Improving the Patient Experience: H-CAHPS

Quality Improvement Project Invasive/Non Invasive

Cardiology

Membership• Cardiology Quality Council

– 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

• Hospital

• Consumer

• Assessment of

• Healthcare

• Providers & • Systems

• The survey and data collection methodology are mandated by the government.

• The survey, methodology and results are in the public domain.

• H-CAHPS is publicly reported on: www.hospitalcompare.hhs.govwww.hcahpsonline.org

Background

• Goals: H-CAPHS– Compare hospital perspective and patient

perspective– Ensure the highest quality of patient care

and understanding

• History:– 2006 Voluntary collection began– 2008 FAHC first participated– 2010 Government regulated– 2011 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

• 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

July

August

SeptemberOctober

Invasive Cardiology HCAHPS Staff Survey Totals

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

July

September

October

H-CAHPS CARDIOLOGY

H-CAHPS CARDIOLOGY

Displayed by Discharged Date

Cardiology M5

August September

SEPTEMBERAUGUST

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

Facility    

Cleanliness of facility 93.0 96.2

Std Test or Treatment    

Friendliness of staff 97.4 96.2

Explanations given by staff 91.7 95.2

Staff's concerns/questions worries 91.5 94.2

Std Personal Issues    

Concern for privacy 93.8 94.0

Response to concerns and complaints 92.1 90.2