The Sonographer’s Role in HCAHPS and Value-Based Purchasing

Abstract

Health care reimbursements are changing from a medical care-based scale to a pay-for-performance system. The Value-Based Purchasing Program uses clinical quality indicators along with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey as part of an incentive program for hospitals to gain reimbursements based on the patient care experience. Although clinical quality indicators are often outside of a sonographer’s scope of practice, several of the HCAHPS items are a routine part of a sonographer’s daily duties, such as communication and responsiveness to the patient and cleanliness of the facility. Providing education concerning HCAHPS and Value-Based Purchasing to clinical sonographers, as well as student sonographers, will improve patient interactions and assist hospitals in gaining reimbursements.

Introduction

The US health care system has undergone some major changes within the past decade. There has been a shift to the foundation of the system from a medical care focus to a patient-centered focus. With the birth of the Affordable Care Act and tighter regulations on Medicare reimbursements, new measures and requirements are causing struggles for some medical institutions but also creating a competitive market with consumers who are more informed about the options available to them for medical care.

Sonography is not immune to the effects of such issues and can play a role in assisting institutions to improve the patient’s health care experience. For sonographers to help improve their organization, they first must understand these new measures and requirements and then develop strategies to make improvements that can affect outcomes. This is not just a job for the staff sonographer. Sonography educators need to incorporate health care issues into the curriculum as well. This knowledge will serve future graduates in their careers, as well as the facilities to which students are assigned for clinical activities. ¹

Literature Review

One new measure is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Pronounced “H-caps,” this survey is administered to individuals who were previous inpatients in an acute care facility to determine the patients’ perceived level of satisfaction with their experience. ² The survey tool was implemented by health care institutions on a voluntary basis starting in 2006. In 2007, participation was required for facilities receiving reimbursement from the Centers for Medicare & Medicaid Services (CMS). ³ Hospitals providing specialized care or research institutions are currently exempt from the survey. ² The number of hospitals participating in the survey has grown from 2421 in 2008 to 4167 in 2015, with approximately 8400 patients completing the assessment daily. ⁴

How It Works

The HCAHPS survey is distributed to a random selection of patients within 6 weeks of discharge.^1,2 Eligible survey participants must be older than 18 years with a minimum of one night’s stay as an inpatient. ³ Other stipulations are that the individual must be without a psychiatric diagnosis and living at the time of discharge. ³

There are a total of 32 questions on the survey. ⁵ Items include key areas such as communication, responsiveness, cleanliness, quietness, pain management, patient education, and discharge instructions. Seven items on the survey are demographic in nature, 4 are screening questions, and 21 are considered substantive. ² Demographic questions are used in an attempt to ensure that hospitals are compared fairly against one another. Although sonography and medical imaging are not specifically mentioned on the HCAHPS survey, items such as responsiveness and cleanliness are those that sonographers can help address.

Survey distribution and data collection are performed by organizations specially trained to handle such information. Survey completion can be accomplished through mailings, phone calls, mixed media, or Active Interactive Voice Response. ³ The CMS is then responsible for analyzing and reporting the data. ² Several of the items on the survey ask patients to answer items with always, usually, sometimes, or never. ⁵ The only answer counted on these items is always, indicating that an action always occurred. For example, “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” ⁵ If a patient answers anything other than always, no score is awarded. ⁶

HCAHPS scores are reported quarterly, with the most recent four quarters being used for public reporting, and can be accessed at www.hospitalcompare.hhs.gov.^3,7 Hospital performance is gauged based on internal and external comparisons. Ideally, hospitals will meet national external comparison benchmarks, but institutions should also demonstrate internal consistency and improvement. ⁷

Why Are HCAHPS Scores Important?

HCAHPS scores are used as part of the CMS Hospital Value-Based Purchasing Program (VBP).^1,7 The VBP, which began in 2012, withholds a percentage of a facility’s normal reimbursements at the beginning of the fiscal year and allows the facility to earn this funding back if it meets certain measures including benchmarks on the HCAHPS survey and clinical quality indicators. Clinical quality indicators include items such as readmission rates, nosocomial infection rates, management of care, and so on.^1,7,8 HCAHPS scores account for 30% of the VBP total, whereas performance on clinical quality indicators accounts for 70%.^1,7 Return of this funding is viewed as an incentive to providing patient-centered care. ⁷

When the VBP began in 2013, 1% of an institution’s funding from the CMS was withheld each year. For a typical 300-bed hospital, this equated to approximately $696,000. ⁹ In 2016, hospitals are risking 1.75% of the projected reimbursements from the CMS.^6,8 This percentage is set to increase to 2% in 2017, which, for the same 300-bed hospital, could result in a loss or gain of $1.4 million. ⁹

In addition to the funding, the reporting of HCAHPS scores also affects the reputation of the facility. Once the information is made public through www.hospitalcompare.hhs.gov, consumers are able to research hospitals and make informed decisions concerning their care. Other websites also make the data available. These include www.leapfroggroup.org and www.healthgrades.com. ¹⁰

Discussion

Armed with this knowledge, sonographers can evaluate their personal actions as well as those of their departments to determine if improvements can be made that will have a positive effect on potential HCAHPS scores. Sonography is a patient-centered role. Communication, responsiveness, and cleanliness are areas within a sonographer’s control that may offer opportunities for improvements and higher facility HCAHPS scores.

Communication

Communication is a key area on the HCAHPS survey in which a sonographer can help the facility excel. Many patients may confuse the sonographer’s role with that of nurses or physicians. This confusion can and will come through on survey questions regarding nurse and physician communication. Improving communication scores begins with actively listening to the patient while obtaining patient history. Active listening techniques include maintaining good eye contact and acknowledging what the patient says.^11,12 Providing direction and explanation of the examination processes and what a patient can expect will go a long way to help alleviate anxiety and fear. ¹²

The hospital environment often does not allow sonographers the luxury of scheduling when inpatient examinations will be performed. For many facilities, inpatients are worked in among scheduled outpatients, emergency rooms, and STAT inpatient examinations. Communicating about delays in examinations/procedures can help ease frustrations, particularly in situations where the patient has been held NPO. Communication is also important at the conclusion of a study, as patients often want to know how and when they will receive test results. Although a sonographer cannot always provide an exact time frame, information regarding the typical process at the institution can be given, along with letting patients know who they can contact if they have questions. ¹²

Responsiveness

Good communication also provides sonographers with the opportunity to be responsive to a patient’s needs. Sonographers need to listen and watch for verbal and nonverbal clues of pain or discomfort and offer assistance to relieve these issues. Although sonographers are unable to offer medication, they can assist patients in changing positions, offer blankets, and communicate with the nurse about the patient’s pain levels. If a sonographer is responsible for transporting patients back to their rooms, offer assistance to the bathroom prior to returning to the department. If performing a bedside examination, ask the patient if anything is needed before you leave the room. These small actions by a sonographer can improve the patient’s perception of their health care experience.

Cleanliness

Cleanliness is not just the responsibility of the housekeeping or environmental services staff member. There may be small issues that sonographers can address, such as picking items off the floor or emptying trash or overflowing linen bags. If the issue is beyond a sonographer’s available resources, it is his or her responsibility to notify the appropriate individuals or department. Other small comfort measures, such as making sure items are within reach of the patient, are well within a sonographer’s capabilities while performing bedside examinations or transporting patients. Within sonography departments, each staff member should strive to keep examination rooms tidy and provide a welcoming environment.

Conclusion

With the changing tides of the health care reimbursement process, sonographers are in a position to assist their facilities in providing excellent patient-centered care. This can affect items such as the HCAHPS survey, which will directly affect the incentive payments received from the CMS. This additional funding can be the difference in updating equipment and hiring additional staff or not having the means to do so. Sonography educators will need to include some discussion of such surveys as part of their curriculum and clinical preparedness information so that students are more aware of their interaction with patients.