Which Hospitals Promote a Sleep-Friendly Patient Experience?

Introduction

In an effort to promote greater transparency in healthcare and to improve the quality of care delivered to patients, the Center for Medicare and Medicaid Services (CMS) disseminates a quality-assessment survey to all hospital patients (1). The survey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), aims to measure patient perceptions of hospital experience to produce comparable data for consumer and hospital utilization. Subject matter ranges from questions about hospital comfort, provider respect, and pain management to assess the universal care received by patients in hospital settings and ascertain a larger care domain score (2,3). The survey results are publicly available and are directly linked to both the hospital reputation and hospital reimbursement, such that if a hospital scores poorly on a single metric it can negatively impact the value-based incentive payments they receive through the Patient Protection and Affordable Care Act (2-4). One of the questions on the HCAHPS survey is a patient-assessed measurement of the nighttime environment and whether it is conducive to sleep as depicted by the “Quiet at Night” variable (3).

Though the “Quiet at Night” metric is only a single measure of hospital care, it is an important one as it addresses both hospital culture and acknowledges the importance of sleep as a healing tool for patients. Sleep is well-documented to benefit health outcomes by decreasing recovery time and medical complications and a lack of it is correlated with both increased morbidity and mortality (5). However, most hospital settings are often subject to constant commotion and frequent disruptions that prevent patients from receiving adequate sleep and thus interfere with patient experience (5-7). Thus far no studies have analyzed the CMS data to qualify the types of hospitals that score well on this question. Given the financial implications of the HCAHPS survey and the positive benefit that sleep has on patient health and healing, this is a highly pertinent question to address. The objective of this study was to analyze the CMS data to better understand the demographics of hospitals that score well on the “Quiet at Night” question and compare them to the scores of the US News World Report (USNWR) honor roll hospitals to identify improvable and sleep-friendly measures that can be used by institutions nationally.

Methods

The HCAHPS dataset contains 4 variables for measuring “Quiet at Night.” Patients are asked to rate the hospital using discrete descriptors (“Always” Quiet at Night, “Usually” Quiet at Night, “Sometimes” Quiet at Night or “Never” Quiet at Night) which are then assigned numeric values. CMS then applies necessary adjustments (patient mix, survey mode, etc) and translates these national survey results into (1) the Linear Mean Score (1-100), an annual 4 quarter average, and (2) the HCAHPS Star Rating (1-5) (1,8,9). The HCAHPS Star Rating is created using the Linear Mean Score and clustering algorithms to identify gaps in the data, thereby grouping the hospitals closest in quality together (8,9). A HCAHPS Star Rating of 5 indicates that a hospital is among the highest quality performers for the “Quiet at Night” metric and a HCAHPS Star Rating of 1 is assigned to the lowest performers. In an effort to identify and understand trends in this survey, this study conducts a secondary analysis on the HCAHPS dataset from 2019, which incorporates information from 4722 hospitals (8,9). Given that this research analyzed pre-existing online datasets, an ethics review board was not consulted for this study.

The CMS database, available publicly, was downloaded and imported into RStudioTM, a statistical programming software. Additional software packages allowed for the original dataset to be filtered down to data only related to the “Quiet at Night” question. The hospitals were then further isolated based on their Star Ratings for this metric and then ranked based on their Linear Scores. Using the Linear Mean Scores and the HCAHPS Star Ratings’ inherent clustering algorithm, the top scorers among the 5 Star Rated hospitals were isolated. These facilities were grouped together as CMS Top Rated “Quiet at Night” Hospitals. The underlying notion being that the Theory of Positive Deviance would shed light on practices that would improve this metric for all hospitals. This theory is predicated on the idea that different hospitals, in this case, have uncommon practices that enable them to find better solutions to universal challenges (10). Thus, the key characteristics of these institutions were then assessed using the American Hospital Database (AHD), an independent organization that provides and publicly reports national hospital data and statistics (11). To ascertain trends in these facilities and determine their predictive value, the US News Honor Roll Hospitals (2019-2020) were used as a comparison group (11,12). A significance threshold of P < .05 was established when comparing the 2 cohorts. For these groups, the Linear Mean Scores and the HCAHPS Star Ratings were isolated from the CMS data and the same key characteristics were assessed utilizing AHD.

Results

The mean HCAHPS Star Rating for CMS Top Rated “Quiet at Night” Hospitals (n = 22, 0.46% of institutions nationally) was 5.00 (out of 5.00), with a standard deviation of 0.00 (Figure 1). These values can be explained by the selection criteria used to isolate these hospitals. The mean HCAHPS Star Rating for US News Honor Roll Hospitals (n = 21, 0.44% of institutions nationally) was 2.67 (out of 5.00), with a standard deviation of 1.24 (Figure 1). Though there was no overlap between these 2 groups, 2 US News Honor Roll Hospitals, Johns Hopkins Hospital and the Mayo Clinic, received a HCAHPS Star Rating of 5. However, these hospitals’ HCAHPS Star Ratings did not place them in the Top Rated “Quiet at Night” Hospitals as that list compounded both HCAHPS Star Ratings and Linear Mean Scores. An unpaired t-test of this data found a 2-tailed P-value of less than .0001, which is considered statistically significant under all conventional significance levels.

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Figure 1.

Comparison of HCAHPS Star Ratings between CMS top rated “Quiet at Night” hospitals and the US News honor roll hospitals derived from the CMS national database.

The key, overarching characteristics of the CMS Top Rated “Quiet at Night” Hospitals were that these facilities are predominantly privately owned (77%), non-trauma-designated (100%), short-term acute care facilities, and are often specialized, surgical facilities (77%) with a mean of 31.73 beds staffed (Figure 2). Of note, these hospitals also appear to be located predominantly in cities throughout the South (Figure 2). In looking at these same characteristics for the US News Honor Roll Hospitals, these facilities are largely composed of voluntary non-profit controlled (76%), trauma-designated (100%), short-term care facilities containing various specialties (100%) with a mean of 1028.43 beds staffed (Figure 3).

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Figure 2.

Descriptive characteristics of the CMS top “Quiet at Night” Hospitals.

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Figure 3.

Descriptive characteristics of the US News Best Hospitals Honor Roll.

Limitations

The results from this study provide a secondary analysis of the CMS data of institutions nationally and identify potential characteristics that may contribute to having success on the “Quiet at Night” measure. This study focused on one variable and found that smaller, surgical hospitals had greater success in comparison to large academic centers. A potential shortcoming of this observation is that the practices that allow these smaller centers to be successful may not be feasible in larger hospitals. Moreover, as with any secondary analysis, this study relies on the primary data and patient perceptions captured by the CMS methodology. Therefore, it should be noted that the overarching themes discussed in this study may be more correlatory than causatory. This data does not capture all factors that influence a hospital's environment, and it is worth acknowledging that while many of the potential solutions (ie, room occupancy, hospital visitation policies, light and noise restrictions, etc) are modifiable, others (ie, size, ownership, services offered) are not. For the modifiable factors, further studies would need to isolate these themes and determine their causatory effects based on the Bradford Hill Criteria (13).

Discussion

This study critically analyzes hospitals that score well on the CMS “Quiet at Night” metric and compares their CMS ratings and demographic information to the US News Honor Roll Best Hospitals, a list of the best hospitals as demonstrated by national rankings. In comparing the ratings for these 2 lists, a stark disparity emerged in the average HCAHPS Star Rating score, the type of hospital, the patient populations targeted (ie, by specialty), and the number of beds staffed for the 2 groups. Most notably, those who score well on the “Quiet at Night’’ question are predominantly privately controlled, specialized, surgical facilities with few total hospital beds staffed. Hospitals recognized by US News are predominantly non-profit controlled, widely specialized, short-term facilities with high patient capacity. Specifically, the patient capacity increases 32-fold between the 2 groups. As noise is a proxy for sleep disturbances within hospitals and sleep is vital for patient health, this observation alone could be detrimental to patient well-being and health outcomes. With the added burden that larger hospitals experience when caring for and managing trauma, these differences in characteristics between the cohorts are not immediately surprising. The “Quiet at Night” metric is only one means of measuring the success of a hospital center and oftentimes more complex patient cases (as seen with trauma) require a multispecialty approach to comprehensive care that smaller facilities are unable to provide. However, ideally the goal would be for these larger centers and their multidisciplinary care teams to also improve their sleep quality practices to aid their patients’ care from every direction. The US News Honor Roll Hospitals are considered outstanding across metrics allowing them to set the standard for quality care nationally. However, the large differences in characteristics observed above and difference in “Quiet at Night” rating highlights the fact that these institutions lack certain qualities that are correlated with an ability to score well on the “Quiet at Night” question and thus optimize patient sleep.

The difference in success may be attributed to sleep-friendly actions taken by top performing “Quiet at Night” Hospitals, such as more programs aimed at promoting sleep through quiet hours and nighttime light reduction, specialized hospital units allowing for more personalized patient care, a less vulnerable/sick patient population and/or overall decreased activity throughout the night due to lower patient acuity and smaller hospital size. The common thread in the potential factors above is that there may be a hospital culture surrounding sleep that is more responsive and better equipped to facilitate patient sleep in the top performing “Quiet at Night” Hospitals compared to those on the US News Honor Roll Report list.

Conclusions

This study provides a comparison of hospitals that excel and fall behind in “Quiet at Night” metrics. Given the importance of sleep hygiene on improving patient health outcomes, sleep-friendly practices could potentially be implemented throughout hospitals nationally in a low-cost, low-tech manner. Moreover, the financial incentives tied to succeeding in this metric could benefit hospital systems and enable these extra funds to be allocated to other technologies and efforts to further improve patient health.

With the knowledge that “Quiet at Night” scores impact patient experience and CMS reimbursement, it is important to learn from those positive deviant hospitals to help the US News Hospitals improve on this metric. A greater understanding of how top CMS hospitals so efficiently provide care in a sleep-protective way may help inform larger institutions about Best Practices. Moving forward it is important to determine the cultural and organizational factors that enable hospitals to be top performers on the “Quiet at Night” metric, that is, through quantitative surveys and/or qualitative interviews of these hospitals. Ultimately, these next steps and further analysis needs to be done to determine how to meaningfully recreate and translate successful sleep programs to US News Honor Roll hospitals and all other hospitals nationally.