2/5/2014. Patient Satisfaction. Objectives. Topics of discussion. Quality for the non-quality Manager Session 3 of 4

Size: px

Start display at page:

Download "2/5/2014. Patient Satisfaction. Objectives. Topics of discussion. Quality for the non-quality Manager Session 3 of 4"

Bruce Anderson
5 years ago
Views:

1 Patient Satisfaction Quality for the non-quality Manager Session 3 of 4 Presented by Paul E. Frigoli, Ph.D.(c), R.N., C.P.H.Q., C.S.S.B.B. Certified Lean Six Sigma Master Black Belt Objectives At the end of the session the learner will be able to identify: Why patient satisfaction is so important How patient satisfaction is carried out The implications of favorable and unfavorable patient satisfaction scores Topics of discussion What types of surveys are available? Why is patient satisfaction so important? Who gets surveyed? What happens if our scores are not so great? 1

2 HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) standardized survey instrument and data collection methodology in use since 2006 to measure patients' perspectives of hospital care. creates a national standard for collecting and public reporting information that enables valid comparisons to be made across all hospitals to support consumer choice. Goals of HCAHPS Produces comparable data for public reporting Creates incentive for organizations to improve Enhances public accountability and transparency Type of CAHPS: Hospital CAHPS Home Health Care CAHPS Clinician and Group CAHPS more to come! HCAHPS Survey instrument composed of 27 items: 18 substantive items that encompass critical aspects of the hospital experience (communication with doctors, communication with nurses, responsiveness of hospital staff, cleanliness of the hospital environment, quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and recommendation of hospital); four items to skip patients to appropriate questions three items to adjust for the mix of patients across hospitals two items to support congressionally-mandated reports. The 2

3 HCAHPS Survey instrument available in English, Spanish, Chinese, Russian and Vietnamese in the mail format, and in English and Spanish in the telephone and Interactive Voice Response formats. On average, it takes respondents about seven minutes to complete the HCAHPS survey items. The core set of HCAHPS questions can be combined with customized, hospital-specific items to complement the data hospitals collect to support internal customer service and quality-related activities History of HCAHPS Voluntary collection of HCAHPS data for public reporting began in 2006 public reporting began in 2008 Since July 2007, PPS hospitals must collect, submit and publicly report HCAHPS data in order to receive their full annual payment update (APU). PPS hospitals that fail to report the required quality measures, which include the HCAHPS survey, may receive an APU that is reduced by 2.0 percentage points. Non-PPS hospitals, such as Critical Access Hospitals, can voluntarily participate in HCAHPS. Guidelines Sampled patients are surveyed between 48 hours and six weeks after discharge, regardless of the mode of survey administration. Interviewing or distributing surveys to patients while they are still in the hospital is not permitted. Data collection for sampled patients must end no later than six weeks following the date the first survey is mailed (Mail Only and Mixed Modes) or the first telephone attempt (Telephone Only and IVR Modes) is made. 3

4 Guidelines Hospitals must obtain at least 300 completed HCAHPS surveys over the 12-month reporting period. Sampling is permitted monthly. Smaller hospitals that are unable to reach the target of 300 completes in a 12-month reporting period must survey ALL eligible discharges and attempt to obtain as many completes as possible. Reports Results are reported for four quarters on a rolling basis Publicly reported on Hospital Compare Topics Composite topics Nurse Communication (Q1, Q2, Q3) Doctor Communication (Q5, Q6, Q7) Responsiveness of Hospital Staff (Q4, Q11) Pain Management (Q13, Q14) Communication About Medicines (Q16, Q17) Discharge Information (Q19, Q20) 4

5 Topics Individual Items Cleanliness of Hospital Environment (Q8) Quietness of Hospital Environment (Q9) Global Items Overall Rating of Hospital (Q21) Willingness to Recommend Hospital (Q22) Why is CAHPS Important? Consumers have access to the data Consumers relate more easily to CAHPS data than to clinical data Some use CAHPS data to choose hospitals CAHPS is in the public eye Media coverage Promotion by hospitals themselves Participation linked to reimbursement Will have volume, revenue, and reputation implications down the road General Survey Guidelines Patient Eligibility All payer types 18 years or older At least one overnight stay in the hospital (admit date & discharge date cannot be the same) All MS-DRGs except: Primary psychiatric diagnosis, discharged from rehab or from skilled nursing Alive at the time of discharge 5

General Survey Guidelines Patient Ineligibility Not sent to patients with an international address Not sent to patients discharged to hospice or correctional facilities Not sent to patients

6 General Survey Guidelines Patient Ineligibility Not sent to patients with an international address Not sent to patients discharged to hospice or correctional facilities Not sent to patients discharged to nursing home or skilled nursing HCAHPS Public Reporting Domains Communication with Doctors Communication with Nurses Responsiveness of Hospital Staff Pain Control Communication about Medicines Discharge Information Questions Cleanliness of Physical Environment Quiet of Physical Environment Overall Rating of Care Likelihood to Recommend HCAHPS Survey Format Evaluative Questions About You Questions Global Rating Questions Screening Questions 6

7 HCAHPS questions Hospital Environment During this hospital stay, how often were your room & bathroom kept clean? Never, sometimes, usually, always During this hospital stay, how often was the area around your room quiet at night? Never, sometimes, usually, always Overall Rating 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-worst 10-best possible hospital Would you recommend this hospital to your friends & family? Definitely no, probably no, probably yes, definitely yes 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 Communication Guidelines Hospitals SHOULD NOT Ask patients for a certain score Indicate that their goal is to receive a certain score Show the HCAHPS survey or cover letter to the patient prior to survey administration Mail pre-notification letter or postcards 7

8 Mode of survey distribution Phone Mail Mixed mode- mail & phone Active Interactive Voice Response Inconsistent use of customer service standards If 80% of your staff perform 80% of the standards 80% of the time =? (0.8 x 0.8 x 0.8 = 0.51) Only 51% of your patients will have the experience you want them to have Measurement of satisfaction The Ideal Reality Sit-down session with every patient Paper surveys 8

9 The patient s perception is their reality Proposed: ED-CAHPS Patient Experience of Care survey Emergency Department Arrival Communication about Medicines Pain Management Tests or Procedures during Emergency Department Visit Interpreter Services Nursing Care Physician Care Discharge Information Overall Rating of Emergency Department Care Willingness to Recommend Emergency Department Many other patient survey possibilities Outpatient Ambulatory Care Sleep Study Cardiac/Pulmonary Rehab And a myriad of home-made surveys No benchmarks Benchmark against yourself over time 9

10 Other types of surveys commonly used Employee engagement surveys Medical Staff surveys Volunteer surveys Interdepartmental surveys Vendor surveys Perception of safety culture surveys Important things to consider in surveys Reliability The degree to which it measures what it is supposed to measure Validity The extent to which a measurement gives results that are consistent Thank you for participating! One final webinar: Feb 14 Risk Management 10

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