Sunday, February 17, 2013

Effect of Hospital Late Discharges on HCAHPS Scores

The observation that Hospital units with the latest discharges (time of day) tend to have lower HCAHPS scores is increasingly being documented and observed nationally.

My explanation for this is a little convoluted but I'll do my best...

* There are virtually no studies that have attempted to find a direct correlation between earlier discharges and the effect this has on HCAHPS scores. This is due to the fact that HCAHPS scores measure patient perception of care with many different measures that have little to do with process flow and most researchers perceive those flow processes to be "invisible" to the patient experience being surveyed.

* Even though there is no documented evidence that early discharges affect HCAHPS scores, there is ample evidence that points to the fact that Hospital or Unit LOS improvements are almost always associated with higher HCAHPS scores. In addition, we feel that Hospital or Unit LOS is a fairly good proxy of consistency achieving early discharges. The reason for this is that most improvements in LOS are aimed towards predicting, controlling and attaining early discharges and shifting discharge curves towards earlier times. Whether an institution establishes multidisciplinary rounding, managed discharge processes, and better bed turnover processes to accomplish Early Discharges...the end-result is invariably lower LOS.

* Having said that, and if we agree that lower Hospital or Unit LOS can be used as a proxy for Early Discharges, it is still unclear is the correlation between lower LOS and higher HCAHS scores is purely incidental (i.e. a byproduct of all the control mechanisms and practices a Hospitals might implement to lower scores holistically), or if there is an actual causal direct correlation.

Although nobody can give a conclusive answer on the above, the association between lower LOS and higher HCAHPS scores is pervasive and almost universal although the mechanism whereby this effect is transmitted has not been elucidated. Nevertheless, The following observations support this correlation hypothesis with some caveats:

1. Most Hospital in the top performance quintile tend to have higher HCAHPS scores and a LOS that is almost 1 day less than those performing at lower percentiles. As a note, these Hospitals are high performers with high brand recognition which might in itself influence patient perceptions of care to a greater extent than actual process excellence which might not be readily visible to them. In addition, these institutions tend to either implement multiple initiatives aimed at improving patient satisfaction or have higher patient satisfaction levels to start with.

2. "Innovation" Units like those at MGH have higher HCAPS scores and a lower LOS than that of the regular units. As a point in favor, most interventions established on this units are aimed towards predicting discharges (Multidisciplinary Rounding), and attaining early discharges (Discharge Pathways). Having said that, there were also other interventions (like hourly nursing rounding and discharged patient callbacks) which might also contribute to the higher HCAHPS scores and might be a greater factor.

3. "High Intensity of Care Hospitals" demonstrate the opposite trend. Namely higher LOS and much lower HCAHPS scores although other dissatisfaction producing factors related to noise, lack of cleanliness, high number of physician encounters and patient complexity might account more for the lower HCAHPS scores than a high LOS on its own. In these cases you could argue that a high LOS might just be affecting HCAHPS scores in these problem-prone institutions by exposing patients to more instances of potential dissatisfactory events for a longer period of time.

a. Conversely, you could make a case that the higher HCAHPS scores in "Low Intensity Hospitals" with lower baseline LOS, could be due to less dissatisfaction producing factors being present at baseline coupled with less chance of repeated exposure to them due to a lower LOS driven by a lower acuity patient mix.

Regardless of whether the improvement in HCAHPS scores is due to a direct effect from lowering LOS or an indirect effect from instituting all the measures and controls that a Hospital might pursue to achieve better scores...the bottom-line is that almost universally; Hospital Units with a higher LOS tends to have Late Discharges and lower HCAHPS scores irrespective of why this is. As such, the only conclusion that can be drawn is that pursuing early discharges and lower LOS is a worthwhile effort that might have the added bonus of helping increase HCAHPS scores even though the root reason is not fully known.

Emilio S. Belaval MD, FAAEM
MS2 President & Founder

*P.S. The MGH "innovation units" and others have credited their higher HCAHPS scores to several interventions (most of which we have been helping implement for years at our client sites), but also place a lot of weight on the scripted Discharged Patient Callbacks strategy. If you are interested in this, one of our strategic partners provides one of the best and most cost-effective turn-key callback services in the industry for both ED and inpatient discharges.

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