Part Two: Adult Inpatient Care

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Patient Experience During the Pandemic: A Three-Part Series from The Leapfrog Group

Spring 2022

Adult Patient Experience at Acute Care Hospitals

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Report Highlights

• Patients’ experience with their inpatient hospital care has declined significantly during the pandemic, with adult inpatients

reporting less favorably across nearly all domains of patient experience.

• Patient-reported experience with Care Transitions remains the least favorable domain and worsened considerably during the

pandemic.

• Worsening areas of patient experience correlate with key patient safety indicators, providing further evidence that the pandemic

has negatively impacted the safety of hospital care.

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Introduction

The COVID-19 pandemic has impacted health care delivery at every level

and setting, from staffing shortages to increased infections to the very

care patients receive. It has never been more critical to assess patient

perspectives, both to assure that the patient voice is accounted for and

heard, and to obtain vital information on the overall safety and quality of

care being delivered. This report is the second in a three-part series from

The Leapfrog Group examining patient experience during the pandemic.

The first report in the series examined outpatient surgical care.

Over the past few years, hospitals specifically faced unprecedented strain

on their workforce. Examining patient experience in hospitals during the

pandemic provides insights on how the delivery of care was impacted.

The Hospital Consumer Assessment of Healthcare Providers and Systems

Survey (HCAHPS) is a systematic way to measure the experience of adult

patients at general hospitals. Results are collected by each hospital and

are publicly reported by the Centers for Medicare and Medicaid Services

(CMS) on its Care Compare website and used to generate HCAHPS Star

Ratings. Unlike other Patient Experience surveys assessing outpatient

surgery and the care of pediatric patients which are voluntary, HCAHPS is

required for all acute care hospitals that participate with Medicare. Other

types of facilities including critical access, Veteran’s Administration, and

Department of Defense hospitals as well as facilities like ambulatory

surgery centers and nursing homes may voluntarily choose to provide

patient experience data to CMS but are not required to do so.

Just as people seek out customer reviews and ratings before making online purchases, they can benefit from

learning about patient perspectives on health care services before they decide where to receive care

. The

systematic reporting of patient experience information is extremely valuable for patients beyond its attractiveness

to consumers. According to studies, reliable patient experience data correlates significantly with safety and quality,

and the collection and use of the data helps put patients at the core of health care delivery

iii

. Though all domains of

patient experience examined through HCAHPS offer critical insight on patient care, five of the domains have been

shown to have the most significant correlation with patient safety outcomes

. Results from these five domains are

used in calculating Leapfrog Hospital Safety Grades.

Where the data comes from

This report analyzes patient experience

data collected by hospitals through a

standardized survey called the

Consumer Assessment of Healthcare

Providers and Systems Hospital Survey

(HCAHPS). This report analyzes

facilities that issued an HCAHPS Survey

to their patients reflecting a time

period of calendar year 2019 (pre-

pandemic), as well as facilities that

issued an HCAHPS Survey to their

patients reflecting a time period of July

1, 2020 - March 31, 2021 (mid-

pandemic), as reported by the Centers

for Medicare and Medicaid Services

(CMS). More information on the

content and interpretation of patient

experience surveys can be found in

Appendix A.

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Patient Experience During the Pandemic: A Three-Part Series from The Leapfrog Group

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Adult Patient Experience in General Hospitals

The ten areas of care covered on HCAHPS surveys include:

• Communication with Nurses

Was the patient treated with courtesy and respect? How often did nurses listen to the patients carefully? Did

nurses carefully explain things about the patients’ care?

• Communication with Doctors

Was the patient treated with courtesy and respect? How often did doctors listen to the patients carefully?

Did doctors carefully explain things about the patients’ care?

• Responsiveness of Hospital Staff

How often did patients get help after pressing the call button? How often did patients get help using the

bathroom or bedpan?

• Communication about Medicines

Did hospital staff explain new medication? Did hospital staff describe possible side effects of new

medication?

• Discharge Information

Did doctors, nurses and other hospital staff discuss whether the patients would have help when leaving the

hospital? Did patients get information about symptoms or health problems to look out for after leaving the

hospital?

• Care Transition

Did hospital staff take patients’ preferences into account when deciding health care needs after leaving the

hospital? Did patients have a good understanding of their care transition? Did patients understand the

purpose of their medications?

• Cleanliness of the Hospital

How often were your room and bathroom kept clean?

• Quietness of the Hospital

How often was the area around you quiet at night?

• Overall Rating of the Hospital

How do patients rate the facility on a scale of 1 – 10?

• Willingness to recommend the facility

Would patients recommend the facility to friends or family?

Details about each measure and underlying questions, along with the response options, can be found in Appendix B

of this report.

Hospitals that administered the HCAHPS survey and submitted their results to CMS were included in this analysis. It

examines patient experience data from before the COVID-19 pandemic (January 1 to December 31, 2019) and during

(July 1, 2020 to March 31, 2021).

Analysis

To evaluate hospital performance on HCAHPS for this report, Leapfrog looked at the percent of survey respondents

who chose the most positive response for a given item. For example, a patient may indicate that nurses always

listened carefully to them or that they would definitely recommend the facility to friends or family. Patient

experience worsened significantly during the pandemic in all domains examined through HCAHPS, with one

exception: quietness of the hospital. Many of these areas have direct correlations to maintaining patient safety and

protecting patient from unnecessary harm. Most notably, on average:

• Patients at hospitals were less likely to give the most favorable responses to the Responsiveness of Hospital

Staff survey questions mid-pandemic (63.4%) than pre-pandemic (67.1%).

• Patients gave less favorable responses to the Communication about Medicines questions mid-pandemic

(61%) than pre-pandemic (64.1%).

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Patient Experience During the Pandemic: A Three-Part Series from The Leapfrog Group

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• Patients reported less favorable responses to the Cleanliness of the Hospital survey questions mid-pandemic

70.7%) than pre-pandemic (73.6%).

• Patients were least likely to give favorable responses to the Care Transition questions both pre-pandemic

(52.1%) and mid-pandemic (50.2%).

Average Percentage of hospital patients who gave the most favorable responses on the

HCAHPS survey pre-pandemic (2019; n=3571 hospitals) and mid-pandemic (Mid-2020-Mid-2021; n=3502 hospitals).

As national trends have indicated, COVID-19 has negatively impacted patient safety in hospitals. Key areas of patient

experience that worsened were likely associated with the strain health care workers endured during the height of

the pandemic. The largest difference comparing adult patient experience in hospitals pre-pandemic and mid-

pandemic is in Responsiveness of Hospital Staff with a 3.7-point decrease. Patients were less likely to receive help

when needed, which can lead to potentially serious safety lapses. Communication about Medicines, reflecting

patients’ feedback on how often hospital staff explained the purpose of new medication and potential side effects, is

another significant patient safety concern. According to research, effective communication about medicine can help

reduce or prevent medication errors, which occur on average once per patient per day among Medicare

beneficiaries

Even before the pandemic, patients indicated the least favorable responses about clearly understanding their care

transition once they left the hospital: whether they were aware of their responsibilities and purpose of their

medications, and if their preferences were taken into account. Providing clear, understandable discharge

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Patient Experience During the Pandemic: A Three-Part Series from The Leapfrog Group

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information, like symptoms or health problems to monitor, can reduce harm and the likelihood of a patient being

readmitted to the hospital. Of the other notable patient experience areas that impact patient safety, the percentage

of favorable responses on whether doctors and nurses carefully listened to and treated patients with respect also

decreased during the pandemic.

The single domain in which patient experience improved during the pandemic was Quietness of the Hospital:

whether or not the area around patients was quiet. This may have been an unintended consequence of visitor

restrictions during the height of the pandemic, indicating that a quieter environment can positively impact patients’

experience with their hospital stay.

Conclusion

Patient experience is a critical indicator of safety in hospitals. Studies show that facilities that provide better

experiences for patients tend to provide safer, higher quality care. Leapfrog’s assessment of the HCAHPS survey

results between a pre-COVD and mid-COVID timeframe uncovers and further confirms patient safety lapses

associated with the pandemic time frame. Areas of patient experience that were already in dire need of

improvement before the pandemic began, like transitioning care once out of the hospital, communicating about

medications, and hospital staff responsiveness, worsened the most during the pandemic. But regardless of the

influence of the pandemic, significant challenges persist across all domains of patient experience, indicative of

serious safety and quality problems that must be addressed. Leapfrog commends CMS for making patient

experience data for adult patients at hospitals easily accessible in a consumer-friendly manner through CMS’ Care

Compare website. Leapfrog and its constituency of employers and purchasers call on CMS to require CAHPS

reporting across all areas of patient care, including outpatient surgery and pediatric care.

Patient Experience During the Pandemic: A Three Part Series From The Leapfrog Group

Part One: Outpatient Surgical Care

Part Two: Adult Inpatient Care

Part Three: Pediatric Care (End of May)

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Spring 2022

Appendix A: How Patient Experience Surveys Work

A random sample of patients who have been

discharged from a hospital are asked to complete an

HCAHPS survey. Surveys are most often administered

by an experienced survey vendor and are distributed by

mail, telephone, or by mail with a telephonic follow-up.

Across all domains on HCAHPS surveys, participants are

asked to check a box reflecting their experience with

their care. Most frequently, these questions are phrased

with response options like Never, Sometimes, Usually,

Always; or Strongly Disagree, Disagree, Agree, Strongly

Agree. Other times questions are phrased to ask for a 1

– 10 response, where 1 is the least favorable and 10 is

the most favorable.

To evaluate overall facility performance on these surveys, Leapfrog looks at the “Top Box Scores,” which is the

percent of survey respondents who chose the most positive response for a given item. For example, a patient may

indicate that nurses always listened carefully to them or that they would definitely recommend the facility to friends

or family. Looking at the Top Box Score is an approach to understanding responses reflecting the most positive

sentiment. In this report, the Top Box Score is referred to as the most favorable response (e.g., Always or Strongly

Agree). To analyze the data included in this report, Leapfrog calculated the average Top Box Score among facilities

for which data is available.

Studies have shown that when used correctly, CAHPS results provide valid and reliable measures of quality and

safety

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Example of a HCAHPS Survey question. In this case "Definitely

yes" is the top box.

The “Top Box Score”

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Appendix B: Consumer Assessment of Healthcare Providers and Systems Hospitals (HCAHPS)

Communication with

Nurses

• During this hospital stay, how often did nurses treat you with courtesy and respect?

(Never/Sometimes/Usually/Always)

• During this hospital stay, how often did nurses listen carefully to you?

(Never/Sometimes/Usually/Always)

• During this hospital stay, how often did nurses explain things in a way you could

understand? (Never/Sometimes/Usually/Always)

Communication with

Doctors

• During this hospital stay, how often did doctors treat you with courtesy and respect?

(Never/ Sometimes/ Usually/ Always)

• During this hospital stay, how often did doctors listen carefully to you? (Never/

Sometimes/ Usually/ Always)

• During this hospital stay, how often did doctors explain things in a way you could

understand? (Never/ Sometimes/ Usually/ Always)

Responsiveness of

Hospital Staff

• During this hospital stay, after you pressed the call button, how often did you get help as

soon as you wanted it? (Never/ Sometimes/ Usually/ Always)

• How often did you get help in getting to the bathroom or in using a bedpan as soon as

you wanted? (Never/ Sometimes/ Usually/ Always)

Communication

About Medicines

• Before giving you any new medicine, how often did hospital staff tell you what the

medicine was for? (Never/ Sometimes/ Usually/ Always)

• Before giving you any new medicine, how often did hospital staff describe possible side

effects in a way you could understand? (Never/ Sometimes/ Usually/ Always)

Discharge

Information

• During this hospital stay, did doctors, nurses or other hospital staff talk with you about

whether you would have the help you needed when you left the hospital? (Yes/ No)

• During this hospital stay, did you get information in writing about what symptoms or

health problems to look out for after you left the hospital? (Yes/ No)

Care Transition

• During this hospital stay, staff took my preferences and those of my family or caregiver

into account in deciding what my health care needs would be when I left. (Strongly

disagree/ Disagree/ Agree/ Strongly agree)

• When I left the hospital, I had a good understanding of the things I was responsible for in

managing my health. (Strongly disagree/ Disagree/ Agree/ Strongly agree)

• When I left the hospital, I clearly understood the purpose for taking each of my

medications. (Strongly disagree/ Disagree/ Agree/ Strongly agree)

Cleanliness of the

Hospital

• During this hospital stay, how often were your room and bathroom kept clean? (Never/

Sometimes/ Usually/ Always)

Quietness of the

Hospital

• During this hospital stay, how often was the area around your room quiet at night?

(Never/ Sometimes/ Usually/ Always)

Willingness to

Recommend

Hospital

• Would you recommend this hospital to your friends and family? (Definitely no/ Probably

no/ Probably yes/ Definitely yes)

Overall Rating of

Hospital

• Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best

hospital possible, what number would you use to rate this hospital during your stay?

Survey Source: Centers for Medicare and Medicaid Services

The HCAHPS survey is a useful tool for a variety of stakeholders, as long as the data is publicly available to them.

According to an HCAHPS Fact Sheet:

Three broad goals have shaped HCAHPS. First, the standardized survey and implementation

protocol produces data that allow objective and meaningful comparisons of hospitals on topics

that are important to patients and consumers. Second, public reporting of HCAHPS results

creates incentives for hospitals to improve quality of care. Third, public reporting enhances

accountability in health care by increasing transparency of the quality of hospital care provided

in return for the public investment.

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References

Press Ganey Associates LLC. Consumer Experience Trends in Healthcare. 2021.

Isaac T, Zaslavsky A, Cleary P, Landon B. The relationship between patients’ perception of care and measures of hospital quality and

safety. HSR. 2010;45(4):1024-1040.

iii

Kennedy G, Tevis S, Kent K. Is there a relationship between patient satisfaction and favorable outcomes? Ann Surg.

2014;260(4):592-600.

Isaac T, Zaslavsky A, Cleary P, Landon B. The relationship between patients’ perception of care and measures of hospital quality

and safety. HSR. 2010;45(4):1024-1040.

Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually; Report Offers Comprehensive Strategies for

Reducing Drug-Related Mistakes. Accessed June 14, 2021.

Isaac T, Zaslavsky A, Cleary P, Landon B. The relationship between patients’ perception of care and measures of hospital quality

and safety. HSR. 2010;45(4):1024-1040.

vii

Kennedy G, Tevis S, Kent K. Is there a relationship between patient satisfaction and favorable outcomes? Ann Surg.

2014;260(4):592-600.

viii

HCAHPS Fact Sheet, April 2022. https://www.hcahpsonline.org Centers for Medicare & Medicaid Services, Baltimore, MD. April 21,

2022.