By Allison King, M.S., Doctoral Student in Applied Behavior Analysis
In 2011, health care abruptly changed with the introduction of the Hospital Value-Based Purchasing (VBP) program. The Centers for Medicare & Medicaid Services (CMS) designed this pay-for-performance system, which rewards hospitals for providing high-quality care to patients with Medicare. Eligible Medicare patients of hospitals participating in this program receive a patient satisfaction survey—the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)— once they are discharged from the hospital. The survey consists of questions that ask the patient to rate the quality of the care they received during their stay at the hospital. The patients’ responses greatly impact the hospitals overall quality score. Therefore, it is critical for hospitals participating in VBP to consistently implement best practices that result in an enhanced patient experience and higher patient satisfaction survey scores.
During the fall of 2013, a large health system in Florida participating in the VBP program met with Florida Tech’s applied behavior analysis (ABA) faculty. Its largest hospital’s overall HCAHPS scores were below the 50th percentile, so its quality scores were lagging. In an effort to fulfill its mission of delivering consistent high-quality and patient-centered care and to increase its VBP incentive payments, the hospital aimed to improve its overall HCAHPS scores to the 90th percentile.
The issue the hospital was facing was not a result of not knowing what best practices to implement—the research showed that consistent and purposeful hourly rounding on patients and conducting shift reports at patients’ bedsides were best practices that would improve patient satisfaction. These practices were already included in the hospital’s policies and training. The issue was identifying the variables that were contributing to the patients’ poor responses to the HCAHPS questions. Were the established best practices not happening consistently enough or were other organizational processes interfering with patient satisfaction?
To answer these questions and make a positive, sustained change, one must be skilled in observing and understanding how the environment impacts behavior. Students studying behavior analysis learn a natural science-based approach to examining and conceptualizing human behavior. They are trained to identify and understand how environmental events influence behavior. With these skills, they can design functional interventions to change behavior and implement practices that result in sustainable change. Two graduate students in the ABA and organizational behavior management (OBM) program were given the opportunity to conduct an organizational needs assessment and implement an intervention to help the hospital reach its goal of improving patient experiences and HCAHPS scores.
The FIT students spent 30 days conducting a needs assessment on a nursing unit that was consistently receiving HCAHPS scores below the 20th percentile. The assessment consisted of analyzing the questions on the HCAHPS survey, conducting behavioral observations of nurses, certified nursing assistants (CNAs), and nurse managers and directors, and collecting objective data on the occurrence of best practices during their patient interactions. After analyzing the assessment results, the students developed a performance improvement plan.
The students implemented a behavior change initiative that gave managers and directors the tools to pinpoint and track leading indicators of patient satisfaction scores, objectively identify performance gaps to design appropriate training methods, and establish an opportunity for oversight and accountability by regularly tracking employee performance. Using this approach also allowed managers to give objective feedback to employees about their performance of practices linked to patient satisfaction and reinforce specific behaviors that drove the patient satisfaction scores. After just one month of training key players and implementing this approach consistently, the nursing unit reached the 99th percentile in the HCAHPS domain that was targeted.
Since then, the students’ approach to solving patient satisfaction problems in this hospital has quickly advanced and has been implemented on a larger scale. One year later, both students and another OBM student work at the hospital. One took a full-time position as the customer experience analyst and the other two continue to work as part-time interns. They have created and taught a two-week course to the managers and directors of all departments in the hospital about managing employee performance by using the science of behavior change. After the course, all managers pursued a project of their own to improve critical hospital outcomes, such as patient safety, patient satisfaction and stewardship, by using a behavioral approach. The managers are currently implementing their plans with help from the students, and many have seen rapid results. The environmental services team recently won a patient experience award for improving their HCAHPS scores and attributed much of their success to using the behavioral approach they learned from the FIT student consultants.