HCAHPS Participation

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1 Oregon Office of Rural Health Medicare Beneficiary Quality Improvement Project Training Series HCAHPS Participation Sara Phillips, RN, BSN, MBA, CPHQ April 25, 2017

2 Agenda Historical Perspective on HCAHPS HCAHPS - The Survey Itself Goals Validity Participation Requirements Value Survey Questions Reporting 2

3 Objectives This session will enable participants to Describe the historical background for HCAHPS State the requirements for HCAHPS participation Explain the HCAHPS survey questions Define the reporting process 3

4 CAHPS Hospital Survey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) The first national, standardized, publicly reported survey of patient perspectives of hospital care. 4

5 HCAHPS: Three goals Allow objective and meaningful comparisons of hospitals on topics important to patients. Create new incentives for hospitals to improve quality of care. Enhance accountability by increasing transparency of the quality of hospital care. 5

6 Development, Testing, Endorsement 2002: CMS partnered with AHRQ to develop and test the survey. 2005: NQF endorsed the survey. 2006: CMS implemented the survey. 2007: Annual payment update for PPS hospitals impacted. 2008: First publicly reported results. 2013: Five new items added. 2016: Hospital Star Ratings implemented. 6

7 Why Participate? Every patient does matter! Meets the quality improvement requirement for continued flex program funding and the Patient Engagement requirement under the Medicare Beneficiary Quality Improvement Project. Provides benchmarking with other CAH. Allows you to be viewed as QI leader. Eventually it will not be optional. 7

8 Participation Requirements Contract with and authorize via the Secure Portal a CMS-approved HCAHPS vendor to submit HCAHPS data to the HCAHPS Data Warehouse. For a list of approved vendors go to: Submit discharge data as instructed by the HCAHPS Vendor. From the QualityNet Secure Transfer Portal, survey data files will be uploaded by an approved vendor to an HCAHPS data warehouse. 8

9 Survey Questions 32 questions 11 composites/domains Seven summary measures, two individual items, and two global items. Two Methods Phone Mailed (paper) 9

10 Communication with Nurses Patients who reported that their nurses Always communicated well. Potential Answers are: Never, Sometimes, Usually, Always 10

11 Communication with Nurses Never, Sometimes, Usually, Always During this hospital stay: 1. How often did nurses treat you with courtesy and respect? 2. How often did nurses listen to you carefully? 3. How often did nurses explain things in a way you could understand? 11

12 Communication with Physicians Patients who reported that their doctors Always communicated well. Potential Answers are: Never, Sometimes, Usually, Always 12

13 Communication with Physicians Never, Sometimes, Usually, Always During this hospital stay: 4. How often did the doctors treat you with courtesy and respect? 5. How often did the doctors listen to you carefully? 6. How often did the doctors explain things in a way you could understand? 13

14 Responsiveness of Hospital Staff Receiving Help Patients who reported that they Always received help as soon as they wanted. Potential Answers are: Never, Sometimes, Usually, Always 14

15 Responsiveness of Hospital Staff Never, Sometimes, Usually, Always During this hospital stay: 7. After you pressed the call button, how often did you get help as soon as you wanted it? 8. Did you need help from nurses or other staff in getting to the bathroom or in using the bedpan? (YES or NO not scored) 9. How often did you get help in getting to the bathroom or in using the bedpan as soon as you wanted? 15

16 Pain Management Patients who reported that their pain was Always well controlled. Potential Answers are: Never, Sometimes, Usually, Always 16

17 Pain Management Never, Sometimes, Usually, Always During this hospital stay: 10. Did you need medicine for pain? (YES or NO not scored) 11. How often was your pain well controlled? 12. How often did the staff do everything they could to help you with your pain? 17

18 Communication about Medicines Patients who reported that staff Always explained about their medicines before giving it to them. Potential Answers are: Never, Sometimes, Usually, Always 18

19 Communication About Medicines Never, Sometimes, Usually, Always During this hospital stay: 13. Were you given any medication that you had not taken before? (YES or NO not scored) 14. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? 15. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? 19

20 Cleanliness of Hospital Environment Patients who reported that their room and bathroom were Always kept clean. Potential Answers are: Never, Sometimes, Usually, Always 20

21 Cleanliness of Hospital Environment Never, Sometimes, Usually, Always 16. During this hospital stay, how often were your room and bathroom kept clean? 21

22 Quietness of the Environment Patients who reported that the area around their room was Always quiet at night. Potential Answers are: Never, Sometimes, Usually, Always 22

23 Quietness of the Environment Never, Sometimes, Usually, Always 17. During this hospital stay, how often was the area around your room kept quiet at night? 23

24 Discharge Information Patients who reported that YES, they were given information about what to do during their recovery at home. Potential Answers are: YES or NO 24

25 Discharge Information 18. After you left the hospital, did you go directly to your home, to someone else s home, or to another health facility? (not scored) 19. During this hospital stay, did doctors, nurses, or other hospital staff talk to you about whether you would have the help you needed when you left the hospital? (YES or NO) 20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? (YES or NO) 25

26 Care Transition Patients who Strongly Agree they understood their care when they left the hospital. Potential Answers are: Strongly Disagree, Disagree, Agree, Strongly Agree 26

27 Care Transition Strongly Disagree, Disagree, Agree, Strongly Agree 21. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. 22. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 23. When I left the hospital I clearly understood the purpose for taking each of my medications. 27

28 Overall Rating Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). Potential Answers: (0 10) 28

29 Overall Rating 24. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? (0 10) Desired answers 9 & 10 29

30 Willingness to Recommend Patients who reported YES, they would definitely recommend the hospital. Potential Answers: Definitely No Probably No Probably Yes Definitely Yes 30

31 Willingness to Recommend 25. Would you recommend this hospital to your friends and family? Definitely no Probably no Probably yes Definitely yes 31

32 General Questions 26. During this hospital stay, were you admitted through the Emergency Room? 27. In general, how would you rate your overall health? 28. In general, how would you rate your overall mental or emotional health? 29. What is the highest grade or level of school you have completed? 32

33 General Questions 30. Are you of Spanish, Hispanic, or Latino origin or descent? 31. What is your race? Please chose one or more? (race categories listed) 32. What language do you mainly speak at home? 33

34 Reporting Scores are posted as a percentage of the overall survey answers that meet the expected answer. Example: 67 surveys Question 17 = 62 answers 49 out 62 answered Always Score = 79% This score is adjusted for mode and patient mix. 34

35 CMS Mode Adjustment Updated in April 2017 Bottom Mix Top Mix HCAHPS Composite Measure Phone Mixed IVR Phone Mixed IVR Nursing Communication 0.1% 1.3% -1.8% -4.2% -3.6% -2.3% Physician Communication -0.6% -0.9% -2.2% -2.8% -1.8% 0.3% Responsiveness of Staff 0.5% 1.9% -0.9% -0.8% -3.4% 2.0% Pain Management -1.7% -0.7% -4.3% -3.7% -2.3% 0.1% Communication about Medicines -1.5% -1.1% -2.3% -1.7% -0.9% -0.1% Discharge Information 1.7% 1.2% 1.6% -1.7% -1.2% -1.6% Care Transitions 1.4% 0.9% -0.5% -0.6% -1.3% -0.1% HCAHPS Individual Items Cleanliness of Hospital Environment -0.8% 0.6% -1.9% -2.8% -3.8% -0.5% Quietness of Hospital Environment 1.6% 2.5% -0.1% -8.6% -5.6% -6.4% HCAHPS Global Items Overall Hospital Rating 1.6% 1.3% -0.5% -2.0% -3.0% 4.0% Recommend the Hospital 0.6% 0.9% -1.8% -3.5% -2.1% 0.1% HCAHPS Survey Mode Adjustment. Centers for Medicare & Medicaid Services, Baltimore, MD. Originally posted April

36 Star Ratings Ratings are one to five stars Twelve ratings appear on Hospital Compare 11 for the measures and one overall. To receive a rating, the hospital must have 100 completed surveys over a four-quarter period. Linear score methodology is used (all scores count) Updated quarterly 36

37 Summary Star Rating Calculation The HCAHPS Summary Star Rating is constructed from the following components: 1. The Star Ratings from each of the 7 HCAHPS Composite Measures Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, Communication about Medicines, Discharge Information, and Care Transition. 2. A single Star Rating for the HCAHPS Individual Items 3. The average of the Star Ratings assigned to Cleanliness of Hospital Environment and Quietness of Hospital Environment. 4. A single Star Rating for the HCAHPS Global Items 5. The average of the Star Ratings assigned to Hospital Rating and Recommend the Hospital. 6. The 9 Star Ratings (7 Composite Measure Star Ratings + Star Rating for Individual Items + Star Rating for Global Items) are combined as a simple average to form the HCAHPS Summary Star Rating. 7. In the final step, normal rounding rules are applied to the 9-measure average to arrive at the HCAHPS Summary Star Rating (1, 2, 3, 4, or 5 stars). HCAHPS Star Ratings Technical Notes. Centers for Medicare & Medicaid Services, Baltimore, MD. Originally posted April 06,

38 Lastly, Check Your Reports QualityNet s your administrator when the report is available. 1. Login and go to My Reports section. 2. Click Run Reports. 3. Select IPFQR. 4. Click Preview Reports. 5. Select the quarter you want to run. 6. Click on Search Reports to view the result. 38

39 Questions? 39

40 Contact Carrie Beck Project Lead Jennifer Wright Sara Phillips

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) MBQIP Educational Session One Phase Two, January 2013

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) MBQIP Educational Session One Phase Two, January 2013 Overview HCAHPS (Hospital Consumer Assessment of Healthcare Providers and