The objective of the Patient Experience project is to predict patients who are most likely to report a sub-optimal inpatient experience in order to initiate service recovery, or other engagement strategies of the patient experience team, prior to discharge. The expectation is that this will increase overall patient satisfaction with their Mount Sinai hospital experience, as measured by the HCAHPS patient experience scores. This in turn would positively impact the MSHS reputation and increase reimbursement from Medicare and other value-based payment structures.

The project was deployed at Mount Sinai Hospital in January 2021 and since then has expanded to almost all hospitals in the Mount Sinai system.

Background Information

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) and Press Ganey

The HCAHPS (“H-caps) survey is a national, standardized, publicly reported survey of patients’ perspectives of their hospital care and experience^[1]. Public reporting of the survey results increases the transparency of the quality of hospital care provided, and can impact both hospital reputation and reimbursement. HCAHPS results typically account for 25% of a hospital’s value-based purchasing score – directly impacting the amount of Medicare payments received^[2]. Press Ganey is the largest HCAHPS administrator in the country, and distributes the survey for Mount Sinai patients. The Press Ganey patient experience surveys may combine the required HCAHPS questions, often focused on how often certain services were provided, with additional questions on how well the service was provided, in order to better capture the overall patient experience.

Patient Eligibility

All patient discharges that adhere to the official HCAHPs inclusion and exclusion criteria are eligible to be selected for the official HCAHPS survey (see below). Approximately 10% of all eligible patients will be randomly selected by Press Ganey for the official mail survey, 75% for the unofficial mail survey, and the remaining 15% for the unofficial email version of the survey (for those patients with a valid email address).

Data

Press Ganey

All inpatient records, including the current version of MS-DRG billing information, are sent to Press Ganey within 35 days of discharge. Press Ganey distributes the paper or email survey, and receives most responses within 3 months (18% / 85% / 95% within 1 / 2 / 3 months, respectively). Mount Sinai receives daily XML feeds from Press Ganey with the latest survey results. The data dictionary for the Press Ganey survey data is shown below.

Column Name

Description

DIS YEAR

All variations and concatenations of the patient discharge date. I use “Discharge Date”, as that is easily linked to Tableau.

DIS MONTH

Discharge Period

Discharge Date DT

Discharge Date

Receive Date DT

Variations of received date, which is the date Press Ganey received the survey back from the patient.

Receive Date

FACID

Ignore—Hospital Identifier from the PG side

Hospital

Unit

Unit description

Specialty

Case specialty based on MRN+Discharge Date

MRN

Patient MRN

Encounter No

Encounter Number

Sex

F/M

Language of Survey

Language of survey

Rate overall health

HCAHPS CMS Demo question: In general, how would you rate your overall health? (Poor to Excellent)

Highest grade-school completed

HCAHPS CMS Demo question: What is the highest grade or level of school that you have completed?

Spanish, Hispanic or Latino

HCAHPS CMS Demo Question: Are you of Spanish, Hispanic, or Latino origin or descent?

Race-White