SOMC Service Dashboard FY 17 Patient-Centered Perfection is the Goal

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1 SOMC Service Dashboard FY 17 Patient-Centered Perfection is the Goal Indicator Goal [Average] Improve Patient Perception of Care Inpatients HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) How Often did Nurses Communicate Well With Patients (DeCamp/Fraulini/ Burchett) HVBP How Often did Doctors Communicate Well With Patients (DeCamp/Fraulini/ Burchett) HVBP How Often did Patients Receive Help Quickly From Hospital Staff (DeCamp/Fraulini/ Burchett) HVBP [80%] [82%] [68%] HC? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD HC HC HC How Often was Patients Pain Well Controlled (DeCamp/Fraulini/ Burchett) HVBP How Often did Staff Explain About Medicines Before Giving Them to Patient (DeCamp/Fraulini/ Burchett) HVBP How Often Were the Patients' Rooms and Bathrooms Kept Clean (DeCamp/Fraulini/ Burchett) HVBP How Often was the Area Around Patients Rooms Kept Quiet at Night (DeCamp/Fraulini/ Burchett) HVBP Were Patients Given Information About What to do During Their Recovery at Home (DeCamp/Fraulini/ Burchett) HVBP How do Patients Rate the Hospital Overall (DeCamp/Fraulini/ Burchett) HVBP [71%] [65%] [74%] [62%] [87%] [72%] HC HC HC HC HC HC Likelihood to Recommend (DeCamp/Fraulini/ Burchett) HVBP [71%] HC Safety t Quality t Service t Relationships t Performance Goal = Perfection Rate (top percentile, 0,, VBP Benchmark [Average] = National Average, Mean, Median, VBP Threshold HC = Hospital Compare? = Explanation/Calculation * = Domain Roll-up HVBP = Value-Based Purchasing Task List

2 SOMC Service Dashboard FY 17 Patient-Centered Perfection is the Goal Indicator Goal [Average] HC? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD Improve Patient Perception of Care Inpatients HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Care Transitions Measure (DeCamp/Fraulini/ Burchett) [52%] HC? Improve Patient Perception of Care CG-CAHPS (Consumer Assessment of Healthcare Providers and Systems) Overall Patient Rating of Provider (Schmidt/Burchett)? Getting Appointments and Health Care When Needed (Schmidt/Burchett)? Provider Communication (Schmidt/Burchett)? Courtesy and Helpful Office Staff (Schmidt/Burchett)? Safety t Quality t Service t Relationships t Performance Goal = Perfection Rate (top percentile, 0,, VBP Benchmark [Average] = National Average, Mean, Median, VBP Threshold HC = Hospital Compare? = Explanation/Calculation * = Domain Roll-up Task List

3 SOMC Service Dashboard FY 17 Patient-Centered Perfection is the Goal Indicator Goal [Average] Improve Patient Perception of Care HOME CARE CAHPS (Home Care Consumer Assessment of Healthcare Providers and Systems) Patient Care Gentleness, Courtesy and Problems With Care * (Thompson/Burchett) Communication With Health Care Providers and Agency Staff * (Thompson/Burchett) Specific Care Issues Related to Pain/Meds Care * (Thompson/Burchett) [88%] [85%] [83%] HC? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD HC HC HC Overall Rating of Care (Thompson/Burchett) Likelihood to Recommend (Thompson/Burchett) Improve Patient Perception of Care Outpatient Ambulatory Surgery CAHPS Overall Facility Rating Would Recommend Communication About The Facility Discharge and Recovery [84%] [78%] HC HC N/A Safety t Quality t Service t Relationships t Performance Goal = Perfection Rate (top percentile, 0,, VBP Benchmark [Average] = National Average, Mean, Median, VBP Threshold HC = Hospital Compare? = Explanation/Calculation * = Domain Roll-up Task List

4 SOMC Service Dashboard FY 17 Patient-Centered Perfection is the Goal Indicator Goal [Average] HC? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD Improve Patient Perception of Care HOSPICE CAHPS (Hospice Consumer Assessment of Healthcare Providers and Systems) Overall Rating of Hospice (Ruby/Burchett) Likelihood to Recommend (Ruby/Burchett) Hospice Team Communication (Ruby/Burchett) Getting Timely Care (Ruby/Burchett) Treating Family Member With Respect (Ruby/Burchett) Providing Emotional Support (Ruby/Burchett) Getting Help For Symptoms (Ruby/Burchett) Getting Hospice Care Training (Ruby/Burchett) Providing Support For Religious and Spiritual Beliefs (Ruby/Burchett) Information Continuity (Ruby/Burchett) Understanding The Side Effects of Pain Medications (Ruby/Burchett) YTD Rate of Perfection 82.8% Safety t Quality t Service t Relationships t Performance Goal = Perfection Rate (top percentile, 0,, VBP Benchmark [Average] = National Average, Mean, Median, VBP Threshold HC = Hospital Compare? = Explanation/Calculation * = Domain Roll-up Task List

5 What CMS Payment/Reporting Programs are Included in $ Indicators? CMS HCAHPS IPPS IQR VBP Acronym Description Centers for Medicare & Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems Inpatient Prospective Payment System Inpatient Quality Reporting Program (formerly Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Program Value Based Purchasing

6 History Service Team Kendall Stewart MD Champion Service SOMC Strategic Value Service Kick off Chip Bell Passports Valuesville FAIR (PACT) Sleighride 1998 Leadership model Graceland Walk-awhile in my shoes Press, Ganey 500 Liz 2000 Taste of Chicago Customer Love 2002 Seven C s SOMC Best Practices Hero Fair Sleigh Bells Press, Ganey National Conference Panel Discussion Complaint Mgt. and Service Recovery 2004 Patient Centered Care Connecting the Dots These Hands National Customer Service Week - Presence 2006 Review verbatim comments weekly Super rounding Thank you notes Weekly Watch Interdepartmental customer survey AIDET competencies Rounding for results competencies Standards of Behavior deployed 2008 PG Employee Opinion Survey AIDET pocket cards Discharge call manager software 1997 Press, Ganey Partnership 1999 Moments of Truth Reward & Recognition Standards of Behavior Pathways (communication) Measure PG employee survey Fix-o-Flat 2001 Tour Standard of Behavior (Bike fair) Just ask me Press, Ganey Success Story National Presentation 2003 Driver s ED Fred Lee 7C s 7C s Cascade learning ( ) 2005 A HEART Service Celebration You Make a Difference video 2007 PG, Compare group changed to all hospital database Org. Excellence Support Teams Communication, Measurement, Recognition, Standards of Behavior Discharge call backs Key words at key times Valet parking HCAHPS pilot run Door greater for front entrance Pt. centered care concepts and education

7 History AIDET Competency PG to PRC Sense of Urgency Call to Action PRC dry run Inpatient s Apr-June 09 Hourly Rounding Key Driver Questions Rounding Calls by Pt. Relations 2009 Leader Rounding (employee) Leader Rounding (patient s) Weekly service meeting for inpatient Discharge Calls by Pt. Relations HCC 4 star award Inpatient Units Best Practices Key Driver Service Journey Hospital wide 8/10 PRC Education 8/ Personal Action Plans Organ. Wide Bedside Reporting Weekly service meetings Inpatient ED Home Care Hospice Ambulatory Surgery Service Journey 4/10 Key Drivers Rounding Bedside Shift Report PRC Education 8/10

8 Patients who Reported That Their Nurses "Always" Communicated Well. Current Data Collection Periods are from to for the Hospital Compare data displays

9 Patients who Reported That Their Doctors "Always" Communicated Well. Current Data Collection Periods are from to for the Hospital Compare data displays

10 Patients who Reported That They "Always" Received Help as Soon as They Wanted. Current Data Collection Periods are from to for the Hospital Compare data displays

11 Patients who Reported That Their Pain was "Always" Well Controlled Current Data Collection Periods are from to for the Hospital Compare data displays

12 Patients who Reported That Staff Always Explained About Medicines Before Giving it to Them. Current Data Collection Periods are from to for the Hospital Compare data displays

13 Patients who Reported That Their Room and Bathroom Were "Always" Clean. Current Data Collection Periods are from to for the Hospital Compare data displays

14 Patients who Reported That the Area Around Their Room was "Always" Quiet at Night. Current Data Collection Periods are from to for the Hospital Compare data displays

15 Patients at Each Hospital who Reported That YES, They Were Given Information About What to do During Their Recovery at Home Current Data Collection Periods are from to for the Hospital Compare data displays

16 Patients who Gave Their Hospital a Rating of 9 or 10 on a Scale From 0 (lowest) to 10 (highest). Current Data Collection Periods are from to for the Hospital Compare data displays

17 Patients Who Reported YES, They Would Definitely Recommend The Hospital Current Data Collection Periods are from to for the Hospital Compare data displays

18 Patients Who Strongly Agree They Understood Their Care When They Left The Hospital. Current Data Collection Periods are from to for the Hospital Compare data displays

19 How Often the Home Health Team Gave Care in a Professional Way This information comes from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Patient Experience of Care Survey during the time period January 2015 December 2015

20 How Well did the Home Health Team Communicate with Patients This information comes from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Patient Experience of Care Survey during the time period January 2015 December 2015

21 Did the Home Health Team Discuss Medicines, Pain, and Home Safety with Patients This information comes from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Patient Experience of Care Survey during the time period January 2015 December 2015

22 How do Patients Rate the Overall Care From the Home Health Agency This information comes from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Patient Experience of Care Survey during the time period January 2015 December 2015

23 Would Patients Recommend the Home Health Agency to Friends and Family This information comes from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Patient Experience of Care Survey during the time period January 2015 December 2015

24 Inpatient Satisfaction: Global Rating Item: Explanation This is a global rating item score. This question is a single item indicator of the hospital experience. It is calculated using the percent of scores rated as a 9 or 10 on a scale of 1-10 with 1 being the worst possible hospital and 10 being the best possible hospital. This benchmark is a National Average as reported by hospitalcompare.gov There are four approved modes of administration for the CAHPS Hospital Survey: 1) Mail Only; 2) Telephone Only; 3) Mixed (mail followed by telephone); and 4) Active Interactive Voice Response (IVR). SOMC uses a telephone survey. The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks following discharge; the survey is not restricted to Medicare beneficiaries.

25 Care Transitions Measure: Explanation The 3-item Care Transitions Measure (CTM) is comprised of the following questions: Q1 During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left. Q2 When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. Q3 When I left the hospital, I clearly understood the purpose for taking each of my medications. The CTM was developed to assess the extent to which hospital staff accomplished essential care processes in preparing patients for discharge and how well patients are prepared to participate in post-hospital self-care activities. In contrast to other measures that address the discharge out of the hospital, the focus of the CTM-3 is on what hospital staff actually did to prepare the patient, rather than what questions hospital staff may have asked the patient. As a significant percent of post hospital care plans include a role (either implicitly or explicitly) for family caregivers, one of the CTM items includes reference to the family (as do the Medicare Conditions of Participation).

26 Service Seize an Opportunity and Make a Change What are our priorities in FY 2017? Project/Task (Plan/Do) Leader(s) (Who) Timeline (Check) Conclusion (Act) Completed (Audit) Service

27 What questions do you have? S a f e t y Q u a l i t y S e r v i c e R e l a t i o n s h i p s P e r f o r m a n c e

Patient Experience & Satisfaction

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