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Improving HCAHPS scores the old fashioned way


THE BODY OF “COMMON LAW” for health care has been established by numerous agencies, from the official ones (such as the Centers for Medicare & Medicaid Services) to the quasi-official (National Committee for Quality Assurance), from hospital accrediting organizations to unofficial but nevertheless influential consumer groups, such as the Leapfrog Group. Today, healthcare quality also is measured by a survey conducted by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Survey results are tied to reimbursement, and are made public and compared to those of other hospitals; patients are the ones doing the assessing. The people most affected by hospital care are finally making their voices heard. Every day, more than 8,400 patients complete the HCAHPS Survey. Questions focus on the hospital patient’s experience, and many involve nursing care. So how are patients rating hospitals? If scores below 60% are considered an F, things look bleak. Why are the scores so low? Because dysfunctional organizations collect irrelevant information demanded by tradition-bound, naïve, arrogant, self-important leaders. With useless information, resource allocation is skewed and caregivers are shorthanded or overextended, while hospital foyers and elegant C-suite offices are elegantly appointed. Here are some “quality” facts:

  • Most quality programs don’t work, and when they don’t work, they’re replaced with another one. Every new program is like a religious experience for management. Employees who deliver the service eventually become immune to the hype and jargon.
  • When employees do the right things for patients, it’s generally in spite of the quality program, not because of it.
  • Quality is in the hands of the “doer”—the one doing the work, whether that means tending a machine, a classroom of students, or a group of patients.

The old fashioned way

Back when many of us were in nursing school, our instructors used certain words intended to teach us how to be “good” nurses. These were our value words, our moral primer, in those days before ethics courses. The words were courtesy, kindness, respect, accuracy, duty, loyalty, commitment, justice, honesty, diligence, compassion, and discipline. Take for example, the age-old ethical norm (and the foundation of nurses’ notes) “honesty is the best policy. ”Close observation and timely reporting had the moral support of countless nursing instructors, head nurses, and nursing supervisors. Not only did we report what happened, including any errors; we also reported near misses. The faculty’s moral certainty was built on the expertise of such nursing luminaries as Bertha Harmer and Virginia Henderson for nursing arts and proper professional deportment. Hildegard Peplau’s Interpersonal Relations in Nursing emphasized the importance of the nurse’s therapeutic relationship with the patient. Florence Nightingale’s Notes on Nursing emphasized cleanliness and close patient observation. We were inspired by the stories of Dorothea Dix, Clara Barton, Lillian Wald, Mary Breckinridge, and Geneviève de Galard-Terraube—those nursing “overcomers” who achieved greatness despite the odds. By the time we graduated, we’d learned about the character of the ideal nurse whose virtues we earnest apprentices were to emulate. We were never to forget the trust placed in us, the lives that depended on our judgment, and the responsibility we bore to promote our noble profession. Patients and their families seem to value many of the same things. Certainly they prefer sufficient, competent, compassionate care to marble lobbies and are downright suspicious of elegant C-suite offices. The latest technology is important, but a clear explanation of why it’s necessary is just as important. Having clean rooms is far more important than having the latest decor. And kindness and gentleness are priceless. Any organization that wants to up its HCAHPS score would do well to remember these things.

Leah Curtin, RN, ScD(h), FAAN
Executive Editor, Professional Outreach
American Nurse Today


  • We have had one quality program after another – but nothing has really changed. I think Dr. Curtin is right about teaching the values that support good and safe health care.

  • Stacy Slater
    July 22, 2014 5:42 pm

    Thank you for your insightful comments. I appreciate your “sharp” view on what is happening in the C-suites vs the reality of bedside nursing trying to cope with the repercussions of moving from volume to value and decreased reimbursement. As you point out – “Quality is in the hands of the doer”.

  • Dr. Curtin,
    Is it fair to assume that you think the older ways of educating nurses; i.e., diploma programs, are superior to today’s colleges and schools?

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