HCAHPS Update and Impacting The Patient

Perception of Care January 28, 2009

Karen Cook, RN, BSNwww.studergroup.com

Nina Setia, Adm. Director, Service ExcellenceHackensack University Medical Center

Webinar Agenda

Understanding the Data

Priority Initiatives and

Cool Ideas

Hardwiring Excellence and

HCAHPS

What it is: An update on HCAHPS

data and overview of recommended

strategies to improve the patient

perception of care.

What it is NOT: A tutorial on the survey tool or

submitting data.

15 min

15 min

20 min

Commit to Excellence

Build a CultureAround Service

Measure theImportant Things

Create and DevelopGreat Leaders

Focus on EmployeeSatisfaction

Build IndividualAccountability

Recognize andReward Success

Communicateat All Levels

Align Behaviorswith Goals and Values

Nine Principles – A Culture of “Always”®

Times… They are a Changing…

No more denial, blaming rationalization, ignoring results, assuming or hoping…

This does not apply to us… we are the only hospital in town…the IPPS payments don’t apply…

41

21

20

19

Patient Experience Physician Decision

Hospital Reputation Location

HCAHPS Aligns with Industry Trends

“…patients and doctors are more likely to base their choice of hospital on non-clinical aspects of a visit – like communication.”

HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems

A standardized survey tool to measure the patient’s perception of quality care provided during their experience while a patient at an acute-care hospital.

The patient perception of care will be publicly reported with other quality metrics on the Hospital Compare website. www.hospitalcompare.hhs.gov

The information will be used to provide meaningful data for improvement efforts as well as provide comparisons between hospitals to help consumers choose a hospital.

What is HCAHPS

Why is it important?

How will it be used?

What Do Patients Want From Us?

Communication with doctorsCommunication with nursesResponsiveness of hospital staffPain managementCommunication about medicinesDischarge informationCleanliness of hospital environmentQuietness of hospital environmentOverall rating of hospitalWillingness to recommend the hospital

Their perception of our

performance is a reportable and

tangible reflection

of yourreputation

HCAHPS Aligns with Clinical Quality

“Patient-Centeredness” is one of the Institute of Medicine’s key dimensions of Quality and CMS’s Quality Improvement Roadmap vision for Right Care, Right Person, Every Time

1. Safe2. Effective3. Patient-Centeredness4. Timely5. Efficient6. Equitable

Institute of Medicine, Crossing the Quality Chasm: A new Health System for the 21st century, March, 2001

“Always” is the response scale

most highly associated with

loyalty

How Will HCAHPS Reinforce Focus on Quality?

Patient-Centered care is a quality indicatorQuality no longer the domain of just the cliniciansGives a voice to the patient perception of safetyHighlights communication issues/barriersPatient-centered care actively involves patients in their careMore senior leaders are engaged and interested in delivering patient-centered care

Physician- hospital relations

Disaster Preparedness

Patient Satisfaction

Governmental mandates

Financial Challenges

Personnel shortages

1%

2%

2%

9%

16%

22%

26%

30%

32%

41%

43%

77%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Patient Safety and Quality

American College of Healthcare Executives, 2008, Annual CEO Survey of Top Issues Confronting Hospitals (Patient Safety and Quality are now combined. They were shown separately in prior years

HCAHPS Aligns with CEO’s Top Issues - (2008)

7%increase

Patient Satisfaction 5% increase

Care for the uninsured

Capacity

Technology

Issues about not-for profit status

Malpractice insurance

HCAHPS Builds the Bridge Between Quality and Service

Quality (Factual)

What actually happened in the care process…

What was the clinical quality/outcome

HCAHPS

Service (Emotional)

How did the patient feel about what happened…

How satisfied were they…

How often the patient perceived it happened… (Frequency of Process)

A Culture of “Always” and Evidence Based Leadership (EBL) SM

Standardization AcceleratorsMust Haves®

Performance Gap

Leader Evaluation

Leader Development

Foundation Breakthrough

STUDER GROUP:

Rev 11.07

Must Haves®

RoundingThank You NotesEmployee SelectionPre and Post Phone CallsKey Words at Key Times

(Principle 3, 5, 6, & 9)

Re-recruit high and middle performers

Move low performers up or out

(Principle 4)

Agendas by pillar

Peer interviewing

30/90 day sessions

Pillar goals

(Principle

1 & 2)

Leader Eval MgrSM (LEM)

Staff Eval MgrSM (SEM)

Discharge Call MgrSM (DCM)

Rounding MgrSM

Idea ExpressSM

Aligned Goals Aligned Behavior Aligned Process

Create process to assist leaders in developing skills and leadership competencies necessary to attain desired results

(Principle 4 & 8)

Implement an organization-wide leadership evaluation system to hardwire objective accountability

(Principle 7)

Technology is Driving Change…

Consumers will have the same access to medical information as providers have… and more time to explore it80% of American population use internet - including Baby BoomersPatients will expect more and tolerate lessPublic reporting is forcing a new direction in patient-centered careMedicare will become the #1 customer of every hospital

Source: Health Management Technology, Aug 1999, Harris Poll, 2007 and Press, Ganey

QQUUAALLIITTYY

QQUUAALLIITTYY

SSEERRVVIICCEE

SSEERRVVIICCEE

GGRROOWWTTHH

GGRROOWWTTHH

PPEEOOPPLLEE

PPEEOOPPLLEE

FFIINNAANNCCEE

FFIINNAANNCCEE

Passion to make healthcare

betterServing the healthcare

needs of the COMMUNITY

Taking Better Care of Patients

MISSION

VISION

STANDARDS OF PERFORMANCE: VALUES

HCAHPS Aligns With A Balanced Approach

Financial Impact of HCAHPS

HCAHPS is voluntary but results must be included in the Pay for Reporting program to receive a full Inpatient Prospective Payment System (IPPS) payment update

Penalty does not apply to those not reimbursed by IPPS… Yet.

Potential impact: Public reporting will impact patient perception and choice (Service,

Quality, and Growth Pillars) Potential downstream impact on revenue if it is tied to pay for

performance (Finance Pillar) Financial indicators such as turnover as employees want to work for

a quality organization (People Pillar)

A comprehensive performance assessment model is developed…

The proposed methodology will score a hospital’s performance and compute an overall VBP score, translating into an incentive payment

Will reward hospitals for performance based on attainment in the measurement year or improvement from the prior year’s baseline performanceFor each measure with a broad differentiation of performance scores, each measure will have a benchmark (top 10%) and an attainment threshold (50th percentile) based on national dataAs scores improve nationally, the goals will change

There will be different measures for different purposes such as incentive payment, public reporting, and measure development

Potential Plans for Transition to Pay For Performance (Baucus-Grassley Bill Draft)

1. FY2009: 1st reporting year for VBP

– Payment: 100% public reporting

– Measures reported are basis for FY2009 “attainment” scores; FY2008 provides baseline for “improvement” calculations

2. FY2010: 2nd reporting year

– Payment: 50% based on performance, 50% on public reporting (potential) (70% clinical quality and 30% HCAHPS metrics)

3. Impact on rural hospitals is unknown

– “The Secretary shall consult with small and rural hospitals on the application of the Program to such hospitals.”

Who knows?? Bottom line is that we should proceed as if our pay WILL be tied to performance!

www.hospitalcompare.hhs.gov

Click this link to find more information on the HCAHPS tool.

Media Coverage March 29, 2008

Real impact of public reporting will effect reputation

Patient choice and downstream revenue

Pride and turnover as employees want to work for a quality organization

Understanding & Impacting the Data

Case Study: Hackensack University Medical Center

Quick Facts About HCAHPS

Scale - top box will be reportedAlways, Definitely Yes, % 9 and 10, Yes

Measures the frequency of events as perceived by the patients (“how often or did xxxx occur?”)

Never, Sometimes, Usually, Always

N – 300 minimum per year

Inpatient Adults over 18 years of age; acute care hospitalsCase and patient mix adjusted

Should be a complementary, not the only tool to be used in identifying performance improvement opportunities (leader rounding, DC Calls, focus groups, verbatim comments etc.)

Should not be considered a new “program” but rather a new method of reporting information

QuestionsRWHC

(all qrtr ave*)United States

SG Partners

Nurses always communicated well 78.4% 74% 75%

Doctors always communicated well 83.7% 80% 79%

Patients always received help quickly 72.4% 62% 62%

Pain was always well controlled 71.6% 68% 70%

Staff always explained about medicines 65.1% 59% 59%

Rooms and bathrooms were always kept clean 78.9% 69% 69%

Area around room was always quiet at night 67.4% 56% 52%

Yes patients were given information about recovery at home 80% 81%

Patient’s overall rating of hospital (9 & 10) 64% 67%

Yes would definitely recommend this hospital 68% 71%

HCAHPS ComparisonApril 1, 2007 to March 31, 2008

Green SG Partners above US Average Yellow Yellow SG Partners equal US Average Red Partners below US Average

Sample of Board CommunicationHCAHPS results: 4th reporting period (April 2007-March 2008 discharges)

Oct 06 - Jun 07 Discharges

Oct 06 – Sept 07 Discharges

Jan 07 – Dec 07 Discharges

April 07 – March 08 Discharges

July 07 – Jun 08 DischargesSuppression linked to loss of APU

2007

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2006 2008 2009

Estimated Timeline We are here: Public Reporting data from April 2007-March 2008

Oct 07– Sept 08 Discharges

Jan 08– Dec 08 Discharges

Apr 08– Mar 09 Discharges

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….but we are REALLY here!

Raw Data reported every

two weeks

Past and Current Future

Financial Impact

As of March 2009 non-participating hospitals’ Medicare payments run the risk of being reduced by at least 2% under market basket.

Senior Leader’s Adopted Composites: Action Plans Report Quarterly

Composite Responsible Leader(s)

Communication with Doctors CMO

Communication with Nurses CNO

Pain Management Chairman of Pain Service

Senior VP of Operations

Cleanliness of Hospital Environment VP of Operations

Quietness of Hospital Environment VP of Operations

CNO

Responsiveness of Staff CNO

Discharge Information CNO

Communication about Medicines Administrator, Patient Safety

Nina Setia, featured in Hardwired 9 for the

HCAHPS Coaching Track for Nurse

Managers

Leader Coaching Track

1 hour a week for 12 weeks

Starts with signing a coaching contract

Covers Employee Satisfaction for first 2 weeks

Includes relevant handouts

Contains a competency check at beginning of each session

Homework given at last session

Evaluation sent and completed electronically

CEU’s awarded (can be converted to Nursing contact hours)

Pain Initiative

Changed pain policyreflects “acceptability” of pain levelRe-assessment within 1 hour

“Pain Rule” implemented because pain scores were poor“Red flag” flashes on computer as a reminder to re-assess pain

Chairman, Pain & Palliative Medicine began rounding on nursing units in 1Q08

Bring pain policy to life and enforced itProvided education to standardize practice within each unit and across all unitsRounding with nurses

Pain Initiative: Unit 4 West

0

10

20

30

40

50

60

70

80

90

100

84

85

86

87

88

89

90

91

92

HCAHPS Pain 67 69 62 68 73 88

Patient Satisfaction Pain 87.8 87.4 86.6 88.2 89.6 90.9

1Q07 2Q07 3Q07 4Q07 1Q08 2Q08

HCAHPS:

•“How often was your pain controlled?

•“How often did the staff do everything they could to help you with your pain?”

Patient Satisfaction:

•“How well your pain was controlled”

Patient Care Initiatives

Quality Leadership Steering Committee for Service ExcellenceStandardize practices, materials and dashboardsDevelop internal coaching experts

Re-launched hourly rounding on all unitsPiloted TCAB project (Transforming Care At Bedside) with a goal to increase nurses time at the bedside

“Nurses are with me all the time.” “Quiet Time” for safe administration of medications

CEO “Expectation” on discharge phone callsKey words “For safety reasons, nurses will be checking your ID band frequently during your hospital stay.”

Increase time at the bedside = increase in communication = increase in HCAHPS scores

Unit based HCAHPS data

Initiatives

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

1st reporting period: Oct 06-Jun 07 7th reporting period: Jan-Dec 08 8th reporting period: Apr 08-Mar 09

US Avg NJ Avg

Discharge follow up

phone calls

Re-launched hourly

rounding, assessed on

discharge phone calls

Increased discharge

calls,Re-launched

hourly rounding

Pain initiative

Hourly rounding,

key words, TCAB

“Quiet Time”

Key Initiatives to Deliver Patient-Centered Care

White boards

Pre-printed Med Card

Leader Rounding

Key Words/AIDET

Caregiver Engagement

Open visitation

Noise Audits – Quiet Time

Private rooms

Hourly Rounding

Discharge phone calls

Bedside Report/Handoffs

Top Priority

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Impact on Patient PerceptionLower Higher

Communication with Nurses

Q1 During this hospital stay, how often did nurses treat you with courtesy and respect?

Q2 During this hospital stay, how often did nurses listen carefully to you?

Q3 During this hospital stay, how often did nurses explain things in ways you could understand?

o Nevero Sometimeso Usually o Always

Studer Group Tactics:

Individualized patient careSit at bedside to review care planWhite boards

Hourly RoundingBedside Shift ReportPeer Interview for communication and empathy talentsAIDETBehavior standards

Slide format adapted from Press, Ganey

Key Words at Key Times is a Must HaveInitiative #1

Key words reflect a communication style that improves the quality of information provided by every person in every interaction

Key times are defining moments that: Occur during times of vulnerability

– Greetings – first impression

– Personal times - like bathroom needs

– Handoffs

– Goodbyes

Are what patients remember and impact the overall perception of the experience

Why are Key Words Important?

Reduce patient anxiety

Improve patient perception of care

Improve coordination of care

Decrease law suits

“Being Kept Informed” was the MOST important characteristic when “returning to a hospital for

future visits.”2007 McKinsey Survey of >2,000 patients with commercial insurance or Medicaid

Key Words to Build Trust and a Culture of Safety

We’ve been expecting you!

We have the best radiology department in the city.

At our hospital, nothing is more important than your safety.

During your stay it is important that each caregiver washes or disinfects their hands before contact with you. This will help decrease the spread of infections and keep you safe. Please do not hesitate to remind us if we forget to clean our hands. Have you seen the staff wash their hands?

You are in good hands with Dr. Jones.

Reducing Potential for Litigation Through Better Patient Communication

Source: The Physician Executive, June 2004

1. Focus on Issues: Rounding, AIDET, Key Words2. Educate the Patient: Rounding, AIDET, Managing Up3. Enlist the Patient: Rounding, Key Words4. Share Decisions: AIDET, Key Words

In this Article….

“The most common cause of malpractice suits is failedCommunication with the patients and their families.Explore ways that better communication could leadTo fewer malpractice claims and allow health careOrganizations to reduce litigation costs.”

Physician Keywords

“I am washing my hands for your SAFETY.”

“I have TIME to answer your questions.”

“I want you to be INVOLVED in your treatment plan”

“I want to be sure I EXPLAIN everything to you…”

“To protect your PRIVACY, let me close the curtain.”

“For your COMFORT, I ordered pain medicine...”

“I want to keep you INFORMED…”

“I want to make sure we are THOROUGH”

“You are in good hands with the nurses on this floor.”

The Key to Key Words is PRESENCE

Nonverbal behavior – be fully present

– Smile, establish and hold eye contact

– Put warmth in your voice

– Be at THEIR level whenever possible

– Face squarely or “heart to heart”

Verbal behavior – be fully present

– Acknowledge, welcome and use their preferred name

– Introduce self and role

– Duration - say what you’ll do and what to expect

– Explain “I am part of the Albany Medical Center team”

– Thank them

Adapted from: Heart to Heart Communication – Wendy Leebov

A

I

D

E

T

Acknowledge

Introduce

Duration

Explanation

Thank You

Improved clinical outcomes and

increased patient and physician

satisfaction

DecreasedAnxiety

IncreasedCompliance

+

AIDET – Five Fundamentals of Communication

Key Words - Designed Handoff’s

I have worked with Cindy for over two years and she will take great care of you.

Mrs. Jones you are doing so much better – you can now be on the step down unit. Do you mind if I share a bit about you with Cindy?

It will take us about five minutes to discuss your care because I want to make sure she is very familiar with your care plan.

We want to make sure we keep you informed about your care as well so we will do the report here in the room if ok with you?

It has been a pleasure taking care of you and I know you will do well. I am working tomorrow and will check in on you.

A

I

D

E

T

Manage Up Co-Workers by Communicating Skill and Training

Source: Sacred Heart Hospital, Pensacola, FL

Patient Satisfaction

Key Words: Written Material

Source: Sierra Vista MC, San Luis Obispo, CA

Key Words

Key Words: Manage UP Co-Workers

Managing UP uses keyword phrases to position something or someone in a positive manner

Conveys a spirit of teamwork

Aligns the organization and demonstrates pride

Instills confidence in ability to provide quality care

Co-workers appreciate the kind words and the “vote” of confidence as well

“Mrs. Smith. This afternoon you will be going to the Cardiac Step-down unit which means you are closer to going home. This floor has excellent staff and state of the art monitors. They are aware you will be down there this afternoon and are well prepared for you…”

Key Words

Customize to reinforce initiatives such as:

Individualized Patient Care

Rounding for pain goals

Managing Up

Aligned with other initiatives like Time Out

Rounding for Outcomes is a Must Have

Rounding on Rounding on Employees, Employees,

Patients, Patients, Physicians Physicians and Other and Other

DepartmentsDepartments

Rounding is a process to PROACTIVELY engage, listen to, communicate with, build relationships with and support the most important customers

Maintains TRANSPARENT communication

Focuses on the positive and what is working well - which is a paradigm shift

Is a requirement of all leaders

Promotes SHARED Decision Making

It is not reactive, focused on “what’s wrong, MBWA, or sporadic when there is “time”

Initiative #2

Rounding for Outcomes on Staff

“The number one person we round on is the employee. And if

we skip the employee, we’re

making a mistake.”Quint Studer, Author of Hardwiring Excellence

Rounding for Outcomes – Employees

Rounding on Employees

Direct reports – 100% monthly

(All staff are rounded at least once per quarter)

3 employees x 15 minutes = 45 min

+ 15 minute F/U

= 60 minutes/day

Concern and Care – relationship connection and open lines of communication

What is Working Well – focus on positives – how did you make a difference today?

People to Recognize – specific people and actions (other depts, physicians etc.)

Systems to Improve – seek input (safety, rework, pet peeves) Trust but VERIFY behaviors

Tools and Equipment – barriers to efficiency

Follow-up – take notes

Rounding for Outcomes – Patients Nurse Leader

Good morning, Mrs. Smith . . . I am Carol, the nurse manager on this unit. Would it be ok if I spent about 3 minutes with you? (sit at the bedside if possible)

I see from the whiteboard that Becky is taking care of you. She is an excellent nurse. (managing up is critical piece of leader rounding)

On our unit, the expectation is that a staff member is in your room every hour to check on you. Have you seen one of our team members approximately every hour? Have you had to use your call light to ask for pain medicine?

Thank you so much for your time. I will be sure to share your compliment with Becky. Is there anything you need before I go?

(Follow up with the staff . . . Either on the spot coaching or reward / recognition.)

Selection and Retention of TalentBehavior Standards Initiative #3

Study conducted by Dr. Gerald Graham, Management Professor at Wichita State UniversityMotivating Today’s Employees, Bob NelsonTalent+, 1998

Top Five Workplace Incentives

1. Written Thanks From Manager/Executive Team Leader

2. Personal Thanks From Manager

3. Promotion for Performance4. Public Praise5. Morale-Building Meetings

Recognition

It’s not a natural skill…

it must be taught!

“65% of Americans reported that they received no recognition for good work in the past year…”

“65% of Americans reported that they received no recognition for good work in the past year…”

Source: How Full Is Your Bucket-Tom Rath, Donald O. Clifton

Focus on the PositiveCompliment to Criticism Ratio

3 to 13

compliments1 criticism

Positive!

2 to 12

compliments1 criticism

Neutral

1 to 1 1 compliment 1 criticism Negative

Source: Tom Connellan, “Inside the Magic Kingdom”, pgs 91-95

Behavior Standards – A Culture of “Always”

Standards in recruitment and application process

Standard of the Month

Are YOU an Effective Team Member?

Better able to predict the needs of other team membersProvide quality information and feedbackEngage in higher level decision makingManage conflict skillfullyUnderstand their role and responsibilityReduce stress on team as a whole through better performance

http://teamstepps.ahrq.gov/abouttoolsmaterials.htm

HCAHPS Toolkit – Aligning Actions to Create a Culture of Always

Over 40 evidence-based recommendations to impact the patient perception of quality

Will be sent by Mary Jon

Order today at www.studergroup.com

The Right Thing to Do

Leader Rounding and Key Words/Managing UP

Ensures strong communicationPromotes a sense of “well-being”Decreases anxiety Exceeds expectationsProvides “individualized” care

Do I take responsibility and ownership of my department?

Do I Manage Up my team and my organization?

It is not about scores, financial indicators,

public reporting, % of always…it is about

compassionate care and saving lives