Protecting, maintaining and
improving the health of all Minnesotans
Staff Update: Patient Experience in the Hospital Quality Composite Score
In June, 2013 the Provider Peer Grouping (PPG) Advisory Committee was asked for input on how to
use patient experience quality measures from the Hospital Consumer Assessment of Healthcare
Providers and Systems Survey (HCAHPS) in future Hospital Total Care reports. In the reports issued
in Spring 2013, patient experience measures were presented separately from other quality results
rather than incorporated into the Total Quality Composite Score. The initial PPG Advisory Group had
recommended this approach with the rationale that public reporting of these measures had only
begun recently.
We wanted to revisit this issue because the patient experience measures have now been publicly
reported in Minnesota for about six years, they are being used in several CMS pay-for-performance
initiatives, and a number of stakeholders have voiced interest in having the measures incorporated
into the composite score. While all Prospective Payment System (PPS) hospitals participate in this
survey, many Critical Access Hospitals (CAHs) do not.
At the June meeting there was general support of these measures as important and valid. Assuming
that Patient Experience would be added as a third domain, discussion focused on how the Outcome
and Process of Care scores should be re-weighted for calculation of the composite quality score and
on how we should approach the issue of incomplete reporting among CAHs. Following the staff
recommendation, the Advisory Committee’s advice was to:

Include and score HCAHPS measures as a third quality domain for PPS Hospitals.
o Weight the Patient Experience score at 20% and re-weight Outcome and Process of Care
scores at 60% and 20%, respectively.

For CAHs with HCAHPS data, include as previously reported:
o Report patient experience measures for hospitals with results.
o Do not include in Total Quality Composite score.
o No change to weighting of Outcome and Process of Care scores (70% and 30%,
respectively).
We will be following the impact of this recommendation in the next iteration of the Hospital Total
Care reports. Initial analysis shows that including patient experience measures in the revised total
quality composite calculation will result in more variation in the total quality composite scores.
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