Arizona Critical Access Hospital Quality Network Working to Improve the Patient Experience March 12, 2013 2 3:30pm Arizona Rural Hospital Flexibility Program
AZ-CAH Quality Network CAH Participants Benson Hospital Teresa Vincifora Ora Goodman Carondelet Holy Cross Hospital Karen Nestor Marilyn Majalca Cobre Valley Community Hospital Kara Holcomb Copper Queen Community Hospital Claudia Romo Sadie Maestas Hopi Health Care Center TBD Hu Hu Kam Memorial Hospital Sarah Wolterman Little Colorado Medical Center Sonia Ybarra Leslie Fusaro Northern Cochise Community Hospital Susan Cazaux Page Hospital Michelle McCabe Parker Indian Health Center Sherry Killingsworth Lily Shimahara Sage Memorial Hospital Christi El-Meligi Southeast Arizona Medical Center Annie Benson Robi Berry White Mountain Regional Medical Center Cherie Passalacqua Wickenburg Community Hospital Linda Brockwell Judy Carroll
Purpose of Today s Webinar Strengthen the AZ-CAH Quality Network Support hospitals in selecting QI project to improve patient satisfaction Discuss process for sharing HCAHPS Scores Introduce MBQIP / Hospital Compare Reports Identify next steps
Agenda I. Welcome and Introductions II. HCAHPS Update III. Pt. Satisfaction QI Projects a. Discussion with members b. Cobre Valley Regional Medical Center Pain Management IV. Next Steps V. Medicare Beneficiary Quality Improvement Project (MBQIP) Quality Reports VI. Summary & Evaluation
HCAHPS Reported by Hospitals Established New to HCAHPS Not currently Carondelet Holy Cross Benson Hospital Hopi Health Care Center Cobre Valley Reg. Medical Ctr. Hu Hu Kam Memorial Hospital Little Colorado Medical Center Copper Queen Comm. Hospital Northern Cochise Comm. Hospital Parker Indian Health Center Page Hospital White Mountain Reg. Med. Ctr. Sage Memorial Hospital Wickenburg Comm. Hospital Southeast Arizona Medical Ctr.
Discussion How are you receiving HCAHPS data? What frequency? What format? What kinds of reports? How are you using HCAHPS information? Who receives reports? What hospital areas Are you satisfied? Examples of use Suggestions for improvement? What questions do you have?
Sample HCAHPS Vendor Report Track performance over time
Sample Healthstream HCAHPS Benchmarking Report
Pt. Satisfaction - QI Project Ideas Category/HCAHP Staff Responsiveness Close the loop of patient falls Proposed QI Projects We have initiated a Pain Management policy, completed staff education regarding the policy and pain assessment, and have initiated chart audits to monitor that pain is being addressed, and re-evaluated. Pain Management Hospital Environment Communication Nursing care areas are using educational tools to assist in developing a pain management plan with patients. Nurses are also required to reassess pain after a pain medication has been given and document it in the medical record. If the reassessed pain score is above the patient s pain goal, the nurse is required to intervene (call physician for additional orders, teach relation techniques, etc.). Compliance is monitored and reported monthly at Quality Council. Quiet at night initiative to raise awareness of needed rest for healing and dedicating quiet time on units Physician communication to increase transparency of reporting scores Top Tactics-Purposeful Patient Rounding, Leading Rounding ED Waiting Times Reduce no show rate Tracking the time it takes from Doctors order to transfer-to-floor Physician communication to increase transparency of reporting scores Follow up phone calls to patients when discharged Discharge Making appointments for follow up when patients leave the hospital Emergency Room patient discharge follow up phone calls Other Need to choose an HCAHPs vendor and then will pick a project.
QI Projects Presentations How did you select the project What data did you use? Who was / is involved? How will QI project information be monitored? How does it fit into existing hospital QI projects Is there an Aim Statement?
AZ-CAH Example Cobre Valley Regional Medical Center HCAHPS Improvement Project: Pain Management
Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Individual Value Individual Value X X X X X X X X X X January-March 2010 April-June 2010 July-September 2010 October-December 2010 January-March 2011 April-June 2011 July-September 2011 October-December 2011 January-March 2012 April-June 2012 July-September 2012 October-December 2012 January-March 2013 January-March 2010 April-June 2010 July-September 2010 October-December 2010 January-March 2011 April-June 2011 July-September 2011 October-December 2011 January-March 2012 April-June 2012 July-September 2012 October-December 2012 January-March 2013 Individual Value Individual Value E Patient Experience: OB Overall Clinical Quality of Care in OB Special Cause Flag Pain Controlled Special Cause Flag 100 90 80 70 60 50 40 30 20 10 0 Patient Experience: OB 0 100 90 80 70 60 50 40 30 20 10 Period Period Reassessed Pain less than Pain Goal Special Cause Flag Pain Assessed Every Hour Special Cause Flag 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 Period Period
Selection of QI Project Hospital Data Lower HCAHPS Scores Incident Reports Patients & Families Family Communication Patient Communication QI Project Selection Direct Reporting to Quality Leadership Team Staff
HCAHPS Survey: Pain Management (Q12-14) Abstracted from Hospital Compare (December 2012, Bullock) * Fewer than 100 patients completed the HCAHPS survey. Use scores with caution, as number of surveys may be too low to reliably assess hospital performance. ** There were discrepancies in the data collection process.
HCAHPS Survey: Medication Management (Q15-17) % Patients who reported that staff "Always" explained about medicines before giving it to them. Arizona Average Page Hospital Carondelet Holy Cross Copper Queen Community Hospital * Cobre Valley Regional Medical Center ** 0 20 40 60 80 100 Abstracted from Hospital Compare (December 2012, Bullock) * Fewer than 100 patients completed the HCAHPS survey. Use scores with caution, as number of surveys may be too low to reliably assess hospital performance. ** There were discrepancies in the data collection process.
Best Practices: Pain kk Management Patients who reported that their pain was "Always" well controlled Tactics that make Always responses more likely 1. Use Individualized Patient Care to Manage Patient Perception of Pain 2. Conduct Hourly Rounding to Consistently Address Pain 3. Pain Poster Source: The HCAHPS Handbook, Studor (2010)
Next Steps Communication develop project ideas - Flex staff and AZ-CAH Quality Network peers - Situational analyses with your hospital teams Identify QI projects - Aim Statements AZ-CAH Quality Network webinar Attend AZ-CAH workshop Technical Assistance available Share HCAHPS data
Effective Aim Statements Answer the question, What are we trying to accomplish? Communicate expectations Are time specific Are measureable Define the specific population or populations affected Are clear and unambiguous Can be used in your elevator speech They aim BIG Source: Dr. Andrea Silvey, HSAG, adopted from Institute for Healthcare Innovation
Upcoming Events Flex Guidance (May 2) Team STEPPS training (April 9-10) AZ-CAH Quality Network webinar (April) AZ-CAH Quality Network workshop (May or June) Location (tbd) Date (tbd) Quality Programs in the IHS, Dorothy Dupree. (April 16) Arizona Telemedicine Program Grand Rounds CME available Live Stream details forthcoming Billing and Coding Boot Camp, (April 22-24), Phoenix Certification Preparation webinar (Date tbd) Computerized Physician Order Entry (CPOE), Peter Catinella, MD & Clint Hinman,PhD Arizona Telemedicine Program Grand Rounds CME available Live Stream details forthcoming
Poll Date / location for face-to-face
Homework Please send HCAHPS scores / reports Develop your QI projects Communicate TA service needs AZ-CAH Workshop (May / June) Aims Statement Needs assessment / situation diagnosis Share quality reports Strategies to improve pt. satisfaction Strategies to analyze data
Medicare Beneficiary Quality Improvement Program (MBQIP) Participation Agreements signed 11 AZ-CAHs 1,139 National CAHs Encourage participation in Hospital Compare / HCAHPS Phase 01 Measures (Pneumonia / HF) Phase 02 Measures (HCAHPS, Outpatient) Phase 03 Measures (ED & Pharmacy, Sept 2013) AZ-Flex working in collaboration with HSAG First MBQIP report release (Dec. 2012) Data Aggregated for four quarters to increase #s Second Data release (expected May 2013)
MBQIP Report: One Year Aggregate Data (Q4, 2011 Q3, 2012) Four Quarter Aggregate Current Quarter Quality Measure A H G K F B D All Reporting AZ-CAHs State Avg. National Avg. Discharge Instructions 30% 67% N/A 100% N/A 33% 80% 47% 67% 83% Evaluation of LVS Function 78% 73% N/A 50% N/A 33% 100% 70% 43% 85% ACEI or ARB for LVSD 100% 100% N/A 100% N/A N/A 100% 100% 100% 87% Blood Cultures Performed in ED Prior to Initial Antibiotic Initial Antibiotic Selection for Community-Acquired Pneumonia in Immunocompetent Patients 100% 90% N/A 0% 95% 67% 89% 90% 77% 95% 85% 88% N/A 0% 100% N/A 100% 100% 89% 89% Source: Teligen, HRSA Office of Rural Health Policy, Dec. 2012 * ACEI or ARB for LVSD: Heart failure patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge.
MBQIP Take Home Messages Report to Hospital Compare (even small numbers) Health Services Advisory Group Resources Hospital Compare & QualityNet cchapin@hsag.com or sgerhart@hsag.com Flex (and SHIP) funding being tied to MBQIP Emphasis on healthcare quality & value
Thank You! Please call us / your peers with any related thoughts / feedback Arizona Rural Hospital Flexibility Program This webinar is made possible through funding provided by the Health Resources and Service Administration, Office of Rural Health Policy, Medicare Rural Hospital Flexibility Program