HCAHPS: Ways to Improve On the Environment Question

The Hospital Consumer Assessment of Healthcare Providers and Systems now includes a new composite: cleanliness and quietness. How can your hospital boost its scores?

Since 2008, the HCAHPS – the Hospital Consumer Assessment of Healthcare Providers and Systems – survey has allowed valid comparisons across hospitals locally, regionally and nationally. Starting in October 2012, HCAHPS scores resulting from patient discharge surveys are being used in the calculation of value-based incentive payments in the Hospital Value-Based Purchasing (VBP) program. The HCAHPS survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 18 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with the care. The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports.1

Inpatient Prospective Payment System: Funds at Risk

Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions must collect and submit HCAHPS data in order to receive their full annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS Survey, may receive an annual payment update that is reduced by 2%.1

HCAHPS & Hospital (VBP) Scoring

The Hospital VBP program links a portion of IPPS hospitals’ payment from the Centers for Medicare & Medicaid Services (CMS) to performance on a set of quality measures. The hospital’s total performance score (TPS) for FY 2013 has two components: the clinical process of care domain (70% of TPS), and the patient experience of care domain (30% of TPS).  The HCAHPS surv ey is the basis of the patient experience of care domain.1

Eight HCAHPS measures are employed in the hospital VBP: the six HCAHPS composites (communication with nurses, communication with doctors, staff responsiveness, pain management, communication and medicines, and discharge information); one new composite that combines the hospital cleanliness and quietness survey items; and one global item (overall rating of hospital).

The percentage of a hospital’s patients who chose the most positive, or “Top-Box,” survey response in these HCAHPS dimensions is used to calculate the patient experience of care domain score. This article focuses on what hospitals are doing to improve their cleanliness and quietness survey item Top Box score.1


For cleanliness, the patient is asked the following question: During this hospital stay, how often were your room and bathroom kept clean?

Departments that are responsible for cleaning patients’ rooms are having their staff (custodial services, environmental services, hospitality services, housekeeping services) perform the following duties:

  • If possible, have a supervisor or manager check in on every newly admitted patient the same day they are admitted
  • Re-training their cleaning staff on how to properly clean an occupied patient room and bathroom
  • Using bleach based germicidal cleaners or alcohol free germicidal cleaners to help the room smell clean
  • Removing trash and soiled linen at the start of the day, and make a second round in the evening after dinner is served
  • Conduct a sample of daily room inspections before and after the room has been cleaned
  • Rotate order of occupied room cleaning. Example: first room cleaned today is not first room cleaned tomorrow
  • Interview a few patients and family members on each patient care unit each day, and leaves a business card
  • Provide AIDET Training (Announce, Introduce, Duration, Explanation, Thank You) to all newly hired staff, quarterly at staff meetings, and annually when giving performance evaluations. In applying AIDET to cleaning staff, these steps are followed: cleaning staff knocks on the door, asks if they may enter to empty trash/linen and/or clean the room, uses alcohol gel when entering and exiting the room, ensuring that the patient sees them rubbing their hands, makes eye contact with the patient and family, says their name and job title, explains what they will do and how much time it will take, asks if there is anything the patient needs, and thanks the patient and family for their time
  • Cleaning staff should have generic department business cards available and offer them to the patient and family; or if the patient is sleep, in the restroom,  or out of the room when the room is being cleaned, a business card should be left to let the patient/family know that the room and restroom has been cleaned
  • Place a tent card on the over bed table, and toilet seat bands on the toilet when the room is discharge cleaned to let the patient know that the room was cleaned, and where to call if they have a cleaning need
  • Use VIP (Very Important Patient) log to identify patients who communicated a cleaning concern, and to follow-up with patient at least daily to ensure that their room and their bathroom is cleaned to their satisfaction
  • Designate an existing housekeeping supervisor as a quality assurance supervisor and trainer, or hire one. Their focus would be on inspecting a agreed number of patient rooms, and follow up with cleaning staff to correct deficiencies
  • Participate on conference calls, or attend seminars or conferences where there is an opportunity to learn what others are doing to improve their HCAHPS score, and to share best practices
    Raise the bar on the caliber of the cleaning staff you hire, to include being customer focused, pleasant, and knowledgeable on cleaning techniques


For quietness, the patient is asked the following question: during this hospital stay, how often was the area around your room kept quiet at night?

Departments are doing the following to make the patient environment quieter:

  • Using “Quiet Zone” signs in the corridors
  • Using noise meters at nurses stations
  • Installing white noise machines that muffled the noise in the environment
  • Offering patients head phones and CDs with relaxing music
  • Offering patients ear plugs. These can be placed in the patient admit kit
  • Providing patients with a notice of construction or repair work that may create noise or vibrations
  • Having set quiet times each day when the lights are dimmed
  • Asking patients if they want their door closed
  • Evaluating all transport carts, and replacing noisy wheels/casters. This may include carts used by nursing, environmental services, material services and linen, facilities, nutritional services, and construction services
  • Turn down the alarm sound level on monitoring equipment if feasible. Some hospitals also have telemetry equipment monitoring away from the patient; e.g., in the nurses station
  • Housekeeping departments perform work using heavy equipment only during the daytime. This includes using battery powered scrubbers, buffers, and other equipment
    In the evening or at nighttime in multi-bed patient rooms, use a portable lantern to only illuminate the area the employee is working in

This is just a sample of the creative ways hospitals are striving to improve their patients’ perception of whether their room and bathroom is always clean, and whether noise is minimized near their room. I also recommend identifying hospitals in your region that have the highest Top Box scores, and visiting them to learn how they are achieving excellence in HCAHPS. Also, hospital systems should freely share best practices information within their system to uncover new and creative ideas.

HCAHPS is here to stay, so we must be ready, willing and excited to meet its challenges.

  1. HCAHPS Fact Sheet (CAHPS Hospital Survey) May 2012.

About The Author