Hospital Performance on Hospital Consumer Assessment of Healthcare Providers and System Ratings: Associations With Nursing Factors

Abstract

Objective: To determine which hospital nursing resources (staffing, skill mix, nurse education, and nurse work environment) are most predictive of hospital Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) performance.

Background: HCAHPS surveying is designed to quantify patient experience, a measure of patient-centered care. Hospitals are financially incentivized through the Centers for Medicare and Medicaid Services to achieve high HCAHPS ratings, but little is known about what modifiable hospital factors are associated with higher HCAHPS ratings.

Patients and methods: Secondary analysis of multiple linked data sources in 2016 providing information on hospital HCAHPS ratings, hospital nursing resources, and other hospital attributes (eg, size, teaching, and technology status). Five hundred forty non-federal adult acute care hospitals in California, Florida, New Jersey, and Pennsylvania, and 11,786 registered nurses working in those hospitals. Predictor variables included staffing (ie, patient-to-nurse ratio), skill mix (ie, the proportion of registered nurses to all nursing staff), nurse education (ie, percentage of nurses with a bachelor's degree or higher), and nurse work environment (ie, the quality of the environment in which nurses work). HCAHPS ratings were the outcome variable.

Results: More favorable staffing, higher proportions of bachelor-educated nurses, and better work environments were associated with higher HCAHPS ratings. The work environment had the largest association with higher HCAHPS ratings, followed by nurse education, and then staffing. Superior staffing and work environments were associated with higher odds of a hospital being a "higher HCAHPS performer" compared with peer hospitals.

Conclusion: Improving nursing resources is a strategic organizational intervention likely to improve HCAHPS ratings.

Figure 1.. Comparison of the Work Environment Subscales Effect on HCAHPS Rating

Note: Output is from independent adjusted OLS regression modeling. Standard deviation and t-score for each subscale as follows: Nursing Foundations for Quality of Care (0.28; 10.79), Collegial Nurse-Physician Relations (0.29; 8.69), Staffing & Resource Adequacy (0.37; 9.00), Nurse Manager Ability, Leadership, and Support of Nurses i.e., Nurse Leadership (0.35; 7.89), and Nurse Involvement in Hospital Affairs (0.38; 10.36).

Figure 2.. Comparison of the Work Environment Subscales on the Odds of a Hospital Being in a Higher HCAHPS Performance Category

Note: Output is from independent adjusted ordered logistic regression modeling. Standard deviation and z-score each given subscale as follows: Nursing Foundations for Quality of Care (0.28; 8.50), Collegial Nurse-Physician Relations (0.29; 7.21), Staffing & Resource Adequacy (0.37; 7.52), Nurse Manager Ability, Leadership, and Support of Nurses i.e., Nurse Leadership (0.35; 7.33), and Nurse Involvement in Hospital Affairs (0.38; 8.30).