David Gifford
David Gifford, M.D.
David Gifford, M.D.

Federal regulators say that nursing homes could eventually come to see patient satisfaction scores included in Five Star Quality Ratings and on the Nursing Home Compare website. 

But that acknowledgement, sent to McKnight’s Long-Term Care News in an email response from a Centers for Medicare & Medicaid Services spokeswoman, is not necessarily reason for providers to start popping corks just yet.

Long-term care advocates have heightened calls recently for publicly reported patient-satisfaction scores. They’ve come in response to some of the administration’s more objectionable efforts to increase “transparency” for consumers. The addition of the open-palmed “abuse” icon on the Nursing Home Compare website in October is one particular flashpoint.

Long-term care lobbyists point out that many other healthcare sectors already post consumers’ satisfaction scores on sites comparable to Nursing Home Compare. It’s a possibility regulators are willing to consider.

“CMS is interested in evaluating how resident or patient satisfaction scores could be added to the Nursing Home Compare website and Five Star Quality Rating System,” the spokeswoman told McKnight’s

Funding, however, is one of the major sticking points, both regulators and providers agree. A data-gathering process has been previously explored and in at least some cases, it proved to be too expensive.

“Several factors would affect implementation of satisfaction scores, including funding, the data collection process, and regulatory construct,” the CMS representative explained. “These factors pose substantial challenges and may take some time to resolve. However, CMS will continue to explore how to address these challenges, as we believe satisfaction scores could be useful information to consumers as they make healthcare choices for themselves or loved ones.”

Movement can’t come fast enough for American Health Care Association Vice President for Quality Affairs David Gifford, M.D. He noted that two years ago, CMS put resident satisfaction rulemaking on a National Quality Forum wish list, but that’s been about it.

“I find it ironic that everyone’s talking about person-centered care and the consumer rights of the resident and family, and how important it is to get their feedback. There’s a lot of concern about quality out there,” Gifford told McKnight’s. “As soon as we advocated that we wanted to be measured on that, they said, ‘No, no, no. It might make them look good.’ We don’t know if it will or not. We believe some people will provide high customer service and others won’t.”

Gifford pointed to a past pilot effort that showed “wide variation” in satisfaction scores.

AHCA and its sister group, the National Center for Assisted Living, developed the CoreQ program a few years ago. It consists of three questions for long-stay residents/family members and four for short-stay and was independently tested as “a valid and reliable” measure of customer satisfaction, AHCA sources say.

But the substance of information gathered and the manner for doing it remain sticking points with regulators.

System already in use

There is a system endorsed by CMS and used by many provider groups already — hospitals, hospice, managed care and dialysis facilities among them. The CAHPS system, however, was deemed insufficient in recent years by nursing home providers themselves, not that it was ever officially used as a possible solution beyond tests in 2006 and 2007. 

SNF testing at the time involved about 25,000 different responses, Gifford said, adding that the National Quality Forum found it valid. But when providers went to CMS to have it added into their quality measurements, progress stalled.

Regulators have their own, varying “silos” of understanding and interest in the subject, Gifford noted.

One sticking point has been how to factor residents with dementia into the information gathering. Face-to-face data collection, which other healthcare settings don’t use, is often required with dementia or extremely frail patients. This adds layers of complications. A few states tried it face-to-face but “it became too costly and nobody was able to sustain that,” Gifford said.

In addition, past research in various fields has shown that proxies do not fill out forms the same as the actual person targeted, Gifford noted. 

Many providers are measuring resident satisfaction on their own already, and many don’t want other complications anyway, given all the staffing and other regulatory burdens already on their radar, Gifford acknowledged. 

But AHCA/NCAL will keep pushing, he said.

“We’ve taken the position that there are four major metrics organizations should be tracking to see how they’re doing in reflection of the broader system: rehospitalization rates, antipsychotics use, functional improvement and customer satisfaction,” he said. “If I were running a building right now, I would want to know how I’m doing relative to everyone else.”

He added, however, that another satisfaction issue often gets in the way. Consumer-advocacy groups want to have it “both ways” — getting more information but then not accepting it — which frustrates efforts, Gifford said. 

“The main thing we’ve heard from the consumer groups is, ‘We don’t trust the answers,’” he explained. “One of the challenges is that whenever we’re trying to do something new, people let the perfect be the enemy of the good. Because there’s no consensus, nothing gets done. That’s what’s holding back progress to make things better.”