OBJECTIVES

Quality improvement (QI) requires data, indicators, and national benchmarks. Knowledge about the usefulness of Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) data are lacking. We examined quality leader and frontline staff perceptions about patient experience measurement and use of Child HCAHPS data for QI.

METHODS

We surveyed children’s hospital leaders and staff about their use of Child HCAHPS for QI, including measures from other studies. We compared scale and item means for leaders and staff and compared means to other studies.

RESULTS

Almost all leaders, but only one-third of staff, received reports with Child HCAHPS data. Leaders found the data more useful for comparisons to other hospitals than did staff. Both agreed on the validity of Child HCAHPS scores and used these data for improving pediatric care experiences. They agreed the data accurately reflect their hospital’s quality of care, provide specific information for QI, and can be used to improve pediatric care experiences. They also agreed on approaches to improve Child HCAHPS scores. Among staff, QI was reported as essential to their daily work and that Child HCAHPS data were integral to QI.

CONCLUSIONS

As uptake of the Child HCAHPS survey increases, our study of one medium-sized, urban children’s hospital revealed that leaders and staff believe Child HCAHPS provides actionable metrics for improvement. Our study fills a gap in research about the use of Child HCAHPS for pediatric QI. A multisite evaluation would provide further information about how the Child HCAHPS survey can improve care.

Improving patient care experiences is integral to quality of care for hospitalized patients, including children and their families. Effective quality improvement (QI) requires incremental changes guided by measurement, monitoring, and performance feedback.1,2  Hospitals use evidence-based approaches3  to provide patient experience information to frontline staff (FS) and quality leaders.46  They also use these experience data for QI.610  To assess care experiences, hospitals caring for adults often use the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (available since 2006) to identify gaps and variation in performance compared with other hospitals.11  The use of HCAHPS data to improve quality is likely boosted by its linkage to payment in value-based purchasing programs.12 

QI efforts involving pediatric care experiences are also centered around the use of data, indicators, and national benchmarks,3,4,6  although they are less often linked to payment. In 2015, the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey was developed to assess inpatient pediatric care.1315  Both HCAHPS and Child HCAHPS have measures of nurse communication, doctor communication, staff responsiveness, hospital environment, overall rating of hospital, and willingness to recommend hospital. Child HCAHPS items are tailored to the pediatric population (eg, how often nurses listen carefully to parent or respondent and to the child). Child HCAHPS contains 3 domains not in HCAHPS: privacy, patient safety, and age appropriateness of care. The Child HCAHPS survey was endorsed by the National Quality Forum and field tested nationally but is not yet mandated for use in national public reporting or pay-for-performance. However, hospital leaders can use it to examine domains of inpatient pediatric and neonatal care and benchmark performance internally and nationally.7,14 

Facilitated by a hospital’s organizational infrastructure and culture, QI can foster collaborative learning, team-based work, and staff communication.16  Hospitals with interdisciplinary pediatric leadership groups that focus on goal setting, sharing data, and collaborative learning are better positioned to conduct QI and motivate change.1720  Regular management meetings, committee meetings, and staff-level meetings, in which staff feel safe to review existing evidence and performance, experiment and raise issues about knowledge and practice deficiencies are perceived as crucial to effective QI.21,22  However, little is known about how children’s hospital quality leaders (CHQL) and FS use Child HCAHPS data for QI. We examine the use and perceived value of Child HCAHPS for QI in a children’s hospital.

We partnered with a medium-sized 131-bed children’s hospital with 2 facilities nested within an academic medical center on the West Coast. Both facilities have PICUs and NICUs; the larger facility also has PICUs and pediatric cardiac ICU units. In July 2017, the hospital started using the Child HCAHPS survey to collect patient experience data from families of hospitalized children. Health informatics staff aggregate and analyze these data using Tableau, an interactive analytics and visualization tool. Monthly reports with open-ended patient comments from these surveys are e-mailed to quality leaders and reviewed in monthly and/or quarterly meetings.

We developed 2 complementary surveys to assess perceptions of and experiences with using the Child HCAHPS survey for monitoring quality of patient and family care experiences and improving quality. The quality leaders survey (ie, CHQL survey) included items unique to patient experience reporting and the FS survey (ie, children’s hospital frontline staff [CHFS] survey) included items unique to work culture and environment.

We developed a new survey on the basis of the national Survey of Hospital Quality Leaders (SHQL). The SHQL (developed in 2017) includes 20 multi-item scales and was fielded with hospital quality leaders by using a national stratified random sample of hospitals that report HCAHPS scores publicly. It asks about using patient experience data and practices surrounding HCAHPS data. We also included items specific to Child HCAHPS to ask about familiarity with Child HCAHPS, timeliness of receiving Child HCAHPS results, whether Child HCAHPS sample sizes were sufficient, frequency of receiving patient experience information, frequency of generating their own reports on patient experiences, and the reporting of specific metrics. These items were not asked of staff.

The 76-item CHQL survey assessed 12 single items and 5 domains: agreement on validity of HCAHPS scores (7 items), HCAHPS domains the hospital worked to improve (18 items), agreement on approaches that can improve HCAHPS scores (12 items), perceptions of hospital priorities (3 items), and importance of patient experience relative to other goals (3 items). Four of these scales and 1 single item on the CHQL survey map to the national SHQL (Supplemental Table 5).

This survey asked FS about patient experience measurement and using Child HCAHPS data. It included unique items about quality of care, QI (eg, attitudes, involvement) and unit culture (eg, teamwork, communication across transitions, burnout) replicating items from 6 relevant surveys: Healthcare Vitality Instrument (ie, single item from engagement and empowerment subscale),23,24  Quality Safety Assessment Application for Nurses (3 items from QI, teamwork, and patient-centered care subscales),25  Gallup’s Q12 Employee Engagement survey (single item about commitment to quality work),26,27  Organizational Culture Inventory in ICUs (single item from perceived effectiveness scale),28  Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (6 items from communication openness, staffing, and handoff and transitions subscales),29  and QI Nursing Attitude Scale (3 items about QI).30  The survey’s development is described in the Supplemental Information.

The 81-item CHFS survey assessed 12 single items and 10 domains: the CHFS uniquely included 5 domains about: communication openness (3 items), communication across transitions (2 items), organizational culture surrounding quality (6 items), inclusion in QI (2 items), attitude about QI being essential (2 items), and 8 single items assessing empowerment, unit-level teamwork, integration of QI into patient care, staff commitment to quality work, having enough staff for the workload, QI negatively affecting workload, reporting of global ratings, and using patient experience data. It also included a 5-item desirability scale.31 

Both the CHQL and CHFS surveys included 5 domains and 4 single items HCAHPS domains that the hospital worked to improve, agreement on approaches that can improve HCAHPS scores, perceptions about hospital priorities, importance of patient experience relative to other goals, and agreement on validity of HCAHPS scores. Both surveys also included 4 items about patient experience measures included in reports.

We administered the CHQL survey to quality leaders online (e-mail invitation with 3 follow-ups) in August and September of 2018 and August and September of 2019. We administered the CHFS survey on paper at recurring staff meetings (with nonphysician staff only) at both facilities from October 2019 through January 2020 (18 total meetings). Staff were given anonymous surveys on arrival and returned them to study staff. No honorarium was provided.

First, we assessed internal consistency reliability for multi-item scales. We compared scale and item means that overlapped on both surveys. We used 2-sample t tests to evaluate the significance of mean differences (P < .05). We used χ2 tests to compare binary and categorical CHFS items. Within the CHFS survey, we also compared results by staff type (eg, nurses) and unit (eg, NICU).

To determine differences between our study leaders’ perceptions and those of a national sample, we compared CHQL scale and item means with the weighted national SHQL estimates for hospitals participating in HCAHPS and American Hospital Association surveys, calculating z scores using the difference of means and the variance from the national study. P values were reported on the basis of the z scores of the mean differences and assuming a null hypothesis of no difference.

To assess whether staff perceptions from our study were like staff perceptions from other studies, we compared our staff means with the reported staff means from other studies on identical items. We calculated t tests and P values using the means, SDs, and sample sizes.

To assess whether social desirability influenced the scales, we fit linear regression models for each scale (the outcome) with indicators for unit (NICU versus pediatric units) and controlled for social desirability.32  We also fit similar models assessing whether staff type was impacted by social desirability. In all models, the point estimate of social desirability was close to 0 and did not meaningfully shift the point estimates for the main model predictors. Given the lack of evidence of social desirability in these scales, we report unadjusted scores to allow for straightforward mean comparisons with future studies.

Analyses were conducted in R version 3.6.1. Study protocols were approved by RAND’s Human Subject Protection Committee (institutional review board assurance number: FWA00003425; institutional review board number: IRB00000051; project identifier: 2018-0536).

Thirty-two quality leaders (ie, 8 hospital leaders, 6 executive leaders, 4 lead physicians, 8 pediatric directors, and 6 nursing directors) completed the CHQL survey (response rate of 50%).

Ninety-seven FS completed the CHFS survey among the 181 staff (of 558 staff hospital-wide), who attended the meetings in which it was administered (response rate of 54%) (Table 1). Of respondents, 28% worked in the NICU and 72% were pediatric-floor nurses.

TABLE 1

CHFS Characteristics

NICU, % (n)Pediatric Units,a % (n)Overall, % (n)
Role    
 Nurse 85 (23) 73 (51) 76 (74) 
 RN 78 (21) 71 (50) 73 (71) 
 Advanced practice nurse 4 (1) 0 (0) 1 (1) 
 Nurse practitioner 4 (1) 0 (0) 1 (1) 
 Clinical nurse specialist 0 (0) 1 (1) 1 (1) 
 Other staff 15 (4) 27 (19) 24 (23) 
 Care partner 11 (3) 24 (17) 21 (20) 
 Occupational therapist 4 (1) 0 (0) 1 (1) 
 ACP and/or MT 0 (0) 1 (1) 1 (1) 
 Child life specialist 0 (0) 1 (1) 1 (1) 
Location    
 Location 1 78 (21) 80 (56) 79 (77) 
 Location 2 22 (6) 20 (14) 21 (20) 
Total 28 (27) 72 (70) 100 (97) 
NICU, % (n)Pediatric Units,a % (n)Overall, % (n)
Role    
 Nurse 85 (23) 73 (51) 76 (74) 
 RN 78 (21) 71 (50) 73 (71) 
 Advanced practice nurse 4 (1) 0 (0) 1 (1) 
 Nurse practitioner 4 (1) 0 (0) 1 (1) 
 Clinical nurse specialist 0 (0) 1 (1) 1 (1) 
 Other staff 15 (4) 27 (19) 24 (23) 
 Care partner 11 (3) 24 (17) 21 (20) 
 Occupational therapist 4 (1) 0 (0) 1 (1) 
 ACP and/or MT 0 (0) 1 (1) 1 (1) 
 Child life specialist 0 (0) 1 (1) 1 (1) 
Location    
 Location 1 78 (21) 80 (56) 79 (77) 
 Location 2 22 (6) 20 (14) 21 (20) 
Total 28 (27) 72 (70) 100 (97) 

We grouped the non-RN staff as “Other staff.” ACP, advanced care partner; MT, medical technician; RN, registered nurse.

a

Includes PICU.

The majority of quality leaders (84%) and FS (68%) were familiar with Child HCAHPS data. Leaders and staff had similar levels of agreement on “perceptions of hospital priorities” including the hospital having “a high level of commitment to measuring clinical outcomes” and on the statement that “measuring the quality of patient experiences is important” (Table 2). Staff had the highest levels of agreement about the “frequency of rounding on patients” as a means to improve Child HCAHPS scores.

TABLE 2

Comparison of Perceptions of CHQL and CHFS, by Domain and Item

Scales and ItemsCHQL (n = 32)CHFS (n = 97)P
Agreement on validity of Child HCAHPS scores (5-point agreement scalea with α = 0.73 and 0.92),b mean (SD) 3.62 (0.58) 3.52 (1.02) .516 
 Child HCAHPS measures the domains of patient experience that are most important to [named children’s hospital]. 4.04 (0.77) 3.77 (1.23) .178 
 Child HCAHPS results accurately reflect the quality of patient experiences at [named children’s hospital]. 3.38 (1.02) 3.24 (1.22) .536 
 Respondents of the Child HCAHPS survey at the hospital are representative of the patients our hospital serves. 3.00 (1.13) 3.33 (1.21) .206 
 It is useful to compare Child HCAHPS scores to the scores of other hospitals that care for children. 4.27 (0.78)c 3.78 (1.21)c .016c 
 Child HCAHPS scores provide fair comparisons between hospitals that care for children. 3.50 (0.76) 3.45 (1.19) .797 
 Child HCAHPS results provide information specific enough for use in QI. 3.54 (1.07) 3.69 (1.09) .542 
 [Named children’s hospital] has enough resources to use Child HCAHPS data for QI. 3.62 (0.94) 3.54 (1.26) .74 
 Child HCAHPS results are provided in a timely manner by our vendor. (single item) 3.50 (1.07) — — 
 Our Child HCAHPS sample size is large enough to meet [named children’s hospital]’s needs. (single item) 1.88 (1.11) — — 
Child HCAHPS domains that the hospital worked to improve in the last 12 mo (yes or no; with α= 0.91 and 0.94),b % yes (SD) 0.75 (0.26)c 0.26 (0.31)c <.001c 
 Communication between parent or guardian and the child’s nurses 0.90 (0.31)c 0.21 (0.41)c <.001c 
 Communication between parent or guardian and the child’s doctors 0.76 (0.44)c 0.31 (0.46)c <.001c 
 Communication about child’s medicines 0.75 (0.44)c 0.19 (0.39)c <.001c 
 Keeping parent or guardian informed about child’s care 0.85 (0.36)c 0.15 (0.36)c <.001c 
 Privacy for the parent or guardian when talking with doctors, nurses, and other providers 0.37 (0.49) 0.41 (0.49) .708 
 Preparing child to leave the hospital 0.86 (0.36)c 0.18 (0.38)c <.001c 
 Keeping you informed about child’s care in the ED 0.41 (0.50) 0.51 (0.50) .352 
 How well nurses communicate with child 0.85 (0.36)c 0.29 (0.46)c <.001c 
 How well doctors communicate with child 0.67 (0.48)c 0.39 (0.49)c .014c 
 Involving teenagers in their care 0.57 (0.50) 0.35 (0.48) .052 
 Preventing mistakes and helping parent or guardian report concerns 0.75 (0.44)c 0.20 (0.41)c <.001c 
 Helping child feel comfortable 0.82 (0.39)c 0.16 (0.37)c <.001c 
 Responsiveness to the call button 0.64 (0.49)c 0.24 (0.43)c <.001c 
 Paying attention to child’s pain 0.90 (0.31)c 0.10 (0.31)c <.001c 
 Cleanliness of hospital room 0.61 (0.50)c 0.26 (0.44)c .002c 
 Quietness of hospital room 0.89 (0.31)c 0.28 (0.45)c <.001c 
 Overall rating of hospital 0.90 (0.31)c 0.20 (0.40)c <.001c 
 Willingness to recommend hospital 0.86 (0.36)c 0.28 (0.45)c <.001c 
 Are there any other patient experience topic areas that [named children’s hospital] has worked to improve in the last 12 mo? (single item; narrative text response) 0.23 (0.43) — — 
Agreement on approaches that can improve Child HCAHPS patient experience scores (5-point agreement scalea with α = 0.93 and 0.91), mean (SD) 4.17 (0.72) 4.30 (0.72) .398 
 Promoting culture change 4.56 (0.91) 4.36 (0.86) .287 
 Frequently rounding on patients 4.52 (0.81) 4.66 (0.80)d .395 
 Improving employee recruitment and retention policies 4.19 (0.90) 4.35 (1.06) .388 
 Reducing the No. patients assigned to each nurse 3.84 (1.04)c 4.43 (0.97)c .008c 
 Training focused on improving nurse communication skills 4.56 (0.80) 4.48 (0.85) .617 
 Training focused on improving doctor communication skills 4.55 (0.81) 4.49 (0.94) .737 
 Providing scripts for nurse communication with patients 3.94 (1.08) 3.57 (1.30) .120 
 Reducing noise 3.97 (0.93) 4.24 (0.92) .156 
 Making improvements to physical space 3.91 (1.00) 4.27 (1.02) .085 
 Making improvements to parking 3.94 (1.13) 4.23 (1.23) .220 
 Making improvements to food service 3.75 (1.16) 4.18 (1.04) .071 
 Making improvements to patient education (eg, supplemental educational materials delivered on paper, online, or via in-room television regarding treatment or follow-up care) 4.38 (0.79) 4.32 (1.00) .765 
Perception of hospital priorities (5-point agreement scale with α = 0.69 and 0.69), mean (SD) 4.28 (0.85)c 3.75 (0.59)c .002c 
 This hospital has a high level of commitment to measuring clinical outcomes. 4.72 (0.77)d 4.47 (0.88) .139 
 Measuring the quality of patient experiences of care is important. 4.67 (0.80)d 4.53 (0.87) .433 
 There is a trade-off between providing technical quality of care and providing quality patient experiences of care.e 3.47 (1.50)c 2.28 (1.26)c <.001c 
Importance of patient experience relative to other goals (3-point less/same/more importance scale with α = 0.44 and 0.66), mean (SD) 1.95 (0.35) 2.10 (0.54) .078 
 Within [named children’s hospital], how important is patient experience compared with patient safety? 1.75 (0.51)c 2.08 (0.72)c .005c 
 Within [named children’s hospital], how important is patient experience compared with clinical quality? 1.84 (0.45)c 2.21 (0.61)c .001c 
 Within [named children’s hospital], how important is patient experience compared with financial performance? 2.25 (0.57) 1.99 (0.75) .043 
Additional single items, % yes (SD)    
 Use of patient experience data: yes or nob    
  Do you receive internally generated reports containing information on patient experiences of pediatric and/or NICU inpatient care such as data from Child HCAHPS surveys quarterly or more often? 69 (0.47) 67 (0.47) .832 
  Do you receive internally generated reports containing narrative data from patient comments about patient experiences of pediatric and/or NICU inpatient care quarterly or more often? 53 (0.51) 35 (0.48) .079 
  Do you receive performance information on patient experiences of pediatric and/or NICU inpatient care quarterly or more often? (single item) 88 (0.34) — — 
  Do you generate your own reports containing information on patient experiences of pediatric and/or NICU inpatient care quarterly or more often? (single item) 48 (0.51) — — 
 Patient experience measures included in reports you received: yes or no    
  Inclusion of Child HCAHPS global ratings in reports 96 (0.19)c 29 (0.45)c <.001c 
  Inclusion of specific domains of Child HCAHPS patient experience in reports 93 (0.27)c 11 (0.32)c <.001c 
  Inclusion of patient comments from Child HCAHPS survey in reports 75 (0.44)c 23 (0.42)c <.001c 
  Does [named children’s hospital] have specific, measurable performance targets for patient experience scores? 69 (0.47) 66 (0.48) .744 
  Do you use, or are you familiar with, the Child HCAHPS survey? 84 (0.37) — — 
 Patient experience measures included in reports you or someone else within [study medical center] generates: yes or no    
  Inclusion of Child HCAHPS global ratings in reports 95 (0.22) — — 
  Inclusion of specific domains of Child HCAHPS patient experience in reports 95 (0.22) — — 
  Inclusion of patient comments from Child HCAHPS in reports 86 (0.35) — — 
Scales and ItemsCHQL (n = 32)CHFS (n = 97)P
Agreement on validity of Child HCAHPS scores (5-point agreement scalea with α = 0.73 and 0.92),b mean (SD) 3.62 (0.58) 3.52 (1.02) .516 
 Child HCAHPS measures the domains of patient experience that are most important to [named children’s hospital]. 4.04 (0.77) 3.77 (1.23) .178 
 Child HCAHPS results accurately reflect the quality of patient experiences at [named children’s hospital]. 3.38 (1.02) 3.24 (1.22) .536 
 Respondents of the Child HCAHPS survey at the hospital are representative of the patients our hospital serves. 3.00 (1.13) 3.33 (1.21) .206 
 It is useful to compare Child HCAHPS scores to the scores of other hospitals that care for children. 4.27 (0.78)c 3.78 (1.21)c .016c 
 Child HCAHPS scores provide fair comparisons between hospitals that care for children. 3.50 (0.76) 3.45 (1.19) .797 
 Child HCAHPS results provide information specific enough for use in QI. 3.54 (1.07) 3.69 (1.09) .542 
 [Named children’s hospital] has enough resources to use Child HCAHPS data for QI. 3.62 (0.94) 3.54 (1.26) .74 
 Child HCAHPS results are provided in a timely manner by our vendor. (single item) 3.50 (1.07) — — 
 Our Child HCAHPS sample size is large enough to meet [named children’s hospital]’s needs. (single item) 1.88 (1.11) — — 
Child HCAHPS domains that the hospital worked to improve in the last 12 mo (yes or no; with α= 0.91 and 0.94),b % yes (SD) 0.75 (0.26)c 0.26 (0.31)c <.001c 
 Communication between parent or guardian and the child’s nurses 0.90 (0.31)c 0.21 (0.41)c <.001c 
 Communication between parent or guardian and the child’s doctors 0.76 (0.44)c 0.31 (0.46)c <.001c 
 Communication about child’s medicines 0.75 (0.44)c 0.19 (0.39)c <.001c 
 Keeping parent or guardian informed about child’s care 0.85 (0.36)c 0.15 (0.36)c <.001c 
 Privacy for the parent or guardian when talking with doctors, nurses, and other providers 0.37 (0.49) 0.41 (0.49) .708 
 Preparing child to leave the hospital 0.86 (0.36)c 0.18 (0.38)c <.001c 
 Keeping you informed about child’s care in the ED 0.41 (0.50) 0.51 (0.50) .352 
 How well nurses communicate with child 0.85 (0.36)c 0.29 (0.46)c <.001c 
 How well doctors communicate with child 0.67 (0.48)c 0.39 (0.49)c .014c 
 Involving teenagers in their care 0.57 (0.50) 0.35 (0.48) .052 
 Preventing mistakes and helping parent or guardian report concerns 0.75 (0.44)c 0.20 (0.41)c <.001c 
 Helping child feel comfortable 0.82 (0.39)c 0.16 (0.37)c <.001c 
 Responsiveness to the call button 0.64 (0.49)c 0.24 (0.43)c <.001c 
 Paying attention to child’s pain 0.90 (0.31)c 0.10 (0.31)c <.001c 
 Cleanliness of hospital room 0.61 (0.50)c 0.26 (0.44)c .002c 
 Quietness of hospital room 0.89 (0.31)c 0.28 (0.45)c <.001c 
 Overall rating of hospital 0.90 (0.31)c 0.20 (0.40)c <.001c 
 Willingness to recommend hospital 0.86 (0.36)c 0.28 (0.45)c <.001c 
 Are there any other patient experience topic areas that [named children’s hospital] has worked to improve in the last 12 mo? (single item; narrative text response) 0.23 (0.43) — — 
Agreement on approaches that can improve Child HCAHPS patient experience scores (5-point agreement scalea with α = 0.93 and 0.91), mean (SD) 4.17 (0.72) 4.30 (0.72) .398 
 Promoting culture change 4.56 (0.91) 4.36 (0.86) .287 
 Frequently rounding on patients 4.52 (0.81) 4.66 (0.80)d .395 
 Improving employee recruitment and retention policies 4.19 (0.90) 4.35 (1.06) .388 
 Reducing the No. patients assigned to each nurse 3.84 (1.04)c 4.43 (0.97)c .008c 
 Training focused on improving nurse communication skills 4.56 (0.80) 4.48 (0.85) .617 
 Training focused on improving doctor communication skills 4.55 (0.81) 4.49 (0.94) .737 
 Providing scripts for nurse communication with patients 3.94 (1.08) 3.57 (1.30) .120 
 Reducing noise 3.97 (0.93) 4.24 (0.92) .156 
 Making improvements to physical space 3.91 (1.00) 4.27 (1.02) .085 
 Making improvements to parking 3.94 (1.13) 4.23 (1.23) .220 
 Making improvements to food service 3.75 (1.16) 4.18 (1.04) .071 
 Making improvements to patient education (eg, supplemental educational materials delivered on paper, online, or via in-room television regarding treatment or follow-up care) 4.38 (0.79) 4.32 (1.00) .765 
Perception of hospital priorities (5-point agreement scale with α = 0.69 and 0.69), mean (SD) 4.28 (0.85)c 3.75 (0.59)c .002c 
 This hospital has a high level of commitment to measuring clinical outcomes. 4.72 (0.77)d 4.47 (0.88) .139 
 Measuring the quality of patient experiences of care is important. 4.67 (0.80)d 4.53 (0.87) .433 
 There is a trade-off between providing technical quality of care and providing quality patient experiences of care.e 3.47 (1.50)c 2.28 (1.26)c <.001c 
Importance of patient experience relative to other goals (3-point less/same/more importance scale with α = 0.44 and 0.66), mean (SD) 1.95 (0.35) 2.10 (0.54) .078 
 Within [named children’s hospital], how important is patient experience compared with patient safety? 1.75 (0.51)c 2.08 (0.72)c .005c 
 Within [named children’s hospital], how important is patient experience compared with clinical quality? 1.84 (0.45)c 2.21 (0.61)c .001c 
 Within [named children’s hospital], how important is patient experience compared with financial performance? 2.25 (0.57) 1.99 (0.75) .043 
Additional single items, % yes (SD)    
 Use of patient experience data: yes or nob    
  Do you receive internally generated reports containing information on patient experiences of pediatric and/or NICU inpatient care such as data from Child HCAHPS surveys quarterly or more often? 69 (0.47) 67 (0.47) .832 
  Do you receive internally generated reports containing narrative data from patient comments about patient experiences of pediatric and/or NICU inpatient care quarterly or more often? 53 (0.51) 35 (0.48) .079 
  Do you receive performance information on patient experiences of pediatric and/or NICU inpatient care quarterly or more often? (single item) 88 (0.34) — — 
  Do you generate your own reports containing information on patient experiences of pediatric and/or NICU inpatient care quarterly or more often? (single item) 48 (0.51) — — 
 Patient experience measures included in reports you received: yes or no    
  Inclusion of Child HCAHPS global ratings in reports 96 (0.19)c 29 (0.45)c <.001c 
  Inclusion of specific domains of Child HCAHPS patient experience in reports 93 (0.27)c 11 (0.32)c <.001c 
  Inclusion of patient comments from Child HCAHPS survey in reports 75 (0.44)c 23 (0.42)c <.001c 
  Does [named children’s hospital] have specific, measurable performance targets for patient experience scores? 69 (0.47) 66 (0.48) .744 
  Do you use, or are you familiar with, the Child HCAHPS survey? 84 (0.37) — — 
 Patient experience measures included in reports you or someone else within [study medical center] generates: yes or no    
  Inclusion of Child HCAHPS global ratings in reports 95 (0.22) — — 
  Inclusion of specific domains of Child HCAHPS patient experience in reports 95 (0.22) — — 
  Inclusion of patient comments from Child HCAHPS in reports 86 (0.35) — — 

—, not applicable; ED, emergency department.

a

The 5-point agreement scale is strongly disagree/somewhat disagree/neither agree or disagree/somewhat agree/strongly agree.

b

Indicates a comparison of scale score means of only the items included in both the CHQL survey and CHFS survey.

c

Indicates statistically significant differences (P < .05) from t tests comparing means.

d

Indicates highest level of agreement/endorsement.

e

Denotes reversed scored.

Leaders were least likely to agree that the “Child HCAHPS sample size is large enough to meet their hospital’s needs” (8% agree or strongly agree) and that Child HCAHPS respondents were “representative of the patients our hospital serves” (31%). The staff’s lowest level of agreement was that “Child HCAHPS results accurately reflect the quality of patient experiences” at their hospital (43%).

Among leaders, 96% reported receiving Child HCAHPS reports, with 69% using Child HCAHPS scores and 53% using Child HCAHPS patient comments. For the staff, 29% reported receiving such reports; among these, 67% indicated using Child HCAHPS scores and 35% using patient comments.

Although there were no statistically significant differences between leaders and staff on “validity of Child HCAHPS scores,” leaders were more likely than staff to agree that “it is useful to compare the Child HCAHPS scores to scores of other hospitals that care for children” and could identify “Child HCAHPS domains that the hospital worked to improve in the last 12 months.” Staff were more likely to agree than leaders that “reducing the number of patients assigned to each nurse” could improve Child HCAHPS scores; both held similar levels of agreement that frequent patient rounds, promoting culture change, and training focused on improving nurse and doctor communication could improve Child HCAHPS scores.

Leaders and staff had significant differences regarding the domains of “perceptions of hospital priorities” and “importance of patient experience relative to other goals.” Leaders and staff agreed that the hospital held similar commitment to measuring clinical quality outcomes and patient care experiences, but leaders agreed less that “there is a trade-off between providing technical quality of care and of patient experiences of care.” Staff were more likely to agree that the patient experience is more important than patient safety and clinical quality, whereas leaders were more likely to agree that the patient experience is more important than financial performance.

Two-thirds of both leaders and staff reported having specific, measurable performance targets for patient experience scores.

We found no statistically significant differences between our quality leaders’ sample and a national sample of hospital quality leaders (Supplemental Table 5).

FS perceptions about QI and unit culture are shown in Table 3. Staff agreed that QI is an essential part of their daily work and endorsed beliefs about their inclusion in QI. Staff reported having communication openness, with “staff freely speaking up if they see something that may negatively affect patient care.” Staff were neutral about communication across handoffs and transitions.

TABLE 3

FS Perceptions of QI and Culture

Scales and ItemsFS Overall (n = 97), Mean (SD)
Communication openness (5-point agreement scalea3.78 (0.95) 
 Staff freely speak up if they see something that may negatively affect patient care.b 3.99 (1.14) 
 Staff are afraid to ask questions when something does not seem right.b 3.55 (1.48) 
 Staff feel free to question decisions or actions of those with more authority.b 3.80 (1.15) 
Communication across transitions (5-point agreement scalea3.07 (1.13) 
 Things “fall between the cracks” when transferring patients from one unit to another.b,c 2.83 (1.23) 
 Important patient care information is often lost during shift changes.b,c 3.31 (1.25) 
Importance of organizational culture surrounding quality (4-point importance scaled3.65 (0.46) 
 Nurse participation in QI projectse 3.70 (0.58) 
 Doctor participation in QI projects 3.28 (0.82) 
 Performance measurement to improve patient outcomese 3.73 (0.51) 
 Teamwork to improve patient outcomes and caree 3.72 (0.61) 
 Using evidence to determine best clinical practicee 3.80 (0.45) 
 Including patient-centered care concepts (such as respecting patients’ unique values and beliefs) in developing a plan of care for each patiente 3.73 (0.51) 
Inclusion in QI (5-point agreement scalea4.29 (0.74) 
 I believe I have value in the institutional efforts to improve care.f 4.13 (0.88) 
 I enjoy being a part of change on my unit to improve quality of care.f 4.48 (0.74) 
Attitude about QI being essential (5-point agreement scalea4.49 (0.75) 
 I believe that continuous QI is an essential part of the daily work of the bedside nurse.f 4.62 (0.67) 
 I believe that continuous QI is an essential part of the daily work of the doctor. 4.36 (0.96) 
Additional single items (5-point agreement scalea 
 If I have an idea about how to make things better on this unit, the manager and other staff are willing to try it. (ie, empowerment). 3.74 (1.20) 
 Overall, our unit functions well together as a team (ie, unit-level teamwork).g 4.26 (0.95) 
 QI efforts are integrated into patient care (versus separate efforts). 4.20 (0.83) 
 Staff are committed to doing quality work.h 4.56 (0.80) 
 We have enough staff to handle the workload.b 3.24 (1.30) 
 QI efforts are a burden, which negatively affects my workload.c 3.45 (1.38) 
Scales and ItemsFS Overall (n = 97), Mean (SD)
Communication openness (5-point agreement scalea3.78 (0.95) 
 Staff freely speak up if they see something that may negatively affect patient care.b 3.99 (1.14) 
 Staff are afraid to ask questions when something does not seem right.b 3.55 (1.48) 
 Staff feel free to question decisions or actions of those with more authority.b 3.80 (1.15) 
Communication across transitions (5-point agreement scalea3.07 (1.13) 
 Things “fall between the cracks” when transferring patients from one unit to another.b,c 2.83 (1.23) 
 Important patient care information is often lost during shift changes.b,c 3.31 (1.25) 
Importance of organizational culture surrounding quality (4-point importance scaled3.65 (0.46) 
 Nurse participation in QI projectse 3.70 (0.58) 
 Doctor participation in QI projects 3.28 (0.82) 
 Performance measurement to improve patient outcomese 3.73 (0.51) 
 Teamwork to improve patient outcomes and caree 3.72 (0.61) 
 Using evidence to determine best clinical practicee 3.80 (0.45) 
 Including patient-centered care concepts (such as respecting patients’ unique values and beliefs) in developing a plan of care for each patiente 3.73 (0.51) 
Inclusion in QI (5-point agreement scalea4.29 (0.74) 
 I believe I have value in the institutional efforts to improve care.f 4.13 (0.88) 
 I enjoy being a part of change on my unit to improve quality of care.f 4.48 (0.74) 
Attitude about QI being essential (5-point agreement scalea4.49 (0.75) 
 I believe that continuous QI is an essential part of the daily work of the bedside nurse.f 4.62 (0.67) 
 I believe that continuous QI is an essential part of the daily work of the doctor. 4.36 (0.96) 
Additional single items (5-point agreement scalea 
 If I have an idea about how to make things better on this unit, the manager and other staff are willing to try it. (ie, empowerment). 3.74 (1.20) 
 Overall, our unit functions well together as a team (ie, unit-level teamwork).g 4.26 (0.95) 
 QI efforts are integrated into patient care (versus separate efforts). 4.20 (0.83) 
 Staff are committed to doing quality work.h 4.56 (0.80) 
 We have enough staff to handle the workload.b 3.24 (1.30) 
 QI efforts are a burden, which negatively affects my workload.c 3.45 (1.38) 
a

The 5-point agreement scale is strongly disagree/somewhat disagree/neither agree or disagree/somewhat agree/strongly agree.

b

Indicates an item on patient safety culture that is a subset of the Hospital Survey on Patient Safety Culture questions.

c

Denotes reversed scored.

d

The 4-point importance scale is not important at all/low importance/moderate importance/high importance.

e

Indicates items from Quality Safety Assessment Application for Nurses.

f

Indicates items from the QI Nursing Attitude Scale.

g

Indicates an item from the perceived effectiveness scale from the Organizational Culture Inventory in ICUs.

h

Indicates and item on commitment that is an item from the Gallup Q12 Employee Engagement survey.

Staff reported moderate importance of organizational culture surrounding quality but agreed least about the importance of “doctor participation in QI projects.” They agreed more on the importance of nurse participation in QI projects, performance measurement to improve patient outcomes, teamwork to improve patient outcomes and care, including patient-centered care concepts when developing patient care plans, and using evidence to determine best clinical practice. Commitment to quality work, unit-level teamwork, empowerment, and QI efforts being integrated into patient care were important to staff, although they were neutral about workload issues.

We compared our staff results to those of other hospital staff studies that administered the same measures on communication openness, communication across transitions, organizational culture, QI, staff commitment, workload, and teamwork (Table 4).25,2730,33  Study staff had higher levels of agreement than other staff about speaking up, daily work including QI, and best practices being derived from evidence and assigned less importance to teamwork to improve patient outcomes and care or the need for patient-centered care concepts in care plans. The differences across NICU and pediatric staff are shown in Supplemental Table 6; given the small sample sizes, we consider these results exploratory.

TABLE 4

FS Perceptions of QI and Culture Compared With Other Hospital Staff Perceptions, By Survey Item

Survey Item, by TopicCHFS SurveyOther Hospital FS SurveyPInformation About Other Hospital Staff Study Using Same Item(s)
Mean (SD)Mean (SD)Survey Source: Study Population (Citation)
Communication openness     
 Staff freely speak up if they see something that may negatively affect patient carea 3.99 (1.14) 3.95 (0.85) .642 HSOPSC: mean and SD from 331 hospitals with 2267 units and 50 513 hospital staff respondents across the United States using HSOPSC (citation: Sorra et al29 
  Average positive response: 77% (0.42)b Average positive response: 79% (not available) with 87% as 90th percentileb — Average positive response and 90th percentile rank from 228 430 respondents from 306 hospitals across the United States using HSOPSC (citation: Famolaro et al33 
 Staff are afraid to ask questions when something does not seem righta,c 3.55 (1.48) 3.67 (0.96) .221 HSOPSC (see above) 
  Average positive response: 60% (0.49)b Average positive response: 62% (not available) with 77% as 90th percentileb — HSOPSC (see above) 
 Staff feel free to question decisions or actions of those with more authoritya,d 3.80 (1.15)e 3.27 (1.07)e <.001e HSOPSC (see above) 
  Average positive response: 70% (0.46)b Average positive response: 50% (not available) with 60% as 90th percentileb; 3.41 (not available) (Thorp et al27 — aHSOPSC: mean and SD from a large academic medical center with a tertiary care level 1 trauma center, behavioral medicine center, and multispecialty clinics that measured patient safety culture by using an aHSOPSC with 9809 employees, of which 4862 (49.5%) completed the survey (citation: Thorp et al27 
Transitions (5-point agreement scale)     
 Things fall between the cracks when transferring patients from one unit to anotherc,d 2.83 (1.23) 2.94 (1.00) .281 HSOPSC (see above) 
 Important patient care information is often lost during shift changesc,d 3.31 (1.25) 3.27 (1.02) .701 HSOPSC (see above) 
Organizational culture surrounding quality (4-point importance scalef    
 Nurse participation in QI projectsg 3.70 (0.58) 3.76 (0.48) .267 QSAAN: 4 acute care hospitals in large midwestern city with 2060 practicing nurses, of which 668 nurses (32.4%) completed the survey (citation: Bradley25 
 Performance measurement to improve patient outcomesg 3.73 (0.51) 3.74 (0.50) .853 QSAAN (see above) 
 Teamwork to improve patient outcomes and careg 3.72 (0.61)e 3.90 (0.37)e <.001e QSAAN (see above) 
 Using evidence to determine best clinical practiceg 3.80 (0.45)e 3.66 (0.53)e .014e QSAAN (see above) 
 Including patient-centered care concepts (such as respecting patients’ unique values and beliefs) in developing a plan of care for each patientg 3.73 (0.51)e 3.84 (0.43)e .023e QSAAN (see above) 
Inclusion in QI (5-point agreement scale)     
 I believe I have value in the institutional efforts to improve careh 4.13 (0.88) 4.19 (0.85) .519 QiNAS: southeastern hospital with 57 registered nurses providing care at the bedside who completed the survey (citation: Dunagan30 
 I enjoy being a part of change on my unit to improve quality of careh 4.48 (0.74) 4.36 (0.71) .124 QiNAS (see above) 
Attitude about QI being essential (5-point agreement scale)     
 I believe that continuous QI is an essential part of the daily work of the bedside nurseh 4.62 (0.67)e 4.36 (0.69)e <.001e QiNAS (see above) 
 I believe that continuous QI is an essential part of the daily work of the doctor 4.36 (0.96) — — — 
Additional single items (5-point agreement scale)     
 Staff are committed to doing quality worki 4.56 (0.80) 4.00 (not available) — Gallup’s Q12 Employee Engagement Survey: a large academic medical center including a tertiary care level 1 trauma center, behavioral medicine center, and multispecialty clinics, measured patient safety culture for 9809 employees, of which 4862 (49.5%) completed the survey (citation: Thorp et al27 
 We have enough staff to handle the workloadd 3.24 (1.30) 3.09 (1.22) .226 HSOPSC (see above) 
 Overall, our unit functions well together as a teamj 4.26 (0.95) 4.04 (1.06) .082 Organizational Culture Inventory in ICUs: random sample of 500 participants of 61094 registered nurses employed in direct care role in all teaching or nonteaching acute care hospitals in Ontario, Canada, of which 214 (42.8%) completed the survey (citation: Read28 
Survey Item, by TopicCHFS SurveyOther Hospital FS SurveyPInformation About Other Hospital Staff Study Using Same Item(s)
Mean (SD)Mean (SD)Survey Source: Study Population (Citation)
Communication openness     
 Staff freely speak up if they see something that may negatively affect patient carea 3.99 (1.14) 3.95 (0.85) .642 HSOPSC: mean and SD from 331 hospitals with 2267 units and 50 513 hospital staff respondents across the United States using HSOPSC (citation: Sorra et al29 
  Average positive response: 77% (0.42)b Average positive response: 79% (not available) with 87% as 90th percentileb — Average positive response and 90th percentile rank from 228 430 respondents from 306 hospitals across the United States using HSOPSC (citation: Famolaro et al33 
 Staff are afraid to ask questions when something does not seem righta,c 3.55 (1.48) 3.67 (0.96) .221 HSOPSC (see above) 
  Average positive response: 60% (0.49)b Average positive response: 62% (not available) with 77% as 90th percentileb — HSOPSC (see above) 
 Staff feel free to question decisions or actions of those with more authoritya,d 3.80 (1.15)e 3.27 (1.07)e <.001e HSOPSC (see above) 
  Average positive response: 70% (0.46)b Average positive response: 50% (not available) with 60% as 90th percentileb; 3.41 (not available) (Thorp et al27 — aHSOPSC: mean and SD from a large academic medical center with a tertiary care level 1 trauma center, behavioral medicine center, and multispecialty clinics that measured patient safety culture by using an aHSOPSC with 9809 employees, of which 4862 (49.5%) completed the survey (citation: Thorp et al27 
Transitions (5-point agreement scale)     
 Things fall between the cracks when transferring patients from one unit to anotherc,d 2.83 (1.23) 2.94 (1.00) .281 HSOPSC (see above) 
 Important patient care information is often lost during shift changesc,d 3.31 (1.25) 3.27 (1.02) .701 HSOPSC (see above) 
Organizational culture surrounding quality (4-point importance scalef    
 Nurse participation in QI projectsg 3.70 (0.58) 3.76 (0.48) .267 QSAAN: 4 acute care hospitals in large midwestern city with 2060 practicing nurses, of which 668 nurses (32.4%) completed the survey (citation: Bradley25 
 Performance measurement to improve patient outcomesg 3.73 (0.51) 3.74 (0.50) .853 QSAAN (see above) 
 Teamwork to improve patient outcomes and careg 3.72 (0.61)e 3.90 (0.37)e <.001e QSAAN (see above) 
 Using evidence to determine best clinical practiceg 3.80 (0.45)e 3.66 (0.53)e .014e QSAAN (see above) 
 Including patient-centered care concepts (such as respecting patients’ unique values and beliefs) in developing a plan of care for each patientg 3.73 (0.51)e 3.84 (0.43)e .023e QSAAN (see above) 
Inclusion in QI (5-point agreement scale)     
 I believe I have value in the institutional efforts to improve careh 4.13 (0.88) 4.19 (0.85) .519 QiNAS: southeastern hospital with 57 registered nurses providing care at the bedside who completed the survey (citation: Dunagan30 
 I enjoy being a part of change on my unit to improve quality of careh 4.48 (0.74) 4.36 (0.71) .124 QiNAS (see above) 
Attitude about QI being essential (5-point agreement scale)     
 I believe that continuous QI is an essential part of the daily work of the bedside nurseh 4.62 (0.67)e 4.36 (0.69)e <.001e QiNAS (see above) 
 I believe that continuous QI is an essential part of the daily work of the doctor 4.36 (0.96) — — — 
Additional single items (5-point agreement scale)     
 Staff are committed to doing quality worki 4.56 (0.80) 4.00 (not available) — Gallup’s Q12 Employee Engagement Survey: a large academic medical center including a tertiary care level 1 trauma center, behavioral medicine center, and multispecialty clinics, measured patient safety culture for 9809 employees, of which 4862 (49.5%) completed the survey (citation: Thorp et al27 
 We have enough staff to handle the workloadd 3.24 (1.30) 3.09 (1.22) .226 HSOPSC (see above) 
 Overall, our unit functions well together as a teamj 4.26 (0.95) 4.04 (1.06) .082 Organizational Culture Inventory in ICUs: random sample of 500 participants of 61094 registered nurses employed in direct care role in all teaching or nonteaching acute care hospitals in Ontario, Canada, of which 214 (42.8%) completed the survey (citation: Read28 

The CHFS 5-point agreement scale is strongly disagree/somewhat disagree/neither agree or disagree/somewhat agree/strongly agree. The CHFS 4-point importance scale is not important at all/low importance/moderate importance/high importance. P values are from t tests comparing means. aHSOPSC, abbreviated version of the Hospital Survey on Patient Safety Culture; HSOPSC, Hospital Survey on Patient Safety Culture; QiNAS, Quality Improvement Nursing Attitude Scale; QNAAS, Quality Safety Assessment Application for Nurses; —, not applicable.

a

The response scale for these 3 communication openness items on the CHFS survey was a 5-point agreement scale (strongly disagree/somewhat disagree/neither agree or disagree/somewhat agree/strongly agree), whereas the response scale for these same items on the HSOPSC was a 5-point frequency scale (never, rarely, sometimes, most of the time, always).

b

The positive response is the sum of the top 2 responses (ie, for the CHFS survey, it is strongly agree + agree and for HSOPSC, it is always + most of the time).

c

Denotes an item is reversed scored.

d

Indicates items from the HSOPSC.

e

Indicates statistically significant differences (P < .05) from t tests comparing means.

f

The 4-point importance scale is not important at all, low importance, moderate importance, high importance.

g

Indicates items from the QSAAN.

h

Indicates items from the QiNAS.

i

Indicates and item on commitment that is an item from the Gallup Q12 Employee Engagement survey.

j

Indicates an item from the perceived effectiveness scale from the Organizational Culture Inventory in ICUs.

To explore attitudes regarding the use of Child HCAHPS in pediatric QI, we examined quality leader and FS perceptions about patient experience measurement, using Child HCAHPS data, QI, and the work environment in a children’s hospital. We found that leader and staff perceptions aligned for many important items, but there were key differences such as on usefulness of comparisons to other hospitals, trade-offs between patient experience and other quality domains.

First, leaders and staff both endorsed the validity of Child HCAHPS scores, but quality leaders were more likely than FS to view the Child HCAHPS survey useful for comparisons to other hospitals. This difference may reflect the leaders’ use of Child HCAHPS more often for organizational benchmarking of performance metrics,34,35  whereas staff more often focus on implementing QI and providing patient- and family-centered care in their specific setting.36,37 

Second, both groups agreed on hospital commitment to measuring clinical quality outcomes and patient care experiences. Leaders saw more alignment between patient experience and other quality domains, whereas staff reported more trade-offs between these goals. These differing viewpoints are important to understand when planning QI focused on patient experiences, requiring more time to be spent in staff meetings discussing the importance of the included patient experience measures in QI efforts.

Leaders reported working more frequently than staff to improve Child HCAHPS scores in the last year, with 75% of leaders compared with 26% of staff indicating they worked to improve Child HCAHPS scores. This might be because quality leaders were more familiar with Child HCAHPS. Additionally, leaders are typically more aware of QI efforts across the entire hospital, whereas staff are primarily aware of unit-specific QI initiatives. Staff may view activities related to working on improving patient experience as part of their job and not as work to improve Child HCAHPS scores.

We also found that leaders and staff agreed on most approaches for improving Child HCAHPS scores, except that staff were more likely to support that reducing the number of patients assigned to each nurse could improve Child HCAHPS scores. Frontline experience with patient care may shape how staff view workload issues. Overall, our findings suggest that leaders and staff alike tend to envision ways to improve Child HCAHPS scores and that these data are useful for specific QI practices. This finding and the fact that both groups agreed on the validity of the scores bode well for buy-in from both leaders and staff for use of Child HCAHPS data in future pediatric inpatient care experience QI efforts.

Additionally, our study leaders had similar perspectives to those in other hospitals on how accurately Child HCAHPS items reflect patient experience at the hospital and the usefulness of HCAHPS score comparisons. Compared with staff in other hospitals, staff in this study had higher levels of agreement that QI was an essential part of their daily work, whereas their attitudes about being part of QI were similar.30  Our findings contrast with some evidence that nurses in acute care hospital settings understand basic QI concepts but do not generally perform QI processes as part of the work.25,38 

Relative to similar studies, staff in this study were more likely to agree that staff feel “free to question decisions or actions of those with more authority.” This indicates the study hospital had an organizational culture of safety because that is known to foster speaking up when care risk is recognized.3941  However, staff in this study had similar views to staff in other studies on other aspects of communication openness,29,33  transitions,29  beliefs about their inclusion in QI,30  having enough staff to handle the workload,29  and unit teamwork.28  This adds descriptive evidence to the literature on hospital staff attitudes about communication openness and the process of QI.

The importance of nurse participation in QI and importance of performance measurement to improve patient outcomes was also similar for the staff in our study and other hospital staff.25  However, study staff were more likely than other hospital staff to consider the “use of evidence to determine best clinical practice” to be important and less likely to consider teamwork and including patient-centered care concepts in care plans to be important. This suggests study staff place more weight on using evidence to determine clinical practice, which may suggest placing more value on using data for QI.

Because our findings about culture, communication, staffing, and teamwork were comparable to other studies of hospital staff,25,2730,33  this implies that Child HCAHPS may be useful for QI for both quality leaders and FS in other children’s hospitals and specifically for improving areas of care measured by Child HCAHPS domains. Staff in our study found QI useful in improving care; leaders and staff also agreed on several approaches to improve pediatric care that could improve Child HCAHPS scores. Our study of 1 medium-sized, urban children’s hospital revealed that both leaders and staff believe that Child HCAHPS provides actionable metrics for improvement. These are important findings for other children’s hospitals to consider as the uptake of the Child HCAHPS survey increases.

Before this study, little was known about the use of Child HCAHPS for QI. Previously, pediatric QI leaders could only generalize from HCAHPS, which asks patients about their adult inpatient stays, to pediatric inpatient care. However, findings from HCAHPS are likely not applicable to children because HCAHPS asks adult patients about their inpatient care, while Child HCAHPS asks about aspects of care specific to pediatric stays and Child HCAHPS respondents are the parent or guardian of the patient. Thus, these findings about Child HCAHPS fill a gap in research about the specific perceptions and use of Child HCAHPS for pediatric QI.

We studied 1 children’s hospital experience with using Child HCAHPS data, so our findings may not be generalizable, but they are instructive given limited research on pediatric QI efforts using Child HCAHPS data.

We also were unable to survey all FS or all quality leaders, with a response rate of ∼50% for both surveys. Leaders who are more positive about patient experience surveys may be more likely to respond, and staff who responded may be more compliant given their attendance at regular staff meetings. Nevertheless, our findings were similar to those of a national sample of hospital leaders and other hospital staff studies staff, with a few exceptions that suggest study staff may find QI more useful in improving care and may place more value on using data for QI.

We identified several important findings with implications that may encourage hospitals to use Child HCAHPS for monitoring quality and for making improvements. Our hospital quality leaders reported wide use of Child HCAHPS data, including for comparisons to other hospitals. Both quality leaders and FS agreed on the validity of Child HCAHPS data, the importance of specific measures, accuracy in reflecting the quality of care experiences, specific information for QI, and its use for improving the quality of inpatient pediatric care. They also agreed on several approaches to improving Child HCAHPS scores within a strong organizational culture surrounding QI and improving Child HCAHPS domains. As a result, quality leaders and staff viewed Child HCAHPS data positively and as useful for their efforts to improve pediatric inpatient care and patient and family care experiences.

Studies used to assess FS and quality leader attitudes toward improving quality are important given that leadership drives and supports QI efforts and FS play a critical role at the bedside providing patients with safe, high-quality care. A multisite evaluation of the use of Child HCAHPS may identify additional insights, lessons, and challenges.

We acknowledge the time and support from all the hospital leaders and FS who participated in the surveys for this study. We also acknowledge Nabeel Qureshi, Chau Pham, and Lynn Polite for assistance with data collection.

FUNDING: Supported by a cooperative agreement from the Agency for Healthcare Research and Quality (U18HS025920). The funder/sponsor did not participate in the work.

Dr Quigley conceptualized and designed the study, advised on the literature review, led the development of the surveys, analyzed and interpreted the data, drafted the article, and revised the article critically for important intellectual content; Dr Slaughter led the analysis of the surveys, advised on the draft of the article, analyzed and interpreted the data, drafted the article, and provided critical input and revisions to the article; Dr Gidengil assisted in developing the survey instruments and provided critical input and revisions to the article; Dr Palimaru assisted in the search for the surveys and items in developing the survey instruments and drafted parts of the article; Drs Lerner and Hays provided input and critical revisions to the article for important intellectual content; and all authors were involved in final approval and approved of the final manuscript as submitted.

1.
Berwick
DM
.
Developing and testing changes in delivery of care
.
Ann Intern Med
.
1998
;
128
(
8
):
651
656
2.
Imai
M
.
Kaizen: The Key to Japan’s Competitive Success
.
New York, NY
:
Random House
;
1996
3.
Sims
DC
,
Jacob
J
,
Mills
MM
,
Fett
PA
,
Novak
G
.
Evaluation and development of potentially better practices to improve the discharge process in the neonatal intensive care unit
.
Pediatrics
.
2006
;
118
(
suppl 2
):
S115
S123
4.
Aldiss
S
,
Ellis
J
,
Cass
H
,
Pettigrew
T
,
Rose
L
,
Gibson
F
.
Transition from child to adult care--‘it’s not a one-off event’: development of benchmarks to improve the experience
.
J Pediatr Nurs
.
2015
;
30
(
5
):
638
647
5.
McErlane
F
,
Foster
HE
,
Armitt
G
et al
.
Development of a national audit tool for juvenile idiopathic arthritis: a BSPAR project funded by the Health Care Quality Improvement Partnership
.
Rheumatology (Oxford)
.
2018
;
57
(
1
):
140
151
6.
Reyes
MA
,
Paulus
E
.
The landscape of quality measures and quality improvement for the care of hospitalized children in the United States: efforts over the last decade
.
Hosp Pediatr
.
2017
;
7
(
12
):
739
747
7.
Toomey
SL
,
Elliott
MN
,
Zaslavsky
AM
et al
.
Variation in Family experience of pediatric inpatient care as measured by Child HCAHPS
.
Pediatrics
.
2017
;
139
(
4
):
e20163372
8.
Calabro
KA
,
Raval
MV
,
Rothstein
DH
.
Importance of patient and family satisfaction in perioperative care
.
Semin Pediatr Surg
.
2018
;
27
(
2
):
114
120
9.
Robertson
S
,
Pryde
K
,
Evans
K
.
Patient involvement in quality improvement: is it time we let children, young people and families take the lead?
Arch Dis Child Educ Pract Ed
.
2014
;
99
(
1
):
23
27
10.
Quigley
DD
,
Palimaru
A
,
Lerner
C
,
Hays
RD
.
A review of best practices for monitoring and improving inpatient pediatric patient experiences
.
Hosp Pediatr
.
2020
;
10
(
3
):
277
285
11.
Elliott
MN
,
Lehrman
WG
,
Goldstein
E
,
Hambarsoomian
K
,
Beckett
MK
,
Giordano
LA
.
Do hospitals rank differently on HCAHPS for different patient subgroups?
Med Care Res Rev
.
2010
;
67
(
1
):
56
73
12.
Hospital Consumer Assessment of Healthcare Providers and Systems
.
HCAHPS and hospital VBP
.
2020
.
Available at: https://hcahpsonline.org/en/hcahps-and-hospital-vbp/. Accessed September 18, 2020
13.
Feng
JY
,
Toomey
SL
,
Elliott
MN
,
Zaslavsky
AM
,
Onorato
SE
,
Schuster
MA
.
Factors associated with family experience in pediatric inpatient care
.
Pediatrics
.
2020
;
145
(
3
):
e20191264
14.
Toomey
SL
,
Zaslavsky
AM
,
Elliott
MN
et al
.
The development of a pediatric inpatient experience of care measure: Child HCAHPS
.
Pediatrics
.
2015
;
136
(
2
):
360
369
15.
National Quality Forum
.
About us
.
2015
.
Available at: www.qualityforum.org/story/About_Us.aspx. Accessed September 18, 2020
.
16.
Fustino
NJ
,
Moore
P
,
Viers
S
,
Cheyne
K
.
Improving patient experience of care providers in a multispecialty ambulatory pediatrics practice
.
Clin Pediatr (Phila)
.
2019
;
58
(
1
):
50
59
17.
Ballweg
DD
.
Implementing developmentally supportive family-centered care in the newborn intensive care unit as a quality improvement initiative
.
J Perinat Neonatal Nurs
.
2001
;
15
(
3
):
58
73
18.
Kilo
CM
.
Improving care through collaboration
.
Pediatrics
.
1999
;
103
(
1 suppl E
):
384
393
19.
Rosenberg
RE
,
Klejmont
L
,
Gallen
M
et al
.
Making comfort count: using quality improvement to promote pediatric procedural pain management
.
Hosp Pediatr
.
2016
;
6
(
6
):
359
368
20.
Taff
K
,
Chadwick
S
,
Miller
D
.
Family experience tracers: patient family advisor led interviews generating detailed qualitative feedback to influence performance improvement
.
Patient Exp J
.
2018
;
5
(
2
):
97
108
21.
Coleman
NE
,
Pon
S
.
Quality: performance improvement, teamwork, information technology and protocols
.
Crit Care Clin
.
2013
;
29
(
2
):
129
151
22.
Nembhard
I
,
Tucker
A
.
Deliberate learning to improve performance in dynamic service settings: evidence from hospital intensive care units
.
Organization Science
.
2011
;
22
(
4
):
907
922
23.
Maguire
DJ
,
Burger
KJ
,
O’Donnell
PA
,
Parnell
L
.
Clinician perceptions of a changing hospital environment
.
HERD
.
2013
;
6
(
3
):
69
79
24.
Shoemaker
SJ
,
Parchman
ML
,
Fuda
KK
et al
.
A review of instruments to measure interprofessional team-based primary care
.
J Interprof Care
.
2016
;
30
(
4
):
423
432
25.
Bradley
KA
.
Quality safety assessment/application for nurses (QSAAN)
.
2012
.
Available at: https://epublications.regis.edu/theses/830. Accessed September 18, 2020
26.
Harter
J
,
Schmidt
F
,
Killham
E
et al
.
Q12 Meta-analysis: The Relationship Between Engagement at Work and Organizational Outcomes
.
Omaha, NE
:
The Gallup Organization
;
2009
27.
Thorp
J
,
Baqai
W
,
Witters
D
et al
.
Workplace engagement and workers’ compensation claims as predictors for patient safety culture
.
J Patient Saf
.
2012
;
8
(
4
):
194
201
28.
Read
EA
.
Nurses’ workplace social capital: development and validation of a self-report questionnaire
.
2016
.
Available at: https://ir.lib.uwo.ca/etd/3767. Accessed September 18, 2020
29.
Sorra
JS
,
Dyer
N
.
Multilevel psychometric properties of the AHRQ hospital survey on patient safety culture
.
BMC Health Serv Res
.
2010
;
10
:
199
30.
Dunagan
PB
.
The quality improvement attitude survey: Development and preliminary psychometric characteristics
.
J Clin Nurs
.
2017
;
26
(
23–24
):
5113
5120
31.
Hays
R
,
Hayashi
T
,
Stewart
A
.
A five-item measure of socially desirable response set
.
Educ Psychol Meas
.
2016
;
49
(
3
):
629
636
32.
DiMatteo
MR
,
Hays
RD
,
Gritz
ER
et al
.
Patient adherence to cancer control regimens: Scale development and initial validation
.
Psychol Assess
.
1993
;
5
(
1
):
102
112
33.
Famolaro
T
,
Yount
N
,
Hare
R
et al
.
Hospital Survey on Patient Safety Culture 2018 User Database Report (Prepared by Westat, Rockville, MD, under Contract No. HHSA 290201300003C)
.
Rockville, MD
:
Agency for Healthcare Research and Quality
;
2018
.
34.
Ellis
J
.
All inclusive benchmarking
.
J Nurs Manag
.
2006
;
14
(
5
):
377
383
35.
Patrick
M
,
Alba
T
.
Health care benchmarking: a team approach
.
Qual Manag Health Care
.
1994
;
2
(
2
):
38
47
36.
Albanese
MP
,
Evans
DA
,
Schantz
CA
et al
.
Engaging clinical nurses in quality and performance improvement activities
.
Nurs Adm Q
.
2010
;
34
(
3
):
226
245
37.
Price
M
,
Fitzgerald
L
,
Kinsman
L
.
Quality improvement: the divergent views of managers and clinicians
.
J Nurs Manag
.
2007
;
15
(
1
):
43
50
38.
Dycus
P
,
McKeon
L
.
Using QSEN to measure quality and safety knowledge, skills, and attitudes of experienced pediatric oncology nurses: an international study
.
Qual Manag Health Care
.
2009
;
18
(
3
):
202
208
39.
Abdi
Z
,
Delgoshaei
B
,
Ravaghi
H
,
Abbasi
M
,
Heyrani
A
.
The culture of patient safety in an Iranian intensive care unit
.
J Nurs Manag
.
2015
;
23
(
3
):
333
345
40.
Cleary
M
,
Walter
G
,
Horsfall
J
,
Jackson
D
.
Promoting integrity in the workplace: a priority for all academic health professionals
.
Contemp Nurse
.
2013
;
45
(
2
):
264
268
41.
Hardy
P
,
Jaynes
C
.
Editorial: finding the voices for quality and safety in healthcare: the never-ending story
.
J Clin Nurs
.
2011
;
20
(
7-8
):
1069
1071

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.