Using HCAHPS Survey Custom Questions to Drive Staff …€¦ · ... without Studer Group...

Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization

Using HCAHPS Survey Custom Questions to

Drive Staff Engagement

Diana Topjian, RN, MSN, D.M., C-ENP

Account Lead/Coach

Studer Group


• Verbalize the value of adding HCAHPS custom questions to the

survey to deepen staff engagement

• Describe how to use the results from custom HCAHPS to engage

staff

• Develop a plan to implement the custom questions in your

organization

2

Outcome Goals


Execution Framework: Evidence-Based LeadershipSM

3

LEADER EVALUATIONImplement an organization-wide

leadership evaluation system to

hardwire objective accountability

LEADER DEVELOPMENTCreate process to assist leaders in

developing skills and leadership

competencies necessary to attain

desired results

MUST HAVES®

Rounding, Thank You Notes, Employee

Selection, Pre and Post Phone Calls, Key

Words at Key Times

PERFORMANCE GAPRe-recruit high and middle performers,

Move low performers up or out

STANDARDIZATIONAgendas by pillar, peer interviewing, 30/90 day

sessions, pillar goals

ACCELERATORSLeader Evaluation Manager®

Validation MatrixSM

Provider Feedback SystemSM

Studer Group Rounding

Patient Call ManagerTM

Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization4

Change

Heath


• Hourly Rounding®

• Bedside Shift Report

• Nurse Leader Rounding

• Post Discharge Calls

5

Focused Behaviors and Tactics: Direct the Rider


Connecting Heart and Mind


Randy Johnson BA

Director of Marketing

THE HEART HOSPITAL Baylor Plano


Did you know? If 99% is good enough, then:

• 12 newborns will be given to the wrong parents daily.

• 103,260 income tax returns will be processed incorrectly this

year.

• Two plane landings daily at O' Hare International Airport in

Chicago will be unsafe.

• 18,322 pieces of mail will be mishandled in the next hour.

• 291 pacemaker operations will be performed incorrectly this

year.

• 20,000 incorrect drug prescriptions will be written in the next 12

months


Did you know? If 99% is good enough, then:

• 107 incorrect medical procedures will be performed by the end of

the day today.

• 2,000,000 documents will be lost by the IRS this year.

• 22,000 checks will be deducted from the wrong bank accounts in

the next 60 minutes.


Finding Meaning through Data

Up to Date

Connects to

Actions

Understandable

Meaningful


Q4 FY ‘15

(Jul 1 –Aug 17)

Current Quarter

n=39

Q3 FY ‘15

(Apr – Jun)

Prior Quarter

n=127

Q2 FY ‘15

(Jan - Mar)

n=128

Q1 FY ‘15

(Oct - Dec)

n=123

FY ‘15

YTD

n=417

FY ‘14

YTD

n=428

Overall Rating of Care 38% 69% 76% 28% 54% 88%

Communication with Nurses 78% 99% 86% 88% 95% 93%

Nurses treat with courtesy/respect 90% 99% 49% 91% 90% 85%

Nurses listen carefully to you 56% 99% 91% 75% 89% 97%

Nurses expl in way you understand 80% 99% 95% 92% 98% 83%

Communication with Doctors 49% 97% 46% 73% 73% 87%

Doctors treat with courtesy/respect 84% 97% 62% 62% 82% 86%

Doctors listen carefully to you 76% 96% 67% 87% 83% 92%

Doctors expl in way you understand 8% 96% 20% 63% 55% 78%

Responsiveness of Staff 11% 84% 76% 60% 64% 81%

Call button help soon as wanted it 25% 83% 80% 66% 69% 83%

Help toileting soon as you wanted 6% 79% 66% 53% 59% 76%

Pain Management 34% 83% 70% 60% 67% 86%

Pain well controlled 7% 73% 70% 51% 58% 65%

Staff do everything help with pain 80% 87% 64% 66% 75% 95%

Communication re Medication 15% 93% 73% 80% 74% 94%

Tell you what new medicine was for 47% 89% 56% 41% 59% 93%

Hospital Environment 74% 98% 95% 86% 92% 92%

Cleanliness of hospital environment 97% 92% 87% 71% 86% 87%

Quietness of hospital environment 38% 97% 93% 87% 89% 90%

Discharge Information 88% 89% 48% 68% 70% 81%

Staff talk about help when you left 90% 85% 42% 72% 66% 75%

Info re symptoms/prob to look for 78% 87% 57% 58% 66% 79%

Transition of Care 46% 92% 36% 70% 65% 70%

Hosp staff took pref into account 50% 95% 59% 59% 73% 80%

Good understanding managing health 43% 87% 27% 55% 55% 60%

Understood purpose of taking meds 40% 96% 19% 72% 62% 60%

HCAHPS (Overall) - Goal - > 80th percentile in 6 of the composites


Action Plan:

12

Communication with Nurses Bedside Shift Report (to include Patient Communication

Board)

Communication with Doctors

Responsiveness of Staff Purposeful Hourly Rounding

Pain Management Establishing a pain goal and managing expectations

Communication re Medication

Hospital Environment

Discharge Information

Transition of Care

Source: Hospital System in the SE


Key Focus Questions for Comparisons:

1.

2.

3.

4.

13

Using Data to Connect the Heart and Mind: HCAHPS

HCAHPS Custom Questions Y/N/Unsure

How often did nursing staff come into your room to check or round on you

during the day? Would you say every hour, every two hours, every few hours,

or a couple of times a day?

Did a nurse leader visit you during your stay?

After discharge, did you receive a phone call from a hospital staff member

regarding your recovery at home?

At shift change, did the nurses include you in their conversation regarding your

plan of care?


8895

1 10

102030405060708090

100

1Q15 2Q15

Did a staff member visit you hourly?

YES NO

n=131 n=49 n=174 n=42

HCAHPS Overall Rating

*Data pulled from Press Ganey by discharge date 7.16.15

**Percentile rankings based on 3Q13-2Q14 CMS results

***Major SE System

Pe

rce

ntile

Ra

nk

Average increase in %ile ranking when

answered yes to staff member visit

91%


73

1

84

1

73

2

79

21

35

1

88

9

89

1

78

2

88

4

0

10

20

30

40

50

60

70

80

90

100

YES NO

Did a Nurse Leader visit you during your stay?

Overall Hospital Rating

Comm. With Nurses

Response of Hosp. Staff

Comm. With Doctors

Hosp. Environment

Pain Management

Comm. about Medicines

Discharge info

Care Transistions

Carolina East


*Data pulled from Press Ganey by discharge date

2.16.16

Date Range Oct. 1, 2015- to date

85.1 81.388.4

94.6

78.7 82.574.9

95.2 95.2

67

42.9

57.1 57.1 57.146.4 41.7

25

73.1 73.1

34.5

0102030405060708090

100

Did a nurse manager from patient care visit?

YES NO

N=

49 N=

31

N=5N=10

6

N=

7

HCAHPS Custom Question: Greenville Hillcrest

Correlation with Nurse Leader visit

N=24

3


HCAHPS Custom Questions: Rutland Regional Medical Center

17

NLR-Nurse Leader Rounding

PDC-Post discharge call


Impact to HCAHPS:

Transition of Care Call Received vs. Not Received

0

10

20

30

40

50

60

70

80

90

100

How often did hospital staffdescribe possible side effects

in a way you couldunderstand?

How often did the hospitalstaff tell you what the

medicine was for?

Did the MDs, Nurses, or otherhospital staff talk with youabout whether you would

have the help needed whenyou left the hospital?

Received Call No Call

Source: Major Hospital in SE region


82

1

94

1

84

1

88

1

49

1

90

1

95

1

87

1

91

1

0

10

20

30

40

50

60

70

80

90

100

YES NO

Leader Round and PCM Call

Overall Hospital Rating

Comm. With Nurses

Response of Hosp. Staff

Comm. With Doctors

Hosp. Environment

Pain Management

Comm. about Medicines

Discharge info

Care Transistions

Carolina East

THE HOW

20


• Verbalize the value of adding HCAHPS custom questions to the

survey to deepen staff engagement

• Demonstration of correlation of behavior to patient’s experience

• Develop a plan to implement the custom questions in your

organization

• Identify key words

• Determine tactic(s) to use (usually those you are struggling to

hardwire)

• Discuss with vendor

• Describe how to use the results from custom HCAHPS to engage

staff

• Huddles, staff meeting, posted on pillar board; connect the

action to the outcome and the difference one person can make

21

Outcome Goals


“Always bring it back to values..."

— Quint Studer


Change


EVALUATION REMINDER:

We want your feedback to get better. Please

remember to take the session evaluation. Thank you!

Diana Topjian, RN, MSN, D.M., C-ENP

Account Lead/Coach

[email protected]

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Next Presentation: Reducing

Readmissions through Recurring Care

Transition Calls

Erin Shipley, RN, Studer Group Coach &

Rachael Johnson, Studer Group Solutions

Specialist

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