Using HCAHPS data to improve the quality of

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 ¡ ¡ ¡ ¡ 60, 000+ employees 1 M+ 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: l l l l 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 High impact areas High use areas Outsourced areas ¡ Privacy and safety Teamwork and sensitivity to family needs Patient Access Food and Nutritional Services Redesigned other questionnaires (OP Surgery, OP Services, and ED) to HCAHPS format

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

Keep current with CMS guidelines Composite / Category Adjustme nt 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 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: l l ¡ ¡ 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 Willing to Recommend Staff worked together as a team Nurses listened carefully Staff helped with pain Nurses courtesy and respect Staff sensitive to families' needs Staff provided safe patient care Nurses explanations clear Call button answered Staff helped with bathroom needs Room and bathroom kept clean Staff explained medicine Staff clearly described side effects Pain well controlled Staff clearly explained financial/insurance matters Staff respected patient privacy Admissions staff courtesy and respect Doctors listened carefully Doctors explanations clear Doctors courtesy and respect Satisfaction with food service Area around room kept quiet at night Staff discussed discharge help Written symptom/health info provided *r = correlation coefficient r* 0. 759 0. 571 0. 564 0. 551 0. 545 0. 511 0. 505 0. 500 0. 496 0. 428 0. 426 0. 417 0. 415 0. 412 0. 409 0. 402 0. 386 0. 360 0. 349 0. 344 0. 335 0. 289 0. 261 Focus areas Questions having a high correlation with overall satisfaction

Current service focus PATIENT SATISFACTION QUESTIONS r* Willing to Recommend Staff worked together as a team Nurses listened carefully Staff helped with pain Nurses courtesy and respect Staff sensitive to families' needs Staff provided safe patient care Nurses explanations clear Call button answered Staff helped with bathroom needs Room and bathroom kept clean Staff explained medicine Staff clearly described side effects Pain well controlled Staff clearly explained financial/insurance matters Staff respected patient privacy Admissions staff courtesy and respect Doctors listened carefully Doctors explanations clear 0. 759 0. 571 0. 564 0. 551 0. 545 0. 511 0. 505 0. 500 0. 496 0. 428 0. 426 0. 417 0. 415 0. 412 0. 409 0. 402 0. 386 0. 360 Doctors courtesy and respect Satisfaction with food service Area around room kept quiet at night Staff discussed discharge help Written symptom/health info provided 0. 349 0. 344 0. 335 0. 289 0. 261 *r = correlation coefficient Focus areas All areas that will be publicly reported

Avoid trying to “Boil the Ocean” PATIENT SATISFACTION QUESTIONS r* Willing to Recommend Staff worked together as a team Nurses listened carefully Staff helped with pain Nurses courtesy and respect Staff sensitive to families' needs Staff provided safe patient care Nurses explanations clear Call button answered Staff helped with bathroom needs Room and bathroom kept clean Staff explained medicine 0. 759 0. 571 0. 564 0. 551 0. 545 0. 511 0. 505 0. 500 0. 496 0. 428 0. 426 Staff clearly described side effects Pain well controlled Staff clearly explained financial/insurance matters Staff respected patient privacy Admissions staff courtesy and respect Doctors listened carefully Doctors explanations clear 0. 417 0. 415 0. 412 0. 409 0. 402 0. 386 0. 360 Doctors courtesy and respect Satisfaction with food service Area around room kept quiet at night Staff discussed discharge help Written symptom/health info provided 0. 349 0. 344 0. 335 0. 289 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 q Some hospitals purchased eyecatching, customized white boards to reinforce initiatives such as: l l l Communication Pain goals Hourly Rounding

AIDET Five simple steps to make a positive first impression and to ensure continuous positive interaction throughout the patient’s experience Acknowledge 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. Introduce Upon introduction give the patient your name and the purpose for the encounter. Duration 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. Explanation 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 You Thank patients for waiting, providing information, choosing your facility, etc.

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

Discharge Information

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 GENERAL Category Average Begin by analyzing the high-level results to identify problems, then drill down to pinpoint what specific area is driving the score Question Score Unit Report Patient Information 24 SPECIFIC

Redesigned our reporting system to complement the approach and “push” the data into the hospital New System Goals ¡ ¡ ¡ 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

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 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 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 Written by Wendy Leebov

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.

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

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