Does better service excellence mean better care quality?

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Does better service excellence mean better care quality?


How many of you have had your inbox flooded with the announcement of final rules for value-based purchasing (VBP), or better yet, the hundreds of media stories and blogs about the sentiment toward them? The reactions of leaders have ranged from enthusiastic and supportive to pessimistic about the effectiveness and required bureaucracy to make VBP operational over the next three to five years. While many of the measures are explicitly linked to quality, a large portion of the program is dedicated to service excellence and patients' perception of care. There appears to be a division among healthcare professionals about the relationship between patients' perception of care and the true nature and quality of care delivered. Do these measures appropriately reflect the quality of care delivered?

The service excellence component of value-based purchasing is the HCAHPS survey. This survey measures patient experience and satisfaction with the hospital. The goal of the survey, whose results are published publicly, is to help consumers make informed choices about where they receive healthcare. It has been one of the first apples-to-apples comparison tools for consumers to use when making healthcare decisions. Administered to discharged patients, the survey consists of 27 questions that relate to the hospital stay, such as communication with doctors and nurses, pain management, and overall hospital ratings. Results of the HCAHPS survey are linked to the rewards and penalties hospitals receive in the new VBP program.

One of the most interesting aspects of the final rules for VBP is the debate about whether scores are a true reflection of care quality. With HCAHPS scores now representing a large portion of hospital reimbursement at risk, the inclusion of these scores in ­reimbursement-based decisions is now justified. Longtime advocates and supporters of the survey strongly link positive survey results to better clinical outcomes for patients.

However, a recent article published in The Washington Post in collaboration with Kaiser1 clearly illustrates the discomfort with indicating that patient perception survey results paint an accurate picture of quality. Some hospital leaders argue that scores like these are "influenced by factors beyond their control." The type of hospital (teaching versus community), geographic differences, cultural factors, or complexity of a given patient population could have an effect on scores.

This is an interesting debate that is being fueled by the financial incentives now at risk. While HCAHPS scores affect just 30% of the at-risk financials (process and outcome quality metrics affect the other 70%), they still represent significant dollars for health systems. I tend to think that the jury is still out on this one, but the progression and demonstrable effects of the VBP program will soon settle the debate. While there is no doubt in my mind that service excellence is a critical aspect of care delivery, patient perceptions of care should not necessarily serve as the be-all and end-all indicator of care quality across the country.