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HCAHPS, Patient Experience Scores Tank During COVID-19 Due to Staffing

The key HCAHPS domains impacted by COVID-19 included cleanliness and responsiveness of staff, showing the effect staffing has on patient experience.

A new RAND Corporation analysis of nearly 4 million HCAHPS surveys showed that hospital patient experience tanked during the COVID-19 pandemic, researchers wrote in JAMA Health Forum.

Compared to 2018-2019 data, HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores fell by 3.6 percentage points by the fourth quarter of 2021.

Declines in hospital patient experience were mostly driven by poor performance in staff responsiveness and cleanliness, potentially underscoring the impact that staffing shortages have had on the overall healthcare experience, the researchers posited.

“This unprecedented decline in patient experience was seen in every region of the United States, with relatively little regional variation,” Marc Elliott, the study's lead author and a senior principal researcher at the nonprofit RAND, said in a press release. “Hospitals with higher staffing levels and better overall pre-pandemic quality were more resilient and slower to see their decline. But eventually even their patients also reported worse experiences.”

COVID-19 left no area of healthcare untouched. While previous data has indicated the stress and burnout experienced by providers at the hands of the pandemic, other studies have shown that patient safety took a hit during that time.

This latest study adds to that literature showing that COVID-19, with its public safety measures, hospital isolation, and quarantining protocols, also hampered the patient experience. The researchers measured experience using HCAHPS, a gold standard for patient engagement measures that informs some value-based payments and hospital Star Ratings rankings.

The analysis of just under 4 million HCAHPS surveys showed a stark decline from pre-pandemic times to the end of 2021, with scores dropping a total of 3.6 percentage points.

That decline didn’t happen all at once, the researchers said. Between the 2018-2019 scores and the Q2 2020 scores, researchers observed a 1.2 percentage point decrease in HCAHPS scores. By the third quarter of 2020, the team observed a drop of 1.9 percentage points and 2 percentage points by Q1 2021. That culminated in the overall decrease of 3.6 percentage points.

As noted by Elliott, the variable decline was driven in large part by hospitals that had better staffing before the pandemic’s outbreak. These hospitals were able to stave off sharp drop-offs in patient experience because they had more staff on hand, but, ultimately, declines did prove inevitable.

Trends in staffing also showed themselves when looking at the specific HCAHPS domains affected by the pandemic. The biggest decreases in scores happened in the staff responsiveness and cleanliness domains, with researchers observing declines of 5.6 and 4.9 percentage points, respectively.

Declines in scores for communication about medicines, communication with nurses, communication with doctors, and care transitions were more moderate, the research team said.

Moreover, declines in overall hospital rating and recommendation were also moderate, plus they lagged drops in other patient experience measure scores. This could indicate that patient expectations were low; although patients scored staff responsiveness low, they did not take away from their likeliness to recommend scores because patients did not have high expectations for the healthcare experience at the height of the pandemic.

“This pattern suggests that global ratings alone do not fully capture changes in specific patient experiences, nor do they identify the areas in need of improvement, especially in the face of unusual events such as a pandemic,” Elliott explained.

Still, drops in overall hospital rating and recommendation—referred to as global scores—did eventually catch up to other HCAHPS domains.

The researchers did acknowledge that the COVID-19 pandemic was an “unusual event.” Patient experience scores during that time do not necessarily reflect the ability of hospitals to deliver a good experience under normal circumstances.

However, this data is crucial in understanding the impact COVID-19 had on the healthcare industry and overall patient experience. It also adds to the literature indicating that COVID-19 exposed deep cracks in the healthcare industry.

It may be fruitful to continue tracking patient experience scores following the pandemic to show how healthcare has been able to—or unable to—recover.

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