HCAPHS scores for St. Johns Hospital in Denver, Colorado


HCAPHS scores were developed with a view to providing a standardized survey mechanism as well as data collection techniques for measuring the perspective of patients’ in regards to hospital care (Cover, 2009). Prior to the development of these scores the United Sates did not have a universal standard for gathering and producing public reports on perspectives held by patients regarding care information capable of enabling effective comparisons across all healthcare facilities despite the efforts by many hospitals to gather patient satisfaction information. Towards this end, there was an urgent need to develop and implement a standardized approach in order to make relevant hospital-to-hospital comparisons with a view to supporting consumer choices. In this regard, HCAHPS scores are core arrays of questions designed to work together with a wider, customized assortment of hospital-centric items (Cameron, 2015) . They are also designed in such as to complement data currently collated by different hospitals in order to avail the requisite support for the enhancement of customer services within hospitals as well as quality-related activities.

This exercise is predicated on the need to develop a strategic leadership and future delivery model for St. Johns Hospital in Denver, Colorado. Towards this end, the assessment will critically analyze survey data from the healthcare system in addition to developing a strategic plan aimed at improving organizational scores for the hospital. The exercise therefore relies on resulted provided through the “Hospital Compare” the United States Medicare website and as such, it will enable consumers to make fair as well as objective comparisons among different hospital, state as well as national averages regarding the significant regarding patients’ distinct perspectives on the kind of acre received.

HCAHPS scores For St. Joseph Hospital

Comparison to State and National Averages

The results of the HCAHPS scores for St. Joseph Hospital are available from the Medicare website as reported by the Center for Medicare& Medicaid Services (CMS). This scores were obtained from the first national and publicly homogeneous HCAHPS  hospital survey as well as data collect technique for assessing perspective among patients regarding hospital care received at the St. Joseph Hospital. I is important to note that the collection as well as the reporting of the survey’s findings were voluntary (Hospital Compare , 2016).

The results presented in the following section were generated from data collected from patients discharged from the facility in the twelve months spanning from April 2014 to March 2015 and are represent the percentage of respondents who responded “always” (“sometime”, “never” or “sometimes”) to 6 composites as well as two distinct “environment” questions in addition to “yes” to a seventh composites. The following section describes the questions coupled with the composites. The benchmarking scores for the hospital were developed by the CMS and were based on data collecting from all participating hospitals in Denver, Colorado as well as nationally. The national and state have been merged into one representative score (Hospital Compare , 2016).

Figure1: HCAHPS scores For St. Joseph Hospital from the HHS State and National Averages

Source: (Hospital Compare , 2016)

The scores relating to question on were  based on a 0-10 scale (worst-best) and are scores obtained from answers provided by the respondents in regards to questions nine and ten. The “recommend to friend” sores weighted against national as well as state averages were determined through a scale ranging from 1-4 (“definitely yes”, to “definitely no”) (Hospital Compare , 2016).

From the scores obtained from the seven composite survey questions, the hospital perfumed relatively well in comparison to national and state averages.

These questions included:

  • Nurse Communication: the results from this question were composite and were obtained from three related questions designed determine how often the nursing staff treated patients with courtesy as well as respect, listening carefully to patients as well as explaining various issues in manage the patients could understand.  Towards this end, the hospital scored 79% against a national and state average of 79 percentage points.
  • MD Communication: the results represent an amalgamation of 3 questions that sought to determine how often the Medical Doctors at the facility treated patients with respect and courtesy, listening carefully to patients, and explaining issues pertaining to treatment in a manner that could be understood easily by the patient. In this regard, the St. Joseph Hospital Scored 82% against and state and national average of 80%.
  • Staff Responsiveness: the scores were obtained from 2 questions designed to determine the regularity of help availed by to patients by nurse and other staff members following request by the patient in regards to accessing the washrooms or using bedpans as well as immediately after activating the patient’s call button. The score in this respect was 70% against a national and state average of 70%.
  • Pain Management: this composite was the result of two survey questions designed to determine the regularity of proper pain control as well as the ability of the staff members to do everything within their power to help patients manage their pain. The score in this regard was 71% against a national and state average of 71%.
  • Medicines Explained: the scores were determined from a composite two survey question designed to provide data on how often the hospital’s staff members informed and explained to patients the rationale behind a new drug as well as the how often the medical staff explained to the patients under their care the side effects of new medication in a simple and straight and forward way.
  • Discharge Information: the scores were determined from two composite questions created to determine if nurse, doctors or other relevant hospital staff members talked to the patient regarding whether or not respective patients would access the required help upon discharge. In this regard, St Joseph scored 90% against a a state and national average of 88%.
  • After Care Understanding/Care Transition: the scores were based on a composite questions that sought to determine patients; level of understanding in regards to after-care upon being discharged from the hospital. St. Joseph Hospital in this regard performed slightly above average (57%) but the score was higher than the national and state average scores (54%).

Comparison to other Hospitals

Based on HCAHPS scores for St. John’s hospital and comparison with two other hospitals in the region (Denver Medical Center and Presbyterian St Luke’s Medical Center) the following table summarizes the scores based on a yes (1) and no response (O) (Hospital Compare , 2016).

St. John Hospital Denver Medical Center Presbyterian St Luke’s Medical Center
Hospital Type Acute Care Acute Care Acute Care
Provision of emergency services Yes (1) Yes (1) Yes (1)
“Able to receive lab results electronically” Yes (1) No (o) Yes (1)
“Able to track patients’ lab results, tests, and referrals electronically between visits” Yes (1) No (0) Yes (1)
“Uses outpatient safe surgery checklist- Opens in a new window “ Yes (1) Yes (1) Yes (1)
“Uses inpatient safe surgery checklist” Yes (1) Yes (1) Yes (1)


Survey Response Rate

Figure 2: St. Josephs HCAHPS Scores response rates to other hospitals

Source: (Hospital Compare , 2016)

From the HHS survey response rate in regards to other hospitals in the region, St. Joseph Hospital performed slightly better than the rest scoring 75% against a state average of 74% in terms of overall patient ratings and 76% against 75% in regards to recommendation to friends (Hospital Compare , 2016).

Demographic Patient Population and Services Provided

St. Joseph Hospital is faith-based health organization that operates eight hospitals in the region, an children’s mental health facility, and 4 “safety net clinics” in the region.  The hospital serves the vulnerable and poor with a view to improving the general wellbeing of individuals as well as the community. It specializes in childbirth and pregnancy, advanced heart treatments, cancer care, emergency medicine, orthopedics, respiratory medicine as well as general surgery (St. Joseph Hospital, 2016).

The Impact of Environmental and Community Factors HCAHPS Scores

Cultural Dynamics

Cultural dynamics especially in regards to cultural competency and communication are critical determinants of HCAHPS scores.  These aspects are especially important in to issues like end-f-life care where the medical professional is obliged to explain in a clear manner to the patient of the expected outcomes on the one hand while being sensitive to cultural differences on the other. In this regard, better cultural competence coupled with cultural competency improves HCAHPS scores in regards to MD communication, hospital recommendation as well as ratings. While it achieves this by improving general patient experiences, it also benefits minorities during their interaction with medical staff (Robert Weech-Maldonado, Schiller, Hall, & Hays, 2012).

Educational Dynamics

     The current HCAHPS scoring system places many vulnerable groups at a disadvantage from an educational dynamics perspective in that big academic medical facilities using the existing scoring approach to report on p[patient satisfaction fair worse than small medical facilities. In other words, big teaching hospitals score poorly than small hospitals that focus on providing medical care as opposed to providing care and focusing on teaching and research (Choctaw, 2015).

Socioeconomic Dynamics

Existing disparities the quality of healthcare are associated with socioeconomic dynamics characterizing patients’, gender, race, age as well as insurance coverage. In this regard, patients with better socioeconomic standing are able to afford insurance cover, which is critical driver of the financial wellbeing of hospitals. This is important in that financial stability of a care facility influences the quality of healthcare and as such improves patient outcome which in turn improves a hospital’s coring rate. The reverse is also true (Blakley, Kroth, & Gregson, 2011).

Strategic Plan to Improve St. Johns HCAHPS scores

Organizational Change

Organizational change can indeed lead to improved HCAHPS scores for St. John Hospital. This stratagem is critical in this regard as it will help the institution to balance different competing priorities, establishing key actions required to improve patient outcomes as well as identifying the specific changes needed to avail the greatest general impact in regards to patient satisfaction (Jha, Orav, Zheng, & Epstein, 2008). These priorities can be realized effectively through integrating quality measures throughout the institutions from an organizational perspective with the view identifying deficiencies in care delivery.

The Structure, Process and Outcomes of the Strategic Plan

            The proposed structure in this respect encompasses the following aspects.


Data collection

Educating Patients

Incorporating constructive Patient experience into the Hospital’s Culture


            This will entail developing appropriate communication tools designed to improve communication between staff members and patients. These tools are also expected to emphasize critical information to different patients which will in turn help them in remembering crucial instructions even after being discharged. The second aspect of this process entails making follow-up-calls after patients have been discharged with a view to ensuring that instructions are adhered to in addition to soliciting information regarding patient’s experiences after the discharge.

Data Collection

This is an improvement initiative developed to help the hospital establish sustainable through the collection, analysis and implementation of results of the data collated from patients in regards to their experiences. This will at the very least help the facility in examining HCAHPS surveys with a view to identifying problematic areas and crafting pragmatic solutions to the same as noted by Cameron, (2015).

Educating Patients

Educating patients during their hospitalization is another critical aspect in term of improving HCAHPS scores. This approach should start with from the first day the patient is admitted with a view to making sure the adequately equipped to take care of themselves after leaving the facility. It is expected that this process will help patients understand their respective conditions better and as such, they will feel involved I the acre process as opposed to being detached.

Incorporating Constructive Patient Experience into the Hospital’s Culture

In order to realize long-term improvements, the hospital will need to relook its organizational culture and success in this respect depends on it (Dossey, 2015). Towards, this end, a facility where the leaders stress the significance of satisfaction among patients and where the workers are adequately trained on strategies to improve satisfaction will realize better outcomes in terms of improving their HCAHPS scores.

Incorporating Evidence-Based Practice and Shared Governance to Improve Organizational Quality

the strategy for incorporating evidence-based practice as well as shared governance with a view to improving St. John’s organizational quality is predicated on three approaches-motivation, innovation as well as celebration of shared values. These will achieved through the creation of a Continuous Quality Improvement (CQI) strategy throughout the organization.  It will in this regard leverage specific knowledge in regards to the “point of care” and therefore develop an integration structure predicated on building adequate HR capacity as well as sustaining quality improvements in addition to safe delivery of care (Burkoski & Yoon, 2013).

Developing the Implementation Plan

Institutionalizing a New Culture

This will be the first aspect of implementing the plan predicated on communication, data collection, educating patients and incorporating constructive Patient experience into the Hospital’s Culture. This will be achieved within a period of no less than 3 moths where the hospitals leadership with the help of capable healthcare consultant will incorporate a new cultural reality based on quality care throughout the organization and reflect the same in different job descriptions (Dossey, 2015).

Modifying Systems

This aspect of the implementation plan will be carried out concurrently with institutionalizing the new culture and is designed to help the hospital to transition successfully to an organizational culture predicated on patient satisfaction (Robert Weech-Maldonado, Schiller, Hall, & Hays, 2012). This will be conducted by the hospitals administrators in collaboration with medical and non-medical support staff.

Making Patient-Focused Care a Team Undertaking

This aspect of the plan will be conducted in a period of three months where the staff members will be appraised on how they can best align their standards as well as benchmarks satisfaction goals among patients (Burkoski & Yoon, 2013). This will be done for each department and Unit through a collaborative approach that will involve every member of the staff as well as all stakeholders impacted by the new changes. Towards this end, a team tasked with establishing the necessary tools in addition to processes will be created with a view to enhancing HCAHPS scores as well as affording them the freedom to assess fresh ideas.

Communicating and Celebrating Success

            This face is designed to specifically involve the hospital’s executive management the creation of patient-centered model seeing that most executives are overly concerned with the “bigger picture” as it were (Cover, 2009). This will enable them to appreciate the smaller success that will cumulatively move the facility towards successful enhancement of patient satisfaction as well as realization of constructive HCAHPS scores.

Evaluation of Success

Evaluating success in regards to attaining positive HCAPHS scores will help the facility to develop a standardized survey mechanism as well as data collection techniques for measuring the perspective of patients’ in regards to hospital care as well as appraising the ability of patients to improve patient satisfaction. The evaluation process will involve a number of crucial steps. To begin with, the evaluation process will identify different behaviors among employees critical to the satisfaction of patients.  The development of this step is informed by the understanding that HCAHPS cores are profoundly shaped by employee behavior in their interactions with different patients (Blakley, Kroth, & Gregson, 2011).

The essence of this evaluation step is to increase staff understanding of the manner in which their conduct influences patients satisfaction given the fact that many professional in healthcare have committed their careers to delivering effective patient care but they may not be fully appraised of how their respective as well as collective actions affect patient satisfaction and thereby HCAHPS scores (Choctaw, 2015).

Secondly the success evaluation criteria will develop performance goals and incorporating the same into work evaluation. In this regard, the assessment will establish the behaviors among employees that are desirable to patients with a view to helping the hospital to develop lucid performance goals based on success levels and realization of critical HCAHPS Scores. Based on the evaluation during this stage, different performance goals will be incorporating the hospital’s management into job descriptions as well as future success evaluations.

Regular Performance Evaluation

Evaluating success in terms of HCAHPS Scores is not enough and therefore it should be complemented by performance with a view to determining the hospitals expectations in regards to these scores (Jha, Orav, Zheng, & Epstein, 2008).  This evaluation criterion is predicated on the need to create job descriptions hinged on successful HCAHPS Scores that includes review of performance goals a critical step towards improving ratings.  This face will therefore assess whether staff members have satisfied these goals with a view to establishing areas requiring improvements and appropriate solutions to the same.


Blakley, D., Kroth, M., & Gregson, J. (2011). The Impact of Nurse Rounding on Patient Satisfaction in a Medical-Surgical Hospital Unit. Medsurg Nursing, 20(6), 327-32.

Burkoski, V., & Yoon, J. (2013). Continuous Quality Improvement: A Shared Governance Model That Maximizes Agent-Specific Knowledge. Nursing Leadership, 7-16.

Cameron, J. L. (2015). Advances in Surgery. New York: Elsevier Health Sciences.

Choctaw, W. T. (2015). Transforming the Patient Experience: A New Paradigm for Hospital and Physician Leadership. New York: Springer.

Cover, F. (2009). HCAHPS Basics: A Resource Guide for Healthcare Managers. Hcpro Incorporated.

Dossey, B. M. (2015). Holistic Nursing. Springer.

Hospital Compare . (2016). St. Joseph HCAHPS Scores. Retrieved April 9th, 2016, from Hospital Compare website: http://www.hospitalcompare.hhs.gov,

Jha, A. K., Orav, J., Zheng, J., & Epstein, A. M. (2008). Patients’ Perception of Hospital Care in the United States. The New England Journal Of Medicine, 359, 1921-1931.

Robert Weech-Maldonado, P. M., Schiller, C., Hall, A., & Hays, R. D. (2012). Can Hospital Cultural Competency Reduce Disparities in Patient Experiences with Care? Med Care, 50, S48–S55.

St. Joseph Hospital. (2016). ABOUT US. Retrieved April 9th, 2016, from St. Joseph Hospital: http://www.saintjosephdenver.org/about/

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