HCAHPS, HSOPS, HACs and HIQRP Connecting the Dots Sharon Burnett, R.N., BSN, MBA Vice President of Clinical and Regulatory Affairs Missouri Hospital Association
Objectives Discuss how the results of the Hospital Consumer Assessment of Healthcare Providers and Systems and the Hospital Survey of Patient Safety can predict Hospital-Acquired Conditions and performance on clinical process measures under the Hospital Inpatient Quality Reporting Program. Describe ways to improve HCAHPS scores and improve your organizational culture of safety.
The 4-H s HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems: A nationally standardized survey developed by CMS and AHRQ for measuring how patients perceive the care they receive in hospitals. HSOPS - Hospital Survey of Patient Safety: Patient Safety Culture Surveys funded by AHRQ and developed to measure and support a culture of patient safety and quality improvement in hospitals. HACs Hospital-Acquired Conditions: An adverse event or condition that was not present on admission. HIQRP Hospital Inpatient Quality Reporting Program: Provides CMS with data for public reporting on Hospital Compare to help consumers make informed health care decisions and gives IPPS hospitals a financial incentive to report the quality of their services. The Hospital Quality Initiative (HQI) includes demonstration projects such as MBQIP to improve the care provided.
Three Goals Shaped HCAHPS 1. Allow objective and meaningful comparisons of hospitals on topics that are important to consumers. 2. Public reporting of the survey results creates new incentives for hospitals to improve quality of care. 3. Public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. www.hcahpsonline.org 4
HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems 9 Hospital CAHPS composites 1. Communication with nurses 2. Communication with doctors 3. Communication about medicines 4. Responsiveness of hospital staff 5. Discharge information 6. Pain management 7. Hospital environment (clean & quiet) 8. Overall rating of hospital (0 worst to 10 best) 9. Willingness to recommend to family & friends
Eligibility for the HCAHPS Survey Eighteen (18) years or older at the time of admission Admission includes at least one overnight stay in the hospital Non-psychiatric MS-DRG/principal diagnosis at discharge Alive at the time of discharge www.hcahpsonline.org 6
Exclusions from the HCAHPS Survey No-Publicity patients Patients who request that they not be contacted Court/Law enforcement patients (i.e., prisoners) Patients with a foreign home Patients discharged to hospice Patients discharged to nursing homes and skilled nursing facilities www.hcahpsonline.org 7
HCAHPS Survey - Timing Surveying of sampled patients must be initiated between 48 hours and six weeks after discharge, regardless of the mode of survey administration. No proxy respondents are permitted in the administration of the HCAHPS survey, not even for patients who are critically ill, elderly, physically or mentally impaired, or are coming to the hospital from other institutions, such as nursing homes. www.hcahpsonline.org 8
HCAHPS - What Can t You Do? Attempt to influence or encourage patients to answer HCAHPS questions in a particular way Imply that the hospital, its personnel or its agents will be rewarded or gain benefits if patients answer HCAHPS questions in a particular way. Do not ask or imply that patients should choose certain responses; do not indicate that the hospital is hoping for a given response, such as a 10, Definitely yes, or an Always. www.hcahpsonline.org 9
HCAHPS Composite Score State Rankings 13 34 5 4 33 30 28 10 25 6 2 7 50 22 24 38 46 4 8 3 40 49 15 31 37 14 2 47 1 35 41 9 29 21 36 8 48 51 3 43 20 23 19 9 2 17 7 12 11 2 16 1 6 32 44 4 5 HANYS report 10
Geographic, Size and Services Offered No Adjustments - CMS Controlling for geographic region (a hospital-level factor) as part of a patient-mix adjustment model could mask important differences in quality across the country. HCAHPS data are not biased by the perceptions of patients in terms of the range of services offered by different hospitals. Smaller hospitals generally tend to do better on HCAHPS relative to larger ones. (VBP Rule) 11
HCAHPS Patient-Mix Adjustments Patient characteristics (variables) that are not under the control of the hospital that may affect patient reports of hospital experiences. Goal of adjusting for patient-mix is to estimate how different hospitals would be rated if they all provided care to comparable groups of patients. Variables self-reported health status (increase with good health) Education (decrease with education) service line (maternity higher than med/surg) age (increase with age till 74) relative lag time, time between discharge and survey completion (decrease with time) primary language other than English 12
HCAHPS Rural Versus Urban Hospitals Rural scored higher than urban on all domains except: Discharge instructions = urban Recommend the hospital < urban Bed size 6 to 24 beds scored higher in all domains 13
Patient Satisfaction Is About Patient Perception Friendliness of the nurses Nurses attitude toward your request Skill of the nurse Courtesy of the person that cleaned your room Physician s concern for your questions and worries Friendliness/courtesy of physician Speed of admission process Courtesy of the person who admitted you
What Does It Take? 3 P s Great People Smooth and Consistent Processes A Safe and Inviting Place
People Nurse communication is the single most critical composite on the HCAHPS survey. Tell employees why, how, and what. It is what is best for the patient. Everyone in the hospital is responsible for our patients not just nursing.
Processes People don t care how nice everyone is if they look unorganized. We have to plan for the necessary communication when things aren t running smoothly. Everyone needs to be committed and empowered to make it right when something goes wrong.
Place Cleanliness and Quietness of Hospital Environment Area around room kept quiet at night Room and bathroom kept clean
HCAHPS Correlation With HACs and HQA Measures Studies show There is a relationship between patient satisfaction and 30 day readmission rates. There are consistent relationships between HCAHPS and reduction in HACs and improved HQI scores.
HSOPS - Hospital Survey of Patient Safety 42 items categorized in 12 dimensions 2 dimensions measure outcomes at dept/unit level Overall perceptions of safety Frequency of events reported 7 dimensions measure culture at dept/unit level 3 dimensions measure culture at hospital level 2 additional items measure outcomes at dept/unit level Number of Events Reported Patient Safety Grade 20
Four Cultures Required for a Culture of Safety REPORTING CULTURE - the willingness of front-line workers to report their errors and near-misses. Do your organizational practices support a Reporting Culture? JUST CULTURE - management will support and reward reporting and discipline only occurs based on risk-taking. Do your organizational practices support a Just Culture? FLEXIBLE CULTURE - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers Do your organizational practices support a Flexible Culture? LEARNING CULTURE - organization will analyze reported information and then implement appropriate change. Does your organization support a Learning Culture? Reason (1997)
A Reporting Culture Is Engineered By Implementing Practices... Successful reporting systems (Leape, 2002) Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Practices/Tools Reporting Form Near miss log Chart audit Secret Shopper Safety Briefings Leadership WalkRounds TM Bulletin board/ suggestion box/telephone hotline
A Just Culture Is Engineered By Implementing Practices... Understand human error Employ Just Culture and behavior (Marx, 2001) Recognize Unsafe Conduct: human error, negligence, reckless, intentional rule violation Use disciplinary decision-making: outcome-based, rule-based, risk-based Acts Algorithm Create disruptive Behavior Policy/Standards
Importance of Just Culture The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement 24
A Flexible Culture Is Engineered by implementing Practices Support Teamwork and Mutual Support Team Strategies & Tools to Enhance Performance & Patient Safety http://teamstepps.ahrq.gov
TeamSTEPPS Tools And Strategies Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS DESC Script Collaboration SBAR Call-Out Check-Back Handoff
What is a Learning Culture? It observes and collects data It reflects and draws correct conclusions from information systems It creates and plans change based on information It has the will to act and implement change Learning disabilities are tragic in children, but they are fatal in organizations. -- Peter Senge Reason, J. (1997). Managing the Risks of Organizational Accidents.
Learning Culture Practices and Tools RCA Action Plans FMEA Safety Briefings Leadership WalkRounds TM Report back aggregate results of error reports and summarize RCA action plans for staff
Leadership WalkRounds TM Senior leaders demonstrate commitment to safety, learn about safety issues by making regular rounds to discuss safety with front-line staff Communication is two-way, leaders and staff talk honestly and listen carefully (reporting) Unannounced or announced but must be regular (weekly) Focus on systems not individuals (just) Close the loop on communication (flexible) Use a notebook and database to track reported events and their resolution (learning) Digital camera can capture unsafe equipment/environment http://www.unmc.edu/rural/patient-safety/toolbox/inteaction/interaction.htm
Focus On The System And Not Individuals Can you think of any events in the past day or few days that have resulted in prolonged hospitalization for a patient? Have there been any near misses that almost caused patient harm but didn t? Have there been any incidents lately that you can think of where a patient was harmed? What aspects of the environment are likely to lead to the next patient harm? Is there anything we could do to prevent the next adverse event?
HSOPS Correlation With HACs and HQA Measures Data and literature suggests hospitals with better patient safety cultures have Lower rates of hospital-acquired conditions Lower AHRQ PSI scores for in-hospital complications and adverse events Higher rates of providing recommended care to patients Data and literature suggests hospitals with poorer patient safety cultures have Higher readmission rates for AMI and HF
Take-Away Messages If you don t do HCAHPS, consider doing it. If you do HCAHPS, consider how to use the results and create action plans. If you haven t done HSOPS, consider doing one. HEN benefit. If you ve done HSOPS, consider how to use the results and create action plans. Repeat HSOPs in 15 to 18 months to see if improvement has been made.
Resources HCAHPS - http://www.hcahpsonline.org/home.aspx HCAHPS HIDI Analytic Advantage https://www.hidionline.com/hidi/ HSOPS - http://www.unmc.edu/rural/patient-safety/ HSOPS www.mocps.org
MBQIP Thanks You! Sharon Burnett, R.N., BSN, MBA 573/893-3700, ext. 1304 sburnett@mail.mhanet.com Wanda F. Marvel, R.N., M.S. wmarvel@mail.mhanet.com 573/893-3700, ext. 1325 William Bryant McNally, J.D., MPH bmcnally@mail.mhanet.com 573/893-3700, ext. 1372