Using HCAHPS Survey Custom Questions to Drive Staff Engagement Diana Topjian, RN, MSN, D.M., C-ENP Account Lead/Coach Studer Group
Outcome Goals Verbalize the value of adding HCAHPS custom questions to the survey to deepen staff engagement Describe how to use the results from custom HCAHPS to engage staff Develop a plan to implement the custom questions in your organization 2
Execution Framework: Evidence-Based Leadership SM LEADER EVALUATION Implement an organization-wide leadership evaluation system to hardwire objective accountability LEADER DEVELOPMENT Create process to assist leaders in developing skills and leadership competencies necessary to attain desired results MUST HAVES Rounding, Thank You Notes, Employee Selection, Pre and Post Phone Calls, Key Words at Key Times PERFORMANCE GAP Re-recruit high and middle performers, Move low performers up or out STANDARDIZATION Agendas by pillar, peer interviewing, 30/90 day sessions, pillar goals ACCELERATORS Leader Evaluation Manager Validation Matrix SM Provider Feedback System SM Studer Group Rounding Patient Call Manager TM 3
Change Heath 4
Focused Behaviors and Tactics: Direct the Rider Hourly Rounding Bedside Shift Report Nurse Leader Rounding Post Discharge Calls 5
Connecting Heart and Mind 6
Randy Johnson BA Director of Marketing THE HEART HOSPITAL Baylor Plano
Did you know? If 99% is good enough, then: 2 newborns will be given to the wrong parents daily. 03,260 income tax returns will be processed incorrectly this year. Two plane landings daily at O' Hare International Airport in Chicago will be unsafe. 8,322 pieces of mail will be mishandled in the next hour. 29 pacemaker operations will be performed incorrectly this year. 20,000 incorrect drug prescriptions will be written in the next 2 months
Did you know? If 99% is good enough, then: 07 incorrect medical procedures will be performed by the end of the day today. 2,000,000 documents will be lost by the IRS this year. 22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes.
Finding Meaning through Data Up to Date Understandable Meaningful Connects to Actions
HCAHPS (Overall) - Goal - > 80 th percentile in 6 of the composites Q4 FY 5 (Jul Aug 7) Current Quarter n=39 Q3 FY 5 (Apr Jun) Prior Quarter n=27 Q2 FY 5 (Jan - Mar) n=28 Q FY 5 (Oct - Dec) n=23 Overall Rating of Care 38% 69% 76% 28% 54% 88% Communication with Nurses 78% 99% 86% 88% 95% 93% Nurses treat with courtesy/respect 90% 99% 49% 9% 90% 85% Nurses listen carefully to you 56% 99% 9% 75% 89% 97% Nurses expl in way you understand 80% 99% 95% 92% 98% 83% Communication with Doctors 49% 97% 46% 73% 73% 87% Doctors treat with courtesy/respect 84% 97% 62% 62% 82% 86% Doctors listen carefully to you 76% 96% 67% 87% 83% 92% Doctors expl in way you understand 8% 96% 20% 63% 55% 78% Responsiveness of Staff % 84% 76% 60% 64% 8% Call button help soon as wanted it 25% 83% 80% 66% 69% 83% Help toileting soon as you wanted 6% 79% 66% 53% 59% 76% Pain Management 34% 83% 70% 60% 67% 86% Pain well controlled 7% 73% 70% 5% 58% 65% Staff do everything help with pain 80% 87% 64% 66% 75% 95% Communication re Medication 5% 93% 73% 80% 74% 94% Tell you what new medicine was for 47% 89% 56% 4% 59% 93% Hospital Environment 74% 98% 95% 86% 92% 92% Cleanliness of hospital environment 97% 92% 87% 7% 86% 87% Quietness of hospital environment 38% 97% 93% 87% 89% 90% Discharge Information 88% 89% 48% 68% 70% 8% Staff talk about help when you left 90% 85% 42% 72% 66% 75% Info re symptoms/prob to look for 78% 87% 57% 58% 66% 79% Transition of Care 46% 92% 36% 70% 65% 70% Hosp staff took pref into account 50% 95% 59% 59% 73% 80% Good understanding managing health 43% 87% 27% 55% 55% 60% Understood purpose of taking meds 40% 96% 9% 72% 62% 60% FY 5 YTD n=47 FY 4 YTD n=428
Action Plan: Communication with Nurses Communication with Doctors Bedside Shift Report (to include Patient Communication Board) Responsiveness of Staff Purposeful Hourly Rounding Pain Management Establishing a pain goal and managing expectations Communication re Medication Hospital Environment Discharge Information Transition of Care Source: Hospital System in the SE 2
Using Data to Connect the Heart and Mind: HCAHPS Key Focus Questions for Comparisons:. 2. HCAHPS Custom Questions How often did nursing staff come into your room to check or round on you during the day? Would you say every hour, every two hours, every few hours, or a couple of times a day? Did a nurse leader visit you during your stay? Y/N/Unsure 3. After discharge, did you receive a phone call from a hospital staff member regarding your recovery at home? 4. At shift change, did the nurses include you in their conversation regarding your plan of care? 3
Percentile Rank HCAHPS Overall Rating 00 90 80 70 60 50 40 30 20 0 0 Did a staff member visit you hourly? 88 95 n=3 n=49 n=74 n=42 Q5 2Q5 YES NO *Data pulled from Press Ganey by discharge date 7.6.5 **Percentile rankings based on 3Q3-2Q4 CMS results ***Major SE System 9% Average increase in %ile ranking when answered yes to staff member visit
Did a Nurse Leader visit you during your stay? 00 90 80 70 73 84 73 79 88 89 78 88 Overall Hospital Rating Comm. With Nurses Response of Hosp. Staff 60 Comm. With Doctors 50 40 35 Hosp. Environment Pain Management Comm. about Medicines 30 20 2 Discharge info Care Transistions 0 0 Carolina East YES 2 NO 9 2 4 5
HCAHPS Custom Question: Greenville Hillcrest Correlation with Nurse Leader visit 00 90 80 70 60 50 40 30 20 0 0 Did a nurse manager from patient care visit? 85. 8.3 42.9 88.4 94.6 57. 57. 57. 78.7 82.5 74.9 46.4 4.7 25 95.2 95.2 73. 73. 67 34.5 N=24 3 N= 49 N= 3 YES N=5 NO N=0 6 N= 7 *Data pulled from Press Ganey by discharge date 2.6.6 Date Range Oct., 205- to date
HCAHPS Custom Questions: Rutland Regional Medical Center NLR-Nurse Leader Rounding PDC-Post discharge call 7
Impact to HCAHPS: Transition of Care Call Received vs. Not Received 00 90 80 70 60 50 40 30 20 0 0 How often did hospital staff describe possible side effects in a way you could understand? Source: Major Hospital in SE region How often did the hospital staff tell you what the medicine was for? Received Call No Call Did the MDs, Nurses, or other hospital staff talk with you about whether you would have the help needed when you left the hospital?
Leader Round and PCM Call 00 90 80 70 60 50 40 30 20 82 94 84 88 49 90 95 87 9 Overall Hospital Rating Comm. With Nurses Response of Hosp. Staff Comm. With Doctors Hosp. Environment Pain Management Comm. about Medicines Discharge info Care Transistions 0 0 YES NO Carolina East 9
THE HOW 20
Outcome Goals Verbalize the value of adding HCAHPS custom questions to the survey to deepen staff engagement Demonstration of correlation of behavior to patient s experience Develop a plan to implement the custom questions in your organization Identify key words Determine tactic(s) to use (usually those you are struggling to hardwire) Discuss with vendor Describe how to use the results from custom HCAHPS to engage staff Huddles, staff meeting, posted on pillar board; connect the action to the outcome and the difference one person can make 2
Always bring it back to values..." Quint Studer 22
Change 23
EVALUATION REMINDER: We want your feedback to get better. Please remember to take the session evaluation. Thank you! Insert Your Photo Here Diana Topjian, RN, MSN, D.M., C-ENP Account Lead/Coach Diana.Topjian@studergroup.com
Next Presentation: Reducing Readmissions through Recurring Care Transition Calls Erin Shipley, RN, Studer Group Coach & Rachael Johnson, Studer Group Solutions Specialist