# Presentation: 737377

## Using HCAHPS data to improve the quality of patient care

- Tenet Healthcare
- Cindy Larkin, Senior Director Measurement

## Discussion Points

**Tenet Overview****Transition to HCAHPS****Service Strategy ****Measurement System Redesign**

## Tenet by the numbers 

- Tenet by the numbers

- 60,000+ employees
- 1M+ Admissions
- 18,149 licensed beds
- 64 free-standing outpatient centers
- 12 states
- 54 acute care
- 2 rehab hospitals

## Tenet’s Patient Satisfaction System

- Tenet has been conducting patient satisfaction surveys since 1982
- Approximately 100,000 telephone surveys conducted annually by Field Research Corporation, founded in 1945
- Programs:
- Inpatient
- Outpatient Surgery
- Outpatient Services
- Emergency Department
- Inpatient Rehab
- Outpatient Rehab
- Mental Health

## Discussion Points

**Tenet Overview****Transition to HCAHPS****Service Strategy ****Measurement System Redesign**

## Transition to HCAHPS 

- Piloted the questionnaire at eight hospitals in the fall of 2004
- Reviewed our system to ensure all CMS guidelines were met.  Other than the questionnaire change, few modifications were necessary since Tenet’s system already met virtually all of CMS’s specifications
- Participated in focus groups with the Agency for Healthcare Research and Quality (AHRQ)
- In January 2005, transitioned to the HCAHPS questionnaire

## Communication is key

- Selected one person from each hospital as the HCAHPS liaison, responsible for internal communication and training
- Explained rationale for transition, which was to prepare for public reporting as soon as possible
- Shared results of the pilot study to prepare hospitals that the scores would likely be lower due to question and scale changes rather than performance
- Based on the pilot results, estimated the potential score impact for each hospital
- Developed training materials to help hospitals understand the reasoning behind various guidelines, such as adjusting the results based on patient characteristics, etc.

## Questionnaire design

- Transitioned entirely to HCAHPS rather than conducting two separate studies
- Involved key hospital personnel in questionnaire design to obtain buy in
- Selected custom questions to address issues not included in HCAHPS
- JCAHO issues			Privacy and safety
- High impact areas		Teamwork and sensitivity to family needs
- High use areas			Patient Access
- Outsourced areas		Food and Nutritional Services
- Redesigned other questionnaires (OP Surgery, OP Services, and ED) to HCAHPS format

## Survey design changes

| 

Hospital | 
Current Sample size | Adjustment Factor |  |  |  | 
Post-Adj
Sample Size |
| --- | --- | --- | --- | --- | --- | --- |
|  |  | Proxies | Language | Service Line | Adj
Total |  |
| A | 400 | 32 | 10 | 8 | 50 | 350 |
| B | 400 | 18 | 20 | 9 | 47 | 353 |
| C | 400 | 64 | 0 | 5 | 69 | 331 |

- Adjusted sample to delete non-HCAHPS patients that would continue to be included in Tenet’s system; i.e., proxy interviews; non-medical, surgical, or OB patients; interviews conducted in non-HCAHPS approved languages.  Unaccepted interviews need to be accounted for at each hospital to ensure we reach the minimum required sample size.

## Keep current with CMS guidelines

| Nurse Communication | -4.2 |
| --- | --- |
| Doctor Communication | -1.4 |
| Physical Environment | -5.9 |
| Responsiveness of Staff | -4.8 |
| Pain Management | -4.9 |
| Comm about Meds | -4.0 |
| Discharge Information | -1.4 |
| Willing to Recommend | -4.5 |
| Hospital Rating Question | -3.0 |

**Composite/ Category**

**Adjustment**

- Changed the scoring methodology to include the mode adjustment.
- While we cannot at this time mirror CMS results exactly, we modify our system when new guidelines are published.

## Discussion Points

**Tenet Overview****Transition to HCAHPS****Service Strategy ****Measurement System Redesign**

## Service restructuring

- Added a corporate-based Service Team to:
- Directly consult with hospitals
- Collect the tools and resources hospitals were using
- Changed priority focus
- Adjusted “key words” used in initiatives

## Previous service focus

| PATIENT SATISFACTION QUESTIONS | r* |
| --- | --- |
| Willing to Recommend  | 0.759 |
| Staff worked together as a team | 0.571 |
| Nurses listened carefully | 0.564 |
| Staff helped with pain | 0.551 |
| Nurses courtesy and respect | 0.545 |
| Staff sensitive to families' needs | 0.515 |
| Staff provided safe patient care | 0.511 |
| Nurses explanations clear | 0.505 |
| Call button answered | 0.500 |
| Staff helped with bathroom needs | 0.496 |
| Room and bathroom kept clean | 0.428 |
| Staff explained medicine | 0.426 |
| Staff clearly described side effects | 0.417 |
| Pain well controlled | 0.415 |
| Staff clearly explained financial/insurance matters | 0.412 |
| Staff respected patient privacy | 0.409 |
| Admissions staff courtesy and respect | 0.402 |
| Doctors listened carefully | 0.386 |
| Doctors explanations clear | 0.360 |
| Doctors courtesy and respect | 0.349 |
| Satisfaction with food service | 0.344 |
| Area around room kept quiet at night | 0.335 |
| Staff discussed discharge help | 0.289 |
| Written symptom/health info provided | 0.261 |
| *r = correlation coefficient |  |

- Focus areas

- Questions having a high correlation with overall satisfaction

## Current service focus

| PATIENT SATISFACTION QUESTIONS | r* |
| --- | --- |
| Willing to Recommend  | 0.759 |
| Staff worked together as a team | 0.571 |
| Nurses listened carefully | 0.564 |
| Staff helped with pain | 0.551 |
| Nurses courtesy and respect | 0.545 |
| Staff sensitive to families' needs | 0.515 |
| Staff provided safe patient care | 0.511 |
| Nurses explanations clear | 0.505 |
| Call button answered | 0.500 |
| Staff helped with bathroom needs | 0.496 |
| Room and bathroom kept clean | 0.428 |
| Staff explained medicine | 0.426 |
| Staff clearly described side effects | 0.417 |
| Pain well controlled | 0.415 |
| Staff clearly explained financial/insurance matters | 0.412 |
| Staff respected patient privacy | 0.409 |
| Admissions staff courtesy and respect | 0.402 |
| Doctors listened carefully | 0.386 |
| Doctors explanations clear | 0.360 |
| Doctors courtesy and respect | 0.349 |
| Satisfaction with food service | 0.344 |
| Area around room kept quiet at night | 0.335 |
| Staff discussed discharge help | 0.289 |
| Written symptom/health info provided | 0.261 |
| *r = correlation coefficient |  |

- All areas that will be publicly reported

- Focus areas

## Avoid trying to “Boil the Ocean”

| PATIENT SATISFACTION QUESTIONS | r* |
| --- | --- |
| Willing to Recommend  | 0.759 |
| Staff worked together as a team | 0.571 |
| Nurses listened carefully | 0.564 |
| Staff helped with pain | 0.551 |
| Nurses courtesy and respect | 0.545 |
| Staff sensitive to families' needs | 0.515 |
| Staff provided safe patient care | 0.511 |
| Nurses explanations clear | 0.505 |
| Call button answered | 0.500 |
| Staff helped with bathroom needs | 0.496 |
| Room and bathroom kept clean | 0.428 |
| Staff explained medicine | 0.426 |
| Staff clearly described side effects | 0.417 |
| Pain well controlled | 0.415 |
| Staff clearly explained financial/insurance matters | 0.412 |
| Staff respected patient privacy | 0.409 |
| Admissions staff courtesy and respect | 0.402 |
| Doctors listened carefully | 0.386 |
| Doctors explanations clear | 0.360 |
| Doctors courtesy and respect | 0.349 |
| Satisfaction with food service | 0.344 |
| Area around room kept quiet at night | 0.335 |
| Staff discussed discharge help | 0.289 |
| Written symptom/health info provided | 0.261 |
| *r = correlation coefficient |  |

- Introduced initiatives that were broad in scope and would address several question areas
- AIDET
- Hourly Rounding
- Empathy Training
- Focused on Discharge Information; the only area Tenet scored slightly below average compared to the HCAHPS Chartbook data

## White Boards

- Some hospitals purchased eye-catching, customized white boards to reinforce initiatives such as:
- Communication
- Pain goals
- Hourly Rounding

**Notes:**
These are customized white board so hospitals can focus on the areas they don’t score as well in.
eminder for staff to align with core initiatives like Time Out for patient to rest...  and discussing the top goals for their individualized care plan.  Rounding for pain goals is a great strategy for pain management.  This is where the nurse and patient set a mutual pain goal and this is checked during hourly rounds and nurse leader rounding.  “I see your pain goal is a 2 today, how are we doing in helping you manage your pain.” 

## AIDET

- Five simple steps to make a positive first impression and to ensure continuous positive interaction throughout the patient’s experience

**First step in forming a relationship with the patient.  Be attentive to and greet your patient in a positive manner with a warm and friendly smile. **
**Upon introduction give the patient your name and the  purpose for the encounter.**
**Manage the patients expectations by educating them about the length of time a particular procedure or request will take.  Better to over-estimate than under-estimate.**
**Make sure the patients are knowledgeable and involved in their treatment.  Use easily understood terms when providing information.  Ask if they have any questions.**
**Thank patients for waiting, providing information, choosing your facility, etc.**

- Thank You

- Explanation

- Duration

- Acknowledge

- Introduce

**Notes:**
This is a Tenet term and each employee should have been trained in the concept.  The following slides are examples of linking our behaviors to our standards.

## Hourly Rounding

- PCAs round on the even hours
- Licensed staff round on the odd hours
- Documentation is kept on a clipboard outside of the room
- Use the “Three P’s”
- 	Pain
- 	Position
- 	Personal Needs

## Slide 19

## Discharge Information

**Notes:**
These hospitals have done an excellent job in improving their results on Discharge Information questions.

Several hospitals have created brightly colored folders for discharge instructions.  This hospital chose to use their logo colors but notice how they have incorporated the key words from the survey right onto the design of the folder.  “Always providing excellent care” and “Discharge instructions including Medication Side Effect Information.”

The other example uses a purchased software to provide patients with written discharge information and key words used by nurses and case managers include “we want you to have this written information about symptoms to look for when you go home.”  Of course they use all the other strategies to help a patient prepare for discharge including connecting with the patient as a “person.”  The nurses are very good about asking the patients to “tell me a little about the person who will be helping you at home.”

## Emphasis throughout all initiatives is continuous, positive, caring communication with the patient, family members, and each other.  

- For example, rather than simply handing patients written instructions or brochures, tell them what they are for, what they include, what they should do with them, and ask if they have any questions.

## Discussion Points

**Tenet Overview****Transition to HCAHPS****Service Strategy ****Measurement System Redesign**

## Highlighted HCAHPS questions in previously existing reports

**HCAHPS area more than 5% below the norm**

## Used a “back to basics” approach to help hospitals systematically review HCAHPS results

**Overall Score**

**Category Average**

**Question Score**

**Unit Report**

**Begin by analyzing**
**the high-level results**
**to identify problems,**
**then drill down to pinpoint what specific area is driving the score**

**GENERAL**

**SPECIFIC**

## Redesigned our reporting system to complement the approach and “push” the data into the hospital

- Expand employee access
- User-friendly (three screens to learn)
- Link Measurement and Service
- Reduce report turnaround time
- Identify problem areas
- Benchmark with high performers

- This is not just a Tenet program.  We helped Field Research design it, but it is being offered to other clients

- New System Goals

## Screen One

_**Screen One**_
**Starting with the general results, the home page of the reporting system provides an overview of hospital results including comparison to previous month, previous year, and Tenet Targets.**

**Internal Star rating system**

## Screen Two

_**Screen Two**_
**Provides drill down to category, question, unit, and patient level to identify problem areas.  **
**A white light bulb indicates the question scores at or above average, a red light indicates a problem area.  **
**Easily creates an Excel file from any screen shot.**

## Clicking on a light bulb accesses the  improvement suggestion section, “Ideas with Impact.”  

**Clicking on a light bulb accesses the  improvement suggestion section, “Ideas with Impact.”  **
**Clicking on the links in the Additional Resources section accesses a toolkits or other resources they can use or refer to.**

## Links to a 103 page workbook describing exactly how to implement empathy training

**Links to a 103 page workbook describing exactly how to implement empathy training**

**Written by Wendy Leebov**

## Screen Three

_**Screen Three**_
**Very Interactive.  View any program, category, question, unit, by any time period selected with a click of a button.**
**Helps hospitals track the specific service initiatives they are working on.**
**Easily creates a PDF report to email or post.**

## Slide 31

## Slide 32

## Slide 33

## Slide 34

## Slide 35

## Slide 36

## Slide 37

## Tenet-wide success in using HCAHPS results to improve the patient experience!!!

**Notes:**
This is the Thank You slide, please leave this at the end of your presentation and customize. 

## Contact Information

- Cindy Larkin
- (469) 893-2444
- cindy.larkin@tenethealth.com