As hospitals scramble to simultaneously cut costs and raise patient satisfaction levels, incorporating the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and scores is of growing importance.

Starting next month, hospitals will begin learning more about their bonus scores and specific reimbursement amounts from the Centers for Medicare & Medicaid Services (CMS). Their reimbursement is being tied directly to quality based upon the facility's HCAHPS scores.

Often, environmental services (ES) departments and the critical role they play in this process are overlooked, but a front line of defense against health care-associated infections (HAIs) is heavily dependent on ES department performance. Improving HCAHPS scores and reducing infections can be a daunting responsibility, but a necessary one for all managers.

Having a well-defined quality program with positive HCAHPS outcomes is an advantage to an ES department and the hospital overall. It establishes improved methods of communication between hospital staff, develops mechanisms to improve accountability for departmental services, indicates staff educational needs, justifies staffing requirements or staffing changes and identifies best-
practice competition between various working groups.

The questions constantly asked are: Where does the ES department begin? What data should be collected? What information is the most meaningful? The following overview tells what must be documented, and why ES departments must have a well-defined standard of cleaning that is effective, objective and quantifiable.

Standardized instrument

The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care. While many hospitals have collected information on patient satisfaction prior to HCAHPS — such as through Press Ganey Associates Inc., South Bend, Ind., or through their own site-specific quality programs — there were no national standards for collecting or publicly reporting patients' perspectives of care information that would enable valid comparisons across all hospitals.

The HCAHPS survey contains 27 questions and 18 patient points of view on care and patient rating items that compare eight key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medication, discharge information, cleanliness of the hospital environment and quietness of the hospital environment.

The survey also includes four screener questions and five demographic items, which are used for adjusting the mix of patients across hospitals. The survey has four modes of administration: mail, telephone, mixed (mail followed by telephone) and active interactive voice response.

There are three broad goals that have shaped the HCAHPS survey. First, the survey is designed to produce comparable data on the patients' perspectives of care that allow objective and meaningful comparisons between hospitals that are important to the consumer of health care. Second, reporting of the survey is designed to create incentives for hospitals to improve their quality of care. Third, public reporting will serve to enhance accountability in health care by increasing the clarity of the quality and process improvement that hospitals are to provide.

Documentation will play a critical role in any attempt to improve the HCAHPS scores. There should be policies and procedures outlining a quality control program, cleaning standards and schedules, staffing models and infection control procedures. This will validate clinical outcomes under the CMS questionnaire.

Accurate record-keeping also will result in professional accountability in the development of environmental cleaning standards. A well-defined quality program also must be supported by established policies and procedures and act as a catalyst for all points of verbal and written communication.

Key players

Many individuals should be involved in a health care quality program. Among the most critical are the front-line staff members. These are the dedicated individuals who are responsible for implementation of policies and procedures. No single group outside of nursing spends more time in the presence of patients and their families. Administration must inform and empower front-line managers and staff to detect and correct problems effectively in a timely manner before they have a negative impact upon the health care consumer's experience.

Administrators and managers are responsible for evaluating the work performed by front-line staff. However, it takes all groups working together and communicating effectively to result in a positive patient experience. Other participants include supervisors, infection prevention staff, and directors of quality and patient services.

The function of management is to provide a supportive role, seek proper resources and provide necessary training to front-line staff to produce favorable outcomes in quality control.

To accomplish this, managers must:

• identify learning needs and seek proper resources and training to satisfy those needs through in-services, continuing education and training, and competency assessment;

• stay updated on best practices by networking, attending conferences, viewing webinars and reading current literature pertaining to quality assurance published by the Association for the Healthcare Environment (AHE) and other professional groups;

• implement cleaning standards and work schedules as outlined in the departmental policy and procedure manual;

• participate as a member of the de­partment's quality assurance committee and serve as a leader, guide and consultant to the hospital quality assurance committee;

• seek and accept accountability and responsibility for professional actions and the provision of quality care within the department and hospital as a whole;

• provide support and encouragement to each staff member and manager in the department for his or her role in the implementation of a quality assurance program;

• communicate the needs and recommendations for implementing a quality assurance program to appropriate hospital staff;

• operate as a successful and positive change agent;

• provide vital resources for the implementation of the program.

Steps for improvement

One of the most important steps for improving the patient experience and achieving an accompanying improvement in an HCAHPS score is developing measurable cleaning standards. These standards should result in patient satisfaction and reduced HAIs.

One of the most critical components of implementing these standards is determining the appropriate number of full-time employees required to produce these outcomes. Once staffing needs have been identified, consistent data collection needs to be implemented to determine whether or not these standards are being met. Effective communication is another vital component of improved patient satisfaction. Well-written policies and procedures shall be established that support the department's mission and goals.

Administrators should communicate clearly with departmental managers about their facility's vision and mission statement, daily operations to achieve the mission and long-term goals for the health care facility. Fostering interdepartmental communication, both formal and informal, is also a key component of patient satisfaction.

One must select key or important aspects of the quality program. It is not as critical to have many options as it is to have one or two methods of collecting and reporting the data to ensure that all staff are familiar with the process and its objectives.

Additionally, facilities must:

  • ensure that the data are collected and completed on a consistent basis;
  • ensure that the data are monitored and that trends, problems and areas of improvement are identified and assessed;
  • ensure that open and effective communication takes place;
  • conduct patient interviews daily so that any problem or issue can be resolved prior to the patient's leaving the facility.

An effective system

Patient satisfaction scores arise from stays in the hospital room, visits to the waiting room, trips to restrooms and any other areas where patients and their families likely will go.

Assigning the importance of patient satisfaction to the entire staff originates from top-level management, but must be supported by all employees. To be successful in achieving desired satisfaction scores, there must be an effective system in place so critical and timely information arrives constantly on the desks of frontline managers.

The core component of any HCAHPS improvement typically will use more than one quality tool system. There should be a real-time daily measurement system in place that includes patient interviews, patient-centered initiatives, environmental monitoring, inspections and other elements.

To guarantee optimal results, the patient experience needs to be tracked and improved continuously.

A good quality improvement program requires problem identification, timely reporting, continuous monitoring, and both intra- and interdepartmental communication as well as testing and validation that quality objectives are being achieved. The focus should be on improvements that matter. The real-time monitoring must identify potential issues or problems easily and rapidly.

Resources should be allocated to departments to resolve problems in a timely manner. Concrete steps must be taken by specific departments to address problems perceived by the patient. The process should be action-oriented, utilizing detailed reports to determine opportunities for improvement at all levels. Each department needs to establish ownership for its services and be accountable so that weaknesses can be addressed.

Finally, all employees should be provided with opportunities for adequate orientation to develop important competencies and receive ongoing continuing education to improve outcomes that are department-specific.

The importance of patient satisfaction has been emphasized at all levels of a health care organization. Well-trained employees, working together and dedicated to excellence, can improve patient outcomes and satisfaction.

Robert M. Hodnik, CHESP, is director, facilities management, at UPMC Health Plan in Pittsburgh, and vice president of the Association for the Healthcare Environment. He can be contacted

Sidebar - Use benchmarks to improve quality

Benchmarking is one of the most powerful tools that can be utilized to improve an organization's quality improvement program and potentially achieve better Hospital Consumer Assessment of Healthcare Providers and Systems scores.

Benchmarking provides the ability to network with other environmental services (ES) professionals to identify best practices. The Association for the Healthcare Environment (AHE) provides its members with opportunities for benchmarking through its continuing education programs, webinars, EXCHANGE conferences, and online discussions and forums. All ES managers would be wise to explore becoming a member of AHE.

For more on benchmarking health care quality, ES managers can log on to to benchmark their operations against other facilities in their region, state or at the national level.