Inpatient Rehabilitation Facilities Patient Satisfaction System

Transcription

1 Inpatient Rehabilitation Facilities Patient Satisfaction System Fleming AOD, Inc th Street, NW Washington, DC Final design and implementation specification may vary from this design document.

2 The purpose of this report is to present an inpatient rehabilitation facility (IRF) patient satisfaction program to be developed and maintained by Fleming-AOD. Patient satisfaction data, in combination with IRF-PAI data, will provide a powerful new way to analyze the inpatient rehabilitation experience, and deliver an important service for the rehabilitation industry and AMRPA members. It is also possible that such a system could be used as a building block for a federal patient satisfaction system for the IRF setting. The information on the following pages outlines the proposed patient satisfaction program, describes the data collection instruments, provides the rationale for item and scale selection, and reviews sample reports that can be created from the combined IRF-PAI and satisfaction databases. The American Medical Rehabilitation Providers Association Data Committee has approved this system for implementation. Questions regarding the patient satisfaction instrument and program should be directed to Sam Fleming, Fleming-AOD sam@aod.cx,

3 Background Inpatient rehabilitation facilities (IRFs) currently have several commercial options for measuring and assessing patient satisfaction. Press Ganey, PRC (Professional Research Consultants), and NRC (National Research Corporation) are three of the dominant vendors of patient satisfaction serving the rehabilitation industry. In addition, the Centers for Medicare and Medicaid Services (CMS) has been piloting a patient questionnaire for acute care hospitals through its Hospital CAHPS program, using questions adapted from the three main vendors and from other organizations. Unfortunately for the inpatient rehabilitation industry, many of the commercial surveys were developed first for acute care hospitals, and then modified for utilization by IRFs. Because the surveys were not initially developed specifically for IRFs, there are several problems that IRFs experience when attempting to implement these surveys: 1. Survey length: Vendors added questions that were more specific to IRFs, but doing so dramatically increased the length of the survey, with some surveys containing as many as questions. 2. IRF PPS: The implementation of IRF PPS by CMS created a new patient classification and measurement system. The IRF-PAI provides a basis for standardized collection of important patient demographic, diagnostic, and functional outcomes information. IRFs dedicate significant amounts of resources on collecting IRF-PAI and patient satisfaction data, but it is difficult to combine these data to create a complete and accurate picture of the impact of rehabilitation. 3. Accreditation issues: Both JCAHO and CARF focus on quality improvement and the factors that impact the provision of quality care. Most notably, CARF has several requirements that are not satisfactorily addressed by the standard vendor surveys. 4. Costs associated with implementation: Surveying methods employed by vendors (mail and phone) each have costs in terms of processing and data entry, and the vendor s pricing for these services can be expensive, especially relative to the facility size of many of the IRFs. Because of these issues, many IRFs have resorted to developing and implementing their own patient satisfaction surveys. This situation is problematic for the IRFs in that these IRFs are not able to participate in a database where comparative benchmarks are provided, and therefore are not able to take advantage of the important information that can be obtained from using external comparisons of performance. It is also possible that this IRF Patient Satisfaction system could be used by AMRPA to guide any future IRF patient satisfaction measurement efforts by CMS. Fleming AOD 1

4 The Patient Satisfaction Program The proposed patient satisfaction program consists of three parts, with each part being optional for participating facilities. The three parts of the program are: Service Recovery Survey: A short questionnaire administered 3 5 days after admission to determine system issues that can be resolved while the patient is still in the facility. Discharge Survey: A questionnaire that measures the patient s satisfaction with the rehabilitation facility and care and is completed by the patient on the day before discharge or the day of discharge. Follow-up Survey: Several questions that can be asked 3-4 months after discharge from the IRF to determine the patient s satisfaction with the long term outcomes of rehabilitation. Service Recovery Survey The Service Recovery Survey consists of 17 questions that focus on the patient s experience in the facility, while the patient is still in the facility. The survey is to be completed by the patient and or family on the third, fourth, or fifth day of the rehabilitation length of stay. The purpose of this survey is to quickly identify areas of specific patient and or family concern that impact the patient s experience of the facility and will affect the degree of satisfaction at discharge. Issues identified by this survey provide the facility with an opportunity to address areas of improvement early in the patient s stay. Discharge Survey The Discharge Survey is a 38 item questionnaire that is distributed to the patient on the day before or the day of discharge and collected before the patient is discharged. Surveys are completed by the patient and or the family of the patient. For patients that are discharged emergently, surveys can be mailed to the patient within 2-3 days of discharge. The Discharge Survey provides a timely method to obtain information on the patient s perception of the rehabilitation stay, while the experience is fresh in the mind of the respondent. Follow-Up Satisfaction Survey The Follow-Up Satisfaction Survey consists of 6 items that can be used in conjunction with the facility s current method of collecting follow-up Functional Independence Measure (FIM) data. The follow-up questions can be administered as part of a mailed or phone survey. Each of the above patient satisfaction components will be described in more detail in later sections of this document, including discussions of question and scale selection. Fleming AOD 2

5 Service Recovery Survey The Service Recovery Survey consists of 17 questions and is distributed to patients on the third to fifth day of the rehabilitation stay. The survey forms will be generated on demand so that individual patient ID numbers may be assigned to the forms. The purpose of the Service Recovery Survey is to help the facility identify issues of patient concern that may negatively affect the patient s care and the patient s eventual overall perception of the facility. The questions on the survey focus on issues that need to be addressed early in the stay and that impact the patient s transition from acute care to rehabilitation. The survey is designed to be short in length, so as to not overwhelm the patient and to focus service recovery efforts. Completed Service Recovery Surveys can be placed in a sealed envelope and handed to a volunteer or nurse, or can be placed in a collection box, easily accessible by the patient and family. The process can be adapted to an individual facility, but care should be taken to prevent physicians, staff, or other administrative employees from directly seeing the completed survey. All completed surveys should be promptly returned to the person or department responsible for data entry, and any quality issues revealed by the surveys should be quickly addressed by a case manager or patient advocate. The Flesch-Kincaid Reading Grade Level score for the Service Recovery Survey questions is 5.6 (fifth grade reading level). The Flesh Reading Ease score is 72.9 out of 100 (over 60 is considered to be acceptable). The Service Recovery Survey uses two different scales. The scale No, Somewhat, Yes is used to assess the occurrence of certain critical events. The scale Never, Sometimes, Usually, Always is used to assess the degree of attention to specific events or services. Scale Selection The first section of the survey asks the patient to assess the frequency of occurrence of critical indicators. The scale selected for this section is a four-point scale, with the following responses: Never = 1 Sometimes = 2 Usually = 3 Always = 4 The rationale for using this scale is as follows: 1. The scale is used in CMS HCAPS survey, and is commonly used when assessing the respondent s perception of frequency. 2. This scale measures the frequency of an occurrence, instead of the quality of the service. Quality of care questions may be best asked toward the end of the rehabilitation length of stay, after the patient has had time to develop an impression of the care. Earlier in the stay, it is more practical for patients to describe the frequency for which services occur. The second section of the survey asks the patient to recall their recollection of the occurrence of specific events or services. The scale selected for this section is a three-point scale, with the following responses: No = 1 Somewhat = 2 Yes = 3 Fleming AOD 3

6 The rationale for using this scale is as follows: 1. The scale is commonly used when assessing a respondent s perception of the occurrence of a service or event, or the respondent s subsequent understanding of that service or event. 2. This scale is also used when the provider of the service wishes to learn if a service or event occurred or did not occur, based on established standards that must be met. Survey Item Selection Survey items selected were based on the critical events that need to occur within the first few days of stay, and with attention to concerns of accrediting agencies (JCAHO and CARF). Of the main patient satisfaction vendors, only Press Ganey has a program to collect satisfaction information while the respondent is still a patient in the facility. The following table lists each item and the rationale for selection, for those items with the response of Never, Sometimes, Usually, Always. No. Item Rationale 1. Are your room and bathroom clean? Public health agency concern 2. Is the equipment you use in good working order? Contributes to the safety of the patient 3. How often are you able to get enough rest at night? Contributes to the patient s ability to adequately participate in rehabilitation 4. How often to do get the food that you ordered? Public health agency concern 5. Are you able to get the help you need with going to the bathroom (or using the bedpan or urinal)? Addresses a common patient complaint and a customer service issue 6. Are your questions and concerns promptly addressed? Addresses a customer service issue 7. How often is your pain controlled to levels that are acceptable to you? (an additional response of I have no pain is included with the scale). Focus of JCAHO, CARF. Participation in therapy and progress in rehabilitation is impacted by pain. Table 1. Service Recovery question set and rationale, first section. The following table lists each item and the rationale for selection, for those items with the response of No, Somewhat, Yes. no. Item rationale 8. When you first came to rehabilitation, were you given information about what your stay here would be like? 9. Did your doctor discuss your treatment and plan of care in a way that was understandable to you? 10. Do you know what goals you are working toward in therapy? Orientation to the facility and rehabilitation are important aspects of the first few days Assesses the communication between the patient and physician A general question that addresses issues with the communication and creation of therapy goals 11. Do you feel safe and secure in our facility? Focus of JCAHO Fleming AOD 4

7 12. Is the staff considerate of your privacy? Focus of HIPAA and accreditation agencies 13. Are you treated with dignity and respect? Addresses concern for the individual patient and an aspect of many facilities mission statements Table 2. Service Recovery question set and rationale, second section. Three additional open-ended questions provide the patient with the opportunity to comment on areas not addressed by the survey, or to describe specific situations. The last question of the survey identifies if the survey was completed by the patient independently or with the assistance of someone else. NO. ITEM RATIONALE 14. Is there anything we can do to make your stay more comfortable? 15. Is there anything we can do to better accommodate family and friends that visit you? Addresses a customer service issue Addresses a customer service issue 16. Do you have any suggestions for improving patient safety? Focus of JCAHO 17. How was this survey completed? - I completed it myself. - Someone read the questions to me or wrote down my answers. - Someone else answered all the questions for me. Survey findings may be impacted by the person who completed the survey. Table 3. Service Recovery final and open-ended question set and rationale. The questions in Tables 1 and 2 were selected in order to create a minimum data set of issues related to customer service, the occurrence of specific actions that generally take place in the first few days of the stay, and items that are focal points of regulatory agencies (pain, security/safety). Items such as information about what your rehab stay would be like and acceptable pain control are also asked on the discharge survey either because of their importance as a predictor of overall satisfaction or their importance to fulfillment of accreditation requirements. Items such as equipment working and getting food that you ordered are included only on the Service Recovery Survey since these items are not related to overall satisfaction with the facility, but they cover topics that are highly visible areas of customer service that the patient is assessing at the beginning of the stay. Questions that concern satisfaction or that requires the patient to assess the effectiveness of a service were not included. These types of questions are not appropriate for general patient assessment during the first week of the stay, as the inclusion of these types of questions may provide misleading information. The Service Recovery database will also include a field to indicate the date that the survey was distributed. This date will be used in conjunction with the IRF-PAI admission date for analysis of potential effects caused by the variability of the 3-5 day survey period. Fleming AOD 5

8 Discharge Survey The Discharge Survey consists of 34 items that use a scale of Excellent, Very Good, Good, Fair, Poor, two multiple choice questions, and two open-ended questions, for a total of 38 questions. The Discharge Survey will be distributed to patients on the day of discharge or the day before discharge. Completed surveys can be collected in several ways. Completed surveys can be placed in a sealed envelope and handed to a volunteer or nurse, or can be placed in a collection box, easily accessible by the patient and family. The process can be adapted to an individual facility, but care should be taken to prevent physicians, staff, or other administrative employees from directly seeing the completed survey. When a patient is emergently discharged, a survey can be mailed to the patient within two or three days from the day of discharge from rehabilitation. All completed surveys should be promptly returned to the person or department responsible for data entry. The Flesch-Kincaid Reading Grade Level score for the Discharge Survey is 7.8 (seventh grade reading level). The Flesh Reading Ease score is 56.1 out of 100 (over 60 is considered to be acceptable). Both measures are calculated using the average number of syllables per word and the average number of words per sentence. Because of the structure of the survey and frequent use of longer, but unavoidable words such as rehabilitation, readability statistics for the Discharge Survey are lower than that of the other two surveys, but this difference is not significant. Scale Selection A five-point Likert scale was chosen as the primary scale for use in the Discharge Survey, and is also used on the Service Recovery Survey. The scale is as follows: Poor = 1 Fair = 2 Good = 3 Very Good = 4 Excellent = 5 The rationale for using this scale is as follows: 1. This scale is commonly used on surveys, including surveys of health related issues such as the Health Status Questionnaire 2.0 and other surveys constructed by companies such as the RAND Corporation. 2. While a scale such as Very Poor, Poor, Fair, Good, Very Good is statistically balanced (it has equal numbers of positive and negative responses, with a middle response), it presents with some weaknesses in practical applications for facilities. These weaknesses are: When presenting data to stakeholders, the word Excellent carries a much stronger connotation of the best in service than does the term Very Good. Very Good typically must be explained to stakeholders that this is the highest score that can be obtained. For the average patient, family, board member, and community stakeholder, presentations of patient satisfaction data should not need footnote explanations. In a review of comparative data from patient satisfaction vendors, most patient responses are clustered at the positive end for many of the survey items. As a percentage of total responses for any given item, very few responses are negative. Fleming AOD 6

9 When using a balanced scale with equal distribution of positive and negative responses, it has been argued that this type of scale is not sensitive enough to the finer distribution of responses, most of which tend to cluster on the positive end. Using a balanced scale can create a situation of clustering on the positive end, so that even very slight changes in responses can result in wide variations of benchmark comparisons such as percentile rankings. While some vendors attempt to compensate for this tendency by converting the scale to an interval scale (0 100) in order to calculate mean scores, the mean scores can be more difficult to translate into improvement of operations. Respondents will interpret the scale options differently. Some respondents are quick to rate all items as Excellent while other respondents consciously choose to, rarely, or never select Excellent. The Very Good response tends to level the playing field between these two extremes of respondent types by providing a highest rating that will be chosen by both. In addressing one problem though, the Very Good top response causes another. It tends to put an artificial ceiling on responses, so that for those respondents who truly believe a service was excellent, they are forced to respond in a similar fashion to services that were felt to be very good, but not excellent. As a result of other surveys that are distributed to and read by our patients, patients are very familiar with interpreting a scale that uses Excellent as the highest response. Lack of an Excellent option can prevent many patients from expressing their actual assessment of service. 3. The use of the five-point Excellent Poor scale permits the patient to provide his or her rating of the service. This is in contrast to scales such as Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree. Survey items constructed to match these scales require a respondent to answer a survey question that already identifies a specific attribute of service, yet this attribute may not describe a quality of the service that is important to the patient, or to the degree that the patient would like to indicate. For example, the item I was satisfied with the care I received does not permit the respondent to indicate that not only were they satisfied, but they thought the care was excellent. Modifying the question to state I was satisfied with the excellent care that I received can confuse the respondent who felt the service was very good or good and therefore might select Disagree or Strongly Disagree. Question #34, recommend the facility, does not use the Poor to Excellent scale since this scale does not match the nature and wording of the question. This question uses a four-point scale Definitely No, Probably No, Probably Yes, Definitely Yes. The open-ended question How can we improve the safety of our patients? was included to meet JCAHO accreditation requirements, and another open-ended question allows the respondent to offer general comments or to comment more specifically on areas that can be improved. The two multiple choice questions at the end of the survey also use different scales secondary to the content and wording of the questions. Item #37 is used to identify if the survey was completed by the patient, an item that may be important to understanding the survey results. The final item of the survey asks for the patient to refuse further contact from the facility, in the event that the facility may want to follow-up on specific comments recorded by the patient. Patients that do not wish to be contacted will have the opportunity to state as such, in accordance with current regulations regarding the right to privacy. Fleming AOD 7

10 Survey Item Selection Survey items selected were based on the need to fulfill accreditation requirements of CARF and JCAHO, and that would address other areas of importance to rehabilitation facility operations. Reports and articles from patient satisfaction vendors were reviewed to identify a minimum amount of questions that were highly correlated with overall satisfaction. The following table lists each question and the rationale for inclusion on the survey. All but the last item in the following table uses the response of Excellent, Very Good, Good, Fair, Poor. The last item, recommend this facility uses the scale Definitely No, Probably No, Not Sure, Probably Yes, Definitely Yes. No. Item Rationale YOUR CARE 1. The orientation to rehabilitation you received after you were admitted Focus of CARF, addresses a customer service issue 2. Courtesy of doctors and staff Addresses a customer service issue 3. The dignity and respect with which you were treated Addresses concern for the individual patient and an aspect of many facilities mission statements 4. The encouragement and support you received from doctors and staff Rate your level of satisfaction with the care you received from the following: Addresses a customer service issue and staff attitude 5. Your Doctor Provides information specifically on the satisfaction with the patient s Physician 6. Nursing Day Shift (7am 3pm) Provides information specifically on the satisfaction with the Nursing day shift 7. Nursing Evening Shift (3pm 11pm) Provides information specifically on the satisfaction with the Nursing evening shift 8. Nursing Night Shift (11pm 7am) Provides information specifically on the satisfaction with the Nursing night shift 9. Physical Therapy Provides information specifically on the satisfaction with Physical Therapy 10. Occupational Therapy Provides information specifically on the satisfaction with Occupational Therapy 11. Speech and Language Therapy Provides information specifically on the satisfaction with Speech and Language Pathology 12. Recreation Therapy Provides information specifically on the satisfaction with Recreation Therapy 13. Social Work/Case Management Provides information specifically on the satisfaction with Recreation Therapy 14. Psychology Provides information specifically on the satisfaction with Psychology 15. Spiritual/Pastoral Care Provides information specifically on the satisfaction with the Spiritual/Pastoral Care services 16. Staff promptness in responding to your requests Addresses a customer service issue, accreditation concern 17. Attention to your individual needs and preferences Addresses a customer service issue, accreditation concern Fleming AOD 8

11 18. The extent of your involvement in setting your rehabilitation goals and plan of care 19. How well the doctors and staff were able to answer your questions and concerns 20. The coordination of your care between the rehabilitation team members 21. The extent to which your pain was controlled to levels that were acceptable to you 22. The extent to which staff expectations matched your ability to perform activities 23. The extent to which your family was given information and included in your care ACCOMODATIONS Focus of CARF Addresses a customer service issue Focus of CARF Focus of JCAHO and CARF Addresses a customer service issue Patient and family education as a focus of JCAHO 24. The cleanliness of your room and other areas Public health agency concern 25. The temperature of your food Public health agency concern 26. The variety of meals offered Public health agency concern DISCHARGE 27. The assistance you received with planning for discharge arrangements Focus of JCAHO and CARF, addresses customer service 28. The training you received about your medications Medications and patient education as a focus of JCAHO 29. Your discharge information packet and other written instructions YOUR OVERALL EXPERIENCE Patient education and instruction as a focus of JCAHO 30. Consideration for your privacy HIPAA, JCAHO, CARF concern 31. Your safety and security as a patient in our facility Focus of JCAHO 32. The extent to which the rehabilitation program helped you meet your goals Focus of CARF 33. Overall satisfaction with your rehabilitation stay A standard question, commonly included on surveys, see comments after Table If a family member or friend needed rehabilitation services, would you recommend this facility? Scale: Definitely No, Probably No, Not Sure, Probably Yes, Definitely Yes A standard question commonly included on surveys to determine a patient s perception of the rehabilitation facility and how that might be conveyed in conversations with others. Table 4: Discharge Survey question set and rationale. In addition, a question regarding who answered the survey, two open-ended questions, and a privacy option question are added to the end of the survey: NO. Item rationale 35. How can we improve the safety of our patients? Focus of JCAHO 36. Other comments or suggestions for improvement A standard question at the end of surveys, allowing the patient to address issues not identified on the survey, and Fleming AOD 9

12 37. How was this survey completed? - I completed it myself. - Someone read the questions to me or wrote down my answers. - Someone else answered all the questions for me. 38. Occasionally we follow-up with selected respondents for further information. If you do not wish to be contacted, please indicate so by checking the box below. I do not wish to be contacted about my comments on this survey. to make final summary comments Survey findings may be impacted by the person who completed the survey. Table 5: Discharge Survey final and open-ended question set. The questions in the Table 4 were selected in order to create a minimum data set of satisfaction indicators that would effectively identify areas of focus for rehabilitation facilities and for which comparative data would be useful. Items not selected for the survey were considered to increase the length of the survey without providing any additional important and useful information. For example, items that are specific to each department (courtesy of doctor, courtesy of nurses, courtesy of physical therapist, etc) were consolidated under the one item Courtesy of doctors and staff. Items regarding services or departments that are typically provided through contract arrangements or have lower patient volumes were not specifically mentioned by name. Additional items for dietary/food services, and room and accommodations were also eliminated because these items, while typically rated the lowest by patients, are not highly correlated to overall satisfaction. Question #33, Overall satisfaction with your rehabilitation stay is one question that may be eliminated from the survey, yet it is included in this paper to trigger a point of discussion. The main issue surrounding this question is one of redundancy. An overall satisfaction score may be calculated by summing the responses from all the previous survey items, eliminating the need to ask the patient to rate overall satisfaction as a particular survey item. Eliminating this question would decrease the length of the survey and contribute to improved survey layout. Some facilities though may have strategic goals based on this particular item, and it is for this reason that it is included in this paper and not eliminated from the list of survey questions. Fleming AOD 10

13 Follow-Up Satisfaction Survey The Follow-Up Satisfaction Survey consists of 4 items that use the scale of Excellent, Very Good, Good, Fair, Poor, one question that uses the scale Much Worse, Somewhat Worse, About the Same, Somewhat Better, Much Better, and one question regarding who answered the survey. The Follow-Up Satisfaction Survey will be referred to as the Follow-Up Survey in this document. This is in contrast to the assessment of FIM items at follow-up, which will be specifically referred to as the Follow-Up FIM Survey. It is recommended that the Follow-Up Survey be administered in conjunction with Follow-Up FIM survey, typically 3-4 months after discharge. The Follow-Up Survey may be conducted by phone or by mail, whichever is the preferred method for the facility. Because phone and mailed survey distribution methods may lead to differences in results and for purposes of accurately reporting the data and comparative benchmarking, facilities will need to complete an additional field to indicate if the patient record was obtained over the phone or by mail. Reports of Follow-Up Satisfaction will be stratified by type of survey methodology. For several reasons, the Follow-Up Survey is intended to be very short in length. To improve the quality of the patient responses, many of the key satisfaction questions were asked at the time of or immediately after the service, through the Service Recovery and Discharge Surveys. Because the Follow- Up Survey is administered months after discharge, the patient may not be able to accurately recall the specifics of the rehabilitation stay. The Follow-Up Survey asks the patient to describe their satisfaction with the services and equipment that the rehab facility ordered at discharge, and to compare functioning at follow-up as compared to discharge. The Follow-Up Survey also provides for questions regarding the actual post-discharge services received, since the services ordered at discharge may not be the same as the services that the patient actually utilized. Questions regarding activities of daily living (ADLs), instrumental activities of daily living (IADLs), and physical status (such as level of pain) should be included as part of the Follow-Up FIM surveying and are not included as part of the Follow-Up Satisfaction Survey. (IADL items include social activities; community activities such as shopping; vocational status; and more strenuous activities such as vacuuming and gardening). The Flesch-Kincaid Reading Grade Level score for the Follow-Up Survey is 6.2 (sixth grade reading level). The Flesh Reading Ease score is 66.4 out of 100 (over 60 is considered to be acceptable). Scale and Survey Item Selection For many of the same reasons mentioned in the Discharge Survey section, the scale used for 4 of the 6 questions is Excellent, Very Good, Good, Fair, Poor. Satisfaction with the overall rehabilitation experience is not asked at this point since it is included in the Discharge Survey. Follow-up provides an opportunity to assess if the patient feels that he or she has improved since discharge from rehabilitation. This type of question requires a different scale, Much Worse, Somewhat Worse, About the Same, Somewhat Better, Much Better. This question and scale are very similar to a question on the Health Status Questionnaire 2.0, published by RAND. When compared to the follow-up FIM data, this question can provide useful information that addresses the patient s perception of the effect of rehabilitation as compared to their actual current physical functioning. The last question identifies who completed the survey, and is the same question used on the Discharge and Service Recovery Surveys. Because of the number of FIM items, the patient satisfaction component of the follow-up survey process needs to be very brief in length. The shorter survey also avoids unnecessary duplication in survey items, and attempts to ask questions that have more recent relevancy to the patient. Fleming AOD 11

14 No. Item Rationale 1. Did you have equipment ordered for you at discharge from rehab? (yes or no) Please rate your satisfaction with the equipment that was ordered for you at discharge. 2. Did you receive home health services? (yes or no) Please rate your satisfaction with the home health services you received. 3. Did you receive outpatient therapy? (yes or no) Please rate your satisfaction with the outpatient therapy you received. 4. Your discharge information packet and other written instructions 5. Compared to when you were discharged from rehabilitation, how would you rate your functioning now? 6. How was this survey completed? - I completed it myself. - Someone read the questions to me or wrote down my answers. - Someone else answered all the questions for me. Table 6: Follow-Up question set and rationale. Addresses the customer satisfaction with equipment that was ordered. Provides information on home care service utilization, and the patient s satisfaction with the service. Provides information on outpatient therapy service utilization, and the patient s satisfaction with the service. Addresses the patient s satisfaction with the discharge instructions, after the patient has had an opportunity to utilize the instructions. This question is also asked on the Discharge Survey. Uses a scale Much Worse, Somewhat Worse, About the Same, Somewhat Better, Much Better. A comparative question is used instead of patient assessment of satisfaction with quality of life because this measure may be affected by many factors, outside of the focus of rehabilitation. Survey findings may be impacted by the person who completed the survey. Fleming AOD 12

15 Facility Implementation Each facility will need to design processes to address issues related to data entry and creation of the survey form. Throughout the survey process, it will be critical that all participating facilities strictly adhere to the survey distribution schedules. Survey Form The survey form will be created by Fleming-AOD and will be downloaded and printed by the facility through erehabdata. The layout of the form will follow these basic rules: 1. Fleming-AOD will create the paper survey form. This step is to ensure consistency between forms and to minimize the effects of form layout on the quality of the responses. Sample survey layouts are presented in the next section. 2. A serif font (i.e. Times New Roman) will be used for printed forms. Sans serif fonts (i.e. Arial) should be used if the facility opts for an electronic survey. Sans serif fonts may also be used to highlight section headings on printed surveys. Font size should be at least 12 point. 3. All surveys should be accompanied by a cover letter, asking the patient to complete the survey, stating how the information will be used, and thanking the patient for their time. Fleming- AOD will provide a sample cover letter. 4. Survey items that are answered with a five-point scale such as Poor, Fair, Good, Very Good, Excellent will have the responses accompanied by the numbers 1, 2, 3, 4, 5, where 1 = Poor and 5 = Excellent. Survey items that are answered with a four-point scale such as Definitely No, Probably No, Probably Yes, and Definitely Yes will have the responses accompanied by the numbers 1, 2, 3, 4, where 1 = Definitely No and 4 = Definitely Yes. By providing a number that is equivalent to the text response, the respondent has another metric for which to use in order to formulate the answer. For purposes of analysis, text responses can be converted to numeric responses, permitting the use of a greater number of statistical measures. 5. Sample Follow-Up forms are not included in the next section as these surveys may be done by phone. The survey directions may be adapted for phone survey methods. 6. The survey will be kept to one or two pages in length, and may be printed on one page, double sided. 7. Based on facility need, surveys can be translated into other languages. Translated surveys should also go through the process of back-translation to assure that the content of the questions have not changed. Facilities opting for translated surveys will consult with Fleming- AOD on the process. Surveys will be individually printed from erehabdata on a per patient basis and will include each patient s erehabdata identification number on each survey. The use of the erehabdata identification number is consistent with HIPAA confidentiality requirements. Because the patient s name, medical record or social security number are not on survey, facilities will need to establish accurate systems for distributing surveys, especially the Service Recovery Survey. Surveys will print from erehabdata in the same manner that is currently utilized for printing consecutive Metrics Pages. Fleming AOD 13

16 Data Entry Satisfaction survey data may be entered into erehabdata by the following: 1. Manual data entry: Data is entered into erehabdata by manually typing each response into erehabdata. Comments may be entered into erehabdata, but must be entered manually. Manual data entry may be more time and cost effective for smaller facilities or units. 2. Data scanning: Based on facility capabilities, survey forms may be created in a scanner-ready format. A mid-range data scanner and software can be purchased for approximately $4000, having the ability to scan 50 double-sided pages per minute. Comments would still need to be entered manually into the system. 3. Data uploading: Data files, created from data scanner software or from another facility electronic system, may be uploaded into erehabdata, similar to what is currently offered for IRF-PAI files. All data, whether entered directly into erehabdata or uploaded, will be matched to IRF-PAI data through the erehabdata identification number. Fleming AOD 14

17 Sample Form Layout: Service Recovery Survey Please tell us about your experience, using the following: 1 = Never 2 = Sometimes 3 = Usually 4 = Always For question #7, select 0 = I have no pain if you do not have pain. 1. Are your room and bathroom clean? Is the equipment you use in good working order? How often are you able to get enough rest at night? How often to do get the food that you ordered? Are you able to get the help you need with going to the bathroom (or using the bedpan or urinal)? Are your questions and concerns promptly addressed? Never Sometimes Usually Always Never Sometimes Usually Always I have no pain 7. How often is your pain controlled to levels that are acceptable to you? Please answer these questions with the following: 1 = No 2 = Somewhat 3 = Yes 8. When you first came to rehabilitation, were you given information about what your stay here would be like? Did your doctor discuss your treatment and plan of care in a way that was understandable to you? Do you know what goals you are working toward in therapy? Do you feel safe and secure in our facility? Is the staff considerate of your privacy? Are you treated with dignity and respect? Is there anything we can do to make your stay more comfortable? Is there anything we can do to better accommodate family and friends that visit you? Do you have any suggestions for improving patient safety? How was this survey completed? O I completed it myself. O Someone read the questions to me or wrote down my answers. O Someone answered all the questions for me. No Somewhat Yes Fleming AOD 15

18 Sample Form Layout: Discharge Survey Please tell us about your experience, using the following: 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Poor Fair Good Very Good Excellent YOUR CARE 1. The orientation to rehabilitation you received after you were admitted Courtesy of doctors and staff The dignity and respect with which you were treated The encouragement and support you received from doctors and staff Rate your level of satisfaction with the care you received from the following: 5. Your doctor Nursing Day Shift (7am 3pm) Nursing Evening Shift (3pm 11pm) Nursing Night Shift (11pm 7am) Physical Therapy Occupational Therapy Speech and Language Therapy Recreation Therapy Social Work/Case Management Psychology Spiritual/Pastoral Care Staff promptness in responding to your requests Attention to your individual needs and preferences The extent of your involvement in setting your rehabilitation goals and plan of care How well the doctors and staff were able to answer your questions and concerns The coordination of your care between the rehabilitation team members The extent to which your pain was controlled to levels that were acceptable to you The extent to which staff expectations matched your ability to perform activities The extent to which your family was given information and included in your care Fleming AOD 16

19 Please tell us about your experience, using the following: 1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent Poor Fair Good Very Good Excellent ACCOMODATIONS 24. The cleanliness of your room and other areas The temperature of your food The variety of meals offered DISCHARGE 27. The assistance you received with planning for discharge arrangements The training you received about your medications Your discharge information packet and other written instructions YOUR OVERALL EXPERIENCE 30. Consideration for your privacy Your safety and security as a patient in our facility The extent to which the rehabilitation program helped you meet your goals Overall satisfaction with your rehabilitation stay If a family member or friend needed rehabilitation services, would you recommend this facility? O Definitely No O Probably No O Not Sure O Probably Yes O Definitely Yes How can we improve the safety of our patients? Other comments or suggestions for improvement: How was this survey completed? O I completed it myself. O Someone read the questions to me or wrote down my answers. O Someone answered all the questions for me. Occasionally we follow-up with selected respondents for further information. If you do not wish to be contacted, please indicate so by checking the box below. I do not wish to be contacted about my comments on this survey. Fleming AOD 17

20 The Reporting System The reporting system consists of three main parts, described in detail in the following sections: The Standard Report; Second Tier Reports; Special Reports. The patient satisfaction data will be linked to the erehabdata database, eliminating the need to collect data from demographic and diagnostic fields already collected through the IRF-PAI. Linkage to the current erehabdata fields will also provide a wealth of information that is typically not associated with patient satisfaction databases. Patient satisfaction reporting, in conjunction with erehabdata IRF-PAI data, will allow facilities to further investigate the many factors impacting patient satisfaction, for example: The potential relationship between patient satisfaction and rehabilitation impairment category (RIC) or RIC grouping, The possible relationships between specific ICD-9 codes, comorbidity tiers, RICs, Case Mix Groups (CMGs) to patient satisfaction, The impact of length of stay (LOS) on patient satisfaction, and for a particular RIC, The impact of the change in functional independence measure (FIM) scores as compared to patient satisfaction scores, The impact of the discharge total FIM score on overall patient satisfaction, as well as the discharge scores for particular FIM items and general satisfaction with the primary department responsible for that outcome, The impact of the discharge destination on discharge and follow-up satisfaction, The relationship between insurance sources and satisfaction, The impact of cognition, as determined by FIM cognitive scores, on the patient satisfaction ratings provided by patients. The continuum of data (admission FIM, service recovery, discharge FIM, discharge satisfaction, followup FIM, follow-up satisfaction) will provide a powerful new tool for rehabilitation facilities to use in order to improve services, determine the underlying factors related to the findings, and to meet and exceed customer expectations and regulatory and accreditation requirements. The erehabdata identification number (assigned by the erehabdata system) will be used to link the data sets databases. Facilities will also have the ability to collect other data that may impact patient satisfaction, including the physician name, the unit, or the referring hospital. Fields such as these may be pre-coded on the surveys in order to eliminate the need for the patient to have knowledge of this information. Pre-coding fields also eliminates the possibility that the survey respondent will record an incorrect answer. Definitions In order to describe the report, several terms must be defined: Item: equivalent to the survey question, or field. Measure: the statistics used in a report. Example: percentile rank. Second Tier Report: the basic report with another level of stratification, such as by the facility specific coding or who completed the survey. Standard Report: the basic report that has multiple options for stratification (timeframe, site, RIC, RIC Group). Fleming AOD 18

21 Stratification: the process of analyzing data by defined characteristics. Record: the data associated with a single survey. RIC Group: a grouping of RICs that reflect general rehabilitation programming. Fleming AOD 19

22 The Reporting System: The Standard Report The purpose of the Standard Report is to show the frequency of each response selected (n) and as the percentage of total for a given item, and to provide comparative benchmarks. For each item of each survey, the following measures will be reported as part of the Standard Report: Frequency (n) and the percentage of respondents (as a percent of the total respondents for any given question), for each response option; The percentile ranking for the percentage of respondents that select Excellent, for each item that uses the Poor to Excellent scale; The national and regional frequency distributions (n) and percentage of respondents, for each item and each response option; national and regional frequency distributions (n) and percentage of respondents, for each item and each response option, calculated in similar fashion to erehabdata IRF-PAI reporting. The standard report will stratified by the following: Timeframe (monthly, quarterly, yearly, similar to current erehabdata IRF-PAI timeframes) Facility/site (similar to current erehabdata IRF-PAI facility and site designations) RIC (each of the 21 RICs and a category All ) RIC Group: Various RICs can be combined to increase the (n) in any given group, as well as combine RICs to match rehabilitation programming. The RIC groups are: RIC Group RIC Stroke 01 Brain Injury 02, 03, 18* Spinal Cord Injury 04, 05, 18* Orthopedic 07, 08, 09, 10, 11, 12, 13, 16, 17 Neurological 06, 19 General Rehab/Medical 14, 15, 20, 21 Table 7: RIC Groupings. * RIC 18, Major Multiple Trauma (with brain or spinal cord injury), will be placed in either the Brain Injury or Spinal Cord Injury RIC Group, depending on diagnosis. The time-frame specifications for patient satisfaction data are very complex as there are three possible options for determining the report timing. These are: 1. Reporting data by the date of admission; 2. Reporting data by the date of discharge; 3. Reporting data by the date the survey was administered. Each of the above options can provide useful and different information. Reporting data by the date of admission may be most useful when reporting Service Recovery Data. Reporting data by the date of discharge may be most useful when reporting the Discharge Survey Data, and reporting data by the date the survey was administered would be best for the Follow-Up Survey. It may be useful to provide timeframes based on multiple options for all reports. The Standard Report will also pull data from the erehabdata IRF-PAI database that is pertinent to the patient satisfaction outcomes. Because of the length of the report, the feature of the erehabdata IRF-PAI Fleming AOD 20

23 report that allows the user to display the entire report or selected sections will also be applied to the Standard Report. The Follow-Up Report will follow this same report structure, but will include the appropriate survey items specific to that survey. The Service Recovery Survey Report will be included in the erehabdata Dashboard, a new report developed March Because the Dashboard is designed to report on the status of the facility s current inpatient population, it would be appropriate and convenient to include the Service Recovery Report in the Dashboard. A sample of the Standard Report for the Discharge Survey is on the following page. Fleming AOD 21