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HCAHPS 101Understanding theBasic FundamentalsKaren Cook, RN, BSNNashville, TN May 14 - 15, 2013

Overall ObjectivesDescribe the basic fundamentals of HCAHPSand list the evidence that links HCAHPS toclinical qualityDefine three actions leaders can take to create asustainable organizational culture change andimpact the patient perception of quality careCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

To Reduce Harm, Build A Culture Of OwnershipWe aspire to a culture ofownership where people arecommitted to the values ofthe organization, are engagedin their work and with theircoworkers, and take pride intheir work and in theirprofessions.Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Teamwork Accountability ExcellenceCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Behavior StandardsThe Thunder organization is held in high regard in ourcommunity and we expect every Thunder Girl tocontribute to this image as an ambassador for thefranchise. Each member becomes a representative of allthe members, as well as the entire Thunder organization,each time she steps out into any public area. Publicareas include, but are not limited to, appearances on thecourt, entering or leaving the Arena, or in any publicplace, gym, restaurant, store, etc. The public sees you asa part of the Thunder organization and your conduct andappearance must be guided accordingly.Or be subject to disciplinary action and dismissal Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Building A Culture of SafetyNational Patient Safety Goals#2 Patient/ family engaged aspartners in their care#3 Promoting effective communicationand coordination of care1:20 will develop infection1:7 Medicare patients will be harmedPatient Perception, Safety, Effectiveness linked togetherSource: Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experienceand clinical safety and effectiveness. BMJ Open 2013;3:e001570.doi:10.1136/bmjopen-2012Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Consumers Bombarded With ContradictionsCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

A Culture of Safety?Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Many Processes Are BrokenSource: Video created by Maring Weisman, a marketing agency specializing in healthcareCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

http://www.medicare.gov/hospitalcompare Hospital CAHPSHome Health Care CAHPSIn-Center Hemodialysis CAHPSClinician and Group CAHPSFamily Eval of Hospice CareHealth Plan CAHPSCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization. Medical Group HomeAmbulatory Surgery CAHPSOutpatient Diagnostic CAHPSEmergency Department(under CMS consideration)

HCAHPS – Hospital Consumer Assessmentof Healthcare Providers and SystemsWhat isHCAHPSA standardized survey tool to measure the patient’sperception of quality care provided during theirexperience while a patient at an acute-care hospital.Promoting transparency, the patient perception of care ispublicly reported with other quality metrics on theWhy is itimportant? Hospital Compare website.http://www.medicare.gov/hospitalcompareHow will itbe used?The information will be used to enhance publicaccountability, provide meaningful data for improvementefforts as well as provide comparisons between hospitalsto help consumers choose a hospital. As an additionalincentive to improve, results will be linked to hospitalreimbursement after July, 2011.Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Patient Perspective of Clinical QualityCommunication with doctors (3)These are aCommunication with nurses (3)tangiblereflection ofResponsiveness of hospital staff (2)your reputationPain management (2)as a qualityCommunication about medicines (2)organizationDischarge information (2)Cleanliness of hospital environment (1)Quietness of hospital environment (1)Transitions of care (3)Overall rating of hospitalWillingness to recommend the hospitalCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Expanded HCAHPS Survey(Jan 1, 2013 Discharges)3 Care Transition Items (4-point Agreement Scale)(Strongly Disagree, Disagree, Agree, Strongly Agree)During this hospital stay, staff took my preferences andthose of my family or caregiver into account in decidingwhat my health care needs would be when I left.When I left the hospital, I had a good understanding ofthe things I was responsible for in managing my health.When I left the hospital, I clearly understood the purposefor taking each of my medications.(Health Literacy, Family Involvement and Teachback)Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.Source: http://www.caretransitions.org

New HCAHPS Questions(Jan 1, 2013 Discharges)Demographic Items in the “About You” section1. During this hospital stay, were you admitted tothis hospital through the Emergency Room?(Yes/No)2. In general, how would you rate your overall mentalor emotional health?(Excellent, Very Good, Good, Fair, Poor)For additional details on these new HCAHPS items from CMS, pleasesee Page 5 of the HCAHPS Quality Assurance Guidelines .Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FAQ’s About HCAHPSShould we just use the HCAHPS survey questions?The average HCAHPS survey takes 7 minutesHow often (frequency) vs How they feel (satisfaction)Following guidelines, questions can be added such as:FoodFamily included in the care planDid a nurse leader visit you during your stay?Did you see staff members wash their hands?Source: HCAHPS Executive Insight, Spring, 2013. hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD.1/24/13 http://www.hcahpsonline.org/Executive Insight/Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FAQ’s About HCAHPSHow many hospitals participate in HCAHPS?The Spring, 2013 results are based on more thanthree million completed surveys from 3,904 hospitalsMore than 8,200 surveys completed per dayAverage response rate of 32%Critical access participation is voluntaryIf less than 100 completes, publicly reported data willhave a footnoteSource: HCAHPS Executive Insight, Spring, 2013. hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD.4/24/13 http://www.hcahpsonline.org/Executive Insight/Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FAQ’s About HCAHPSIs this just for Medicare Patients?Random sample of all eligible patients on a monthly basisAll medical, surgical or maternity care patients with a differentadmission and discharge date except the following:– Patients under 18 years old– Psychiatric patients (principal diagnosis)– Patients who die in the hospital setting– Patient with a foreign address– Patients admitted from a corrections facility– Patients discharged to Skilled Nursing facility (03), SNFSwing Bed (61) or Certified Medicaid nursing facility (64)– Documented “No Publicity” patients– Other patients excluded by law in your stateCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FAQ’s About HCAHPSWhat about the “no publicity” patient?Defined as “those who voluntarily sign a “no publicity” requestwhen admitted to the hospital or directly request a survey vendornot to contact them. They should be excludedDocumentation of patients’ “no publicity” status must be retained,and kept in the patient’s medical recordFacilities must maintain documentation that is easily retrievedThe number of “no publicity” patients is reported to CMS andhigher numbers could trigger an auditIf abuse of this exclusion is determined during an audit, thehospital’s Medicare Annual Payment Update could be withdrawnSource: HCAHPS Executive Insight, Spring, 2013. hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD.4/24/13 http://www.hcahpsonline.org/Executive Insight/Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FAQ’s About HCAHPSWho can fill out the survey?No proxy surveysBut we know families can certainly impact their perceptionWill they get the survey before they get their bill?Sampled patients are surveyed between 48 hours and six weeksafter discharge, regardless of the mode of survey administrationData collection must end no later than six weeks following the firstattemptSource: HCAHPS Executive Insight, Spring, 2013. hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD.4/24/13 http://www.hcahpsonline.org/Executive Insight/Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FAQ’s About HCAHPSWhat about Outpatient Surgery Departments and ASC’s?CMS is developing this survey and plans to submit it toAHRQ for recognition as a CAHPS surveyAccess to CareDoctor CommunicationCommunication Between Patient and ProvidersPre and Post Procedure EducationPatient and Family Engaged As Partners in Their CarePatient PreferencesEnvironment/SafetyNote: There is a Surgical Survey created by American College of Surgeons , but it focuses on the surgeon, not the facilityCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.Source: Federal Register Request for Information 1/25/13

Early Support By American College of EmergencyPhysicians (Response letter 8/12)Communication by Provider TypeDoctors Listening to Your ConcernsDoctors Using Words and Terms You Could UnderstandDoctors Involving You in Decisions about Your CareDoctor's Understanding and CaringDoctor's Instructions/Explanations of Treatment/TestsNurses' Responsiveness to Your Needs and RequestsNurses' Understanding and CaringNurses' Instructions/Explanations of Treatments/TestsInstructions for Care at HomeHospital Staff's Courtesy and Friendliness to YouTimeliness/ThroughputTransitions of carePain ManagementCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

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Patient Experience of Care Domain (HCAHPS)Green increased threshold from 2013Red decreased threshold from 2013Floor2013201420132014National NationalNationalNationalThreshold Threshold Benchmark BenchmarkCommunication with Nurses42.84%75.18%75.79%84.70%84.99%Communication with s of Hospital Staff32.15%61.82%62.21%77.69%78.08%Pain ion about Medicines36.01%59.28%59.85%70.42%71.54%Hospital Cleanliness & Quietness38.52%62.80%63.54%77.64%78.10%Discharge Information54.73%81.93%82.72%89.09%89.24%Overall Rating of Hospital30.91%66.02%67.33%82.52%82.55%Note: Implementation FY 2014Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

National Average Year to Year Change in TopBox Results has Declined Over TimeRate Hospital a 9 or 10 - Avg. Change in Top Box TrendsStuder Group Partners vs. National AverageStuder Group Avg.National Avg.Change in Top Box Results in One Year2.502.001.501.00.50Change 3Q08-2Q09 to 3Q09- Change 4Q08-3Q09 to 4Q09- Change 1Q09-4Q09 to 1Q10-Change 2Q09-1Q10 to 2Q10- Change 3Q09-2Q10 to 3Q10- Change 1Q10-4Q10 to 1Q112Q103Q104Q101Q112Q114Q11Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Patient-Centered Care and MortalityFigure 11Percent of AMI Patients Surviving To One Year Post DischargeStratified by Level of Patient-Centered Care 0.9780.960Percent of Patients 440.9300.920.9Low PCC (n 372)High PCC (n Level of PCC was defined using the composite average of Picker dimension scalescores (see Fig. 8.1). Low PCC bottom fifth of the distribution (scores 56.85);high PCC top fifth of the distribution (scores 97.14).0.81234567Months After Discharge89101112A different source: Glickman SW et al, Patient Satisfaction and Its Relationship with Clinical Quality and Inpatient Mortality in AcuteMyocardial Infarction, Circa Cardiovasc Qual Outcomes 2010;3:188-195.Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Clear Connection between Patient-CenteredCare and Clinical Quality OutcomesCompared Hospital Quality Alliance (HQA) scores for the Qualityof Clinical Care to HCAHPS Global Rating for 2,429 hospitalsHCAHPS RatingAMICHFPNASurgeryLowest quartile93.582.788.582.8Second quartile94.585.290.184.3Third quartile94.685.990.785.2Highest quartile95.386.090.885.7P value for trend 0.001 0.001 0.001 0.001Source: Jha et al. New England Journal of Medicine 359, no. 18 (2008): 1921 -1931.Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Patients’ Perception of Care QualityVascular Catheter-Associated InfectionCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Engage Patient/Families in Reducing InfectionsDuring bedside report, listen for reasons thatcatheter is still presentAsk your nurse about procedures to preventcentral line infectionsTell nurse if bandage over central line is loose,soiled or wet or skin is red/inflamedWatch that doctors/nurses wash handsMake sure visitors do not touch catheter or tubingKeep catheter ends clean and dryIf to go home with catheter, teach-backappropriate careCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

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High Patient Perception of Care EqualsLower Preventable Readmissions1/5 of Medicare Beneficiaries arereadmitted within 30 days with anannual cost of 17.4 rce: The American Journal of Managed Care; Relationship Between Patient Satisfaction With Inpatient Care and HospitalReadmission Within 30 Days; 2011; Vol. 17(1)Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Plan for the Day, Plan for the StayPlan for the DayPatient goal for the shiftPatient and family included incare and decisionsPlan for the StayAnticipated discharge dateand what needs to happenbefore patient can go homeIdentifies key .html?ID 11199Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

2,217 Hospitals Will Have Payment ReducedHospital Readmissions Reduction Program (ACA 3025)To account for “excess readmissions,” effective October 1,2012, DRG payment rates will be reduced based on ahospital’s ratio of actual to expected readmissions.1% in FY 2013, 2% in FY 2014, and 3% in FY 2015Acute Myocardial Infarction, Heart Failure, PneumoniaPayments reduced on or after October 1, 2012 with anexcess ratio as compared to the three year period(July 1, 2008 – June 30, 2011)Expected to cost hospitals 280 million or 0.3% of thetotal Medicare revenue to hospitalsSource: Federal Register. Volume 77. No 92, May 11, 2012Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Overview - Value-Based Purchasing (VBP)What isVBP?Why is itimportant?How will itbe used?Another word for Pay-for-Performance, this is a programintended to transform healthcare by fostering a joint clinicaland financial accountability system.This new payment system will change CMS from a“passive payer” of services into an “active purchaser” ofvalue which is high quality, affordable, safe healthcare.Hospitals will be reimbursed based on their performance,not just reporting, of quality metrics, including the patientperception of quality.If you perform “better” – you’ll be paid moreBetter patient-centered, efficient, quality careSource: “Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program” ,CMS, Nov. 27, 2007Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

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Measure in the Outcomes Measures for 2015AHRQ PSI-90Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Measure in the new Efficiency DomainMSPB-1 Medicare Spending perbeneficiaryA claims-based measure thatinclude risk-adjusted and pricestandardized payments for allPart A and Part B servicesprovided from 3 days prior to ahospital admission (indexadmission) through 30 days afterthe hospital s/NPC-MSPB-09Feb12-Final508.pdfCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

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2013 and 2014Process of Care MeasuresGreen increased threshold from 2013Red decreased threshold from 2013Measure ID MeasureFibrinolytic Therapy Received Within 30 Minutes of HospitalAMI–7a .00000.90770.92661.00001.0000Blood Cultures Performed in the Emergency Department Priorto Initial Anti-biotic Received in Hospital0.96430.97301.00001.0000Initial Antibiotic Selection for CAP in Immunocompetent .94921.00000.9983Prophylactic Antibiotic Received Within One Hour Prior toSCIP–Inf–1 Surgical IncisionSCIP–Inf–2 Prophylactic Antibiotic Selection for Surgical PatientsProphylactic Antibiotics Discontinued Within 24 Hours AfterSCIP–Inf–3 Surgery End TimeCardiac Surgery Patients with Controlled 6AM PostoperativeSCIP–Inf–4 Serum GlucosePostoperative Urinary Catheter Removal on Post OperativeSCIP–Inf–9 Day 1 or 2SCIP–Card–22014 NationalBenchmark0.6548Primary PCI Received Within 90 Minutes of Hospital ArrivalAMI–8aHF–1 Discharge InstructionsPN–3b2013 National 2014 National 2013 NationalThresholdThresholdBenchmarkSurgery Patients on a Beta Blocker Prior to Arrival ThatReceived a Beta Blocker During the Perioperative PeriodSurgery Patients with Recommended VenousGone2015SCIP–VTE–1 Thromboembolism Prophylaxis OrderedSurgery Patients Who Received Appropriate VenousThromboembolism Prophylaxis Within 24 Hours Prior toSCIP–VTE–2 Surgery to 24 Hours After SurgeryCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

FY 2015 Baseline Measure Report April, 2013Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

HCAHPS Was Created So Consumers Could“Choose a Hospital”10 million people per month visitHealth Grades93.8% reported being willing togo out of their way (drive further,reschedule appointments)64.9% said they would pay moreto seek care at a more highlyrated hospital60.7% feel the governmentshould pay highly-performinghospitals moreSource: HealthGrades, Inc. 2010 surveyCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Nashville, TN May 14 - 15, 2013Source: Valley Healthlink Spring 2010

Overall ObjectivesDescribe the basic fundamentals of HCAHPS andlist the evidence that links HCAHPS to clinicalqualityDefine three actions leaders can take to createa sustainable organizational culture changeand impact the patient perception of qualitycareCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Tip #1: Think How Patients/Families THINKAre you proud of thestories you hear frompatients about yourunit, department ororganization?Always?Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Typical Verbatim Comments . . .Why did it take 2 maintenance guys 2 hours to fix the light inthe other bed. There was dust flying in a surgical patientroom.Doctors and nurses ignore each other.I asked for fresh linens and the housekeeper acted angry. Iwas afraid to ask to her to clean off the sticky bedside table.They asked me for money while I was sick in ICU andtreated me like I was asking for free care. I have insurance.I had to have my husband call from home to tell 9th floor Ihad been waiting on potty chair for 25 min and the personthat answered the phone was rude about it.Very poor attitude – radiology tech kicked door closed and Iheard her complaining that I wasn’t scheduled for today.Copyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

What Is A Moment of Truth?MOTMOTMOTMOTMOTMOTCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.Moments of Truth areevents, observations,and interactions thatcreate impressions.Moments of Truthcreate impressions infive areas.

Tip #2: Engage and Train ALL StaffCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Every Employee Has A RoleWelcome to Methodist Hospitals.We hope that as you experienceus via the web, or at our hospitals,physicians’ offices and otherfacilities, it will be obvious thatyour care, comfort and safetyare the absolute highestpriorities for every member ofour exceptional team ofphysicians, nurses and staff.Ian McFadden, CEOCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Tip #3 – Focus on the EDAs ED Percentile Ranking Increases, So Does OverallCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Median Wait Time by Hospitals Score onHCAHPS “Patients That Rate Hospital a 9 or 10”Reflects data from 3500 ED's reporting to CMSCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Median Wait Time by Hospitals Score onHCAHPS “Patients That Rate Hospital a 9 or 10”Reflects data from 3500 ED's reporting to CMSCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Excellence in the Emergency Department:Hardwiring Flow and Patient ExperienceJune 19-20, 2013, Chicago, ILNovember 6-7, 2013 Dallas, TXGet It Right in the ED and Set theStage for Getting It Right EverywhereElseJoin Stephanie Baker, RN, MBA, CEN, Dan Smith, MD, FACEP,& Kirk B. Jensen, MD, MBA, FACEP at our two day ED institute.Participants will learn evidence-based tools and tactics toimprove their Emergency Department results and the results oftheir entire hospitals, including HCAHPS.www.studergroup.com/institutesCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

“We are present inunwelcome moments.”Donald Berwick, MDCopyright Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

Expanded HCAHPS Survey (Jan 1, 2013 Discharges) 3 Care Transition Items (4-point Agreement Scale) (Strongly Disagree, Disagree, Agree, Strongly Agree) During this hospital stay, staff took my preferences and