Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op,...

70
Exemplary Professional Practice Quality Care Monitoring and Improvement EP23EO Unit or clinic level patient satisfaction data (related to nursing care) outperform the mean or median of the national database used. Provide eight quarters of inpatient ambulatory/outpatient satisfaction data at the unit for clinic level collected within the previous 30 months before documentation submission. Select four of the nine categories. SJO has selected the following four categories: 1. Care Coordination 2. Patient Education 3. Courtesy and Respect 4. Responsiveness and Service Recovery SJO started utilizing Professional Research Consultants (PRC) as the external vendor in 2Q 2013 for the inpatient units comparisons. Prior to this Avatar had been the vendor of choice. Outpatient and the Emergency Care Center (ECC) were not transitioned to PRC until 3Q 2013; therefore, data for the outpatient and ECC will be presented by two vendors. Questions have been approved by ANCC Magnet ® for both PRC and Avatar for the categories chosen. The reason for changing vendors was to have a standard patient satisfaction benchmarking survey across St. Joseph Health. SJO benchmarks against other hospitals of similar size and patient service structures. SJO compares results to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national database. The PRC survey is administered via a live voice telephone call to the randomly selected patients. The survey may be started as early as 24 hours post discharge. The sample size for our hospital is between 50 to 80 patients per quarter as this is a snapshot of the care received at SJO. PRC data is displayed on each unit for review by the healthcare team; data is updated monthly. The patient satisfaction survey questions and categories include:

Transcript of Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op,...

Page 1: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Quality Care Monitoring and Improvement

EP23EO Unit or clinic level patient satisfaction data (related to nursing care) outperform the mean or median of the national database used. Provide eight quarters of inpatient ambulatory/outpatient satisfaction data at the unit for clinic level collected within the previous 30 months before documentation submission. Select four of the nine categories.

SJO has selected the following four categories:

1. Care Coordination 2. Patient Education 3. Courtesy and Respect 4. Responsiveness and Service Recovery

SJO started utilizing Professional Research Consultants (PRC) as the external vendor in 2Q 2013 for the inpatient units comparisons. Prior to this Avatar had been the vendor of choice. Outpatient and the Emergency Care Center (ECC) were not transitioned to PRC until 3Q 2013; therefore, data for the outpatient and ECC will be presented by two vendors. Questions have been approved by ANCC Magnet® for both PRC and Avatar for the categories chosen. The reason for changing vendors was to have a standard patient satisfaction benchmarking survey across St. Joseph Health. SJO benchmarks against other hospitals of similar size and patient service structures. SJO compares results to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national database. The PRC survey is administered via a live voice telephone call to the randomly selected patients. The survey may be started as early as 24 hours post discharge. The sample size for our hospital is between 50 to 80 patients per quarter as this is a snapshot of the care received at SJO. PRC data is displayed on each unit for review by the healthcare team; data is updated monthly. The patient satisfaction survey questions and categories include:

Page 2: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Inpatient units PRC questions 2Q 2013-1Q 2015

Category Question Units

Care Coordination

How would you rate the overall teamwork between the doctors, nurses and staff? During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

MICU-DSU, Observation, General Surgery Labor & Delivery/Antepartum, Medical Telemetry, Pulmonary Renal, Mother-Baby Unit, Oncology, Orthopedics.

Patient Education

Before giving you any medicine, how often did hospital staff tell you what the medicine was for? During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

General Surgery, Mother-Baby Unit, Observation Labor & Delivery/ Antepartum, MICU-DSU, Medical Telemetry, Pulmonary Renal, Oncology, Orthopedics

Courtesy and Respect

During this hospital stay, how often did nurses treat you with courtesy and respect?

All data collection areas

Responsiveness and Service Recovery

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help to the bathroom or in using a bedpan as soon as you wanted?

General Surgery, Labor & Delivery/Antepartum, Observation, Oncology, Orthopedics

MICU-DSU, Medical Telemetry, Pulmonary Renal, Mother-Baby Unit

Outpatient and Emergency Services Avatar questions 2Q 2013

Care Coordination

There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Courtesy and Respect

I consistently received respect and compassion while at St. Joseph Hospital.

Responsiveness and Service Recovery

Staff tried their best to help me if there was a problem. The nursing staff was responsive in answering my calls or requests.

ECC and Outpatient Diagnostic Outpatient Surgery

Patient Education

Tests and procedures were adequately explained to me before they were done.

ECC and Outpatient Diagnostic

Page 3: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Medications and care at home were explained to me in a way I could follow.

Outpatient Surgery

Outpatient and Emergency Services PRC Questions 3Q 2013-1Q 2015

Care Coordination

How would you rate the overall teamwork between the doctors, nurses, and staff?

Courtesy and Respect

How would you rate the staff's respect for your values, beliefs and faith?

Responsiveness and Service Recovery

How would you rate the responsiveness of staff to any concerns or complaints you have had?

Patient Education

How would you rate the explanations/staff’s instructions provided about how to care for yourself at home?

Analysis and evaluation of data Results are trended over time in graphs displaying eight quarters from 2Q 2013-1Q 2015. The graphs display the mean for inpatient, ECC and outpatient units and the national mean (either PRC or Avatar) for that specific comparison group. Five RNs are in Radiology Administration cost center and are deployed to different outpatient radiology departments as needed so they are not counted in patient satisfaction. The units with no sampling because they were not included in PRC sampling and not counted in patient satisfaction include: Women’s Heart Center, Mother-Baby Assessment Center, Cardiac Rehab, Renal Center Acute, Renal Chronic, Renal Home, Dialysis Santa Ana, La Amistad, Main Post Anesthesia Care Unit (PACU), Outpatient PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall performance summary

Care Coordination: 13 of 21 hospital and outpatient units (62%) outperformed the national mean for five or more of the eight quarters submitted

Patient Education: 16 of 21 hospital and outpatient units (76%) outperformed the national mean for five or more of the eight quarters submitted

Courtesy and Respect: 13 of 21 hospital and outpatient units (62%) outperformed the national mean for five or more of the eight quarters submitted

Responsiveness and Service Recovery: 11 of 21 hospital and outpatient units (52%) outperformed the national mean for five or more of the eight quarters submitted

Page 4: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

PRC and Avatar Patient Satisfaction Unit Performance 2Q 2013 - 1Q 2015 Green - outperforms benchmark majority of quarters Red - underperforms benchmark majority of quarters

Inpatient Units Care

Coordination Patient

Education Courtesy

and Respect

Responsiveness and Service

Recovery

Medical ICU-DSU 5/8 6/8 6/8 5/8 Medical Telemetry

Unit 7/8 6/8 5/8 5/8 Pulmonary Renal Unit 4/8 7/8 2/8 2/8

Observation Unit 4/7 5/7 5/7 2/7 General Surgery Unit 4/8 5/8 4/8 3/8

Oncology Unit 7/8 8/8 4/8 6/8 Orthopedic Unit 5/8 6/8 4/8 5/8

Mother Baby Unit 4/8 5/8 7/8 5/8 Labor & Delivery 7/8 7/8 5/8 5/8

Emergency Services

Emergency Department 6/8 5/8 4/8 4/8 Outpatient Diagnostic

Heart Center 2/5 2/5 3/5 2/5 Maternal Fetal

Testing 4/8 1/8 5/8 4/8 Kidney Transplant

Center 7/8 6/8 6/8 6/8 Pavilion MRI 5/8 6/8 8/8 8/8

Radiation Therapy 1/8 1/8 4/8 3/8 Wound Care Center 0/8 3/8 3/8 2/8

Cardio Vascular Interventional Lab 5/8 6/8 5/8 4/8

Multidisciplinary Clinic 2/1 1/2 1/2 2/2 Infusion Center 2/2 2/2 2/2 1/2

Outpatient Surgery

Pavilion Outpatient Surgery 7/8 7/8 7/8 8/8

Pavilion Endoscopy 3/8 5/8 5/8 6/8 Total units

outperforming five or more of eight

quarters submitted 13 of 21 units outperformed

16 of 21 units outperformed

13 of 21 units outperformed

11 of 21 units outperformed

Page 5: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Departments with less than eight quarters of data:

Multidisciplinary Clinic and Infusion Center have only two quarters of data 2Q 2013 the last Avatar data point. These two units were not picked up by PRC until 1Q 2015.

Heart Center has five quarters of data. When transitioned to PRC this department was combined with the Wellness Center a non-nursing department and was not separated until 3Q 2014.

Observation Unit has seven quarters of data. Data not available 2Q 2013 because there was no vendor sampling from Avatar.

Page 6: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

CARE COORDINATION

Care Coordination: Inpatient: PRC: Medical ICU and Definitive Step Down

Care Coordination: Inpatient: PRC: Medical Telemetry and Pulmonary Renal

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MICU-DSU 64.0 47.1 61.0 57.7 66.7 75.0 57.8 57.1

PRC 50th Percentile 58.4 57.4 57.4 57.4 57.4 57.8 57.8 57.8

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Care Coordination, Medical ICU & Definitive Step Down Unit, Critical Care

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

64.0 61.0 57.7 66.7 75.0

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Medical Telemetry 82.0 81.4 83.6 84.1 85.7 84.6 85.2 91.7

Pulmonary Renal 87.7 79.7 73.7 79.5 86.2 90.6 80.0 89.4

PRC 50th Percentile 81.2 82.6 82.6 82.6 82.6 83.0 83.0 83.0

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Medical Telemetry Unit & Pulmonary Renal Unit, Medical

Pe

rce

nt

Pe

rce

nt

Care Coordination During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

PRC = Professional Research Consultants, Inc.

82.0

86.2 90.687.7

83.6 84.1 85.7 84.6 85.2 91.7

89.4

Page 7: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Inpatient: PRC: Observation Unit

Care Coordination: Inpatient: PRC: General Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Observation 46.2 55.6 68.8 58.3 46.9 55.6 56.6

PRC 50th Percentile 57.4 57.4 57.4 57.4 54.6 54.6 54.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Observation Unit, Medical-Surgical

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

68.8 58.3 55.6 56.6n.d.

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

General Surgery 54.4 50.0 59.6 54.3 53.2 60.7 61.5 63.6

PRC 50th Percentile 57.2 59.5 59.5 59.5 59.5 58.7 58.7 58.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, General Surgery Unit, Medical-Surgical

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

59.6 60.7 61.5 63.6

Page 8: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Inpatient: PRC: Oncology

Care Coordination: Inpatient: PRC: Orthopedic

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Oncology 88.5 93.0 87.0 94.2 92.5 80.6 93.5 86.4

PRC 50th Percentile 82.9 85.8 85.8 85.8 85.8 85.6 85.6 85.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Oncology Unit, Medical

Pe

rce

nt

Pe

rce

nt

Care Coordination During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

PRC = Professional Research Consultants, Inc.

88.5 93.0 87.0 94.2 92.5 93.5 86.4

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Orthopedics 92.0 92.9 96.4 95.2 97.7 79.5 97.4 88.9

PRC 50th Percentile 90.9 93.5 93.5 93.5 93.5 92.3 92.3 92.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Orthopedic Unit, Surgical

Pe

rce

nt

Pe

rce

nt

Care Coordination During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

PRC = Professional Research Consultants, Inc.

96.4 95.2 97.7 97.492.0

Page 9: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Inpatient: PRC: Mother Baby Unit

Care Coordination: Inpatient: PRC: Labor & Delivery / Antepartum

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Mother Baby Unit 95.4 83.3 93.2 96.9 91.9 75.9 76.2 71.1

PRC 50th Percentile 86.3 86.8 86.8 86.8 86.8 87.0 87.0 87.0

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Care Coordination, Mother Baby Unit, Women's Services

Pe

rce

nt

Pe

rce

nt

Care Coordination During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

PRC = Professional Research Consultants, Inc.

95.4 93.2 96.9 91.9

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

L&D/Antepartum 92.3 90.0 91.7 100 100 100 100 83.3

PRC 50th Percentile 86.3 86.8 86.8 86.8 86.8 87.0 87.0 87.0

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Labor & Delivery/Antepartum, Women's Services

Pe

rce

nt

Pe

rce

nt

Care Coordination During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

PRC = Professional Research Consultants, Inc.

92.3 90.0 91.7 100 100 100 100

Page 10: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Avatar: Emergency Services

Care Coordination: PRC: Emergency Services

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 83.6

Avatar Mean 86.8

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Emergency Department Care Coordination There was good teamwork among the Emergency physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 52.0 55.6 52.5 52.0 53.0 49.0 53.3

PRC 50th Percentile 48.7 48.7 48.7 48.7 49.3 49.3 49.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Emergency Department Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

52.0 55.6 52.5 52.0 53.0 53.3

Page 11: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Heart Center

Care Coordination: Ambulatory Services: PRC: Heart Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 95.1

Avatar Mean 93.32

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Heart Center, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

95.1

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 57.1 53.2 53.2 64.0

PRC 50th Percentile 61.5 63.3 63.3 63.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Heart Center, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

Data unavailable; not collection by PRC

64.0

Page 12: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Maternal Fetal Testing

Care Coordination: Ambulatory Services: PRC: Maternal Fetal Testing

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 89.7

Avatar Mean 93.3

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Maternal Fetal Testing, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 60.0 68.0 76.0 70.0 52.0 70.0 58.0

PRC 50th Percentile 66.0 66.0 66.0 66.0 67.3 67.3 67.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Maternal Fetal Testing, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

70.068.0 76.0 70.0

Page 13: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Kidney Transplant Center

Care Coordination: Ambulatory Services: PRC: Kidney Transplant Center

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 100

Avatar Mean 93.32

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Kidney Transplant Center, Outpatient Diagnostic

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

100

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 66.7 71.8 66.7 54.5 84.6 71.9 66.7

PRC 50th Percentile 60.2 60.2 60.2 60.2 61 61 61

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Kidney Transplant Center, Outpatient Diagnostic

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

84.6 71.9 66.766.7 71.8 66.7

Page 14: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Pavilion MRI

Care Coordination: Ambulatory Services: PRC: Pavilion MRI

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 95

Avatar Mean 93.32

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Pavilion MRI, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

95

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 70.8 56.3 71.4 60.4 71.4 67.3 58.3

PRC 50th Percentile 62.2 62.2 62.2 62.2 63.5 63.5 63.5

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Pavilion MRI, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

70.8 71.4 71.4 67.3

Page 15: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Radiation Therapy

Care Coordination: Ambulatory Services: PRC: Radiation Therapy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 95.71

Avatar Mean 93.32

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Radiation Therapy, Outpatient Diagnostic

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicicians, and other staff who cared for me.

Avatar = Avatar Solutions

95.71

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 70.2 66 62 67.3 72 70 56

PRC 50th Percentile 74 74 74 74 76.4 76.4 76.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Radiation Therapy, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

Page 16: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Wound Care Center

Care Coordination: Ambulatory Services: PRC: Wound Care Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 86.84

Avatar Mean 93.32

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Wound Care Center, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Care Coordination There were good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 55.1 56.9 58 60 64 50 63.3

PRC 50th Percentile 66.5 66.5 66.5 66.5 64.9 64.9 64.9

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Wound Care Center, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

Page 17: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Cardiovascular Interventional Lab

Care Coordination: Ambulatory Services: PRC: Cardiovascular Interventional Lab

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 92.39

Avatar Mean 95.79

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Cardiovascular Interventional Lab, Outpatient Cardiology

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 68 70 61.2 72 64 70 56

PRC 50th Percentile 61.5 61.5 61.5 61.5 63.3 63.3 63.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Cardiovascular Interventional Lab, Outpatient Cardiology

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

68 70 72 64 70

Page 18: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Outpatient Surgery

Care Coordination: Ambulatory Services: PRC: Outpatient Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

99.2

Avatar Mean 95.8

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Pavilion Outpatient Surgery, Outpatient Surgery

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

99.2

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

75.5 84.0 66.0 78.0 82.4 74.5 80.0

PRC 50th Percentile 71.2 71.2 71.2 71.2 72.4 72.4 72.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Pavilion Outpatient Surgery, Outpatient Surgery

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

75.5 84.0 78.0 82.4 74.5 80.0

Page 19: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Pavilion Endoscopy

Care Coordination: Ambulatory Services: PRC: Pavilion Endoscopy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 99.04

Avatar Mean 95.79

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Pavilion Endoscopy, Outpatient Surgery

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

99.04

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 77.6 60 68 79.6 69.2 68 70

PRC 50th Percentile 71.4 71.4 71.4 71.4 71.4 71.4 71.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Pavilion Endoscopy, Outpatient Surgery

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

77.6 79.6

Page 20: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Multidisciplinary Center

Care Coordination: Ambulatory Services: PRC: Multidisciplinary Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter

99.1

Avatar Mean 93.3

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Multidisciplinary Center, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

99.1

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter Clinics

66.1

PRC 50th Percentile 61.0

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Multidisciplinary Center, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

Data unavailable 66.1

Page 21: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Care Coordination: Ambulatory Services: Avatar: Infusion Center

Care Coordination: Ambulatory Services: PRC: Infusion Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 97.2

Avatar Mean 93.3

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Care Coordination, Infusion Center, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Care Coordination There was good teamwork among the physicians, nurses, technicians, and other staff who cared for me.

Avatar = Avatar Solutions

97.2

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 79.7

PRC 50th Percentile 61.0

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Care Coordination, Infusion Center, Outpatient Diagnostic

Pe

rce

nt

Care Coordination How would you rate the overall teamwork between the doctors, nurses and staff?

PRC = Professional Research Consultants, Inc.

Data unavailable 79.7

Page 22: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

PATIENT EDUCATION Patient Education: Inpatient: PRC: Medical ICU and Definitive Step Down

Patient Education: Inpatient: PRC: Medical Telemetry and Pulmonary Renal

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MICU-DSU 95.2 96.9 90.7 93.0 87.8 93.3 96.7 88.7

PRC 50th Percentile 90.0 89.3 89.3 89.3 89.3 91.3 91.3 91.3

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Patient Education, Medical ICU & Definitive Step Down Unit, Critical Care

Pe

rce

nt

Pe

rce

nt

Patient Education During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

PRC = Professional Research Consultants, Inc.

95.2 96.9 90.7 93.0 93.3 96.7

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Medical Telemetry 85.7 90.9 83.6 97.8 92.9 90.0 96.3 93.9

Pulmonary Renal 91.7 79.7 89.5 91.3 89.3 94.0 96.9 94.0

PRC 50th Percentile 85.8 87.0 87.0 87.0 87.0 87.7 87.7 87.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Medical Telemetry Unit & Pulmonary Renal Unit, Medical

Pe

rce

nt

Pe

rce

nt

Patient Education During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

PRC = Professional Research Consultants, Inc.

90.9 97.8 92.9 90.0 96.3 93.9

91.7 89.5 91.3 89.3 94.0 96.9 94.0

Page 23: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Inpatient: PRC: Observation

Patient Education: Inpatient: PRC: General Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Observation 55.6 55.6 71.4 57.1 53.2 76.9 33.3

PRC 50th Percentile 55.0 55.0 55.0 55.0 55.0 55.0 55.0

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Patient Education, Observation Unit, Medical-Surgical

Pe

rce

nt

Pe

rce

nt

Pe

rce

nt

Patient Education Before giving you any medicine, how often did hospital staff describe possible side effects in a way that you could understand?

PRC = Professional Research Consultants, Inc.

55.6 55.6 71.4 57.1 76.9n.d.

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

General Surgery 80.0 70.8 87.1 77.3 90.9 68.8 88.5 95.0

PRC 50th Percentile 78.8 81.1 81.1 81.1 81.1 81.9 81.9 81.9

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, General Surgery Unit, Medical-Surgical

Pe

rce

nt

Pe

rce

nt

Pe

rce

nt

Patient Education Before giving you any medicine, how often did hospital staff tell you what the medicine was for?

PRC = Professional Research Consultants, Inc.

80.0 87.1 90.9 88.5 95.0

Page 24: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Inpatient: PRC: Oncology

Patient Education: Inpatient: PRC: Orthopedic

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Oncology 94.3 95.7 91.2 94.0 92.9 94.9 98.0 93.6

PRC 50th Percentile 90.2 90.7 90.7 90.7 90.7 92.2 92.2 92.2

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Oncology Unit, Medical

Pe

rce

nt

Pe

rce

nt

Patient Education During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

PRC = Professional Research Consultants, Inc.

94.3 95.7 91.2 94.0 92.9 94.9 98.0 93.6

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Orthopedics 96.1 90.9 91.2 97.7 95.3 95.2 100 100

PRC 50th Percentile 93.2 93.9 93.9 93.9 93.9 94.8 94.8 94.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Orthopedic Unit, Surgical

Pe

rce

nt

Pe

rce

nt

Patient Education During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

PRC = Professional Research Consultants, Inc.

96.1 97.7 95.3 95.2 100 100

Page 25: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Inpatient: PRC: Mother Baby Unit

Patient Education: Inpatient: PRC: Labor and Delivery / Antepartum

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Mother Baby Unit 93.5 100 81.0 91.7 93.8 80.0 93.3 76.2

PRC 50th Percentile 86.7 88.7 88.7 88.7 88.7 89.7 89.7 89.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Mother Baby Unit, Women's Services

Pe

rce

nt

Pe

rce

nt

Pe

rce

nt

Patient Education Before giving you any new medicine, how ofter did hospital staff tell you what the medicine was for?

PRC = Professional Research Consultants, Inc.

93.5 100 91.7 93.8 93.3

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

L&D/Antepartum 92.3 100 100 100 100 100 100 100

PRC 50th Percentile 97.1 96.9 96.9 96.9 96.9 97.1 97.1 97.1

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Labor & Delivery/Antepartum, Women's Services

Pe

rce

nt

Pe

rce

nt

Patient Education During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

PRC = Professional Research Consultants, Inc.

100 100 100 100 100 100 100

Page 26: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Emergency Services: Avatar

Patient Education: Emergency Services: PRC

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 88.3

Avatar Mean 86.8

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Emergency Department Patient Education Tests and procedures in Emergency were adequately explained to me before they were done.

Avatar = Avatar Solutions

88.3

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 53.0 49.5 48.5 49.7 47.2 47.0 41.9

PRC 50th Percentile 48.1 48.1 48.1 48.1 48.4 48.4 48.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Emergency Department Patient Education How would you rate the nurses' instructions or explanation of your treatment or tests?

PRC = Professional Research Consultants, Inc.

53.0 49.5 48.5 49.7

Page 27: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Heart Center

Patient Education: Ambulatory Services: PRC: Heart Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 92.45

Avatar Mean 92.85

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Heart Center, Outpatient Diagnostic

Patient Education Tests and procedures were adequately explained to me before they were done.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 66 65.3 52.1 63.3

PRC 50th Percentile 61.3 63.6 63.6 63.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Heart Center, Outpatient Diagnostic

Patient Education Overall, how would you rate the staff's instructions or explanations of treatment or tests?

PRC = Professional Research Consultants, Inc.

Data unavailable; not collected by PRC

66 65.3

Page 28: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Maternal Fetal Testing

Patient Education: Ambulatory Services: PRC: Maternal Fetal Testing

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 87.5

Avatar Mean 92.9

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Maternal Fetal Testing, Outpatient Diagnostic

Me

an S

core

Patient Education Tests and procedures were adequately explained to me before they were done.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 68.0 63.3 87.5 69.4 52.0 66.0 63.3

PRC 50th Percentile 70.6 70.6 70.6 70.6 71.2 71.2 71.2

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Maternal Fetal Testing, Outpatient Diagnostic

Patient Education Overall, how would you rate the staff's instructions or explanations of treatment or tests?

PRC = Professional Research Consultants, Inc.

87.5

Page 29: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Kidney Transplant

Patient Education: Ambulatory Services: PRC: Kidney Transplant

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 100

Avatar Mean 92.28

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Kidney Transplant Center, Outpatient Diagnostic

Patient Education Medication and care at home were explained to me in a way I could follow.

Avatar = Avatar Solutions

100

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 62.9 70.3 65.8 35.5 73.1 64.3 55.2

PRC 50th Percentile 58.3 58.3 58.3 58.3 59.1 59.1 59.1

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Kidney Transplant Center, Outpatient Diagnostic

Patient Education How would you rate the instructions given to you upon discharge?

PRC = Professional Research Consultants, Inc.

62.9 70.3 65.8 73.1 64.3

Page 30: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Pavilion MRI

Patient Education: Ambulatory Services: PRC: Pavilion MRI

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 94.59

Avatar Mean 92.85

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Pavilion MRI, Outpatient Diagnostic

Patient Education Tests and procedures were adequately explained to me before they were done.

Avatar = Avatar Solutions

94.59

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 74 66.7 70.8 74 75 73.5 59.2

PRC 50th Percentile 67.3 67.3 67.3 67.3 69.5 69.5 69.5

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Pavilion MRI, Outpatient Diagnostic

Patient Education Overall, how would you rate the staff's instructions or explanations of treatment or tests?

PRC = Professional Research Consultants, Inc.

74 70.8 74 75 73.5

Page 31: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Radiation Therapy

Patient Education: Ambulatory Services: PRC: Radiation Therapy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 98.86

Avatar Mean 92.28

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Radiation Therapy, Outpatient Diagnostic

Patient Education Medication and care at home were explained to me in a way i could follow.

Avatar = Avatar Solutions

98.86

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 66.7 60 55.6 51.2 64.4 59.6 51

PRC 50th Percentile 70.9 70.9 70.9 70.9 71.5 71.5 71.5

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Radiation Therapy, Outpatient Diagnostic

Patient Education How would you rate the instructions given to you upon discharge?

PRC = Professional Research Consultants, Inc.

Page 32: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Wound Care Center

Patient Education: Ambulatory Services: PRC: Wound Care Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 79.17

Avatar Mean 92.85

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Wound Care Center, Outpatient Diagnostic

Patient Education Tests and procedures were adequately explained to me before they were done.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 51.1 60.8 56.3 57.1 62 50 68

PRC 50th Percentile 56 56 56 56 61.7 61.7 61.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Wound Care Center, Outpatient Diagnostic

Patient Education Overall, how would you rate the staff's instructions or explanation of treatment or tests?

PRC = Professional Research Consultants, Inc.

60.8 68

Page 33: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Cardiovascular Interventional Lab

Patient Education: Ambulatory Services: PRC: Cardiovascular Interventional Lab

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 90

Avatar Mean 94.68

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Patient Education, Cardiovascular Interventional Lab, Outpatient Cardiology

Patient Education I was well informed about what to expect related to my recovery at home.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 56 67.3 66.7 58.7 58.3 63.3 61.2

PRC 50th Percentile 56.1 56.1 56.1 56.1 57.8 57.8 57.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Cardiovascular Interventional Lab, Outpatient Cardiology

Patient Education How would you rate the instructions given to you upon discharge?

PRC = Professional Research Consultants, Inc.

67.3 66.7 58.7 58.3 63.3 61.2

Page 34: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Outpatient Surgery

Patient Education: Ambulatory Services: PRC: Outpatient Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

96.0

Avatar Mean 94.7

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Pavilion Outpatient Surgery, Outpatient Surgery

100100

Patient Education I was well informed about what to expect related to my recovery at home.

Avatar = Avatar Solutions

96.0

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

66.7 71.4 58.0 67.3 64.7 68.1 72.0

PRC 50th Percentile 63.0 63.0 63.0 63.0 62.2 62.2 62.2

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Pavilion Outpatient Surgery, Outpatient Surgery

100

Patient Education How would you rate the instructions given to you upon discharge?

PRC = Professional Research Consultants, Inc.

66.7 71.4 67.3 64.7 68.1 72.0

Page 35: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Pavilion Endoscopy

Patient Education: Ambulatory Services: PRC: Pavilion Endoscopy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 96.15

Avatar Mean 94.68

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Pavilion Endoscopy, Outpatient Surgery

Patient Education I was well informed about what to expect related to my recovery at home.

Avatar = Avatar Solutions

96.15

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 63.8 53.1 55.6 66.7 70 55.1 71.4

PRC 50th Percentile 62.2 62.2 62.2 62.2 62.5 62.5 62.5

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Pavilion Endoscopy, Outpatient Surgery

Pe

rce

nt

Patient Education How would you rate the instructions given to you upon discharge?

PRC = Professional Research Consultants, Inc.

63.8 66.7 70 71.4

Page 36: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Multidisciplinary Center

Patient Education: Ambulatory Services: PRC: Multidisciplinary Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter

97.9

Avatar Mean 92.9

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Multidisciplinary Center, Outpatient Diagnostic

Patient Education Medication and care at home were explained to me in a way I could follow.

Avatar = Avatar Solutions

97.9

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter Clinics

60.7

PRC 50th Percentile 62.9

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Multidisciplinary Center, Outpatient Diagnostic

Patient Education Overall, how would you rate the staff's instructions or explanations of treatment or tests?

PRC = Professional Research Consultants, Inc.

Data unavailable

Page 37: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Patient Education: Ambulatory Services: Avatar: Infusion Center

Patient Education: Ambulatory Services: PRC: Infusion Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 97.1

Avatar Mean 92.9

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Patient Education, Infusion Center, Outpatient Diagnostic

Me

an S

core

Patient Education Medication and care at home were explained to me in a way I could follow.

Avatar = Avatar Solutions

97.1

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 68.6

PRC 50th Percentile 59.1

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Patient Education, Infusion Center, Outpatient Diagnostic

Patient Education How would you rate the instructions given to you upon discharge?

PRC = Professional Research Consultants, Inc.

Data unavailable 68.6

Page 38: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

COURTESY AND RESPECT

Courtesy and Respect: Inpatient: PRC: Medical ICU and Definitive Step Down

Courtesy and Respect: Inpatient: PRC: Medical Telemetry and Pulmonary Renal

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MICU-DSU 91.7 88.6 98.3 76.9 92.9 93.8 90.6 90.9

PRC 50th Percentile 92.3 87.1 87.1 87.1 87.1 90.4 90.4 90.4

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Courtesy & Respect, Medical ICU & Definitive Step Down Unit, Critical Care

Pe

rce

nt

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

88.6 98.3 92.9 93.8 90.6 90.9

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Medical Telemetry 91.9 83.0 84.2 89.1 87.0 88.4 93.0 90.7

Pulmonary Renal 86.0 93.5 78.3 81.1 75.0 80.4 89.2 87.0

PRC 50th Percentile 88.1 87.4 87.4 87.4 87.4 87.8 87.8 87.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Medical Telemetry Unit & Pulmonary Renal Unit, Medical

Pe

rce

nt

80

100

St. Joseph Hospital

Courtesy & Respect, Medical Telemetry Unit & Pulmonary Renal Unit, Medical

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtes and respect?

PRC = Professional Research Consultants, Inc.

91.9 89.1 88.4 93.0 90.7

93.5 89.2

Page 39: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Inpatient: PRC: Observation

Courtesy and Respect: Inpatient: PRC: General Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Observation 92.0 100 75.0 95.8 85.6 90.6 91.1

PRC 50th Percentile 89.0 89.0 89.0 89.0 89.4 89.4 89.4

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Courtesy & Respect, Observation Unit, Medical-Surgical

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

92.0 100 95.8 90.6 91.1n.d.

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

General Surgery 91.2 82.6 84.7 95.7 85.1 93.7 86.5 90.9

PRC 50th Percentile 87.1 87.5 87.5 87.5 87.5 88.6 88.6 88.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, General Surgery Unit, Medical-Surgical

Pe

rce

nt

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

91.2 95.7 90.993.7

Page 40: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Inpatient: PRC: Oncology

Courtesy and Respect: Inpatient: PRC: Orthopedic

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Oncology 89.1 87.2 94.7 88.9 90.5 88.5 88.2 91.3

PRC 50th Percentile 87.0 89.0 89.0 89.0 89.0 90.3 90.3 90.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Oncology Unit, Medical

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

89.1 94.7 90.5 91.3

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Orthopedics 91.5 86.8 89.9 90.0 83.6 78.8 84.4 94.3

PRC 50th Percentile 87.3 88.7 88.7 88.7 88.7 88.4 88.4 88.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Orthopedic Unit, Surgical

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

91.5 89.9 90.0 94.3

Page 41: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Inpatient: PRC: Mother Baby Unit

Courtesy and Respect: Inpatient: PRC: Labor & Delivery / Antepartum

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Mother Baby Unit 90.7 92.9 94.7 91.7 50.0 95.5 100 100

PRC 50th Percentile 89.7 88.8 88.8 88.8 88.8 90.3 90.3 90.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Mother Baby Unit, Women's Services

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

90.7 92.9 94.7 91.7 95.5 100 100

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

L&D/Antepartum 84.6 100 100 90.9 100 100 77.8 83.3

PRC 50th Percentile 89.7 88.8 88.8 88.8 88.8 90.3 90.3 90.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Labor & Delivery/Antepartum, Women's Services

Pe

rce

nt

Courtesy & Respect During this hospital stay, how often did nurses treat you with courtesy and respect?

PRC = Professional Research Consultants, Inc.

100 100 90.9 100 100

Page 42: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Avatar: Emergency Services

Courtesy and Respect: PRC: Emergency Services

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 80.9

Avatar Mean 87.2

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy and Respect, Emergency Department

Courtesy & Respect I consistently received respect and compassion while in Emergency.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 55.3 54.9 48.7 52.1 49.5 47.7 52.0

PRC 50th Percentile 51.6 51.6 51.6 51.6 50.9 50.9 50.9

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy and Respect, Emergency Department

Courtesy & Respect How would you rate the emergency room staff's respect for your values, beliefs, and faith?

PRC = Professional Research Consultants, Inc.

55.3 54.9 52.1 52.0

Page 43: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Heart Center

Courtesy and Respect: Ambulatory Services: PRC: Heart Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 95.19

Avatar Mean 94.58

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Heart Center, Outpatient Diagnostic

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

95.19

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 61.4 62.8 62.9 56.8

PRC 50th Percentile 61.8 60.8 60.8 60.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Heart Center, Outpatient Diagnostic

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

Data unavailable; not collected by PRC

62.8 62.9

Page 44: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Maternal Fetal Testing

Courtesy and Respect: Ambulatory Services: PRC: Maternal Fetal Testing

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 97.4

Avatar Mean 94.6

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Maternal Fetal Testing, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

97.4

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 71.4 76.1 75.0 66.0 51.0 71.4 64.6

PRC 50th Percentile 67.5 67.5 67.5 67.5 66.8 66.8 66.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Maternal Fetal Testing, Outpatient Diagnostic

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

71.4 76.1 75.0 71.4

Page 45: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Kidney Transplant

Courtesy and Respect: Ambulatory Services: PRC: Kidney Transplant

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 100

Avatar Mean 94.58

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Kidney Transplant Center, Outpatient Diagnostic

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

100

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 63.9 70 66.7 50 81.5 73.3 59.4

PRC 50th Percentile 59.6 59.6 59.6 59.6 60.6 60.6 60.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Kidney Transplant Center, Outpatient Diagnostic

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

63.9 70 66.7 81.5 73.3

Page 46: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Pavilion MRI

Courtesy and Respect: Ambulatory Services: PRC: Pavilion MRI

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 95.11

Avatar Mean 94.58

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Pavilion MRI, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

95.11

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 70.5 65.1 64.4 69.8 72.7 69 65.9

PRC 50th Percentile 58.9 58.9 58.9 58.9 60 60 60

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Pavilion MRI, Outpatient Diagnostic

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

70.5 65.1 64.4 69.8 72.7 69 65.9

Page 47: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Radiation Therapy

Courtesy and Respect: Ambulatory Services: PRC: Radiation Therapy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 96.05

Avatar Mean 94.58

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Radiation Therapy, Outpatient Diagnostic

Me

an S

core

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

96.05

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 67.5 55.6 65.1 59.6 68.1 67.3 54

PRC 50th Percentile 65.4 65.4 65.4 65.4 65.4 65.4 65.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Radiation Therapy, Outpatient Diagnostic

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

67.5 68.1 67.3

Page 48: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Wound Care Center

Courtesy and Respect: Ambulatory Services: PRC: Wound Care Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 85

Avatar Mean 94

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Wound Care Center, Outpatient Diagnostic

Me

an S

core

Courtesy & Respect Clinical staff showed concern and sensitivity to my needs.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 53.1 58.8 65.3 62.5 66.0 60.0 62.0

PRC 50th Percentile 62.0 62.0 62.0 62.0 63.5 63.5 63.5

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Wound Care Center, Outpatient Diagnostic

Courtesy & Respect Overall, how would you rate the staff's understanding and caring?

PRC = Professional Research Consultants, Inc.

65.3 62.5 66.0

Page 49: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Cardiovascular Interventional Lab

Courtesy and Respect: Ambulatory Services: PRC: Cardiovascular Interventional Lab

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 98.47

Avatar Mean 95.8

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Courtesy & Respect, Cardiovascular Interventional Lab, Outpatient Cardiology

Me

an S

core

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

98.47

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 57.8 59.5 63 54.8 69.8 63.8 64.4

PRC 50th Percentile 61.8 61.8 61.8 61.8 60.8 60.8 60.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Cardiovascular Interventional Lab, Outpatient Cardiology

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

63 69.8 63.8 64.4

Page 50: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Outpatient Surgery

Courtesy and Respect: Ambulatory Services: PRC: Outpatient Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

99.0

Avatar Mean 95.8

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Pavilion Outpatient Surgery, Outpatient Surgery

Me

an S

core

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

99.0

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

68.9 78.3 73.9 64.4 73.5 70.5 77.3

PRC 50th Percentile 64.8 64.8 64.8 64.8 65.9 65.9 65.9

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Pavilion Outpatient Surgery, Outpatient Surgery

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs and faith?

PRC = Professional Research Consultants, Inc.

68.9 78.3 73.9 73.5 70.5 77.3

Page 51: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Pavilion Endoscopy

Courtesy and Respect: Ambulatory Services: PRC: Pavilion Endoscopy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 98.21

Avatar Mean 95.8

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Pavilion Endoscopy, Outpatient Surgery

Me

an S

core

Me

an S

core

Courtesy & Respect I consistently received respect and compassion while at St. Joseph Hospital.

Avatar = Avatar Solutions

98.21

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 71.7 59.1 56.8 68.3 77.1 63.8 74.4

PRC 50th Percentile 65.2 65.2 65.2 65.2 65.2 65.2 65.2

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Pavilion Endoscopy, Outpatient Surgery

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, beliefs, and faith?

PRC = Professional Research Consultants, Inc.

71.7 68.3 77.1 74.4

Page 52: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Multidisciplinary Clinic

Courtesy and Respect: Ambulatory Services: PRC: Multidisciplinary Clinic

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter

97.0

Avatar Mean 94.6

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Multidisciplinary Center, Outpatient Diagnostic

Courtesy & Respect Clinical staff showed concern and sensitivity to my needs.

Avatar = Avatar Solutions

97.0

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter Clinics

60.0

PRC 50th Percentile 60.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Multidisciplinary Center, Outpatient Diagnostic

Pe

rce

nt

Courtesy & Respect How would you rate the staff's respect for your values, belief and faith?

PRC = Professional Research Consultants, Inc.

Data unavailable Data unavailable

Page 53: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Courtesy and Respect: Ambulatory Services: Avatar: Infusion Center

Courtesy and Respect: Ambulatory Services: PRC: Infusion Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 98.8

Avatar Mean 94.6

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Courtesy & Respect, Infusion Center, Outpatient Diagnostic

Courtesy & Respect Clinical staff showed concern and sensitivity to my needs.

Avatar = Avatar Solutions

98.8

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 78.0

PRC 50th Percentile 65.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Courtesy & Respect, Infusion Center, Outpatient Diagnostic

Pe

rce

nt

Courtesy & Respect Overall, how would you rate the staff's understanding and caring?

PRC = Professional Research Consultants, Inc.

Data unavailable Data unavailable 78.0

Page 54: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

RESPONSIVENES AND SERVICE RECOVERY

Responsiveness and Service Recovery: Inpatient: PRC: Medical ICU and Definitive Step Down Unit

Responsiveness and Service Recovery: Inpatient: PRC: Medical Telemetry and Pulmonary Renal

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MICU-DSU 93.8 69.6 88.1 78.4 64.0 81.8 71.4 85.0

PRC 50th Percentile 76.1 75.4 75.4 75.4 75.4 78.8 78.8 78.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Medical ICU & Definitive Step Down Unit, Critical Care

100

Responsiveness How often did you get help to the bathroom or in using a bedpan as soon as you wanted?

PRC = Professional Research Consultants, Inc.

93.8 88.1 78.4 85.081.8

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Medical Telemetry 62.9 64.7 77.1 70.6 80.8 67.7 71.8 71.0

Pulmonary Renal 67.3 70.4 54.5 55.6 63.2 65.7 61.1 73.3

PRC 50th Percentile 72.7 69.6 69.6 69.6 69.6 69.4 69.4 69.4

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Medical Telemetry Unit & Pulmonary Renal Unit, Medical

100

Responsiveness How often did you get help to the bathroom or in using a bedpan as soon as you wanted?

PRC = Professional Research Consultants, Inc.

77.1 70.6 80.8 71.8 71.0

70.4 73.3

Page 55: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Inpatient: PRC: Observation

Responsiveness and Service Recovery: Inpatient: PRC: General Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Observation 65.0 66.7 53.8 55.6 56.2 72.0 72.7

PRC 50th Percentile 68.0 68.0 68.0 68.0 71.1 71.1 71.1

0

20

40

60

80

100P

erc

en

t

St. Joseph Hospital

Responsiveness, Observation Unit, Medical-Surgical

100100

Responsiveness During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

PRC = Professional Research Consultants, Inc.

72.0 72.7n.d.

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

General Surgery 59.1 59.5 58.8 55.8 53.5 69.5 73.5 68.0

PRC 50th Percentile 63.5 62.2 62.2 62.2 62.2 63.5 63.5 63.5

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, General Surgery Unit, Medical-Surgical

100100

Responsiveness During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

PRC = Professional Research Consultants, Inc.

69.5 73.5 68.0

Page 56: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Inpatient: PRC: Oncology

Responsiveness and Service Recovery: Inpatient: PRC: Orthopedic

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Oncology 75.0 66.7 64.7 78.8 57.5 60.7 69.6 84.8

PRC 50th Percentile 60.3 59.3 59.3 59.3 59.3 62.1 62.1 62.1

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Oncology Unit, Medical

100100

Responsiveness During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

PRC = Professional Research Consultants, Inc.

75.0 66.7 64.7 78.8 69.6 84.8

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Orthopedics 67.2 56.5 64.5 61.7 51.9 68.9 70.0 73.9

PRC 50th Percentile 63.7 62.7 62.7 62.7 62.7 63.7 63.7 63.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Orthopedic Unit, Surgical

100100

Responsiveness During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

PRC = Professional Research Consultants, Inc.

67.2 64.5 68.9 70.0 73.9

Page 57: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Inpatient: PRC: Mother Baby Unit

Responsiveness and Service Recovery: Inpatient: PRC: Labor & Delivery / Antepartum

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Mother Baby Unit 85.2 89.7 85.3 95.8 76.7 87.8 71.9 75.0

PRC 50th Percentile 84.2 85.0 85.0 85.0 85.0 85.7 85.7 85.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Mother Baby Unit, Women's Services

100

Responsiveness How often did you get help to the bathroom or in using a bedpan as soon as you wanted?

PRC = Professional Research Consultants, Inc.

85.2 89.7 85.3 95.8 87.8

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

L&D/Antepartum 61.5 75.0 66.7 81.8 75.0 88.9 55.6 100

PRC 50th Percentile 73.1 72.6 72.6 72.6 72.6 74.3 74.3 74.3

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Labor & Delivery/Antepartum, Women's Services

100100

Responsiveness During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

PRC = Professional Research Consultants, Inc.

75.0 81.8 75.0 88.9 100

Page 58: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Emergency Services: Avatar

Responsiveness and Service Recovery: Emergency Services: PRC

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 89.6

Avatar Mean 86.3

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Responsiveness, Emergency Department Responsiveness Emergency staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

89.6

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Emergency Department 44.6 43.7 38.3 42.9 45.6 39.7 43.0

PRC 50th Percentile 43.5 43.5 43.5 43.5 43.8 43.8 43.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Emergency Department

Pe

rce

nt

Responsiveness How would you rate the responsiveness of the emergency room staff to any concerns or complaints you have had?

PRC = Professional Research Consultants, Inc.

44.6 43.7 45.6

Page 59: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Heart Center

Responsiveness and Service Recovery: Ambulatory Services: PRC: Heart Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 90.69

Avatar Mean 91.84

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Heart Center, Outpatient Diagnostic

Responsiveness My need was taken care of promptly and to my satisfaction if there was a problem.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Heart Center 60 52.6 58.5 54.1

PRC 50th Percentile 55 57.6 57.6 57.6

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Heart Center, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

Data unavailable; not collected by PRC

60 58.5

Page 60: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Maternal Fetal Testing

Responsiveness and Service Recovery: Ambulatory Services: PRC: Maternal Fetal Testing

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 90.2

Avatar Mean 92.5

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Maternal Fetal Testing, Outpatient Diagnostic

100

Responsiveness Staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Maternal Fetal Testing 64.4 66.7 87.5 63.0 45.2 77.8 64.6

PRC 50th Percentile 64.4 64.4 64.4 64.4 64.2 64.2 64.2

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Maternal Fetal Testing, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

66.7 87.5 77.8 64.6

Page 61: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Kidney Transplant

Responsiveness and Service Recovery: Ambulatory Services: PRC: Kidney Transplant

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 97.5

Avatar Mean 92.54

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Responsiveness, Kidney Transplant Center, Outpatient Diagnostic

Responsiveness Staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

97.5

2Q 2013 3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

Kidney Transplant Center 64.9 65.8 52.6 41.9 74.1 59.4 60.7

PRC 50th Percentile 55.7 55.7 55.7 55.7 58.7 58.7 58.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Kidney Transplant Center, Outpatient Diagnostic

100

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

64.9 65.8 74.1 59.4 60.7

Page 62: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Pavilion MRI

Responsiveness and Service Recovery: Ambulatory Services: PRC: Pavilion MRI

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 93.75

Avatar Mean 92.54

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Pavilion MRI, Outpatient Diagnostic

Responsiveness Staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

93.75

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion MRI 69.2 61.9 70.7 75.6 72.2 67.4 75.6

PRC 50th Percentile 58.6 58.6 58.6 58.6 58 58 58

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Pavilion MRI, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

69.2 61.9 70.7 75.6 72.2 67.4 75.6

Page 63: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Radiation Therapy

Responsiveness and Service Recovery: Ambulatory Services: PRC: Radiation Therapy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 99.06

Avatar Mean 92.54

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Radiation Therapy, Outpatient Diagnostic

Responsiveness Staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

99.06

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Radiation Therapy 65.9 56.8 55.6 52.1 60.4 64.6 59.5

PRC 50th Percentile 62.7 62.7 62.7 62.7 62.7 62.7 62.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Radiation Therapy, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

65.9 64.6

Page 64: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Wound Care Center

Responsiveness and Service Recovery: Ambulatory Services: PRC: Wound Care Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 88

Avatar Mean 92.54

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Wound Care Center, Outpatient Diagnostic

Responsiveness Staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Wound Care Center 54.8 57.4 51.2 57.8 61.7 46.8 60.9

PRC 50th Percentile 57.8 57.8 57.8 57.8 57.8 57.8 57.8

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Wound Care Center, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

61.7 60.9

Page 65: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Cardiovascular Interventional Lab

Responsiveness and Service Recovery: Ambulatory Services: PRC: Cardiovascular Interventional Lab

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 97.1

Avatar Mean 95.42

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Cardiovascular Interventional Lab, Outpatient Cardiology

Responsiveness The nursing staff were responsive in answering my calls or requests.

Avatar = Avatar Solutions

97.1

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

CVIL 50 71.4 62.5 58 61.2 71.4 64.6

PRC 50th Percentile 64.2 64.2 64.2 64.2 62.9 62.9 62.9

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Cardiovascular Interventional Lab, Outpatient Cardiology

Responsiveness How would you rate the staff's responding to your requests?

PRC = Professional Research Consultants, Inc.

71.4 71.4 64.6

Page 66: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Outpatient Surgery

Responsiveness and Service Recovery: Ambulatory Services: PRC: Outpatient Surgery

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Outpatient Surgery 98.5

Avatar Mean 95.4

0

20

40

60

80

100

Me

an S

core

St. Joseph Hospital

Responsiveness, Pavilion Outpatient Surgery, Outpatient Surgery

Responsiveness The nursing staff were responsive in answering my calls or requests.

Avatar = Avatar Solutions

98.5

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion OutpatientSurgery

79.5 76.0 70.8 70.0 77.1 72.9 79.6

PRC 50th Percentile 67.1 67.1 67.1 67.1 67.1 67.1 67.1

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Pavilion Outpatient Surgery, Outpatient Surgery

100

Responsiveness How would you rate the staff's responding to your requests?

PRC = Professional Research Consultants, Inc.

79.5 76.0 70.8 70.0 77.1 72.9 79.6

Page 67: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Pavilion Endoscopy

Responsiveness and Service Recovery: Ambulatory Services: PRC: Pavilion Endoscopy

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 99.39

Avatar Mean 95.42

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Pavilion Endoscopy, Outpatient Surgery

Responsiveness The nursing staff were responsive in answering my calls or requests.

Avatar = Avatar Solutions

99.39

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Pavilion Endoscopy 72.3 54.3 62.2 80 80.8 68.8 79.6

PRC 50th Percentile 66.3 66.3 66.3 66.3 67.7 67.7 67.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Pavilion Endoscopy, Outpatient Surgery

Responsiveness How would you rate the staff's responding to your requests?

PRC = Professional Research Consultants, Inc.

72.3 80 80.8 68.8 79.6

Page 68: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: Avatar: Multidisciplinary Clinic

Responsiveness and Service Recovery: Ambulatory Services: PRC: Multidisciplinary Clinic

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter

98.2

Avatar Mean 91.8

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Multidiscipliary Center, Outpatient Diagnostic

Responsiveness My need was taken care of promptly and to my satisfaction if there was a problem.

Avatar = Avatar Solutions

98.2

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

MultidisciplinaryCenter Clinics

42.6

PRC 50th Percentile 58.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Multidisciplinary Center, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

Data unavailable

Page 69: Quality Care Monitoring and Improvement EP23EO Unit or ...PACU, Main Pre-op, Outpatient Pre-op, Behavioral Health Services (BHS) Inpatient, BHS Outpatient, and Cardio Short Stay. Overall

Exemplary Professional Practice

Responsiveness and Service Recovery: Ambulatory Services: PRC: Infusion Center

Responsiveness and Service Recovery: Ambulatory Services: PRC: Infusion Center

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 97.4

Avatar Mean 91.8

0

20

40

60

80

100M

ean

Sco

re

St. Joseph Hospital

Responsiveness, Infusion Center, Outpatient Diagnostic

Responsiveness Staff tried their best to help me if there was a problem.

Avatar = Avatar Solutions

97.4

2Q2013

3Q2013

4Q2013

1Q2014

2Q2014

3Q2014

4Q2014

1Q2015

Infusion Center 73.1

PRC 50th Percentile 58.7

0

20

40

60

80

100

Pe

rce

nt

St. Joseph Hospital

Responsiveness, Infusion Center, Outpatient Diagnostic

Responsiveness How would you rate the responsiveness of the staff to any concerns or complaints you may have had?

PRC = Professional Research Consultants, Inc.

Data unavailable 73.1