HHC Update: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) HCAHPS Health and Hospital Committee September 29 2011 Linda Smith, Chief Executive Officer, Carolyn Brown, RN Director Quality and Safety, Trudy Johnson, Chief Nursing Officer, Shari Hurst, Customer Service, Alice Naqvi Mugler, Director of Nursing Professional Practice
How are we doing? Reported on www.hospitalcompare.hhs.gov Public reporting period: October 2009 to September 2010 Current Previous Current Previous Current Previous Current Previous Current Previous Current Previous Current Previous Current Previous Current Current HCAHPS Questions 10/09-9/10 2/09-4/10 10/09-9/11 2/09-4/11 10/09-9/11 2/09-4/11 10/09-9/12 2/09-4/12 10/09-9/12 2/09-4/12 10/09-9/13 2/09-4/13 10/09-9/13* 2/09-4/13 10/09-9/14 2/09-4/14 10/09-9/13 10/09-9/14 Patients who reported that "always" VMC VMC CA CA NATL NATL LA County-USC SF General uc san diego El Camino Washington Hospital Alameda Contra Costa Their nurses communicated well 65% 67% 71% 70% 76% 76% 61% 60% 64% 65% 72% 75% 73% 73% 68% 68% 62% 71% Their doctors communicated well 74% 74% 76% 76% 80% 80% 73% 74% 71% 71% 77% 79% 79% 80% 76% 76% 76% 80% Received help quickly from hospital staff 45% 48% 57% 57% 64% 64% 56% 51% 49% 50% 60% 61% 61% 63% 51% 53% 42% 56% Their pain was well controlled 60% 62% 66% 65% 69% 69% 65% 62% 57% 57% 67% 68% 70% 71% 65% 67% 63% 65% Staff explained about medicines before giving it to them 52% 52% 56% 56% 61% 60% 50% 48% 56% 54% 56% 59% 58% 56% 56% 57% 53% 64% Room was always clean 54% 59% 68% 67% 71% 71% 55% 56% 59% 55% 64% 70% 75% 70% 56% 54% 57% 57% Area around room was quiet at night 34% 41% 48% 47% 58% 58% 46% 48% 42% 40% 50% 54% 52% 44% 41% 45% 43% 37% They were given information about what to do during their recovery 74% 76% 79% 79% 82% 81% 77% 75% 83% 82% 82% 83% 82% 80% 82% 79% 76% 84% Patients who gave hospital 9 or 10 score, from 1-10 (highest) 55% 59% 64% 63% 67% 67% 68% 67% 55% 56% 72% 71% 74% 70% 59% 61% 56% 65% Yes patients would recommend hospital overall 58% 60% 68% 67% 69% 69% 71% 69% 63% 65% 76% 78% 82% 78% 69% 70% 55% 70% *( discrepancies in data collection process) 2
What are we doing to improve? Formed a Customer Experience Committee with an interdisciplinary membership from across the organization and integration with a CLT team to accelerate change and improvement Objectives: Engage leadership for cultural change Identify and implement recognition strategies Encourage communication and participation Assess effects of operational integration Subgroups Quiet Team to reduce noise in the hospital Way Finding Team to improve directions on the Bascom Campus First Contact Team to improve impressions on first interaction Education Plan for rollout of the CARES principles and above work 3
What are we doing to improve? Every Contact Counts rolled out from May 9 June 20, 2011 3,500 employees in all departments in the hospital and in ambulatory care have attended the class on all shifts and locations. Acknowledgement committee posted pictures throughout SCVMC and clinics of employees nominated for their excellence in customer service Services submitted videos exemplifying excellent customer service Academy Award program to show to all staff in October Beginning April June 2011, the preliminary results show some modest improvement; results will be on CMS website in 9 months. Every Contact Counts (Version 2) Being created with a focus on teamwork and will be launched later this fall. 4
APPENDIX Santa Clara Valley Medical Center is owned and operated by the County of Santa 5
How is HCAHPS measured? The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay; it is not restricted to Medicare or Medi-Cal beneficiaries. Results are rolled up to 10 reporting categories. The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge; SCVMC contracts with a vendor PRC to collect this data The questions are about critical aspects of patients hospital experiences such as communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and whether they would recommend the hospital to others Would they recommend the hospital to family and friends is considered one of the most important questions of the survey as it establishes the brand reputation of SCVMC 6
Why is HCAHPS important? The Center for Medicare and Medicaid Services (CMS) will be linking reimbursement to results of patient experience surveys This represents a shift from pay for reporting to pay for performance as defined by CMS Patient Experience is one measure included in the 1115 Waiver Delivery System Reform Incentive Pool (DSRIP) in which California Public Hospitals will receive funding based on performance against defined measures over 5 years 7
What is HCAHPS? The first national standardized survey to be publicly reported of patient s perspective on hospital care that can be compared locally, regionally and nationally This is different than patient satisfaction data which evaluates how satisfied are consumers versus measuring the perception of their hospital experience The goals of the Centers for Medicare and Medicaid Services were threefold: Create comparisons that are meaningful to consumers Provide incentive to hospitals to improve the quality of care Enhance accountability with transparency of hospital quality data 8
The CARES Standard for Excellence SCVMC CARES Compassionate Accountable Respectful Excellent Safe We provide comfort and hope for physical, emotional, psychological and cultural needs. We commit to responsible use of all resources and assets We honor the dignity and diversity of each individual We empower individuals and integrated teams to meet customer needs We utilize best practices for clinical, environmental and occupational safety 9
Committee Members Customer Experience Committee Members Dolly Goel, MD Chris Wilder Medical Staff/Admin VMC Foundation Sonia Menzies, RN Daisy Brown, RN Ambulatory RNPA Nari Singh, PharmD Cliff Wang, MD Pharmacy/Rehab Medical Staff Carolyn Brown Gina Davis Quality&Safety Patient Business Services Kathleen Dolci MyMy Phu Volunteers Pharmacy Services Jill Sproul, RN Nursing Trudy Johnson, RN Administration Linda M. Smith Chief Executive Officer Ngoc Bui-Tong Ambulatory Admin Alice Naqvi Mugler, RN Nursing Admin Martin Muratore Patient Access Craig Ivie Respiratory/Support Svc Michele Tipton Burton Rehab Shari Hurst Customer Service 10