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Executive Summary
One-third of UHC’s academic medical
center members ranked below the national
25th percentile in a value-based purchasing (VBP) analysis of Hospital Consumer
Assessment of Healthcare Providers and
Systems (HCAHPS) scores, conducted for
UHC’s Patient Experience (HCAHPS)
Benchmarking Project in 2010-2011. This
weak performance indicates that patients
are not receiving the level of service and
satisfaction that they need and deserve.
With less than 10% of members achieving
scores above the national 75th percentile,
many UHC member organizations risk
significant revenue loss due to VBP implementation beginning in 2013.
The benchmarking project highlighted
areas with the biggest opportunities for
improvement: responsiveness, quietness,
cleanliness, and communications. These
4 focus areas were addressed in the Patient
Barriers to Cultural Transformation
• Lack of buy-in
• Lack of accountability
• Entrenched culture and behaviors
• Competing priorities
Important takeaway about culture change:
Simply implementing a new process and
holding the staff accountable did not
truly change the culture, according to
some collaborative participants. They
found that staff members were compliant but performed new procedures as a
“checklist item” without making a real
connection with patients. Inviting patients and families to share their stories
with staff was the most powerful driver
for meaningful cultural transformation.
table of contents
Experience (HCAHPS) Improvement
Collaborative in 2011-2012; 46 teams
from 41 organizations participated.
Successful Strategies
The following successful strategies were
implemented by collaborative participants:
Establish the patient experience as a
high-priority goal, supported by senior
leaders who dedicate resources for staff
training and empowerment related to
patient satisfaction. Use data and feedback
from patients and families to identify
areas for improvement and gauge progress. Collaborate with patient and family
advisers to evaluate data, design improvement strategies, and educate staff about
patient and family needs, experiences,
and perceptions.
Focus on staff responsiveness to patient
needs, using patient and staff surveys to
better understand perceptions of responsiveness and integrating satisfaction data
into unit dashboards to highlight key
challenges. Use hourly nursing rounds
to address the 4 P’s (pain, positioning,
personal needs, and possessions), manage patient expectations, and help reduce
call-light requests. Train non-nursing staff
to support responsiveness initiatives, and
consider implementing a no-pass zone to
encourage a culture of “every patient is
my patient.”
Create a quiet healing environment by
using designated quiet hours, in-house
quiet campaigns that serve as reminders
for staff and visitors, and noise-reducing
technology. Some teams interviewed patients to better understand personal noise
concerns and offered earplugs, eye masks,
headphones, and other personal devices to
mask ambient disturbances.
Meet cleanliness goals by recruiting and
training staff with a customer service
orientation. Share patient satisfaction
data to ensure understanding, and standardize cleaning practices with checklists
and picture guides. Train environmental
services staff on communicating with patients, provide a 24/7 phone number for
service recovery, and make patients aware
of cleaning that occurred while they were
absent or sleeping.
Enhance patient communications during the hospital stay through the use of
up-to-date whiteboards, bedside interdisciplinary rounds, and nursing change-ofshift reports at the bedside. Obtain physician buy-in for rounds by emphasizing
the results: fewer delays and phone calls.
Contact patients within 48 to 72 hours of
discharge to assess their condition, check
compliance, and resolve problems. Use
training tools such as scripts, skill labs,
mentors, and films to define new standards, reinforce skills, and hold leaders
and staff accountable.
Executive Summary ..................................................................................................... 1
About the Project........................................................................................................ 2
Successful Strategies.................................................................................................... 2
1
The Next Step Is Yours...............................................................................................
10
Improving Patient Experience: HCAHPS
About the Project
staff training and empowerment related to satisfaction. In
the collaborative, leaders used data to understand where the
patient experience needed improvements, held providers
and staff accountable for necessary changes, and recognized
and rewarded excellence as part of the culture change. Some
leaders engaged consultants to help change the organizational culture.
The Patient Experience (HCAHPS) Improvement Collaborative focused on helping UHC members implement strategies
to enhance the patient experience and improve patient satisfaction scores. A total of 46 project teams were fielded from
41 participating organizations.
Using data and patients’ stories to understand the care experience. The team from University Hospitals Case Medical
Center (UH/CMC) faced wide-ranging performance in Press
Ganey scores across different units. There were also swings
in scores due to electronic medical record implementation,
variations in census and acuity levels, and difficulties in sustaining improvements.
A collaborative process was followed, with monthly networking calls held from July 2011 through January 2012. Participants formed 3 work groups—on responsiveness, environment, and communications—to focus efforts where the most
improvement was needed. Teams shared tools, resources, and
strategies for changing processes and attitudes.
The team strove to align leadership and staff efforts to
improve the patient experience by focusing on the related
HCAHPS domains, beginning with sharing data more
frequently (biweekly) to provide a real-time snapshot of unit
performance. The team also embarked on physician and staff
education about why HCAHPS and VBP scores are important and how those metrics are affected by provider and staff
performance. In addition to data, storytelling by patients
and families at a system-wide retreat had a huge impact and
improved understanding of patients’ feelings and frustrations.
The organization has seen gains in its HCAHPS scores for
2011-2012 (Table 1).
Reasons for Joining the Collaborative
Why did the team from University Hospitals Case Medical
Center participate?
• UHC identified top performers and best practices.
• Members shared tactical plans for overcoming
common barriers.
• Members provided creative twists for implementing
•
•
best practices, such as asking physicians to alert staff
before arriving for interdisciplinary rounds.
UHC facilitated the collaborative calls and led detailed
discussions to identify solutions.
The collaborative spurred the team to develop and
execute plans with renewed clarity.
The UH/CMC team learned the importance of getting all
stakeholders, including patients and families, on the same
page and dispelling myths about the value and validity of
satisfaction scores, especially among providers.
Successful Strategies
Turning HCAHPS data into action. The executive team
at The Methodist Hospital System (The Methodist Hospital) built exceptional service into the “pillars of excellence”
and 2012 focus areas. Executive dashboards clearly show
HCAHPS performance and are accompanied by an accountability matrix and action plan that assign responsibility for
improvement target areas and define metrics for success.
Participants implemented or refined several successful strategies to improve the patient experience and related satisfaction scores.
Establish the Patient Experience as a
High-Priority Goal
Focus on Staff Responsiveness to
Patient Needs
Senior leadership focus. Collaborative participants found it
was very important for senior leaders to focus on the patient
experience. This focus was often linked with modeling the
concepts of patient- and family-centered care within the
organization. Some teams invited patients and families to
share their stories with the board and staff members to give a
more personal perspective on problems and the importance
of service excellence.
Data-driven approach. Some teams used surveys of patients
and staff to better understand perceptions about the patient
experience. This approach was particularly helpful in uncovering what staff behaviors needed to be clearly defined and
implemented.
Data were also used to conduct root cause analyses of delays
in service, and teams worked with staff and patient advisers
to establish standards. Responsiveness data were incorporated
To achieve their patient experience goals, senior leaders must
dedicate sufficient resources to customer service, including
2
Patient Experience (HCAHPS) Improvement Collaborative 2012 Field Brief
Table 1. HCAHPS Scores for University Hospitals Case Medical Center, 2009-2012
CAHPS
2009
Top Box
2010
Top Box
2011
Top Box
2012
Top Box
Rate hospital 0-10
Recommend the hospital
Cleanliness of hospital environment
Quietness of hospital environment
68.2 p
75.0 p
61.6 p
46.7 p
68.3 p
75.5 p
63.2 p
45.0 q
70.2 p
77.0 p
66.2 p
49.3 p
74.2 p
77.2 p
67.5 p
58.5p
Communication with nurses
Response of hospital staff
Communication with doctors
Hospital environment
Pain management
Communication with medicines
Discharge information
74.1 p
53.2 p
76.0 q
54.2 p
66.1 q
57.3 p
81.5 p
74.5 p
52.9 q
76.0
54.1 q
66.4 p
59.4 p
82.1 p
76.7 p
56.5 p
78.6 p
57.8 p
68.8 p
62.3 p
85.2 p
79.2 p
57.9 p
79.8 p
63.0 p
71.1 p
65.8 p
86.5 p
Source: Adapted from Vidal K, Dragon MA, Furnari R, Milter C. Improving HCAHPS by increasing communication. Presented at: UHC Patient Experience
(HCAHPS) Improvement Collaborative Knowledge Transfer Web Conference; April 16, 2012. https://www.uhc.edu/docs/49016628_UHCaseApril162012.pdf.
Accessed September 2012.
HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems.
implemented, ongoing reminders and education were used to
reinforce behaviors. Unit leaders often rounded on patients
to verify that nursing rounds were properly conducted.
and reviewed in dashboard format to enhance understanding from the top down. The team from Shands Jacksonville
Medical Center, Inc., decided to revise unit dashboards to
feature responsiveness data.
To manage expectations, participants informed patients about
hourly rounds at admission. When patients realized that
someone would stop by every hour, they often waited for the
next visit to make minor requests, thus smoothing workflow.
Nurses were required to leave a phone number for sleeping or
absent patients as a way of informing them of the visit.
Current satisfaction data were regularly shared with appropriate teams to help individuals connect their behaviors to
scores. Clinical outcome measures such as falls and pressure
ulcers were also used to evaluate the success of staff responsiveness initiatives.
Getting results with the “Iowa greeting.” The University
of Iowa Hospitals and Clinics team pursued “A NOD and A
Thanks” as its hardwired communication framework, defined
as acknowledge and greet, provide name and occupation,
explain duty or task, ask if anything else can be done, and
thank the patient. This process—used in every interaction
with patients, families, and visitors—helps ensure a common
language and promotes courtesy, respect, and relationship
building.
To ensure long-term success, teams collected both patient
and employee feedback before finalizing any process changes.
The frequent use of pilots among participants helped finetune practices before broader implementation.
Hourly nursing rounds. A structured approach to rounds
was employed by participants, such as having a nurse or aide
round on each patient every hour with a special focus on
the 4 P’s: pain, positioning, personal needs, and possessions.
Some teams found that pain management and toileting assistance are patients’ top priorities and require prompt attention. The team from University of Wisconsin Hospital and
Clinics used hourly rounds to drive an 11% overall increase
in patient satisfaction scores and a 21% improvement in
toileting scores.
In addition, Iowa’s environmental services employees became
involved in rounding from 3:30 pm to 9:00 pm, engaging
patients and auditing their perceptions of daily room cleaning. The employees verify that the whiteboard has been
updated with caregivers’ names and contact information,
assist with on-the-spot service recovery, and ask about other
ways they can help, including handling requests or concerns
Creating a rounding system often required the development
and testing of new workflows by unit staff. Once rounds were
3
Improving Patient Experience: HCAHPS
The Loyola team learned several lessons: Develop a core
group of charge nurses to sustain changes. Hardwire the
supervisors. Create a process to quickly orient float staff
during challenging periods. Measure the number of call
lights both before and after the implementation of rounding,
and use a decrease in call lights as a staff motivator. Keep the
staff ’s focus on “this isn’t extra work; this is how we do our
work.” Hold charge nurses and staff accountable for behaviors
and outcomes.
related to quiet at night and other nonclinical needs, so that
the patient does not have to call a nurse. Another strategy
involves conducting hourly nursing rounds to reduce call-light
requests and keeping a paper log of visits so that patient’s
families can see evidence of rounding activity. Iowa’s inclusive
approach to managing the patient experience has increased
patient satisfaction scores, especially related to call lights and
toileting assistance.
The Iowa team learned that best practices can break down
when team members are not available and when days become
hectic. Support for hourly nursing rounds increased when
staff members understood that the number of call-light
requests can be reduced and that “rounding isn’t an extra
job, just a different way of doing the job.”
No-pass zone. To encourage a culture of “every patient is my
patient,” some teams piloted the concept of mandating that
staff cannot walk past a call light without responding. Nonnursing staff (including housekeepers and clerical staff ) were
trained to respond to minor requests or notify appropriate staff
of patients’ requests. The charge nurse or other designated
individual on each shift facilitated a prompt response to patients’ needs. For this strategy to work, staff on all shifts must
be able to easily see call lights so they can respond quickly.
Clarifying the definition of and implementing hourly
rounding. In talking with staff, the Loyola University Medical Center team discovered a disconnect in understanding
between the goal of hourly rounding and the actual practice
of rounding hourly. Some staff members believed they were
fulfilling the rounding requirement by making a quick stop
in patient rooms and asking, “Are you okay?” from the doorway. This informal behavior needed to be replaced by a more
formal and consistent rounding process.
Ongoing training. Participants found it helpful to frame
tasks as “it is the job, not an extra job” to effect culture
change. They presented staff responsiveness as critical to
patient safety, and unit-specific responsiveness data were
regularly shared so that staff members could understand the
impact (positive and negative) of their behaviors. A reduction in call lights was a desirable goal that encouraged buy-in
from staff.
To implement hourly rounds, the Loyola team first had to
change the staff ’s perception that rounds were already being
done when nurses made only a quick stop in patient rooms.
Staff education was developed and delivered by a staff nurse,
focusing on the 4 P’s and emphasizing both the benefits and
the process of rounding. Patients’ expectations about rounds
were shaped during the admission process. Staff members
were reminded about rounding through signs in patient
rooms, posters in the break room, and huddles at the start
of every shift.
Training was offered for all shifts to model behaviors and
reinforced during staff huddles and meetings. In some cases,
patient and family advisers were invited to speak to staff
about how it feels to wait for a call-light response.
Create a Quiet Healing Environment
Designated quiet hours. Participants established or recommitted to quiet hours for every shift and informed patients,
families, and staff about the importance of restful healing,
aided by a quiet environment. Patients and families were
asked to alert staff about noise issues so that they could be
resolved. The Vanderbilt University Medical Center team
even gave patients the option to use the interactive television
system in their rooms to notify staff about noise.
To encourage buy-in, the team stressed that when hourly
rounding is done well, patients are safer, their needs are better met, and nurses have more time for charting and other
duties. When nurses expressed frustration, they were given
data on the proven benefits of hourly rounding. To avoid
confusion, nurses worked with patient care technicians to
coordinate rounding hours, often with one handling odd hours
and the other handling even hours. Managers also round on
patients to validate that hourly rounding is happening in
accordance with standards.
Some participants conducted an audit to identify other
departments (e.g., housekeeping or nutrition) whose staff perform activities during quiet hours. Teams then collaborated with
these departments to arrive at noise-reducing solutions. Vendors
were also involved and asked to change pickup and delivery
times to lessen noise. Nurses were empowered to ask physicians
and others to keep their voices down during quiet hours.
The use of call lights is periodically measured and found to
be reduced, even with a higher patient census. In addition,
hourly rounding moved patient satisfaction scores from the
18th to the 55th percentile for “my needs were handled
promptly” in the pilot unit.
4
Patient Experience (HCAHPS) Improvement Collaborative 2012 Field Brief
Increasing quiet at night. As part of a Quiet at Night initiative, the Methodist team conducted a 4-week assessment in
6 pilot areas. The responses of 63 patients and 25 employees
helped the team better understand opinions about quiet areas
and provided a frame of reference for defining quiet hours. The
most bothersome noises to patients were loud talking or laughing, medical equipment, alarms, and noise from other patients
and visitors. Patients said that keeping room doors closed when
medically appropriate and not waking them for unnecessary
reasons would reduce noise and promote restfulness.
meter data will continue to be collected and assessed. Weekly
and monthly HCAHPS analysis continues to track patient
satisfaction levels against changes.
Patient unit HCAHPS scores are mixed but improving
since the Quiet at Night initiative began in October 2011.
For example, Figure 1 shows a surgical unit improving its
HCAHPS quiet-related score from 70 to more than 80 since
the initiative began. Similarly, a cardiovascular unit improved
its score from 40 to nearly 70.
The Methodist team learned that patient perceptions about
quiet may differ from staff perceptions. The team recommends conducting pilots to obtain feedback unit by unit and
using noise data to show staff how and when noise thresholds
are exceeded.
The Methodist team focused on the HCAHPS standard for
quiet at night by setting a 2012 target score of 63.8, with
70.3 considered a superior achievement; 2011 results were 61.
The team aimed to meet the very challenging decibel limits
established by the World Health Organization: 45 dB for day,
35 dB for night. The team especially wanted to address the
most common noise complaints: loud talking, televisions, cell
phones, alarms, nursing station phone calls, rolling equipment/carts, overhead paging, and construction noise.
Quiet campaigns. To emphasize the importance of a quiet
environment, some participants launched in-house campaigns to remind staff and visitors of the need for quiet.
Posters, tent cards, and other visual reminders were used to
raise awareness.
The team installed noise meters that light up when a specific
level (set at 65 dB) is exceeded. Noise reports were sent to
various departments, showing a week’s data with suggestions
on ways to lessen noise. The team plans to expand the pilot
and use noise meters in more units.
Managers were provided with tools to train staff about noise
reduction. Training was often reinforced during staff meetings and through articles posted on the hospital’s intranet.
Managers were tasked with stopping, listening, and giving
immediate feedback to staff about noise levels. Leaders
from other areas were also encouraged to round and assess
noise levels.
To counteract noise, quiet hours were standardized throughout the hospital, and education was developed and implemented to address the noise level of staff conversation. Noisy
carts were fixed to further reduce hallway noise. The team
also implemented a closed-door policy and process, when
feasible, to address patients’ wishes.
Creating and marketing quiet solutions. The University of
Michigan Hospitals & Health Centers team collaborated with
marketing staff to develop a quietness campaign, including
hallway signs (Figure 2) and tabletop cards.
Patient and staff impressions about noise will be obtained
and compared with the original benchmark level, and noise
Figure 1. Changes in HCAHPS Quietness Scores in 2 Patient Units at The Methodist Hospital,
October 2011-March 2012
Surgical Unit
Cardiovascular Unit
100
Score
80
60
40
20
0
Week
Oct ’11
Nov ’11
Dec ’11
Jan ’12
Feb ’12
Mar ’12
Source: Adapted from Hackett CJ, Cook J, Creany P. Quiet at night: The Methodist Hospital HCAHPS noise reduction initiative. Presented at: UHC
Patient Experience (HCAHPS) Improvement Collaborative Knowledge Transfer Web Conference; April 11, 2012. https://www.uhc.edu/docs/49016625_
MethodistQuietatNightInitiative41112.pdf. Accessed September 2012.
5
Improving Patient Experience: HCAHPS
Once solutions were in place, the team followed up with patient
focus groups and input from hospitalists, nurse managers, and
medical directors. Press Ganey data are shared to track results.
Figure 2. Hallway Sign for Quiet Campaign at
University of Michigan Hospitals & Health Centers
The Michigan team learned that reminder materials need to be
visually refreshed to continue to capture staff attention. Influencing long-term change, the physical building structure, and
budget constraints are constant challenges. Multidimensional
solutions are needed to produce sustainable improvements.
Noise-reducing technology. Collaborative participants made
equipment less noisy by adjusting the default alarm and volume settings on monitors and setting pagers and phones to
vibrate, not ring. Another idea was providing flashlights to the
night staff so that they could avoid disturbing patients at rest.
Participants also used measuring equipment to monitor noise
levels and then implemented several strategies:
Source: Rutherford R, Bear P. The Michigan difference: creating a clean and quiet
healing environment. Presented at: UHC Patient Experience (HCAHPS)
Improvement Collaborative Knowledge Transfer Web Conference; April 11, 2012.
https://www.uhc.edu/docs/49016626_UofMCreatingaCleanandQuietHealing
EnvironmentApril2012.pdf. Accessed September 2012.
• Changing noisy door latches and cart casters
• Using trash cans with quiet lids, door bumpers, and blackout bed curtains
•U
sing sound-absorbing materials and white-noise generators
The team’s quietness analysis (based on patient feedback)
revealed that roommates, staff behavior, and facilities and
equipment were the major sources of noise. The team
developed systematic countermeasures for each noise source,
including noise-suppression devices and process changes
(Table 2).
• Evaluating new housekeeping equipment for noisereduction potential
• Asking vendors to replace noisy equipment
Some teams offered patients earplugs, eye masks, headphones,
or pillow speakers to mask noise or reduce the volume of their
Table 2. Countermeasures for Noise at University of Michigan Hospitals & Health Centers
Noise Source
Roommates (e.g., talking, phone calls, television)
Staff behavior
Facilities and equipment
Practices (e.g., open/closed doors, floor cleaning)
Neighbors (e.g., television, loud voices, nurses in
adjoining rooms)
Countermeasures
• Headphones, earbuds, and earplugs
• Increased use of private rooms
• Hallway signs as quiet reminders
• Noise meters
• Screen savers as quiet reminders
• Door gaskets and hydraulic door closers to dampen sound
• Door latches that reduce banging
• Plastic custodial carts
• Microfiber mops
• Quiet reminders
• Different floor-cleaning time
• White-noise machines
• Headphones, earbuds, and earplugs
• Ceiling panel
Source: Adapted from Rutherford R, Bear P. The Michigan difference: creating a clean and quiet healing environment. Presented at: UHC Patient Experience
(HCAHPS) Improvement Collaborative Knowledge Transfer Web Conference; April 11, 2012. https://www.uhc.edu/docs/49016626_
UofMCreatingaCleanandQuietHealingEnvironmentApril2012.pdf. Accessed September 2012.
6
Patient Experience (HCAHPS) Improvement Collaborative 2012 Field Brief
Keeping it clean. The Michigan team initiated the Patient
Perception Program, which included environmental services
staff training, business cards, a C-L-E-A-N hotline (Figure 3),
“while you were out” reminders, and patient education about
cleaning schedules.
own television or music. For example, the Rush University
Medical Center team tested offering earplugs and eye masks to
patients and improved their “quiet at night” score by 5%.
Patient Perception P
Quietness Tips From Collaborative Participants
•
•
•
•
•
C
ollect baseline noise levels and set improvement goals.
Assess and address major sources of noise.
Interview patients to understand their noise concerns.
Partner with vendors to develop quieter work processes.
Alert patients about unusual sources of noise and the
expected duration, and then meet that expectation.
Figure 3. Card for C-L-E-A-N Phone Line at
University of Michigan Hospitals & Health Centers
Staff traini
Business c
C-L-E-A-N
“while you
Customer
Meet Cleanliness Goals by Recruiting, Training
Staff With a Customer Service Orientation
Professional, efficient staff. Environmental services staff
members are a linchpin in the patient experience and should
therefore be recruited and trained for a customer service
orientation. Collaborative teams educated environmental
services staff on the importance of hospitality and communication and frequently shared patient satisfaction data with
staff to ensure understanding and support.
Source: Rutherford R, Bear P. The Michigan difference: creating a clean and quiet
healing environment. Presented at: UHC Patient Experience (HCAHPS)
Improvement Collaborative Knowledge Transfer Web Conference; April 11, 2012.
https://www.uhc.edu/docs/49016626_UofMCreatingaCleanandQuietHealing
EnvironmentApril2012.pdf. Accessed September 2012.
Sometimes staff needed retraining to help standardize certain
procedures. Some participants found it helpful to provide the
custodial staff with a checklist and pictures to help guide how
they clean rooms after a patient is discharged. In its Picture
Perfect process, the Medical University of South Carolina team
created visual tools to help environmental services staff set up
inpatient rooms in a standardized way across the campus.
An environmental services patient representative program was
also launched, in which representatives greet newly admitted
patients, keep daily contact and follow-up logs, secure services
when needed, and recognize high-performing employees.
Managers were encouraged to shadow cleaning staff to identify gaps in service and take advantage of coaching opportunities. It was important to recognize and reward high performers for exceptional service so that behaviors became ingrained.
The Michigan team learned that environmental services staff are
accustomed to being in the background and need training and
encouragement to actively engage with patients and families.
Patient input. Participants found patient input to be invaluable in identifying and resolving cleaning issues. Leaders
interviewed patients to proactively identify concerns and
used this information to change work processes. Environmental services staff members were encouraged to work with
patients to find a mutually agreeable time for room cleaning.
Cleanliness Tips From Collaborative Participants
• M eet regularly with nursing staff to identify and address
unit-cleanliness issues.
• Include patient satisfaction goals in housekeeping evaluations (in-house and contracted services).
• R ecord, analyze, and act on cleaning audits.
• F ocus on the appearance of public areas too.
• A sk leaders from other areas to help assess cleaning quality.
• Interview staff, review patient satisfaction comments,
and change staffing and work patterns, if needed.
• E nsure that staff members have the necessary supplies
Scripts were developed for staff to explain housekeeping
activities and schedules to patients. Some teams provided a
24/7 “clean line” phone number for patients to call if problems arose or if service recovery was needed. It was important
to show physical evidence of cleaning, including leaving a
“sorry I missed you” card when the patient was absent from
the room or sleeping. Some teams selected clean-smelling
products to reinforce the cleanliness of the room.
and tools.
7
Improving Patient Experience: HCAHPS
Enhance Patient Communications
of the pain management board, confirming that it gives the
patient a sense of control and positively changes interactions
with the care team. The board helps patients and staff assess
different levels of pain and makes a useful distinction between pain and discomfort. The patient adviser commented
that the board’s structured approach is more helpful than
open-ended questions, which can be difficult for patients to
answer when they are hospitalized and feeling unwell.
Communication boards. Patient communication was
strengthened through the use of in-room whiteboards to
display important information, including names and contact
information for caregivers. The boards were updated at shift
changes and at other times as needed. Some participants
customized the boards for specific units and developed other
eye-level tools to enhance bedside education.
The UH/CMC team learned that listening to the stories of
patients and families brings their experiences into sharp relief
and helps create results-oriented solutions.
Using whiteboards to identify pain problems and solutions. The UH/CMC team piloted a new pain management
process that moved satisfaction performance from the 8th to
the 75th percentile for the pilot unit. The team’s pain management strategy incorporated a standardized pain bundle,
patient and staff education, and interdisciplinary communication between the care team and the patient. A special pain
management whiteboard was created and used in patients’
rooms as a visual representation of what interventions are
available, what has been tried, what works, and what does
not work for each patient (Figure 4).
Bedside interdisciplinary rounds. Collaborative participants encouraged care team members to gather at the bedside to discuss key issues with patients, family members, and
each other as way of keeping communication lines open.
Permission for these rounds was obtained from patients in
semiprivate rooms. If family members could not be present,
a designated point person was briefed by phone.
Physicians were asked to call ahead to notify staff about the
most efficient time to gather. To obtain buy-in for rounds,
teams emphasized the benefits: safety enhancements, fewer
delays, and fewer phone calls.
This customized technique involves the patient in his or her
own pain management decisions and facilitates the exchange
of information during staff handoffs. A patient adviser working with the UH/CMC team provided feedback on the value
Nursing change-of-shift communication at the bedside.
At many participant organizations, nurses used change-ofshift times to communicate at the bedside with each other
and their patients. Aides were asked to round and provide
comfort care during the bedside report. Some teams displayed a tabletop sign to alert others about the need for
uninterrupted time to talk. Whiteboards in the patients’
rooms were updated during the report.
Figure 4. Pain Management Plan Whiteboard at
University Hospitals Case Medical Center
Some collaborative participants offered simulation labs to
help nursing staff seamlessly transition to the new reporting
process. Nurses were reminded to ask patients in semiprivate
rooms for permission to conduct beside conversations.
Postdischarge calls. Patients were called within 48 to
72 hours of discharge by discharging nurses or other appropriate staff to assess their health condition, check compliance,
identify problems, and answer questions. Collaborative teams
won staff support for these calls by sharing patient feedback
and “saves” from negative situations, publishing rates of completed calls, and training float or light-duty staff to assist with
calls. Electronic medical records and other existing electronic
systems were adapted to capture and analyze the information
obtained during the calls.
MacDonald Women’s Hospital
Source: Vidal K, Dragon MA, Furnari R, Milter C. Improving HCAHPS 5by
increasing communication. Presented at: UHC Patient Experience (HCAHPS)
Improvement Collaborative Knowledge Transfer Web Conference; April 16, 2012.
https://www.uhc.edu/docs/49016628_UHCaseApril162012.pdf. Accessed
September 2012.
Connecting with patients at home. The Stanford Hospital & Clinics team focused on postdischarge calls because
nursing units frequently received phone calls from patients
8
Patient Experience (HCAHPS) Improvement Collaborative 2012 Field Brief
with follow-up questions but did not have a standardized
process for addressing those concerns. In addition to a positive effect on HCAHPS discharge communication scores, the
success of postdischarge phone calls is linked to lower readmission rates, higher quality outcomes, and the likelihood of
recommending the hospital.
Training and accountability. Communication training
helped collaborative participants define new standards, instill
and reinforce skills, and hold staff accountable for the patient
experience. Staff members were taught to knock first, introduce
themselves, call patients by their desired names, explain their
roles, make eye contact, smile, invite questions, and then listen.
Beginning in April 2011, calls were placed by nurses, with the
goal of contacting 100% of patients at home within 72 hours
of discharge. Making 2 attempts to contact each patient, the
callers have been able to connect with 96% of patients, compared with 59% at the program’s start (Figure 5). Stanford
has experienced substantial improvements in Press Ganey
scores related to instructions at home, moving from the 45th
to the 99th percentile since the pilot began. Nurses enjoy
hearing directly from patients and have been able to prevent
adverse events for several patients by addressing issues with
medications and follow-up appointments.
Scripts, skill labs, films, and question prompts were helpful training tools. Patients and family members were invited
by some teams to serve as faculty for training programs and
provide different perspectives. Leaders also participated in the
training sessions to demonstrate support and commitment.
To promote a permanent change in behavior, some teams
arranged for a trainer to observe and coach staff. Training
effectiveness was validated by interviewing patients and auditing
staff practices. At Vanderbilt University Medical Center, coaches
are available to observe the interactions between providers and
patients and assist in improving communication skills.
The Stanford team learned that leadership buy-in and demonstration of support for staff are crucial to success. Phone
calls must be viewed as a culture change and an extension
of patient care, not an extra duty. Patients appreciate the
personal phone calls, which provide opportunities for service
recovery when needed.
Participants worked to embed service expectations in
hiring, orientation, and evaluation processes to underscore
their importance. Teams also shared performance data and
patient comments with staff to reinforce the impact of
positive and negative behaviors.
Figure 5. Patients Contacted Within 72 Hours of Discharge From Stanford University Hospital & Clinics,
April 2011-February 2012
Percentage of Patients Contacted
120
96%
100
79%
80
60
59%
67%
46% 46%
86%
85%
72%
45%
42%
40
20
0
Apr
May
Jun
Jul
Aug
Sep
Oct Nov
Dec
Jan
Feb
(n= 59) (n= 90) (n= 56) (n= 71) (n= 43) (n= 71) (n= 63) (n= 72) (n= 87) (n= 104) (n= 80)
Source: Adapted from Abbott K. Stanford discharge phone calls program. Presented at: UHC Patient Experience (HCAHPS) Improvement Collaborative Knowledge
Transfer Web Conference; April 16, 2012. https://www.uhc.edu/docs/49016627_StanfordDischargePhoneCalls41612pptx.pdf. Accessed September 2012.
9
Improving Patient Experience: HCAHPS
The Next Step Is Yours
Consult your organization’s customized quarterly Imperatives
for Quality Report to compare your performance with that of
your peer groups by HCAHPS domain and identify areas for
improvement and better performers.
Patient satisfaction and its related reimbursement incentives
make it an essential element of UHC’s Improving Patient
Experience imperative, which includes HCAHPS, Clinician
and Group CAHPS, and palliative and hospice care.
Collaborative participants are progressing with their improvement initiatives, moving pilots into full-scale operation, and
expanding the patient experience to encompass care beyond
the inpatient setting. UHC member networking and problem
solving continues via the Patient Satisfaction listserver. Contact
Jorie Garbacz at (312) 775-4265 or garbacz@uhc.edu if you
want to participate.
Other UHC resources on best practices and improvement
strategies include the Patient Satisfaction (HCAHPS) Benchmarking Project 2011 Field Brief, Patient Experience Tools
and Resources Web page, HCAHPS suggested best practices,
Value-Based Purchasing Web page, interactive VBP Calculator,
and Performance Improvement Tool Kit.
For More Information
To learn more, contact Kathy Vermoch, project manager, at (312) 775-4364 or
vermoch@uhc.edu.
10
Patient Experience (HCAHPS) Improvement
Collaborative Participants
Duke University Health System (Duke University Hospital)
UCSF Medical Center*
Fletcher Allen Health Care
University Hospitals Case Medical Center
Froedtert & The Medical College of Wisconsin
University of Arizona Health Network (The University of
Arizona Medical Center–University Campus)
Georgia Health Sciences Medical Center*
Greenville Hospital System (Greenville Memorial Hospital)
University of Colorado Hospital*
Hennepin County Medical Center
The University of Connecticut Health Center, John
Dempsey Hospital
Highland Hospital*
University of Iowa Hospitals and Clinics
Indiana University Health
The University of Kansas Hospital Authority
Loyola University Medical Center
University of Kentucky Hospital
Medical University of South Carolina
University of Michigan Hospitals & Health Centers*
The Methodist Hospital System (The Methodist Hospital)
University of North Carolina Hospitals
The Nebraska Medical Center
University of Pennsylvania Health System
(Hospital of the University of Pennsylvania)
NYU Langone Medical Center
Oregon Health & Science University
Penn State M.S. Hershey Medical Center
Rush University Medical Center*
Shands Jacksonville Medical Center, Inc.
Stanford Hospital & Clinics
St. Luke’s Episcopal Hospital
Stony Brook University Medical Center
University of Rochester Medical Center Strong
Memorial Hospital
University of Utah Hospitals and Clinics
University of Wisconsin Hospital and Clinics
Upstate University Hospital
Vanderbilt University Medical Center
Vidant Health (Vidant Medical Center)
SUNY Downstate Medical Center/University Hospital
Virginia Commonwealth University Health System
(MCV Hospital)
Thomas Jefferson University Hospital
Wexner Medical Center at The Ohio State University
* Had 2 teams in the collaborative
155 North Wacker Drive
Chicago, Illinois 60606
312 775 4100 main
312 775 4580 fax
uhc.edu
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