImpact  0.14

The table above identifies 6 statistically significant drivers of the patient experience that best determines Willingness to Recommend Hospital.  The key performance indicators suggest the following:

  1. R-Square:  the subset of characteristics, outlined here, are a 74% driver of patient satisfaction.  Other variables (26%) may also drive Patient Satisfaction but may not be captured by the survey.
  2. P-Value:  we can be 99.9999979% confident these are the appropriate drivers of patient satisfaction for this facility.

Critical to Satisfaction Characteristics

The model indicates, a one-point improvement in “Treated with Courtesy and Respect by Doctors” drives Willingness by 0.35 points; a one-point improvement in “RNs Listened Carefully” drives Willingness by 0.50 points etc…  (Linear Relationships)

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Drivers of Patient Satisfaction – Dependent Relationships

Now that we have determined the fundamental drivers of patient satisfaction, we move forward to discover the extent to which patient satisfaction is dependent upon them.  Here, we evaluate the relationship between the attribute “Treated w/ C&R by RNs” and “Willingness to Recommend.”  The approach tells us the extent to which Willingness to Recommend is dependent on Treated w/C&R by RNs.

The basic idea of the method is to compare the observed performance of the driver with its expected performance.  If there is no dependent relationship between the potential driver and outcome, the actual frequencies at which willingness to recommend is observed will be close to their expected frequencies (in the norm).

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All other things remaining equal – the analysis indicates that we can be 99.995% confident – patients punish Very Good performance but reward Excellent performance in this category.  It appears performing very good in this category is not good enough. The hospital must be excellent to be rewarded with a willingness to recommend rating. For Very Good performance, patients are 59% less likely to “Definitely Recommend Hospital”.  For Excellent Performance in this category, patients are 89% more likely to “Definitely Recommend Hospital”.  Only 23% of patients give an excellent rating for this category!  

At the end of the day, we can safely conclude Willingness to Recommend Hospital is not only strongly driven by Treated with Courtesy and Respect by RNs, but it is also dependent on the driver for improvement.   In addition, the opportunity for improvement (OFI) is substantial!    The charter for the patient experience initiative should include an objective and key result (OKR) for this driver, like:  Improve the percentage of respondents for “Treated w/ C&R by RNs” with an excellent rating by 77% (predicted target date – here). 

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at:  TPMG Global® – Improving HCAHPS Scores and The Patient Experience

Gerald Taylor is the Managing Director at TPMG Global®


Improving Patient Satisfaction Via Lean Six Sigma

Lean Six Sigma in Healthcare Learn how The Juran Institute used Lean Six Sigma to help a medical telemetry unit in a medium-sized hospital, increase their HCAHPS percent ratings.

Problem Statement

A medical telemetry unit, in a medium-sized hospital, reported HCAHPS percent ratings below the competition for “Overall Unit Rating” and “Would You Recommend This Hospital.” The baseline scores of 9–10 responses on “Overall Unit Rating” were 56% and the percentage of “Definitely Yes” responses for “Would You Recommend This Hospital” was 61%.

Project Goals

The team defined the project goal to meet or exceed the highest percent ratings in the county for “Overall Unit Rating” and “Would you Recommend This Hospital” by:

  • 0 – 20% improvement by November 2009
  • 20 – 50% improvement by January 2010
  • 50% improvement by March 2010

Project Team

The team was composed of representatives from the Telemetry Unit, Physical and Occupational Therapy, Pharmacy, Food and Nutrition Services, Respiratory, Care Coordination, Environmental Services, Transportation, Materials Management, Organizational Development, and Center for Nursing Practice.

Project Scope

The project scope was unsecured patient accounts. The beginning boundary for the project was the time a patient arrived in the E.D. The ending boundary was when the patient was discharged from the E.D. and financial responsibility was secured.

SIPOC Process

The team proceeded to develop a SIPOC (Supplier, Input, Process, Output, and Customer) on the “admission to discharge” patient process. This high-level process map is used to identify suppliers at the front end affecting the process, materials and inputs entering the process, materials and outputs exiting the process, and ultimately, customers impacted by the process.

Understanding the Needs of the Medical Telemetry Unit’s Audiences

The team conducted patient, family, and staff surveys and interviews to collect voice of the customer data on the patient’s experience. The team understood the importance of engaging the patient and family in the design of their care.

They acknowledged that it is not about the organization behind the services, rather it is about how the patient receives those services. In other words, it is all about the patients’ perception of their experience. The team took verbatim voice of the customer (VOC) data and translated it into themes and critical-to-quality requirements (CTQs). CTQs are defined as measureable customer needs and are considered by the team as solutions are designed and implemented.

Below are examples of the voice of the customer data from a patient’s perspective.

Several patients and family members commented that they have never been
asked before what is important to them and what the staff could do to provide the best experience. The team translated voice of the customer to key themes/issues and identified a critical to quality measure for affinity groups.

Understanding the Process

The team created a current state value stream map from the time the patient was admitted to the floor until discharge. Mapping proved to be challenging for the team due to the variation in care processes.

Understanding Non Value Added Work

The team analyzed the current state value stream map from the time the patient was admitted to the floor until discharge. The analysis helped the team identify non-value added work, bottlenecks, and issues impacting the patient experience.

Generating Solutions

Solutions were generated, prioritized and ranked by the Team. Five design teams were created: Patient Hospitality and Comfort, Discharge Preparation, Patient Education, Staff Education, and Noise Level. The project teams designed their solutions around key patient-centered design principles.

Shared Decision-Making

Patients vary widely regarding how much information they want and how much of a role they wish to play in making decisions. The Patient Discharge Team developed several robust strategies to encourage shared decision-making. With input from patients and families, the team created a patient communication board which serves two purposes: first, to provide information to the patient and family such as activity level and when the next pain medication is due, and second, to provide an opportunity for the patient to communicate with caregivers and physicians things that are important to them during their stay. It also helped to plan for discharge by recording the date and time of expected discharge. Patients and families are oriented to the board during the admission process (example board is shown below).

The team also designed patient discharge rounds every afternoon with the Care Coordinator, Unit Director, and Manager in order to identify patients for early discharge the next day. In addition, a discharge checklist was instituted.

Patient Education About Their Disease Process

The primary purpose of this education is to increase the patient’s understanding and responsibility for care. The Patient Education Team developed a Patient Guide on Congestive Heart Failure. The guide provides a roadmap for patients regarding what to expect each day during their hospital stay. The team also developed a list of questions for patients to ask upon admission and included them in the Patient Admission Guide.

Patient Engagement in the Design of Their Care

Patient and family needs were considered by the Patient Hospitality and Comfort Team. The team developed a tagline: “Going the extra mile to make our patient smile” and implemented the following solutions based on expressed needs:

  • Waterless shampoo
  • Hourly patient rounds to improve patient comfort and safety
  • Scripting: addressing patients by name, sitting during conversations with patients and asking the patient upon leaving the room, “Is there anything else I can do for you before I leave? I have the time.” Also, telling the patient when you will return.

Staff Engagement in the Patient’s Care

The Staff Education Team developed a monthly newsletter to enhance communication amongst caregivers, management, and physicians. The newsletter discussed new clinical practices, changes to processes, educational offerings, and a story about a key contact. The staff also developed a Unit Performance Excellence Scorecard so that everyone understood what quality metrics were being monitored, how often, and the current status of performance. The language on the unit changed and staff began to link solutions to performance metrics.

Patient Centered Environment

The Noise Team was tasked to reduce the noise level on the unit and improve the cleanliness of the environment. The team implemented more frequent room checks, nursing and environmental manager morning rounds to identify areas that needed more personal attention, quiet hours from midnight to 5 AM, lowering ring tones on desk phones, and the use of Spectra Link® phones and OptiVox® to standardize patient handoffs.

Ensuring Long Term Solutions

The Control Phase provides the necessary methods and tools for an organization to hold the gains and continually improve the patient experience.

The team completed the necessary plans and transferred ownership of the plans to the Unit Director.

  • Control plan: Provides roadmap of actions to hold the gains and continue improvement.
  • Communications plan: Describes how and when information of process changes will be disseminated to staff and other key stakeholders throughout the organization.
  • Training plan: Defines the training content, schedule, and outcomes for training staff on new process changes.
  • New and revised policies and procedures: Documentation representing revised processes.


Perseverance and commitment by the team to meet on a monthly basis following two rapid improvement events resulted in their exceeding all project goals. The team is likely to see even greater results in the future as they continue to listen to the voice of the customer and implement new solutions.

HCAHPS scores for “Would You Recommend” have shown a steady increase since September of 2009, improving nearly 35% in 5 months. The Standard HCAHPS Overall Average scores have shown an increasing trend over six months, culminating in a high score of 93.8%.


Upward trends for each of the HCAHPS measures are evident as of February 2010. Each measure has an improved score when compared with the initially recorded scores in September 2009.

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at:  TPMG Global® – Improving HCAHPS Scores and The Patient Experience

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