Working to Improve the
Patient Experience
March 12, 2013 2 – 3:30pm
Arizona Critical Access Hospital Quality Network
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
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
Agenda
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.
• 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?
Discussion
Sample HCAHPS Vendor Report
• Track performance over time
Sample Healthstream HCAHPS Benchmarking Report
Pt. Satisfaction - QI Project Ideas
Category/HCAHP Proposed QI Projects
Staff Responsiveness Close the loop of patient falls
Pain Management
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.
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.
Hospital Environment
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
Communication Physician communication to increase transparency of reporting scores
Discharge
Follow up phone calls to patients when discharged
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.
• 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?
QI Projects Presentations
Cobre Valley Regional Medical Center
HCAHPS Improvement Project: Pain Management
AZ-CAH Example
Patient Experience: OB
E
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Special Cause Flag
Indiv
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Pain Controlled
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0
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Special Cause Flag
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idual V
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Reassessed Pain less than Pain Goal
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Special Cause Flag
Indiv
idual V
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Pain Assessed Every Hour
Patient Experience: OB
QI Project Selection
Staff
Hospital Data Patients & Families
Patient Communication
Lower HCAHPS Scores
Leadership Team
Incident Reports
Family Communication
Direct Reporting to Quality
Selection of QI Project
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)
0 20 40 60 80 100
Cobre Valley Regional Medical Center **
Copper Queen Community Hospital *
Carondelet Holy Cross
Page Hospital
Arizona Average
% Patients who reported that staff "Always" explained about medicines before giving it to them.
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.
kk Best Practices: Pain 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
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
Effective Aim Statements
• 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
Upcoming Events
Date / location for face-to-face
• Poll
• 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
Homework
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
100% 90% N/A 0% 95% 67% 89% 90% 77% 95%
Initial Antibiotic
Selection for
Community-Acquired
Pneumonia in
Immunocompetent
Patients
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 –
• [email protected] or [email protected]
• Flex (and SHIP) funding being tied to MBQIP
• Emphasis on healthcare quality & value
Thank You!
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
Please call us / your peers with any
related thoughts / feedback