HCAHPS Analysis and Strategic Plan for LA Community Hospital

Introduction: Life Expectancy and the Role of HCAHPS

The issue of life expectancy at birth is a relatively novel one. Before the 19th century, the United Kingdom — the country with the longest time-series of measured life expectancy — had not measured this variable at all. It is nevertheless estimated that life expectancy at birth was between 30 and 40 years at that time; today it stands at around 80 (Roser, 2016). Within the United States, life expectancy is 79 years; in Japan it is 84, and Monaco — the highest in the world — is 89 years (Central Intelligence Agency, 2016). There are still countries with lower life expectancies, but people in all countries across the globe are expected to live at least 49 years, with Chad recording this lowest figure, followed by Guinea-Bissau and Afghanistan at 50 years, and Namibia and Somalia at 51 years (Central Intelligence Agency, 2016).

In all respects, life expectancy has increased significantly over the past two centuries. This trend is observed in both developed and under-developed regions of the globe and results from a multitude of forces, including rising living standards, greater access to health care, improved population education, and better technologies. In this new global context, patients are becoming increasingly demanding and expect higher quality medical services.

In response to this growing demand, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) was created as a standardized method of collecting and measuring information about the patient experience in hospitals (Centers for Medicare and Medicaid Services, 2016). Based on its findings, patients can analyze hospitals, compare them, and choose to seek medical attention at the facility they find most suitable for their needs. Medical care providers, in turn, can use HCAHPS surveys to understand how their patients view them, compare themselves with other hospitals and sector averages, and develop new methods to improve their delivery of care. This is therefore the scope of the present project: to assess the current state of Los Angeles Community Hospital and to propose methods of improvement within the facility.

HCAHPS Scores for Los Angeles Community Hospital

The HCAHPS survey is a national standardized set of assessments collected from recent patients and targeting eleven specific quality issues. The current project assesses the HCAHPS data for Los Angeles Community Hospital in an effort to improve the quality of medical care provided to patients with fewer available resources. The institution's most recent HCAHPS data (as of May 2016) is presented below.

1. Patients who reported that their nurses communicated well: Always 57% | Usually 22% | Sometimes/Never 21%

2. Patients who reported that their doctors communicated well: Always 62% | Usually 17% | Sometimes/Never 21%

3. Patients who reported that they received help as soon as they wanted: Always 44% | Usually 28% | Sometimes/Never 28%

4. Patients who reported that their pain was well controlled: Always 52% | Usually 27% | Sometimes/Never 21%

5. Patients who reported that staff explained medicines before giving them: Always 44% | Usually 20% | Sometimes/Never 36%

6. Patients who reported that their room and bathroom were clean: Always 48% | Usually 24% | Sometimes/Never 28%

7. Patients who reported that the area around their room was quiet at night: Always 28% | Usually 29% | Sometimes/Never 43%

8. Patients who reported they were given information about home recovery: Yes 73% | No 27%

9. Patients who understood their care when they left the hospital: Strongly agree 32% | Agree 50% | Disagree/Strongly disagree 18%

10. Patients who gave their hospital a rating of 9 or 10: 9 or 10: 42% | 7 or 8: 27% | 6 or lower: 31%

11. Patients who reported they would recommend the hospital: Yes, definitely 38% | Probably 30% | Probably/Definitely not 32%

At an overall level, Los Angeles Community Hospital reveals a series of patient dissatisfactions: 32 percent of patients stated they would not recommend this hospital, and nearly a third rated it 6 or lower on a 10-point scale. A fuller picture emerges in the following section, where these results are compared with state, national, and peer hospital data.

Analysis: Comparing Scores Against Benchmarks

Comparison with State and National Averages

When compared with California and national averages, Los Angeles Community Hospital underperforms across all eleven quality dimensions. Key findings include:

Nurse communication: Los Angeles Community Hospital recorded 57% "always," compared with a California average of 75% and a national average of 80%. The share reporting "sometimes or never" was 21% at the hospital, versus 6% for California and 4% nationally.

Doctor communication: Los Angeles Community Hospital recorded 62% "always," against 78% (California) and 82% (national). The "sometimes or never" share was 21%, compared with 6% and 4% respectively.

Responsiveness to patients: 44% "always" at Los Angeles Community Hospital, compared with 62% (California) and 68% (national); the "sometimes or never" figure was 28% versus 12% and 9%.

Pain management: 52% at Los Angeles Community Hospital, compared with 69% (California) and 71% (national).

Medication explanation: 44% "always" versus 61% (California) and 65% (national); "sometimes or never" reached 36% at Los Angeles Community Hospital compared with 20% and 18% elsewhere.

Room and bathroom cleanliness: 48% "always" versus 70% (California) and 74% (national); the "sometimes or never" share was 28%, compared with 10% and 8%.

Quiet at night: Only 28% of Los Angeles Community Hospital patients reported quiet "always," versus 51% (California) and 62% (national). The "sometimes or never" figure was 43%, starkly higher than the national figure of 9%.

Home recovery information: 73% at Los Angeles Community Hospital received this information versus 85% (California) and 86% (national).

Understanding care upon discharge: Only 32% "strongly agreed" they understood their care at Los Angeles Community Hospital, versus 49% (California) and 52% (national). The "disagree or strongly disagree" share was 18%, versus 7% and 5%.

Overall hospital rating: 42% of patients gave a rating of 9 or 10, compared with 68% (California) and 71% (national). The share rating 6 or lower was 31%, versus 10% and 8%.

Likelihood to recommend: Only 38% would "definitely" recommend the hospital, compared with 69% (California) and 71% (national). The "probably or definitely not" share was 32%, compared with 7% and 5%.

Score Comparison with Cedars-Sinai Medical Center and Good Samaritan Hospital

The pattern of underperformance holds when Los Angeles Community Hospital is compared with two regional peers. Against Cedars-Sinai Medical Center and Good Samaritan Hospital, all eleven quality dimensions show significant shortfalls:

Nurse communication: 57% "always" at Los Angeles Community Hospital versus 75% (Cedars-Sinai) and 73% (Good Samaritan).

Doctor communication: 62% at Los Angeles Community Hospital versus 78% (Cedars-Sinai) and 80% (Good Samaritan). While only 6% and 4% of respondents at the two peer hospitals reported poor doctor communication, 21% of Los Angeles Community Hospital patients reported that doctors communicated well only "sometimes or never."

Responsiveness: 44% at Los Angeles Community Hospital versus 62% (Cedars-Sinai) and 60% (Good Samaritan).

Pain management: 52% versus 70% (Cedars-Sinai) and 69% (Good Samaritan); medication information: 44% versus 61% and 60%.

Quiet and cleanliness: Both significantly lower at Los Angeles Community Hospital. Room quiet "always" was 28% versus 52% at both peer hospitals; cleanliness "always" was 48% versus 71% (Cedars-Sinai) and 65% (Good Samaritan).

Discharge information and understanding: Fewer patients at Los Angeles Community Hospital reported receiving home-recovery information (73% versus 86% and 85%), and fewer strongly agreed they understood their care upon leaving (32% versus 49% and 41%).

Recommendation: 81% of Cedars-Sinai patients and 73% of Good Samaritan patients would "definitely" recommend their hospital, versus 38% at Los Angeles Community Hospital. Conversely, 32% of Los Angeles Community Hospital patients stated they would not recommend the institution, compared with only 3% at Cedars-Sinai and 5% at Good Samaritan. The differences are striking, and Los Angeles Community Hospital shows significant shortfalls in all eleven quality aspects relative to both peer hospitals.

Based on HCAHPS scores, Los Angeles Community Hospital is rated as a one-star medical facility, while both Good Samaritan Hospital and Cedars-Sinai Medical Center are rated three-star facilities in Los Angeles. The maximum possible on the HCAHPS scale is five stars.

Survey Response Rates

In computing the HCAHPS data for Los Angeles Community Hospital, a total of 602 surveys were completed at a response rate of 17%. The Medicare website notes that this figure is an educated estimate and that discrepancies were registered during data collection (Medicare.gov, 2016).

For Good Samaritan Hospital, 527 surveys were completed at a response rate of 22%. Numerically fewer surveys were completed than at Los Angeles Community Hospital, but patients at Good Samaritan were proportionally more inclined to provide feedback.

For Cedars-Sinai Medical Center, 618 surveys were completed at a response rate of 23%. Both in absolute terms and by response rate, data collected from Cedars-Sinai exceeds that collected from Los Angeles Community Hospital.

Community Context, Demographics, and Environmental Factors

Hospital Profile and Services

Los Angeles Community Hospital is one of five medical institutions operated by Alta Hospitals Systems LLC, all located in Los Angeles County and collectively totaling 590 licensed beds and 721 physicians. All five hospitals are accredited by Det Norske Veritas Healthcare Inc. (DNV) and aim to operate within their communities in a manner that creates a reputation for "delivering high quality care to the communities that we serve while providing easy access to our services" (Alta Hospitals Systems LLC, 2016).

As part of the Alta Hospitals System, Los Angeles Community Hospital operates 130 beds and is categorized as a general acute care hospital — the dominant hospital category in the United States, providing the widest array of medical services. The hospital strives to provide quality and comprehensive care in the following service areas: heart attack care, heart failure care, pneumonia care, surgical care, emergency care, preventive care, children's asthma care, stroke care, blood clot prevention and treatment, and pregnancy and delivery care (Medicare.gov, 2016).

The hospital is able to electronically receive and track laboratory results and make electronic referrals between visits. It uses an inpatient safe surgery checklist but does not use an outpatient safe surgery checklist — a tool employed by both Cedars-Sinai and Good Samaritan. In terms of medical imaging, quality appears reduced, though Medicare has been unable to collect sufficient data to produce solid findings, as too few patients underwent imaging investigations at this facility to constitute a reliable sample (Medicare.gov, 2016). The hospital is not a teaching hospital and does not operate a trauma section. Its emergency department is often on standby, with patients sometimes redirected to other facilities (Healthcare Atlas, 2010).

Los Angeles Community Hospital is investor-controlled and registers a 37.3% reimbursement rate on the dollar paid by patients, meaning it also receives government funds through the Medicaid program. Through its collaboration with the state and adherence to necessary reporting standards, it is classified as a disproportionate share hospital, aiming to make medical care more accessible and affordable to the broader population, especially those least able to afford it.

Patient Demographics

Los Angeles Community Hospital serves people in Los Angeles County and has not extended its services to other counties. It seeks to provide medical care to the low-income population, who are often unable to pay for services elsewhere. The core market is characterized by the following demographics:

An estimated 2.8 million people are served across a total area of 240 square miles, yielding a population density of 11,734 people per square mile. This is slightly higher than the community average of 10,800 per square mile, and significantly higher than the statewide density of 226 per square mile.

In terms of race, patients in the core market are approximately 68% Hispanic, 13% Black, 8% White, and 7% Asian. At the state level, only 8% of the population is Hispanic and 0.5% is Black. These groups are significantly underserved by other medical institutions and represent the primary patient populations at Los Angeles Community Hospital.

Age-wise, the majority of patients are between 18 and 64 years old (62%), followed by patients under 18 (29%), and only 8% are 65 or older — suggesting a lower effective life expectancy among those seeking care at this facility.

In terms of poverty, more than half of Los Angeles Community Hospital's patients live in poverty: 22% at the 100% poverty level and 44% at the 200% poverty level. At the state level, 45% of the population lives in poverty (Healthcare Atlas, 2010). Ultimately, Los Angeles Community Hospital provides medical care — to the best of its limited abilities — to the people who need it most but can afford it least.

Environmental and Community Factors Affecting HCAHPS Scores

Cultural dynamics: The hospital primarily serves community members living below the poverty line (over 60% of patients live in poverty). Its stated purpose is to serve those who cannot afford high-end medical care. This status quo means that patients are often unable to pay for treatment, which in turn constrains the hospital's financial resources. The resulting pressure likely produces overworked and understaffed personnel who are unable to provide high-quality bedside care, contributing to low nurse and doctor communication scores.

Educational dynamics: Patients treated at the hospital live in poverty — some in extreme poverty — with limited economic means. Data on the educational levels of Los Angeles Community Hospital patients are not available, but given the well-established link between high income and high education, it is reasonable to assume that many patients have lower levels of formal education. This may affect patients' ability to complete surveys accurately, contributing both to low response rates and to the data discrepancies reported by Medicare.gov.

Socioeconomic dynamics: Given the marketplace in which the hospital operates, it is widely understood that its patients have a lower socioeconomic status and limited ability to pay for medical services, resulting in lower hospital resources overall. The socioeconomic conditions of the community thus contribute directly to the hospital's HCAHPS scores.

Potential Financial Impact on the Organization

The scope of Los Angeles Community Hospital — as its name implies — is to provide medical care for the community rather than to generate high profits or function as a teaching or innovative hospital. However, the problem it faces relates to long- and short-term sustainability. In the short term, the hospital may still be able to continue operations, but only barely. Over the long term, patients who research hospitals online and review HCAHPS scores may choose to seek care elsewhere. This is especially consequential given that the hospital's emergency services are currently uncertain, meaning that patients with emergencies may already be avoiding it. The second category — patients seeking non-emergency care — will conduct thorough research to identify the hospital that best serves their needs, has the most experience with their condition, employs the best-reviewed physicians, and uses the most up-to-date technology. In the long run, the very patients who could afford to pay for services are likely to avoid Los Angeles Community Hospital altogether.

The low HCAHPS scores may trigger a vicious cycle in which poor quality assessments lead to fewer patients, reduced government reimbursement interest, reduced investor and community interest, and an overall diminished ability to improve quality outcomes. In other words, the current HCAHPS scores risk damaging the hospital's image and further eroding future performance.