In 2007, CMS started publishing star ratings on the web for healthcare consumers to review as part of their healthcare decision-making process. The application of those ratings now covers an array of hospital performance metrics including quality, safety, efficiency and patient experience. Every quarter, hospital star ratings are updated and published.
Since this rating system was launched, there has been vigorous debate in the healthcare community about its value. I believe any discussion of star ratings in healthcare needs to begin with a reality check about the world and culture around us. We live in a time where customer ratings are ubiquitous. Nearly all of us use ratings as a tool in our decision making. Healthcare is not exempt from this reality.
I also agree with many of my colleagues that what we provide in healthcare is not the same as a restaurant meal, an airline flight or an Amazon purchase. We are in the business of providing a service that is deeper and much more consequential. Still, we need to acknowledge the reality that star ratings and consumer reviews are a fact of life. We need to find appropriate ways to allow consumers to assess our services that are honest and build trust with those we serve.
At NewYork-Presbyterian, we operate in a market that is highly conscious of ratings. Like everyone in our industry, we see the strengths and weaknesses of these assessments. However, we have found ways to use star ratings like the ones published by CMS in a positive and productive manner.
Star ratings, with all of their limitations, do give our health system a sense of our performance relative to peers and competitors locally and nationally. They resonate with our teams. We can internalize what a 2 or 3 star rating for a performance element means relative to a 5 star rating. At NewYork-Presbyterian, we aspire to be the best healthcare system in the country. Thus, we are not satisfied with anything less than top ratings. When our ratings are below that, we strive to understand and improve them.
Specifically, in the realm of patient experience, star ratings have proven to be a valuable tool for engaging our caregivers in improvement efforts. I meet regularly with unit and department leaders who are engaged in the hard work of improvement and celebrate with their teams when a category like educating patients about medications or communication by nurses and doctors "gains a star." When I round with our teams, I often hear front-line colleagues speak about how they are trying to raise performance to a higher star category.
Our teams also understand that star ratings are derived from the collective perceptions of the people we serve. That's what gives them meaning. In other words, our teams "speak stars." We know they don't encompass the totality of what we are trying to do, but they are one way to chart our progress.
That said, there are limitations to star ratings that must be acknowledged. I am co-chair of the Patient Experience Policy Forum (PXPF), a policy and advocacy group that is part of The Beryl Institute global community. PXPF includes a vibrant group that thinks about patient experience ratings and the operational and policy implications of them. The Beryl Institute also has an Experience Leadership Council of Chief Experience Officers from across the country.
When these groups think about ratings — and especially about how they can be improved — some issues come forward. One is equity. When you look at hospital star rankings across the spectrum, safety-net hospitals tend to have fewer stars than hospitals that are better resourced. Star ratings are also tied to reimbursement, so lower ratings can exacerbate the difficult financial situation that safety-net hospitals can find themselves in. There are also equity issues with regard to how the survey is administered — both the languages offered and the survey modes — that can make it harder for some communities to provide feedback. This issue should be examined more deeply.
Another concern is that the star ratings related to patient experience are based on the HCAHPS survey, which was first implemented in 2006 and is overdue for evaluation and updating. Fortunately, some updates are being implemented for the survey beginning in January 2025, and CMS deservescredit for taking this step. However, the HCAHPS survey should still be regularly reviewed and evolve in a much more dynamic way, with much more input from actual patients and hospital stakeholders.
Finally, I think it is safe to say that star ratings are looked at much more within hospitals than they are outside by consumers. The CMS ratings are relatively hard to find and not easy to interpret. If star ratings are here to stay, a fresh look at how to make them more accessible and relevant to consumers is needed.
Perhaps it's best to end a column like this with a reminder. Sometimes, we forget that behind the numbers and the star ratings are actual patients giving us their feedback. The comprehensive star ratings are also based on actual data from patient encounters. Even though they aren't perfect, they do flow from the real, lived experience of the patients we serve.
While we should seek to make these ratings and how they are used more meaningful and impactful, they are an important signal about how we are doing in our mission to bring expert, safe and compassionate care to all.