INTRODUCTION.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patients' experiences of hospital care and publishes the results on Medicare's Hospital Compare website. The HCAHPS (pronounced "H-caps") survey results are used for the Medicare Hospital Value-Based Purchasing program, meaning that the results are used to determine how much Medicare will pay the hospital. Still, the validity of HCAHPS patient experience scores remains controversial among some clinicians (Jones, 2019). Loma Vista Hospital is the largest of three hospitals in the WellFront Health System (WHS) located in northern New Mexico. The system includes Loma Vista Hospital, St. Mary's Hospital, and WellFront Hospital. Dr. Samuel Scroggins is the chief medical officer (CMO) of Loma Vista Hospital, whose HCAHPS scores are below state and national averages. However, Dr. Scroggins remains unconvinced that time, energy, and resources should be devoted to improvement of patient experience scores. Charles Larkley, the Loma Vista CEO, developed an unorthodox plan to convince Dr. Scroggins to engage in patient experience quality improvement initiatives, and the CEO and CMO of the other hospital, St. Mary's Hospital, have agreed to play along.

The Secret Shopper "I'm not sure what is more unbelievable, that I missed the 6-foot putt or that you are actually making me stay the night at the hospital," said the Loma Vista Hospital CMO, Dr. Samuel Scroggins.

"A bet is a bet," replied Charles Larkley, the Loma Vista CEO. "It's only one night, and acting as a Secret Shopper over at St. Mary's might do you some good." "Nonsense! I'm not sick, so how can I evaluate the care that St. Mary's provides?" Scroggins asked. "I am not asking you to evaluate the care as much as the patient experience. As you know, our overall hospital score is 75%, which is below the 75th percentile benchmark for HCAHPS," said Larkley. "St. Mary's HCAHPS scores are not much better, which is why their people agreed to let you act as a Secret Shopper for patient experience." "Take a look at these scores," said Larkley as he showed Dr. Scroggins the HCAHPS summary scores compared to the 75th percentile New Mexico and national benchmarks from the last reporting period (Table C10.1). "Charley, we've talked about this. HCAHPS scores don't measure quality of care," Scroggins insisted. "The data collected are nonrandom, slow to be collected, and create incentives for bad care that I can't abide. Catering to patient satisfaction scores might encourage our doctors to provide unnecessary care, which would only increase our costs and probably would reduce health outcomes. One doc called it 'death by patient satisfaction.'"

"Yes, I've heard your criticisms, Dr. Scroggins. Take a look at this report, and tell me what you see. Where are we struggling?" Larkley quizzed. Scroggins reviewed the report. "Overall, we're not rated so good. And a couple of measures are way below the benchmark, Quiet-at-Night, especially. What poppycock! Hospitals are just noisy places. What do you want the medical staff to do about it?" "I want you to support our new chief patient experience officer. I heard that you were not very professional in your interaction with her," Larkley said looking over his reading glasses. "I just told her that her job was meaningless. We just get dinged for things outside our control," Scroggins dismissed. "Well, maybe. But unless you improve your putting, I'm going to continue to make my point about improving patient experience. You may pick sometime within the next month to spend the night at St. Mary's," said Larkley. "Oh, and the admitting physician will be your old practice partner. He promised to keep your identity a secret."

The Former Partner

"Good afternoon, my old friend!" said Dr. Jake Marley as he entered the St. Mary's Hospital room. "How are you feeling?" Dr. Marley was not only Scroggins's old partner but also the CMO of St. Mary's Hospital. "You well know how I'm feeling," Scroggins grumbled. "No, you have a heart condition, that's why you're here," Marley said. "Play along, now." Marley opened the electronic medical record on his tablet and made a few clicks. "Yup, says here that your symptoms include a case of the 'yips.' Still can't make 6-foot putts, I see."

"Very funny. Leave me to pay off my debt in peace," Scroggins said. "Have you been admitted or spent time with your family in the hospital before?" Marley asked. "No, I haven't. And you know very well that I don't have family," Scroggins snorted. "The practice of medicine is my only family." "Yes, which is why I want to warn you," resumed Scoggins's old partner. "Listen, you will be visited by three nurses. Without their care, you won't be able to complete your Secret Shopper quality check." "Couldn't I see them all at once and get it over with, Jake?" hinted Scroggins. "I'm afraid not," Marley said as he backed out of the hospital room. "Sleep well, Dr. Scroggins."

The First of Three Nurses

Scroggins shared the hospital room with another patient, a young man whose family had come to visit him. Long past the end of the visiting hours, a young child trilled in response to his father's incessant raspberry sounds. Scroggins had once hoped to get a good night's rest. A young nurse came in to check on Scroggins. She was a lovely Puebloan woman with an angelic and caring spirit. "Nurse," Scroggins complained, "Isn't it past visiting hours?" 211 "Yes, my dear, it is," said the nurse. "But can't we wait just a bit more? The family lives a long way away, and Mr. Fezziwig gets so much energy from the love of his family." Scroggins harrumphed. He supposed that he once laughed like the child, full of joy and wonderment. But still, Scroggins thought, a man has to get some sleep. Sometime later, just as Scroggins nodded off, the public address system made a bong sound followed by, "Code Orange. Unit 3A." A startled Scroggins paged the nurse. "What was that sound, nurse?" Scroggins asked as the nurse came into his room. "It was nothing. Just a biohazard spill that needs cleaning. Go back to sleep, Mr. Scroggins." "It's Dr. Scroggins," he griped as he hammered his pillow into shape. As he lay there trying to return to his slumber, Scroggins noticed how the mix of beeps and whirrs climbed to a cacophony. The cardiac telemetry electrode patches began to tingle and the lead wires started to tangle as he tossed and turned. An alarm sounded as Scroggins accidently detached a telemetry patch from his skin. The nurse did not come; instead Scroggins heard her talking on the phone at the nearby nurses' station. A phone line rang without anyone answering. Ring, ring, ring. Scroggins couldn't stand it. He threw his cup of water against the closed hospital room door. Scroggins stared at the puddle on the floor, wondering if he should call for a nurse. He decided against it figuring he'd prefer to sleep. The Second of Three Nurses And yet, sleep did not come. The tick-tock of the wall clock seemed to get louder and louder. The elevator door opened and closed repeatedly. Someone kept slamming doors throughout the unit. An equipment cart with a wonky wheel bumped and thumped in the hallway. Finally, the door opened and a flood of light entered his room. A huge shape stood in the light's glow. "Oops!" said a male nurse with dark brown curls and a big grin. "Did we have an accident? No worries. We'll clean it up for you, Mr. Scroggins." "It's doctor ... never mind," Scroggins muttered. The jolly giant took Scroggins's blood pressure.

"Oh, wow! Your blood pressure is really elevated," the large male nurse said. "Are you feeling okay?" "No, I can't sleep," Scroggins whined. "I will let the doctor know," the nurse said. Just as Scroggins drifted off to sleep, a woman with a bucket entered the room, slopped a mop twice across the floor, squeezed the excess water, squeaked the floor with her sneaker, and then left. Unbelievable, Scroggins thought. The Last of the Nurses Deep into the night, Scroggins was not sure he was even sleeping when another nurse slowly, gravely, silently, approached his bedside with an outstretched hand. "What are you doing?" said Scroggins lamely. The dark figure pricked his arm to draw his blood. Scroggins, afraid and disoriented, wondered why the previous nurse had not taken blood at the same time as the blood pressure measure. Once affixed with a cotton swab and bandage across the crook of his arm, Scroggins sat quietly and listened to a conversation outside his room. 212 "I don't know why we're here either," said one man to another in the hallway outside Scroggins's room. "We were supposed to get this done yesterday. I was just told to replace these stained ceiling tiles and do it very quietly." As they unfolded the creaking ladder as quietly as possible, the maintenance man said, "The CMO of the hospital is coming by later this morning. We gotta make sure everything looks tip-top." Scroggins wanted to scream, but he thought of poor Mr. Fezziwig sleeping soundly next to him. Instead, he concentrated on his breathing. In. Out. In. Out. His thoughts calmed then began to make little sense. Scroggins knew he was falling asleep.

A time later, the shadowy figure said in the dark, "Mr. Scroggins. The doctor wanted you to take this sleeping pill. Sit up now." The Secret Shopper Quality Check Ends As the daylight leaked through the hospital window blinds, Scroggins awoke again with his former medical practice partner, Dr. Marley, shaking his shoulder. "Is it over?" Scroggins asked. "What time is it?" "It's 6 a.m. I'm rounding early. How are you feeling?" Marley asked. "I ache all over. That was my worst experience ever in a hospital," Scroggins answered. "Even worse that our residency days?" Marley asked. "Residency was nothing next to this nightmare!" Scroggins said. He ripped off the electrodes, kicked off the blanket, and arose from the hospital bed. He patted Marley on the chest and gave him a wry smile. "I've made a great mistake." He stripped off the gown and threw on his trousers. "Where are you going?" Marley called to Scroggins as he ran from the hospital room. Scroggins had no further reason to sleep at the hospital or to berate the patient experience staff at Loma Linda Hospital. "I have to apologize to our chief patient experience officer!" Scroggins said. He even became a member of the Patient Experience Governance Committee and rededicated his approach to patient healing and the power of a sound night's sleep.

1. Do you think Dr. Samuel Scroggins is correct that patient experience is unrelated to patient health outcomes? Do you subscribe to the idea of "death by patient satisfaction?" Give examples.

2.How was Dr. Samuel Scroggins's behavior to the chief patient experience officer unprofessional? How could Dr. Scroggins have more positively expressed his criticisms?

3.In what way was Dr. Samuel Scroggins changed by his experience? Do you think another approach could have changed his opinion of patient experience measurement? If so, what approach would you recommend?

4.Describe the manner in which the Quiet-at-Night score is a nurse-sensitive patient experience measure. How is the measure related to physician behaviors? The healthcare administrator? Other hospital staff?

5.Describe the benefits of a Secret Shopper approach to assessing patient experience. Do you think it is a reliable and valid method to evaluate health services? Why or why not?