Closing the HCAHPS Knowing-Doing Gap

Kevin Kruse

Published October 19, 2013

It's amazing how important 21 simple questions have become.

The HCAHPS patient perspective survey has risen ever higher on the priority list of healthcare administrators and practitioners as it has moved from a CMS pay-for-reporting system to a pay-for-performance system in 2013. Yet, despite many years of focus, training and communication, many are still struggling to attain the HCAHPS scores they desire. Why?

The "knowing-doing gap" is the reason so many have hit a ceiling with their HCAHPS scores.

This gap is the classic problem of someone knowing how to do something but failing to actually do it; it's the difference between knowledge and action. This phenomenon is well-known in a variety of different industries. It is estimated that corporations spend $60 billion a year on training programs, and yet the actual ROI from all that investment is very small. Millions of workers are given new knowledge and skills, and yet so few actually apply them back on the job.

When it comes to best practices for HCAHPS results, it's easy to know what to do. For example, hourly rounding has been shown to increase staff responsiveness scores by 7–13 points if they focus on the "4 P's":

Potty — check if patient needs to use bathroom
Position — check for comfort and risk of ulcers
Pain — check for comfort
Placement — check that desired items are within reach

When it comes to the "quiet at night" question, once again, we know what to do. Mass General has developed a model staff training guide on this issue. Among the many suggestions are: proper signage and communication, limiting overhead paging, offering patients earplugs, installing "Yacker Tracker" noise monitors and conducting "secret shopper" audits.

Beyond HCAHPS scores, the knowing-doing gap applies to all other areas of delivering superb care. We know how to reduce infections: frequent hand washing, cleaning around the catheter, checking that the drainage bag is below the bladder. We already know what to do.

So why isn't everyone doing it, consistently?

It comes down to caring. The knowing-doing gap exists when the amount someone cares is less than what they know. It sounds callous and simplistic, but when someone knows what to do and fails to do it, it's because they don't care enough to remember and to make it a priority.

You can't train caring.

In addition to being trained in best practices for care and communication, physicians and nurses need to be "engaged" in their work and with their employer.

Employee engagement isn't the same as employee happiness. You might be happy at work, but not working hard on behalf of the hospital. Employee engagement also doesn't mean employee satisfaction. A nurse might show up for his shift, do the minimum required of him and still be very satisfied.

Employee engagement is the emotional commitment an employee has to the organization and to the organization's goals.

Plainly speaking, when your employees are engaged, they care about your hospital, their team and your patients. When they care, they give the magical thing called discretionary effort.

In essence, when healthcare practitioners are engaged, they will care about HCAHPS scores.

So if engagement solves the knowing-doing gap, how do you increase employee engagement?

The research is conclusive that the top four drivers of engagement are communication, growth, recognition and trust.

Communication — is there frequent two-way communication?
Growth — am I learning new things and being challenged?
Recognition — do I feel appreciated? Do my ideas count?
Trust — do I know where the organization is going, and do I trust senior leadership to get us there?

It also turns out that most of how we feel about work is correlated to our relationship with our direct manager. It is front-line leadership that must create a culture that fosters communication, growth, recognition and trust on a daily basis.

Do you want to overcome the knowing-doing gap and take your HCAHPS scores to new highs? It starts with training your team in HCAHPS best practices but must continue with training your managers to become wholehearted leaders who drive employee engagement.

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