How satisfied are you with the care you received while in the hospital? 

The ways in which patients answer that question after they’re discharged now directly affect hospitals’ financial health. And perhaps more importantly, changes in incentives are shaping how hospitals in Iowa and throughout the country are engaging with patients. 

Under the Value Based Purchasing program (also referred to as value based performance) enacted as part of the Patient Protection and Affordable Care Act, hospitals now earn a bonus or are penalized in the amount they receive in Medicare reimbursements, based on scores that take patient satisfaction and quality of care into consideration. Those scores are based in part on recently discharged patients’ responses to 32 questions in a survey known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The questions range from asking how well the doctor communicated to how quiet a patient’s room was, or how responsive the nurses were to the patient’s requests. 

In response, one of Iowa’s largest hospital systems, UnityPoint Health - Des Moines, now has “patient care facilitators” whose primary purpose is to serve as the focal point of communication between patients and staff. In the same vein, Mercy Medical Center - Des Moines this year plans to hire an executive-level director to oversee the “Mercy experience” for patients, vistors and staff. Mercy is also developing a center of innovation that will explore ways to improve its “guest experience.” 

According to an analysis by Press Ganey Associates Inc., the company that develops the patient experience survey tool used by more than half of U.S. hospitals, nurses’ communication with patients is a “rising tide measure,” which, if improved, drives higher scores in a number of other HCAHPS scores measuring patient satisfaction. In other words, health systems would do well to pay close attention to the effectiveness of nurse communications. 

So, how did Greater Des Moines hospitals stack up in the first set of publicly available results? Well, the short answer is Mercy and UnityPoint were essentially neck-and-neck and Broadlawns Medical Center wasn’t counted. 

What’s clear is that each system is working through the changes, working within the complicated formula and strategizing ways to improve the patient experience.
How the scoring system works

Patient satisfaction is one piece of a larger scoring system that Medicare uses to incentivize hospitals to focus on improving quality. 

Here’s how it works: Beginning in October 2012, the Centers for Medicare and Medicaid began reducing payments to hospitals for each Medicare patient by 1 percent to create an incentive pool. That percentage of Medicare payments at risk will increase by one-quarter of a percent each year until reaching 2 percent in fiscal year 2017. In the first year of the program, the bonuses or penalties were based on two areas: patient experience and clinical processes.  

In the current fiscal year, which began Oct. 1, 2013, patient experience will make up 30 percent of a hospital’s total score, while another 45 percent will be based on how well the hospital follows basic clinical standards of care. And beginning this year, 25 percent of the scores will be driven by the hospital’s mortality rate, based on the number of Medicare patients who die while in the hospital or within a month of being discharged. 

How Iowa’s hospitals scored

For the first fiscal year of the program, just over half (55 percent) of the 33 Iowa hospitals required to participate received a net bonus, while 45 percent were penalized by forfeiting some portion of the 1 percent that was withheld. Among all the states, Iowa fared 10th best in percentage of bonuses received by hospitals, which ranged from 79 percent of hospitals in Maine to just 13 percent of Wyoming hospitals getting bonuses. 

In Greater Des Moines, Iowa Lutheran Hospital, Iowa Methodist Medical Center, Mercy Medical Center and Broadlawns Medical Center each lost a portion of their Medicare funds at risk in the past fiscal year, based on their total Value Based Purchasing scores. Broadlawns won’t be scored or subject to possible penalties or bonuses this fiscal year, however, because it does not have a sufficient number of cases to be measured in the newly added mortality outcomes.

Scott McIntyre, communications director for the Iowa Hospital Association, said the program is succeeding in improving quality both in Iowa and nationwide. 

“This is evidenced by the fact that since the program began, Iowa hospitals as a whole have steadily recouped more and more of the Medicare payment put at risk through the Value Based Purchasing program,” he said. “It should also be noted that the program takes into account both how high a hospital scores as well as how much it improves to reach that score. In many cases, Iowa hospitals were already scoring at a relatively high level when the program began, leaving little room for improvement. Nonetheless, quality improvement is being achieved, and that is the central point of the program.”

When comparing the scores of Mercy’s and UnityPoint Health’s flagship hospitals in Des Moines, Mercy Medical Center and Iowa Methodist Medical Center, the two institutions had very similar scores for factors such as wilingness of nurses and doctors to listen and cleanliness and quietness of the hospital rooms. Nevertheless, a higher percentage of Iowa Methodist’s patients, 74 percent, indicated they give the hospital the highest 9 or 10 rating on a 1-10 scale, compared with 67 percent of Mercy patients. By comparison, 63 percent of Broadlawns patients indicated they would give the county hospital those top ratings; the Iowa average was 75 percent. 

Would patients definitely recommend the hospital to friends or family? Seventy-nine percent of discharged Iowa Methodist patients said they would, compared with 70 percent of Mercy patients and 62 percent of Broadlawns patients. Statewide, an average of 74 percent said they would definitely recommend the hospital. 

To see how the hospitals fared in other scoring areas, see the table:


How the hospitals are adapting:

Mercy Medical Center

“We are all very focused on the issue of patient satisfaction, and not only because it’s related to the value-based performance measure,” said Bob Ritz, president of Mercy Medical Center. “It makes sense because as consumers, we all tend to want to evaluate what’s the best thing to spend our money on. It’s reasonable that people should be able to do the same with their health care. The whole value-based performance system will at least give an index at some level of how people are performing.” 

As part of its push to improve patient satisfaction, Mercy is in the process of developing a new executive position that will be known as the director of the Mercy Experience. “That person’s function will be to really assess and continue to improve the overall service that we provide to all of our guests,” Ritz said. Patients will be just one focus of the total experience, along with family members, visitors and staff, he said.  

“Our ability to provide the best experience for all the guests that we serve in part relates to what experience we have (as employees),” he said. “So the notion of a director of the Mercy Experience is really to work with us to make sure we’re focused and to identify opportunities to continue to improve our performance.” 
Better coordination of patients’ care is another major focus tied to improving satisfaction. That effort requires improved communication and smoothing out what can be a fragmented process, Ritz said. 

“It’s not just about how their surgical procedure goes,” he said. “It’s about providing them with information about Mercy before they get here; it’s about how to get here; it’s greeting them in the lobby and showing them how to get where they’re going; it’s making sure somebody (checks) on them every hour and asks about their needs. And when they’re discharged, it’s following up with them by phone to see how they’re feeling; did they get all the medications they were supposed to get; do they have a physician office visit scheduled?”

Mercy is now developing a center of innovation that will examine ways to improve guest experiences, and it has an ongong patient advisory council that meets monthly. Every other month, a former patient is invited to meet with the council’s quality committee to talk about his or her experience. 

“We’ve got a number of initiatives underway, but I think perhaps the most exciting one is assessing the hospitality of our health care services,” Ritz said. “We’re focusing a lot of time on just what is the current experience, and what is the ideal experience we want all of our family members to have?” 

Overall, the Value Based Purchasing system has the potential to improve the overall performance of the health care system, Ritz said. 

“It takes what 4,800 hospitals are doing and refocuses on two or three things that are really critical,” he said. “So with everybody working on those measures, we’re going to improve. 

“On the other hand, every patient’s clinical and sociological situation is different. So we can do everything 100 percent perfectly right for the same set of clinical circumstances for 10 different patients, and we would likely get not the same identical outcome with each one. So I think the value-based performance model will improve performance, but we shouldn’t assume everybody’s results will be identical.” 

UnityPoint Health

As hospitals across the United States focus more on patient experience and quality, the bar continues to be raised higher, said Chris Blair, chief administrative officer of Methodist West Hospital in West Des Moines. Blair coordinates patient satisfaction initiatives for all of UnityPoint Health’s Greater Des Moines hospitals. 

UnityPoint made a significant change in how patient care is coordinated with the creation of a patient care facilitator role when Methodist West opened in October 2009. 

“As a patient in a hospital, you can easily interact with 50-some people if you’re here for three days,” Blair said. “It’s hard in a 24/7 world to let everyone know what’s going on, so the patient care facilitator is the air traffic controller, for lack of a better term. They’re the hub, they’re in the middle with the patient while everybody else is helping support them, so they have the big picture of what’s going on with that patient.” 

Based on the favorable results it has seen from the program, UnityPoint Health recently implemented patient care facilitators at its other two hospitals - Iowa Methodist Medical Center and Iowa Lutheran Hospital, she said. Approximately 45 patient facilitators, each experienced nurses with graduate degrees, make rounds with physicians at the three hospitals. 

Another initiative that has proved to be very popular with patients is a practice called the bedside report, Blair said. 

“When our nurses do a shift handoff, it’s done in the patient’s room and involving the patient and their family if they’re present,” she said. “So we’re talking about the patient with the patient, and they really like that. The feedback is they’re feeling more aware of what’s going on. They and their families love knowing that the nurse coming on knows what’s going on, because they heard it. They just feel more confident about their care.” 

In the past year, UnityPoint Health has focused on training to ensure that the reporting process is standardized at each hospital, Blair said. And as a quality check, nurse leaders conduct rounds with the patients to ensure that a bedside report was done and to see if any issues need to be addressed while the patient is still in the hospital.

UnityPoint Health is now in the process of rolling out a software program to make it easier for its nurse leaders to perform those quality checks. The program, called iRound, enables nurse leaders to review reports and track trends on an iPad Mini. 

“So if I’m a nurse manager or supervisor, I can see the results from (patient rounds)  the day before as well as text comments to see if any issues need to be followed up on,” said Paige Moore, the UnityPoint marketing and planning information strategist in charge of the project.  

Overall, each of UnityPoint Health’s three hospitals has improved its patient satisfaction scores from year to year, said David Kading, director of planning and business development. “Last year, 2013, was our best year ever, and we’ve set goals to improve from there, so we expect that trend to continue,” he said. 

Part of the reason that UnityPoint Health has seen continuous improvement in its scores is that the staff understand the elements that are being evaluated, Blair said. Several years ago, Moore developed a “tool kit” to educate employees on what patients are asked about when they receive a satisfaction survey. Additionally, new supervisors receive that training as part of a “New Leader U” program they take when they’re first hired. 

Broadlawns not subject to scoring 

Although Broadlawns Medical Center won’t be subject to Medicare rewards or penalties this year, it’s still paying close attention to patient satisfaction and quality measures, said Susan Kirstein, chief nursing officer for the county hospital.  “We’ve had a lot of changes in the hospital – remodels to make it a more inviting environment, wayfinding signs, remodeled bathrooms – and lots of training in customer services skills,” she said. “We do lots of programs to make sure that patients are checked on every hour. And it’s really rewarding to talk with patients and get feedback from them.” 

Kirstein said Broadlawns has seen gradual increases in its patient satisfaction scores, and the hospital is working to increase the survey response rate, which is currently only 9 percent. 

Broadlawns is also in the pilot phase of introducing a real-time electronic patient satisfaction survey for its Family Health Center patients, she said.