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Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS

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Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS

This assessment will require you to analyze a healthcare system’s survey data (Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS) and develop a strategic plan for improvement of organizational scores. The HCAHPS results posted on Hospital Compare, which is part of the government’s Medicare website, allow consumers to make fair and objective comparisons between hospitals and state and national averages on important measures related to the patient’s unique perspective of the care received. You will need to incorporate the most recent survey scores data analysis (including comparison scores/benchmarking), impact of scores (financial and quality), organizational structure/design, use of technology, and influential cultural and social/environmental factors into this project. You may select a method of presentation that involves either a media presentation or a business plan document that will provide a thorough analysis, a plan that includes stakeholder involvement, and a timeline for implementation, evaluation, and outcome measurement.


You are the newly appointed chief nursing officer of a hospital and have been tasked with improving the most recently reported HCAHPS score for the entire organization. The hospital board is requesting a detailed report, analysis, and plan to improve these results. You are instructed to complete the full data and impact analysis; develop a detailed strategic plan to improve the scores in all areas of the hospital, incorporating quality improvement, shared accountability, technology, care delivery model, and financial stability; propose a rapid implementation timeline; and outline the process of evaluation in an effective presentation that you will present at the next board meeting.


Create a multimedia presentation or business plan document in which you do the following:

Note: If a multimedia presentation is selected, presenter notes must be included for each slide in order to fully cover the level of explanation, analysis, and discussion necessary.

A. Provide the HCAHPS scores for a hospital of your choice.

Note: Refer to the web link to find HCAHPS scores for various hospitals.

B. Analyze the HCAHPS scores of your chosen hospital by doing the following:
1. Compare the scores to state and national averages.
2. Compare the scores to two other hospitals in the region.
3. Compare the survey response rates to two other hospitals in the region.
4. Describe the hospital’s demographic patient population and services provided.
5. Discuss how the following environmental and community factors could potentially influence HCAHPS scores:
a. cultural dynamics
b. educational dynamics
c. socioeconomic dynamics
6. Explain potential short- and long-term financial impact on the organization.
a. Discuss potential impact on quality outcomes.

C. Discuss the potential cause of the chosen hospital’s HCAHPS scores.

D. Develop an organizational strategic plan to improve the chosen hospital’s HCAHPS scores throughout the organization by doing the following:
1. Explain how organizational change can help improve the chosen hospital’s HCAHPS scores.
2. Discuss the structure (i.e., framework), process (i.e., actions), and outcomes of the strategic plan.
3. Discuss how you would incorporate evidence-based practice and shared governance to improve organizational quality.
4. Explain methods you would use to incorporate concepts of shared accountability among patients, medical providers, payers (e.g., insurance providers, Medicare, Medicaid), and personnel.
5. Explain methods you would use to incorporate technology trends within healthcare.
6. Explain methods you would use to improve the care delivery system, including the topics of quality, cost, access, and patient-centered care.
7. Explain methods you would use to improve financial stability.

E. Develop an implementation plan and timeline for the strategic plan you developed in part D by doing the following:
1. Discuss key roles and responsibilities of stakeholders.
2. Discuss how you would ensure stakeholder accountability and involvement.
3. Discuss any training staff would need in order to implement the plan.
4. Outline a timeline for implementation of your plan, including periodic review checkpoints to measure progress.

F. Discuss the process you would use to evaluate the success of the strategic plan, including the following:
• method of measurement that would be used
• evaluation of the timeline
• method of analysis
1. Discuss how you would involve key stakeholders in the evaluation process.
2. Explain how the evaluation results will be communicated internally and externally.

G. When you use sources, include all in-text citations and references in APA format

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