A great Patient Experience = Positive hcahps scores Topics of discussion

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A Great Patient Experience = Positive HCAHPS Scores

Topics of discussion

    • HCAHPS and Updates
    • Value Based Purchasing Reimbursement
    • National Trends
    • Evidence Based Best Practices
    • Hourly Rounding
    • Call Bell Response
    • A Quiet Hospital Environment
    • Scripting for Effective Communication


What is HCAHPS?

HCAHPS Survey Format

Updated Survey Question

New Patient Eligibility Criteria

  • Beginning with July 1, 2011 discharges –

    • Patients discharged to a nursing home or skilled nursing facility
    • DCG_STAT = 3 – Skilled Nursing Facility
    • DCG_STAT = 64 – Certified Medicaid Nursing Facility
    • Clients should continue to upload these patients
    • Beginning with July 1 discharges they will automatically be excluded from receiving an official HCAHPS survey

Communication Guidelines

  • Hospitals SHOULD

    • Encourage response to the survey
    • “It is permissible to notify the patient while in the hospital or at discharge that they may receive a survey after discharge.”
    • Improve the patient experience
    • Distribute the communication guidelines
  • Hospitals SHOULD NOT

    • Ask patients for a certain score
    • Indicate that their goal is to receive a certain score
    • New: Show the HCAHPS survey or cover letter to the patient prior to survey administration
    • New: Mail pre-notification letter or postcards

Value Based Purchasing

VBP Outlook

  • Fluid Scope

    • FFY2013: Combination of clinical and satisfaction measures
    • FFY2014: Outcomes, HAC, AHRQ composite measures
    • Expect additional changes to clinical domain
  • Financial Implications

    • 1.0% of baseline DRG at stake in FFY13 grows to 2.0% by FFY17
  • Consequent implications

    • Bandwagon effect: states, private payers will implement similar schemes, resulting in a major proliferation of P4P programs
    • CMS plans for applying VBP to Medicaid population
    • Cost containment more critical than ever

Financial implications of VBP

  • Dollars at-stake across all U.S. acute care hospitals:

    • $850MM at initial implementation
    • $1.7BN at full implementation
  • For the average hospital

    • Mean: approximately $500,000
    • Minimum: just over $100,000
    • Maximum: just over $6 Million
  • Most hospitals will lose money under VBP

  • Tip of the ice berg

CMS Quality Based Payment Initiatives

FY 2013 Program

  • 70/30 weighting (clinical/satisfaction) in Total Performance Score (TPS) has not changed

  • Hospitals earn back part of the withheld payments based on performance.

    • Baseline period:
      • July 1, 2009 – March 31, 2010
    • Performance period:
      • July 1, 2011 – March 31, 2012
    • Payments affected: FFY 2013 (Commences October 1, 2012)

No Changes to HCAHPS Measures

  • Nurse Communication

  • Doctor Communication

  • Cleanliness and quietness

  • Responsiveness of hospital staff

  • Pain management

  • Communication about medications

  • Discharge information

  • Overall Rating

  • 8 Measures = 80 Possible Points

  • Plus 20 possible points for “Consistency”


To Be Included In VBP

  • General acute care hospitals

    • Critical Access Excluded
  • At least 10 cases per clinical measure (reduced from 25)

  • At least 4 clinical measures reported (reduced from 10)

  • At least 100 HCAHPS surveys

Three Ways to Earn Points

  • Achievement points: 0-10 based on how you compare nationally

  • Improvement points: 0-9 based on your improvement over baseline year

CMS will apply the higher of these two scores
  • Consistency points: 0-20 based on your lowest performing measure*

Achievement Calculations

  • Between 1-10 points awarded for exceeding the 50th percentile from the baseline year

  • Higher achievement = higher points

  • All 10 points awarded for reaching the mean rate of performers in the top decile

  • Replaced “Attainment” term with “Achievement”

Scoring on Achievement (Attainment)

Improvement Calculations

  • Between 0-9 points awarded for improving between baseline and performance period

  • Greater improvement = higher points

HCAHPS Consistency Points

  • Incentivize hospitals to continually improve all HCAHPS measures

  • Select the lowest performing HCAHPS measure

  • Identify if HCAHPS measure performance falls below the 50th percentile

  • Based on a sliding scale from 0 to the 50th percentile 0 to 20 additional point will be awarded

National Trends

Hospital Compare Data

Hospital Compare Data

Key Data from Baseline Period

Hourly Rounding

Pursue Consistency

Hourly Rounding: A Known Best Practice

Hourly Rounding: Industry Findings

Effective Hourly Rounding

Successful Hourly Rounding

  • Frame patient expectations upon admission

    • Consistent talking points to introduce rounding practice
    • Environmental Reminders
  • Call it Hourly Rounding – so patients know the difference

  • Every element, every round, every time

    • “I am here to do my hourly rounds with you.”
    • Personal needs (3 P’s) to address care and comfort
    • Environmental assessment – steps articulated to patients
  • Prepare your employees to be successful

  • Manager Validation rounding

    • “I am here to do my validation rounds with you.”
    • Observe: coach and recognize
  • Link to performance appraisals and incentives

Effective Monitoring

  • Self report

    • Set the expectation
      • Tools: script/send a key message, door card, rounding log
      • Consistency: audit rounding logs, compare with observations, patient rounds
      • Accountability: regularly review and report audit logs, be transparent, use as a coaching tool

Effective Monitoring

  • Nurse Leader/Manager round on patients

    • Make your rounding as a leader more effective by asking about hourly rounding
    • Tools: Key Question: How often has your nurse been in to check on you today?
    • Consistency: measured by this question, compare to self report logs
    • Accountability: immediate feedback and coaching
  • Observation: Manager or secret shopper

    • First-hand look at rounding
    • Tools: know the expectations - key messages to be conveyed during the round, etc.
    • Consistency: tone of interaction, body language, quality of interaction
    • Accountability: use as an opportunity for feedback and coaching

Tune Up Nurse Hourly Rounding

How could your senior leaders help?
    • Communicate the vision
    • Recognition, positive reinforcement
    • Maintain the focus on hourly rounding as a foundation of care

How you can manage up:
    • Provide specific questions or topics for leader rounding
    • Develop an e-mail or letter for their signature
    • Invite them to attend a kickoff , huddle or staff meeting
    • Share hourly rounding success stories

Lessons from the Field: Keep It Simple

To more accurately measure the impact of new and improved hourly rounding practice, a health system in the northeast added a new background question to the Press Ganey survey on 2/15/2011

  • To more accurately measure the impact of new and improved hourly rounding practice, a health system in the northeast added a new background question to the Press Ganey survey on 2/15/2011

    • Hourly rounding question: “Did someone from the hospital check on your care and comfort on an hourly basis?”
    • Yes or No response
    • Subjective
  • Analysis will:

    • Show the overall sample size and scores by site;
    • Compare the percentage of surveys answered “yes” vs. “no”
    • Display raw scores (“yes” or “no”) on select HCAHPS domains
    • Calculate difference in percentage points between raw scores

Initial Results

Overall Hospital Ranking

Communication with Nurses

Pain Management


  • Consistent hourly rounding practice has a significant, positive impact on the patient experience

    • Increased trust = stronger caregiver-patient relationships
    • Improved pain management
    • Improved safety and efficiency of care
    • Promotes improved results in these HCAHPS domains
    • Nurse Communication
    • Responsiveness of Hospital Staff
    • Pain Management
    • Overall Hospital Rating
    • Note: It is common to implement hourly rounding several times before achieving the consistency of practice necessary for sustained improvements in scores

Call Bell Response

HCAHPS Question

“During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”
    • Never
    • Sometimes
    • Usually
    • Always
    • I never pressed the call button

Hourly Rounding is the Foundation

  • Global standards for call bell response time

    • Acknowledgement
    • Resolution
  • “No Pass Zone”

    • Restroom rounds - A supplement to hourly rounding
    • Patients high risk for falls
    • After meals and before bed
  • Service Volunteer Rounding programs

“No Pass Zones”

  • Anyone can answer a call bell

  • Establish Service Expectations

    • Standard response time to call light
    • Non-clinical personnel guidelines
    • Adequately fulfill call light requests
    • Provide proper training
    • Responsibilities of support staff
    • Scripting
    • Role Play
    • Create a recognition program for support staff – make it fun!

Montefiore Medical Center – No Passing Zone

  • S-T-O-P

  • Created a Skill Building Manual

    • Purpose
    • Priority Lights
    • Equipment
    • Restrictions/Isolated Rooms
    • Hand Hygiene
    • “Words that Work”
    • Non-Nursing Associate guidelines
    • Process Map

A Quiet Hospital Environment

HCAHPS Question…

“During this hospital stay, how often was the area around your room quiet at night?”
    • Never
    • Sometimes
    • Usually
    • Always

The Importance of a Healing Environment

  • “Unnecessary noise is the most cruel abuse of care which can be inflicted on the sick or the well” (Florence Nightingale, Notes on Nursing, 1859)

  • Noise in the hospital environment . . .

    • Patient Impact
    • Primary cause of sleep disruption and deprivation
    • Results in increased stress, pain and use of medications
    • Leads to elevated blood pressure and cardiac risk
    • Increased risk of privacy issues, injuries and falls
    • Staff Impact
    • Emotional exhaustion and burnout
    • Increased stress, fatigue and annoyance
    • Miscommunication and error

The Importance of a Healing Environment

  • Sources of noise in the hospital environment

    • Typical hospital environment: hard, reflective surfaces that are easily cleaned but reflect a lot of noise
    • Equipment noise
    • Few effective behavioral protocols in place to increase staff awareness
    • Sheer volume of caregivers

Evidence Based Design Meets Evidence-Based Medicine: The Sound Sleep Study

  • Harvard Researchers at Massachusetts General Hospital’s Sleep Laboratory

  • Tested 14 typical hospital sounds found in a medical/surgical unit

  • Arousal information commonly experienced by patients confirmed that the 14 sounds significantly impacted sleep

    • Lowest sound level tested, 40 dB, intravenous alarm and phone signals aroused 88% to 94% of subjects
    • Human voices aroused 70% to 75% of subjects
    • Sounds of an automatic towel dispenser, ice dispenser, door closing and toilet flushing aroused 35% to 73% of subjects.

Key Findings and Recommendations

  • Phone and IV pump alarms

    • Answer alarms promptly and lower background sound levels
    • Reduce telephone ring tone volume and stop rings after a specific amount
    • Staff conversations and voice paging
    • Modify behaviorally and through design
    • Limit sound transmission from nursing stations
    • Allocate space for nurses to communicate away from open hall areas
    • Dim hall lights as a “quiet cue”
    • Exterior noises – least arousing level tested
    • Other noises: Towel dispenser, door close, toilet flush, ice machine
    • Isolate ice machines from patient areas
    • Proper door hardware and maintenance
    • Implement quieter or low-tech alternatives

Strategies for a Quieter Environment

  • Understand the patient experience of noise in your environment

    • Analyze your HCAHPs and Patient Satisfaction results
    • Review patient comments
    • Identify areas of best practice and opportunity
    • Conduct regular “noise audits” – engage staff and visitors
    • Hold staff accountable for ensuring certain levels of quiet are maintained for all patients
  • Adapt your facilities and environment

    • Decentralized nursing stations
    • Sound-absorbent walls and ceilings
    • Workflow redesign
  • Quiet Times

    • Signage
    • Dimmed lights
  • Relaxation Toolkits for Patients and Families

Scripting for Effective Communication

Scripting – a Part of Every Best Practice

Involve Staff in Development

    • Get the right people
    • Passionate about customer service
    • Willing to be champions for the project
    • Influential (formally or informally)
    • Cross-functional team
    • Start with brainstorming sessions such as “Moments of Truth”
    • Gets an understanding of issues from the frontline – as processes actually happen, rather than how we may think they happen
    • Provides an opportunity for frontline staff to show expertise and shape the direction of improvement and scripting

“Service” Moments of Truth

Involve Staff in Implementation

    • Involve frontline staff in your implementation
    • Peer to peer interaction
    • Explain how scripts were developed
      • Process
      • Who was involved
    • Explain why scripts were developed
      • What are we trying to address, explain, save time, avoid confusion, etc.
    • Develop common objections to prepare for
    • What’s in it for me?

Enjoy Your Own Style

    • Use a different name: ‘key messages’, ‘every time words’, ‘standard messaging’
    • Allow people to be themselves and be genuine
    • Everyone does not say the exact same thing every time
    • Assure that this is not a substitute for professional judgment
    • Shows confidence in staff ability to communicate and empowers to make decisions

Return on Investment

    • What’s in it for me?
    • Save time by addressing common questions, concerns or confusion before they occur
    • Staff tool for handling difficult situations
    • Set patient expectations
    • Get started on the right foot - first impression during a patient encounter

How does this impact patients?
    • Proactive rather than reactive
    • Consistent message and experience throughout your facility
    • Understanding of why an activity is occurring
    • Reduce anxiety and show concern
    • Fulfillment of mission: excellence, compassion, patient-centered, respect

Before Implementing Any Best Practice . . .

  • Did you tie to your mission, vision, values?

  • Did you have senior leadership help deliver this message?

  • Did you answer the question “what’s in it for me?”

  • Did you explain why this is good for patients?

  • Did you involve frontline staff?

  • Did you remove barriers?

  • Did you give managers the tools to coach staff and handle objections?

Thank you for your time!

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