Your Impact on HCAHPS
Sarah D. Ponder
Improvement Manager
Press Ganey Associates
HCAHPS 101
What is CAHPS?
Consumer Assessment of Healthcare Providers and Systems
Produces comparable data for public reporting
Creates incentive for organizations to improve
Enhances public accountability and transparency
Hospital CAHPS
Home Health Care CAHPS
Clinician and Group CAHPS
… more to come!
CAHPS provides an apples to apples metric for public
reporting—additional measurement may be needed for ongoing
quality improvement activities and monitoring.
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Why is CAHPS ® Important?
Consumers have access to the data
Consumers relate more easily to CAHPS data than to clinical data
Some use CAHPS data to choose hospitals
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CAHPS is in the public eye
Media coverage
Promotion by hospitals themselves
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Participation linked to reimbursement
Will have volume, revenue, and reputation implications down the road
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HCAHPS Survey
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HCAHPS Survey Format
Evaluative Questions
About You Questions
Global Rating Questions
Screening Questions
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Questions you Impact
Hospital Environment
During this hospital stay, how often were your room & bathroom kept
clean?
 Never, sometimes, usually, always
During this hospital stay, how often was the area around your room quiet
at night?
 Never, sometimes, usually, always
Overall Rating
Using any number from 0 to 10, where 0 is the worst hospital possible
and 10 is the best hospital possible, what number would you use to rate
this hospital during your stay?
 0-worst—10-best possible hospital
Would you recommend this hospital to your friends & family?
 Definitely no, probably no, probably yes, definitely yes
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General Survey Guidelines
Patient Eligibility
All payer types
 18 years or older
 At least one overnight stay in the hospital (admit date & discharge
date cannot be the same)
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All MS-DRGs except:
 Primary psychiatric diagnosis, discharged from rehab or from
skilled nursing
 Alive at the time of discharge
Not sent to patients with an international address
 Not sent to patients discharged to hospice or correctional
facilities
New: Not sent to patients discharged to nursing home or skilled
nursing
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Communication Guidelines
Hospitals SHOULD
 Encourage response to the survey
 “It is permissible to notify the patient while in the hospital or at
discharge that they may receive a survey after discharge.”
 Improve the patient experience
 Distribute the communication guidelines
Hospitals SHOULD NOT
 Ask patients for a certain score
 Indicate that their goal is to receive a certain score
 New: Show the HCAHPS survey or cover letter to the patient prior
to survey administration
 New: Mail pre-notification letter or postcards
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Public Reporting
HCAHPS Public Reporting
Domains
Communication with Doctors
Communication with Nurses
Responsiveness of Hospital Staff
Pain Control
Communication about Medicines
Discharge Information
Questions
Cleanliness of Physical Environment
Quiet of Physical Environment
Overall Rating of Care
Likelihood to Recommend
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General Guidelines: Adjustments
Data are adjusted based on the following:
 Patient Characteristics (“patient mix adjustment”)
– Examples
– Type of Service (Medical, Surgical, OB)
– Self Reported Health
– Age
– Education
– Language
– Emergency room admission
Mode of survey distribution (“mode adjustment”)
 Phone
 Mail
 Mixed mode- mail & phone
 Active Interactive Voice Response
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Updated Public Reporting Schedule
April 2011: Discharges from July 2009 – June 2010
July 2011: Discharges from October 2009 – September 2010
October 2011: Discharges from January 2010 – December 2010
January 2012: Discharges from April 2010 – March 2011
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Tables- Distribution of Responses
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Graphs - Percentage of “Always” Responses
The yellow bars
indicate the National &
State averages.
The blue bars indicate
the averages for
facilities selected.
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State Reporting Programs
Additional reporting programs through the states of California, Rhode
Island, Minnesota, Ohio, Maryland, Maine
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Value Based Purchasing
Value-Based Purchasing
Common Terminology: Pay for performance or Pay for quality
Health Reform Updates
Value Based Purchasing will start in fiscal 2013
Current hospital VBP program will transition from “Pay-for-Reporting” to “Pay-for
Performance”
Up to 2% of your Medicare reimbursement will be at stake
 Hospitals will lose reimbursement unless their performance is at benchmark
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levels
Includes HCAHPS performance and Core Measures
Will start at 1% and this will be ramped up to 2% by 2017
Who will be reimbursed for HCAHPS performance?
 Top performing healthcare providers
 Greatest improving healthcare providers
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Hospital Value Based Purchasing - Measures
Future Measures
 AHRQ patient safety indicators, inpatient quality indicators and composite
measures
 Nursing sensitive care
 AMI, heart failure and pneumonia mortality rates
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HCAHPS Measures
Used In Value Based Purchasing
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Nurse Communication
Doctor Communication
Cleanliness and quietness
Responsiveness of hospital staff
Pain management
Communication about medications
Discharge information
Overall hospital rating
Copyright © 2011 Press Ganey Associates
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Value Based Purchasing Model

Hospitals will be awarded points toward their earn back of
withheld DRG payments.
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Earn Achievement Points based on your performance on
HCAHPS publicly reported measures.
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Earn Improvement Points based on improvement from the
baseline period.
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The spread between the threshold to benchmark
Baseline to 95th
HCAHPS
 8 Measures – 80 Possible Points
 1 Consistency Score- 20 Possible Points
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HCAHPS “Consistency” Points

Up to 20 Points Based on Lowest Ranking HCAHPS
Measure
Points
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10
10
20
30
•
40
50
60
70
Percentile Rank
© MHA 2009
Copyright © 2011 Press Ganey Associates
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80 90
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Proposed Timeline
Key Timeframes for VBP

The “Baseline Period” discharges July 1, 2009 – March 31, 2010. The
“Performance Period” discharges July 1, 2011 – March 31, 2012.
Copyright © 2011 Press Ganey Associates
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Moving from Measurement to Action:
Improvement Strategies
So where do we do focus?
 Patient Priorities
 Lowest Ranking Question
 Most Opportunity to Earn Money Back
 Create Performance Improvement
Teams Around Each Publicly Reported
Measure
National HCAHPS data by Service Line
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Step 1: Identify a Goal
[S] Specific. Exactly what is it you wish to accomplish?
[M] Measurable. Identify the means by which you will achieve each goal.
How will you know when you have reached it? Keep in mind that you will
always have more control over performance than you will over outcome so
set performance goals whenever possible.
[A] Action-oriented. Describe your goals using action verbs. What will
you do (step by step) to reach your goal?
[R] Realistic. Choose goals that are possible and achievable. Goals set
too high will discourage while goals set too low will not challenge and
motivate.
[T] Timed. Determine deadlines for each of your goals. Deadlines can be
flexible & adjusted as needed but deadlines help keep you focused and
moving.
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Step 2: Identify the Cause
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Look at patient comments for trends or patterns
Conduct patient & employee focus groups
Fishbone Diagram at a high level
Patient
Expectations
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“5 Why’s”
What is causing area of poor performance?
Root cause analysis
Flowcharting
What are the CTQs?
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Cause- Solution Relationship
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Thinking backwards from the score itself
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What is the perception of patients?
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What do they experience? (long wait, conflicting information, being
alone, in pain, etc.)
How does it make them feel? (unvalued, confused, lack of trust, lonely,
afraid, stressed, etc.)
Causes don’t create a score, they create an environment in
which a patient feels a certain way- that is what shapes how
they evaluate care
Determining cause is extremely important- it ensures you are
efficient in your choice of strategy for improvement
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Cause Solution Activity
 Make two columns: one with patient experiences & one with
patient feelings
 Then make chart (below)- with your own ideas
 Then take this back to staff & get their input
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Cause Solution Activity (cont.)
Selecting a Course of Action:
 We have identified that we can impact the following
causes:
 Because we can either:
 Modify the cause itself
 Modify how patients feel
 We are selecting the following viable practice to match the
causes of the patients’ current experience:
 It should address the experience of patient (i.e. reduce
wait time) or change the way a patient currently feels (i.e.
reduce anxiety):
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Step 3: Recommend a Solution
 Which causes are you trying to address?
 Which causes do you have control over?
 Will you modify a cause or shape perception?
 Does the selected solution address the causes or perceptions
you have control over?
 Will the selected solution be visible to patients?
 Will it be big enough to change?
 Will it impact all patients?
 Is there anything you need to fix first, before you can
implement this solution?
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Room & Bathroom Kept Clean
“During this hospital stay, how often were your room &
bathroom kept clean?
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Ask patients when leaving the room if the room meets
their cleanliness standards & if they would like anything
else cleaned.
Increase frequency of non-daily cleanings (i.e. washing
walls, waxing the floor, etc.)
Reinforce cleanliness by emptying waste baskets
multiple times a day, offering to change sheets, etc.
Make all staff accountable for the appearance, not just
environmental services
Include environmental services on unit cross functional
teams
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Quiet at Night
“During this hospital stay how often was the area around your
room quiet at night?”
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Modify equipment:
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Foam on trash cans, squeaky wheels on carts fixed, oil on doors, no
overhead announcements, dim lights, phone ringers turned down
Use a dosimeter to measure noise levels on unit & track for a
period of time
Work cross functionally with other departments to get
feedback regarding building or equipment noise
Provide patients with a welcome kit that talks about “Quiet
hospitals help healing” that contains ear plugs, eye covers, &
note that says: “one who has a good night’s rest awakes to a
glorious morning”
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Rate & Recommend this Hospital
“Using any number from 0 to 10, where 0 is the worst hospital possible
and 10 is the best hospital possible, what number would you use to rate
this hospital during your stay?”
“Would you recommend this hospital to your friends & family?”
 Empower all staff with power to “make it right” with patients
 Hire for attitude over aptitude, it is easier to teach skills than
service
 Share data openly with all levels of the organization
 Focus on employee satisfaction, happy employees make for
happy patients
 Use multiple outlets for patient feedback, especially creating a
patient advisory council
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Universal Viable Practices
Rounding
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“Maintenance” Rounds
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Conducted a minimum of once per shift, environmental services staff
visit each patient on the floor to make sure the cleanliness of the room
meets their standards
Introduction Rounds
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Each morning environmental services staff brings the morning paper to
the patient with a sticker on it that says the staff member’s name & a
contact number if at any point the room needs attention
Appearance Rounds
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Once a day the building services director rounds on specific units &
areas to get feedback from unit directors & managers on their current
needs (i.e. light is out in room 203 or heater is not operational in conf
room)
Cross Functional Team Rounds
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A member of both the environmental services team & the building
services team should sit on the patient satisfaction committees
throughout the organization to help address related patient needs
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Key Messages
 Key messages should be used when there is an important
message all patients should receive
 Make sure a key message is:
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Staff that are going to use the key messages help to develop them
Clear, short, and easy to understand
Sounds natural and can be customized by staff
 Limit 4-5 key messages per staff member
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Examples:
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Greeting patients and families
Entering and leaving patient rooms
Communicating about actions that protect privacy/safety
Informing patients of hospital services
Patient rounds
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Service Moments of Truth
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Employ a Service Recovery Strategy
 Keep it simple & easy for
everyone to remember
 Have one toolkit for every
department
 A no questions asked policy
should be enforced for
toolkit usage
 Have tracking spreadsheet
to look for service patterns
 Not all complaints warrant
toolkit usage, most issues
just require a sincere
apology
“6 A’s”
 Awareness
 Acknowledgement
 Apology
 Active Listening
 Action, Amendment
 Avoiding
“H.E.A.R.T.” Philosophy
 Hear the patient
 Empathize with the patient
 Apologize to the patient
 Respond to the patient
 Thank the patient
“H.E.A.T.” Philosophy
 Hear
 Empathize
 Apologize
 Take responsibility
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“Relate” Philosophy
 Recognize concern
 Empathize
 Listen
 Apologize
 Take responsibility
 Explain what you are going to do
Reward & Recognition
 Read patient comments to see if your staff members are
mentioned by name
 Have a recognition program that allows staff members to
nominate each other for going above & beyond
 Have a service hero of the month in your department
 Customize your recognition to the individual staff member

In your one on one meetings with them ask them what their favorite
food, restaurant, pasttime, etc.
 Celebrate birthdays & recognize anniversaries
 Celebrate your improvement with banners or trophies
 Schedule team outings or treats (i.e. pizza parties or ice cream
socials)
 Hand written notes sent to their home
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Data Sharing
 Have a bulletin board outside your department that contains:
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Patient satisfaction scores
Patient comments that mention your department or staff
Priority for the quarter or six month period
Letters from patients
Customer hero of the month
Employee to employee recognition
 Educate new staff members on the survey process & your
goals
 Create monthly electronic/printed dept. newsletters & dedicate
a section to patient satisfaction data
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Other General Practices
 “Director of First Impressions”
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Security, front desk staff, volunteers, etc.
 “Fresh as a Daisy”
 Color choices in patient rooms & hallways
 No flyers/posters taped to the walls or elevators
 Way-finding/signage
 Employee satisfaction focus
 Anticipate patient needs
 Separate areas on the units for physician/family consults
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Step 4: Implement a Solution
 Two main phases:
1. Preparation
a) Project team & roles
b) Communication
c) Development of training
d) Preparing measurement
e) Preparing accountability
f) Prepare logistics
2. Execution
a) Educate
b) Roll-out: follow through on your plan
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Steps 5 & 6: Monitor & Review
Monitor:
 Measure Behavior
 Tracking
 Observation
 Self-Reporting
 Auditing
 Feedback
Review:
 Did you meet your Goal?
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Yes
 Celebrate
 Increase Goal or Sustain
No
 Why Not?
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Thank you for attending!