NURS 8302 Discussion Measurement Systems and Methods ANSWER

NURS 8302 Discussion Measurement Systems and Methods ANSWER

By Day 3 of Week 5

Post a brief description of the healthcare organization or nursing practice setting you selected. Summarize the measures on the scorecard or dashboard in which patient experience of care is measured, tracked, and used to set improvement goals. Be specific. Explain whether goals at your organization are established, for these metrics you reviewed, and whether or not they are currently being met. Then, describe the potential impacts of meeting or not meeting these metrics for your healthcare organization, and explain why. Be specific and provide examples.

RE: Discussion – Week 5

The extent to which the patient’s experience of care is measured, tracked, and set for

improvement goals.

Hospital’s board of directors can use performance scorecards, or dashboards as a tool to promote quality of care in its institution. Dashboard reports make use of graphics to provide essential facts in a simple and easy-to-understand format. For hospital boards devoted to fostering quality improvement inside their organizations, information dashboards have emerged as a critical tool. There is a link between dashboard implementation and quality performance, according to research. A well-designed dashboard, for example, can enhance awareness of areas where the hospital is underperforming. This gives the board the information it needs to figure out what has to be done to improve performance. Although the dashboard idea is common to many larger metropolitan hospital systems, smaller community hospitals might benefit from this technology to connect systems, jumpstart quality improvement programs, and align incentives of all stakeholders. The degree to which patients’ expectations are met can be an important predictor of patient satisfaction. The patient’s personal experience with the quality of treatment received is one of the quality aspects assessed in today’s health care settings. It is critical to address patient expectations, perceptions, and personal experiences with health care not just through diagnostics, treatment equipment, procedures, and systems, but also through patient expectations, perceptions, and personal experiences with health care. This experience has a subjective effect on their sense of well-being, recuperation, personal health, and even patient outcomes (Jung, et al., 2018).

Organizational goal to established patient satisfaction metrics

Most health care facilities require patients to complete private patient satisfaction surveys, which include questions on the health care services delivered. It is often administered following the service and frequently returned to the organization through drop box or mail. I’ve worked for a company that used the HCAHPS system. The findings were utilized by an organization to identify areas where treatment might be improved. It was a tool that allowed patients to evaluate the treatment they were receiving. Patient satisfaction surveys frequently revealed gaps and areas for development that were not on the administration’s radar. This approach allowed organization team to realize that what might seem high quality care for an organization might be perceived as poor service for patients.

Considering hospital experience, the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) is a standardized questionnaire that has been used to gather consumer perceptions about their hospital stay. This tool includes key areas that include questions regarding staff communication, the hospital atmosphere, pain treatment, and care transitions, with multiple-choice answers such as Never, Occasionally, Usually, and Always. Additionally, the HCAHPS asks patients to rate their hospital stay on a scale of 0 to 10, with a higher score indicating a higher level of satisfaction with their hospital stay (Okafor & Chen, 2019). In my current practice patient satisfaction data is applied to the development of new guidelines for the identification of deficiencies, achievements, and improvements in quality of care and health service delivery. This has proven helpful in assisting clinicians understand how to improve patient outcomes, patient satisfaction is a multidimensional concept that can be impacted by factors unrelated to the actual quality of care. It is now understood that an optimal patient care experience is associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety within hospitals, and less health care utilization (Okafor & Chen, 2019)

Impacts of meeting or not meeting these metrics for your healthcare organization

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized survey instrument that is administered to randomly selected patients after discharge from a hospital, was the first such instrument to be incorporated into required public reporting and, ultimately, value-based purchasing initiatives (Nash et al. 2019).  The drawbacks of patient surveys is that hospitals that treat patients with a higher degree of disease will have lower HCAHPS scores, which might result in CMS reducing their compensation. Hospitals with less degree of illness, on the other hand, will be compensated more. The present HCAHPS reporting system has a significant weakness that needs to be fixed: it fails to appropriately compensate for the severity of illness.


Jung, E., K., Srivastava, K., Abouljoud, M., Okoroha, K., & Davis, J. (2018). Does hospital

consumer assessment of healthcare providers and systems survey correlate with traditional

metrics of patient satisfaction? The challenge of measuring patient pain control and

satisfaction in total joint replacement. Arthroplasty Today, 4(4), 470-474. Doi:


Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.). (2019). The healthcare quality book: Vision,

strategy, and tools (4th ed.). Health Administration Press.

Okafor, L., & Chen, A.F. (2019). Patient satisfaction and total hip arthroplasty: a review. Arthroplasty 1, 6

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Among the centre of focus of healthcare organizations and nursing settings are ensuring that patients get appropriate care, are satisfied, and are safe in such environments. It is usually important to ascertain whether the organizations meet such goals. While measuring outcomes such as safety may be easier by considering some vital data, it is more challenging to measure patient satisfaction. Healthcare organizations and nursing institutions have used various tools such as scorecards and dashboards for measuring and improving patient satisfaction (Bergeron, 2017)

Even though formulating a balanced scorecard to track patient satisfaction can be controversial due to factors like effectiveness level, data analysis, and implementation, it is important to use the scorecard as a tool. The purpose of this week’s discussion is to identify a healthcare organization or nursing setting that uses a scorecard or dashboard to track patient satisfaction and give a description of the measures used. Besides, the discussion will explore whether the metrics are currently being met and the possible impacts of either meeting or not meeting the metrics.

The Description of the Organization

The organization chosen for discussion is Cleveland Clinic. Even though it is a teaching hospital, the organization also engages in patient care, training and research. In addition, Cleveland Clinic has close to ten community hospitals and over fifteen family health centers. Cleveland also offers its services to both international and local patients (“Cleveland Clinic,” n.d). In the last decade, the organization has been working with various quality indicators through the use of the PSI module, largely informed by the private payers and Federal Payment programs that consider quality indicators when reimbursing.

The Measures Used In the Score Card

Cleveland Clinic uses various measures as an organization, including customer, financial, internal, and employee growth and learning. These categories have various specific measures allied to them that the organization uses to track and improve quality. The organization uses three major patient-focused measures on its scoreboard to measure, track and set improvement goals related to patient experience. The three measures include positive press, referrals, and long-term patient relationships. All these metrics are patient-survey related. For instance, upon discharge, patients are prompted to state whether they can refer other patients to the facility, among other survey questions (“Cleveland,” n.d).  The organization values patient and family feedback and enhances the positive paths by sharing the written compliments and survey scores with the staff make them feel valued and improve quality.

Establishment of Goals for the Metrics

Since starting to deal with the quality measure indicators a decade ago, Cleveland Clinic has set goals and reviewed them at various intervals to evaluate how well they are being met. So the organization establishes goals for the discussed metrics. For some time now, the organization has been having patients experience strategic goal and ensure that patients come first. As such, they engage in various services such as listening to the patients and their family members and utilizing the feedback obtained to improve quality, managing data and applying the information in quality improvement, and offering quality training to their caregivers (“Cleveland,” n.d).  Currently, at Cleveland Clinic, these metrics are largely being met. Indeed, eight of the Cleveland clinic’s facilities recently got a five-star rating for patient service quality and safety. This indicates that the organization is meeting the patient experience metrics.

Potential Impacts of Not Meeting the Metrics

When an organization fails to meet the patient experience metrics, it implies that various operations are not going well, and specific changes could be needed or even overdue. When the metrics are not met, one of the major impacts is that patients would prefer getting services in other healthcare facilities and a shrinking customer base (Bergeron, 2017). In addition, the facility may fail to attract more competent staff due to a tainted image. If the metrics could not have been met, then the Cleveland clinic could not have been among the top healthcare facilities in America. As such, if it happens that the hospital fails to meet the metrics in the future, the ranking would be lower, and many patients would prefer to go to other facilities. Another potential impact is that the organization may have to take drastic and calculated measures to evaluate the various leadership positions that influence the operations and make necessary changes.


Bergeron, B. P. (2017). Performance management in healthcare: from key performance indicators to balanced scorecard. Productivity Press.

Cleveland Clinic. (n.d). Institutes and departments.

Cleveland Clinic. (n.d). Patient experience measurement

Cleveland Clinic. (n.d). Patient experience.

In my specific practice at the new Baptist Hospital in Brent Lane, Pensacola, FL, the interpretation of patient experience measures aligns with a focus on continuous improvement and patient-centered care within our recently established facility (Baptist Health Care, 2023). The introduction of scorecards and dashboards allows us to meticulously measure and track patient experience and care, providing valuable insights to set improvement goals (Baptist Health Care, 2023). Our commitment to transparency and accountability is demonstrated through our participation in HCAHPS, a national, standardized survey that publicly reports patients’ perspectives on hospital care (Baptist Health Care, 2023).

The star ratings derived from HCAHPS surveys serve as a tangible representation of our performance over the years, reflecting the period from July 2014 through June 2015. Regular reviews of patient satisfaction by our President and CEO ensure that we consistently meet and exceed performance expectations. The emphasis on 11 publicly reported measures in the HCAHPS survey reinforces our dedication to understanding and addressing every aspect of patient experience.

Moreover, our recent success in passing the DNV survey with flying colors affirms our commitment to high-quality care and safety standards. On my floor, we take a proactive approach to performance measurement, focusing on key nurse-sensitive indicators such as patient falls, hospital-acquired pressure injuries (HAPI), catheter-associated urinary tract infections (CAUTI), and central line-associated bloodstream infections (CLABSI). Recognizing the potential impact of these indicators on hospital-wide scores, we prioritize patient safety to maintain our reputation for excellence.

The significance of these nurse-sensitive indicators is underscored by their potential impact on overall hospital scores. Nash et al. (2019) aptly highlight the shift in healthcare toward patient-centered care, moving away from traditional fee-for-service models. As we embrace this transformation, the patient experience surveys become vital tools that capture the essence of our care delivery directly from the patients themselves.

In summary, at Baptist Hospital, the patient experience measures serve as not only benchmarks for our performance but also as catalysts for continuous improvement (Baptist Health Care, 2023). By focusing on nurse-sensitive indicators and aligning our practices with patient-centered care principles, we aim not only to meet but to exceed patient expectations, ensuring that our healthcare services are reliable, adequate, and responsive to the ever-evolving needs of our patients (Baptist Health Care, 2023).