Improving the Patient
Experience: H-CAHPS
Quality Improvement Project
Invasive/Non Invasive
Cardiology
Membership
• Cardiology Quality Council
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Theresa Fortner -Nurse Manager Invasive Cardiology
Joelyn Niggel - Nurse Manager NI Cardiology
Karen McKenny - Nurse Educator
Julie Eastman - RN Invasive Cardiology
Kristin Pelkey - Cardiology Tech NI Cardiology
Kathy Getty - RN Invasive Cardiology
Judy Rent - RN Invasive Cardiology
Heidi Igneri - RN Invasive Cardiology
Melissa Lambert - Supervisor Cardiology Tech Dept.
Mike Socha - Supervisor Cardiac Ultrasound
Karen McKnight - Quality Consultant
What is the H-CAHPS Survey
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Hospital
Consumer
Assessment
Healthcare
Providers &
Systems
• The survey and data collection
methodology are mandated by the
government.
of
• The survey, methodology and results
are in the public domain.
• H-CAHPS is publicly reported on:
www.hospitalcompare.hhs.gov
www.hcahpsonline.org
Background
• Goals: H-CAPHS
– Compare hospital perspective and patient
perspective
– Ensure the highest quality of patient care
and understanding
• History:
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2006
2008
2010
2011
Voluntary collection began
FAHC first participated
Government regulated
Value based purchasing rule finalized
Background
– Not a satisfaction survey
– Measures the behaviors of staff from the
patients perspective
– Patient Mix Adjusted (age, health, medicine,
surgery, OBS)
– Not limited to Medicare patients
– Nursing and Physician based questions
Background
• Reimbursement
– Government will hold 1% of Medicare payments
– FAHC can earn back the 1% if we meet National
Bench Mark Performance
– Reimbursement is based on a %
– This is expected to increase to 2% by 2017
Objectives
• Educate the staff regarding H-CAPHS
• Develop a Cardiology Code of Conduct for
improving patient experience.
• Improve the patient experience in procedural areas.
• Distribute Thank You cards to all invasive
outpatients post procedure
Methodology
• Education of Staff:
– Presentations by content experts
– Staff meetings in all departments addressing
H-CAHPS and concerns regarding:
communication, privacy, noise, and
environment
– Email
• Cardiology Quality Council to develop a Cardiology
Code of Conduct based on staff feedback
• Redesign the current AIDET survey tool to meet the
needs of a procedural area.
• Monthly auditing of all procedural areas
• Review results: H-CAHPS and Press Ganey Surveys
Implementation
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Cardiology Code of Conduct
Staff Education
Monthly Audits
Thank You Note
Cardiology Code of Conduct
Ways to impact the patient experience in a positive manner
• Communication:
Cardiology Staff/Providers/Fellows
– Communicate with patient and patient’s family
of delays. Use “blameless apology”
– Show concern for patient verbally as well as
nonverbally
– Introductions
– Shows patient respect, courtesy, and confidence
– Delays and updates
• Privacy
– Maintain the patient’s physical privacy in the
testing areas at all times.
Cardiology Code of Conduct
• Noise
– In testing areas- pre and post procedure.
• Music
• Television
• Staff
– Schedulers
– Vendors
– Monitor control room
– Physician pagers during procedures
• Environment
– Environmental Services
Action Plan/Next Steps
• Further revision of the AIDET tool
– Forming it to fit the needs of the testing area
– Clarifying aspects of AIDET
• Continued education for staff
• Education of auditing staff
– How to use tool
– Inter-rater reliability
• Continued monthly auditing
• Thank you cards:
– Roll out to Non Invasive testing areas in 2012
Non Invasive Cardiology
HCAHPS
Staff Survey Totals
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
u
Yo
Th
an
k
Ex
pl
ai
n
en
t
En
vi
ro
nm
n
Du
ra
tio
In
tro
du
ct
io
n
Ac
kn
ow
le
ge
0%
July
August
September
October
Invasive Cardiology HCAHPS
Staff Survey Totals
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
u
Yo
Th
an
k
Ex
pl
ai
n
en
t
En
vi
ro
nm
Du
ra
tio
n
In
tro
du
ct
io
n
Ac
kn
ow
le
ge
0%
July
September
October
H-CAHPS CARDIOLOGY
H-CAHPS CARDIOLOGY
Displayed by Discharged Date
Cardiology M5
AUGUST
SEPTEMBER
August
September
Inpatient Cardiology – M5
Aug '11
Sept '11
Friendliness/courtesy of the nurses
96.7
97.0
Nurses kept you Informed
91.9
92.7
Nurses checked ID
97.5
96.1
Explanations happened during T&T
92.2
93.3
Staff concerned for privacy
91.7
91.9
Staff include decisions regarding treatments
90.3
90.5
Outpatient Cardiology Testing
Aug 2011
Sept 2011
93.0
96.2
Friendliness of staff
97.4
96.2
Explanations given by staff
91.7
95.2
Staff's concerns/questions worries
91.5
94.2
Concern for privacy
93.8
94.0
Response to concerns and complaints
92.1
90.2
Facility
Cleanliness of facility
Std Test or Treatment
Std Personal Issues