The HCAHPS and Competency Connection
OBJECTIVES:
• Understand the HCAHPS
initiative and VBP
• Identify key components of
HCAHPS that are linked to
competency
• Explore the impact of
competencies on HCAHPS
performance
• Discover how to select appropriate
competencies
• Learn how to standardize
competency selection process
• Uncover ways to promote
employee accountability
HealthStream’s
VISION
To improve the quality of healthcare
by assessing and developing the people
that deliver care.
Insights Online
HCAHPS Impact Report
Learning Platform
Measurement
Learning
Insight
Action
through through
Research Learning
VBP Report Card
Improved
Performance
Call Center
Improvement Courseware
Understanding the HCAHPS Initiative and Value
Based Purchasing
What is CAHPS?
Consumer Assessment of Healthcare Providers and Systems
H-CAHPS: Hospital Inpatients
HH-CAHPS: Home Health Patients
CG-CAHPS: Physician Clinic & Group Office Patients
ICH-CAHPS: In-Center Hemodialysis Patients
LTC-CAHPS: Nursing home residents and family
members
• More to come!
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Differences in Survey Question
Scales
Overall, how would you rate the care you received?
Very Good
53%
Good
Fair
Poor
22%
14%
9%
Very Poor
2%
During this hospital stay, how often did nurses explain things in a way
you could understand?
Always
Usually
Sometimes
Never
40%
25%
25%
5%
The H-CAHPS Survey
• Six Domains
• Communication with nurses
• Communication with doctors
• Responsiveness of hospital staff
• Pain management
• Communication about medicines
• Discharge information
• Two Individual Questions
• Cleanliness of hospital
• Quietness of hospital
• Two Overall Questions
• Overall hospital rating (0 – 10 point scale)
• Would recommend (4 point scale-definitely yes)
HCAHPS USES
FREQUENCY
SCALE:
Always
Usually
Sometimes
Never
Data Adjustments
CMS will take the data collected and adjust
for…
• MODE: type of methodology used (phone vs. mail vs. mixed)
• PATIENT MIX: Service line, age, education, health status, language
spoken in home, time since discharge, etc.
Public Reporting of H-CAHPS Results
How often did nurses communicate well with patients?
www.hospitalcompare.hhs.gov
Patient Protection and Affordable
Care Act
VBP: Value Based Purchasing Program
• Enacted March 23, 2010
• Repealed January 19, 2011
• A specified percentage (1-2%)
of hospital payments will be
conditional on performance
• Critical Access Hospitals were not previously
required to participate in HCAHPS
Value Based Purchasing (VBP)
• CMS released VBP details January 7, 2011
• A percentage of a hospital’s base DRG rate is impacted
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Reimbursement FY2013:
Reimbursement FY2014:
Reimbursement FY2015:
Reimbursement FY2016:
Reimbursement FY2017+:
1.00% of payments
1.25% of payments
1.50% of payments
1.75% of payments
2.00% of payments
70% of reimbursement based on 15 clinical and outcome measures
30% on HCAHPS survey results
MBQIP
Medicare Beneficiary Quality Improvement Project
• Office of Rural Health Policy (ORHP):
“This initiative takes a proactive approach to ensure CAH’s
are well prepared to meet future quality requirements.”
• September 2012 – Phase II Began – included HCAHPS
• “Voluntary”
Identifying Key Components of HCAHPS
Linked to Competency
The H-CAHPS Survey
• Six Domains
• Communication with nurses
• Communication with doctors
• Responsiveness of hospital staff
• Pain management
• Communication about medicines
• Discharge information
• Two Individual Questions
• Cleanliness of hospital
• Quietness of hospital
• Two Overall Questions
• Overall hospital rating (0 – 10 point scale)
• Would recommend (4 point scale-definitely yes)
HCAHPS USES
FREQUENCY
SCALE:
Always
Usually
Sometimes
Never
Hospitals Nationally Are
Achieving High Scores
Top Box Results from the CMS National Database
(2nd Quarter 2011 Release)
Discharge Information
81%
Willingness to
Recommend
68%
Doctor
Communication
80%
Overall Rating of
Hospital
66%
Nurse Communication
75%
Responsiveness of
Staff
63%
Cleanliness of Room /
Bathroom
70%
Communication
about Medicines
59%
Pain Management
69%
Quietness
57%
HCAHPS Overall Performance
Date
Jul `07 - Oct `07 - Jan `08 - Apr `08 - Jul `08 - Oct `08 - Jan `09 - Apr `10 Jun `08 Sep `08 Dec `08 Mar `09 Jun `09 Sep `09 Dec `09 Mar `11
Change
over 2
years
Hospital Count
3,711
3,746
3,765
3,766
3,775
3,773
3,792
3,798
Nurse Communication
74%
74%
74%
74%
75%
75%
75%
76%
2%
Doctor Communication
80%
80%
80%
80%
80%
80%
80%
80%
--
Responsiveness of Hospital Staff
62%
62%
62%
62%
63%
63%
63%
64%
2%
Pain Management
68%
68%
68%
68%
68%
69%
69%
69%
1%
Communication About Medicines
59%
59%
59%
59%
59%
59%
60%
60%
1%
Cleanliness of Room/Bathroom
Quietness of Area Around Room at
Night
69%
69%
69%
70%
70%
70%
70%
71%
2%
56%
56%
56%
56%
57%
57%
57%
58%
2%
Discharge Information
80%
80%
80%
80%
81%
81%
81%
81%
1%
Overall Rating of Hospital
Willingness to Recommend
Hospital
64%
64%
64%
65%
65%
66%
66%
67%
3%
68%
68%
68%
68%
68%
68%
69%
69%
1%
HCAHPS Composite
68%
68%
68%
68%
69%
69%
69%
70%
2%
Exploring the Impact of Competency on
HCAHPS
Linking Employee and Physician
Satisfaction and Competency
to HCAHPS Results
Results of a Recent Multivariate Study: Employee and Physician
Predictors of HCAHPS Scores:
What factors/variables predict HCAHPS scores?
Methodology
Sample:
The sample included 237 HealthStream client
hospitals.
Data used were employee satisfaction scores,
physician satisfaction scores and HCAHPS
inpatient scores. Total Beds and Average Length of
Stay were obtained from an external data source.
Methodology
• A multiple regression analysis was conducted on the data.
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Independent (predictor) Variables:
Employee Ratings of Administration
Employee Ratings of Immediate Supervisor
Employee Satisfaction/Loyalty
Physician Ratings of Administration
Physician Ratings of Hospital Efficiency
Physician Ratings of Nursing Skill
Total Beds
ALOS
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Dependent Variable:
HCAHPS Overall Hospital Score
Summary of HCAHPS Predictors
Three variables significantly predicted HCAHPS scores:
Standardized
Beta
Significance
Employee Satisfaction & Intent to Stay
.78
p<.001
Employee Perceptions of Upper Management
-.46
p<.001
Physician Perceptions of Nursing Skill
.27
p<.001
Significant Predictors
Implications
• Employee satisfaction/loyalty and HCAHPS scores
• Employee satisfaction is critical to inpatient care
• Physician rating of nursing skill and HCAHPS scores
• Importance of physicians’ perceptions of nursing skill
• Employee ratings of administration and HCAHPS
scores
• This unexpected finding can help administrators understand
potential low employee administration ratings in the quest
toward HCAHPS improvement efforts
Selecting Appropriate Competencies:
A New Era In Competency Assessment
What is Competency
Assessment?
• Advances in patient care necessitate and
compel nurses to continuously address
evolving competency needs
• The skills and abilities nurses mastered and
excelled in just a few years ago may no longer
be as valuable or necessary today
The Evolution
In the past, the focus has been clinical knowledge and
mastery of technical skills.
Today foundational competencies include:
Teamwork and interpersonal skills
Commitment to professionalism
 Implementing evidence-based practice
 Assessing communication abilities
Fostering safety improvements
Competency Defined
Competency is the application of knowledge.
It is measured at the bedside, in the job role.
It is not assessed by:
• Passing a test
• Taking a course
• Using a checklist
The Strategic Importance
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Patient Safety
Quality Outcomes
Employee satisfaction
Patient Satisfaction
Physician Satisfaction
Verification of clinical expertise
Reflective Practice
Accountability
Competency Goals
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Drives standards of practice
Standardization
Accountability
Establishes and determines
your baseline
Quality Measures
• Interpretation of quality indicators serve as
the baseline for competency assessment
• If quality indicators fall short or you have no
evidence of any baseline data, this is the
starting point
Empowered Assessments
• Don’t give out or choose the competency to be
evaluated
• Establish a process to identify competencies
selection
• Reinforce the process for competency selection
• Provide process to identify what competency
needs to be assessed and they are not given the
competency itself
Standardization
• Standardized the competency process rather
than individual competency itself
• Competency will differ across units
Static vs. Dynamic
• Competency is an ongoing dynamic process
• Competency is ever changing
• Don’t repeat the same competencies year after
year
• Your organization needs to focus it’s energy on
the ongoing competency selection process
• Initial Orientation competency drives safety
• Annual competency drives organizational changes
Brainstorm First, Prioritize
Second
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What is new?
What is changing?
What is problematic?
What is high risk?
• What is important to
the employee?
• What is time sensitive?
Data help drive process
Collect quality data in a central location
Review data to see if a gap can be identified
No problem = no competency needed
Gap identified? Show and discuss how you
arrived at this conclusion and assign competency
accordingly
• You may demonstrate something was considered,
but a competency was not ultimately needed
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What are the Competencies?
Medication Error
• A medication error occurred
• Situation investigated
• Asked an RN to demonstrate how he/she would
calculate a pediatric drug dose
• RN did not routinely work with pediatric patients
• The RN could not do the calculation
• Corrective action…all RNs must take a
medication exam annually
• True or False: Medication test proves
competency?
The Truth
• Medication tests prove very little
• Nurses who are required to calculate medication
doses for an unfamiliar patient population may:
• Demonstrate ability to utilize internal resources to calculate
medication dose
• Use drug dose applications on mobile devices
• Call pharmacy
• Call pediatric units for staff support
• Ask for another RN to double check calculation
Educators or Shared Governance
• They should not select all competencies
• They should reinforce the model to clarify
infrastructure
• In the past, leaders select competencies and
educators do the “doing”
• It’s a new era!
• Educator s demonstrate critical thinking
• Leaders should hold their team accountable
Education vs. Accountability
• How much money is spent on inappropriate
education?
• Accountability issue or competency issue?
• When baseline or advanced competency level is
achieved, but outcomes are not met, it is an
accountability issue
• It is an educational issue, when skill is lacking
• It is an accountability issue, when will is lacking
Evidence of Achievement
• Place the employee in the center of the
process
• Ask the employee to provide evidence of
verification
• If employee refuses to provide verification,
then an accountability issue is present
A New Approach
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Application of Knowledge
Professional Practice Standards
Evidence of Achievement
Outcomes
Not simply a check list any longer
Common Mistakes
• Don’t fall into the common competency traps
• Don’t repeat the same competencies year
after year
• Don’t validate
• Don’t perpetuate
• Lets identify some common mistakes
Does someone follow in another car?
In Summation
• Competency enables healthcare organizations to
create business alignment, promote a culture of
accountability, develop people, strengthen
relationships between managers and employees and
improve overall satisfaction of employees , physicians
and patients.
Recommended Reading
Questions?
Thank you!
Kylie B. Taylor
Regional Director,
Research Solutions
kylie.taylor@healthstream.com
Lynn Howe, RN, MS
Director of National Accounts,
Talent Management
lynn.howe@healthstream.com