The Three Fatal Flaws of Relying on HCAHPS

It seems to me that every mention of a hospital attempting to improve patient experience is a misnomer.

While an improved experience may be an adjunct result of the hospital’s efforts, the hospital does not call a meeting to improve patient experience.  The hospital calls a meeting is to improve their HCAHPS score.  Net-net, the actual purpose of the meeting is to avoid the financially penalty that results from having the hospital’s HCAHPS scored ranked in the bottom fifty percent.

For example, suppose a hundred hospitals in Canada or the UK set goals to improve patient experience.  The executives in charge of the effort meet at Crayola World for a week in of barn-storming sessions to determine the drivers of patient experience and to agree upon the specific things they need to address to improve patient experience.

What would that meeting look like?

Maybe they would start by defining patient experience. 

US providers as a whole do not have a definition of what constitutes patient experience. Ninety-percent of US hospitals do not even have a definition of patient experience for their own institution. Perhaps that is because providers believe CMS subsumed that responsibility through HCAHPS.

The definition from which US hospitals assess how well patients are experiencing their hospital has three fatal flaws:

  • It knows nothing of the experiences of most of the people who interact with the hospital:
    • 70% of the inpatients
    • Outpatients
    • Discharged patients
    • Former patients
    • Prospective patients
  • It knows nothing of all of the experiences people have before and after they enter the hospital
  • It knows nothing about the experiences of an individual—HCAHPS provides an aggregate score of a percentage of inpatients several months after the fact.

Suppose aliens landed in the bohemian Haight Ashbury district of San Francisco.  Their mission was to report to their constituents about the people who live in America. Dude. Or, perhaps they landed in Montreal with the goal of profiling Canadians—the pen of my aunt was on the desk of my uncle (this only makes sense if you took French in the eighth-grade…Je vais aller à la bibliothèque.) Or perhaps they landed in West Virginia, and everyone they encountered drove a pickup truck loaded with sheetrock.  Would the assessment the aliens provided of Americans or Canadians be accurate?

To bet that the data provided by a provider’s HCAHPS scores told a hospital’s leadership everything they need to know about patient experience requires the hospital’s leadership to suspend reality. It requires the leadership to believe that everything they need to know about patient experience can be learned from a small subset of the people they survey. It also requires the leadership to believe that everything that is important to your individual experience has been assayed by the hospital’s purchase of aggregated survey data.

Suppose you spent two hours on the phone trying to schedule an appointment? Suppose you received several letters from the hospital stating that your unpaid pill had been sent to a collection agency even though you have the cancelled check? Suppose you asked to speak with a nurse and you were told that someone would contact you within 48 to 72 hours?

You know that the next time you need healthcare that you will choose another hospital. Your hospital knows that former inpatients rated that the noise factor of their hospital rooms are better than the noise factors of eighty-two percent of all of the other hospitals.

HCAHPS are egregiously misleading. Do you want to be led, or do you want to lead?

3 thoughts on “The Three Fatal Flaws of Relying on HCAHPS

  1. Classic case of hospital systems trying to find the right answers to the wrong question. It is the same problem that we have in our educational system. We tend to focus our energy on students passing standardize testing versus being focused on critical and analytical learning. This leads to take the emphasis off of actually making the curriculum about actually learning something, to getting test score averages over a certain level, so the school can remain accredited. Direct correlation to the healthcare system — focus on getting your HCAHPS scores to a certain point, instead of focusing on what the patient wants & needs are.

    There is a big difference between worthless information and data that is actually impactful towards improving the patient experience.


    • I completely agree that retrospective aggregate data can not describe what a patient experiences. The missing ingredient are the stories patients tell through their complaints and grievances and anecdotal comments on surveys. There lies the experience. Patients come to healthcare providers with an innocent trust believing in the hospital’s stories of success and compassion. When we break that trust by unintentionally creating an experience full of anxiety, poor communication and lack of teamwork (regardless of clinical quality), the hospital’s claims of patient centeredness sound hollow.
      Listen to patients…they are telling you what they need.


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