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HCAHPS: Update for Trustees Mary Therriault RN MS Senior Director, Quality and Research Initiatives Healthcare Association of New York State July, 2012. HRET Curriculum: A New Way of Thinking about HCAHPS. H ospital C onsumer A ssessment of H ealthcare P roviders and S ystems.

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HCAHPS: Update for TrusteesMary Therriault RN MSSenior Director, Quality and Research Initiatives Healthcare Association of New York State July, 2012

Hret curriculum a new way of thinking about hcahps

HRET Curriculum: A New Way of Thinking about HCAHPS



Assessment of


Providers and


What hcahps means
What HCAHPS Means


Can you



Patients/ Providers


Ahrq hret patient safety learning network psln project
AHRQ/HRET Patient Safety Learning Network (PSLN) Project

  • HANYS, HRET and AHRQ are partners in bringing you this free program of technical assistance for 6 months.

  • AHRQ has retained HRET to partner with health care leaders in creating Patient Safety Learning Networks to support hospitals that wish to use AHRQ’s patient safety improvement tools.

  • HRET will support learning network members in using HCAHPS, as well other AHRQ patient safety tools in 25 States during 2012.


  • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET).

  • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education.

  • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

  • Faculty: Carrie Brady, MA, JD

    • Primary HCAHPS trainer

    • Former Connecticut Hospital Association staffer

    • Previous V.P. at Planetree

Hcahps and hen priority challenges care transitions and adverse drug events
HCAHPS and HEN Priority Challenges: Care Transitions and Adverse Drug Events

Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs:

  • RN Communication

  • Responsiveness

  • Medication Communication*

  • Discharge Information*

    * HCAHPS domains addressed by a patient-centered discharge process

Our goal
Our Goal

To support hospital teams in effectively using HCAHPS as a tool for improving quality, safety, and the patient experience.

Our strategies
Our Strategies

  • Provide expertise, research, and practical tools

  • Harness participants’ institutional wisdom

  • Build internal teams and external communities for ongoing improvement work

Pop quiz
Pop Quiz!

In the United States,

how many HCAHPS surveys:

Will be administered today?

Will be completed today?

Hcahps today

More than 25,000 surveys administered

More than 7,500 surveys completed

More than 7% of all hospitalized patients

complete the survey

Source: HCAHPS Executive Insight, October 2011. hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD. http://www.hcahpsonline.org/Executive_Insight/.

Hcahps in a nutshell
HCAHPS In a Nutshell

  • HCAHPS is a national standardized survey of hospital inpatients

  • 27 questions

    • 18 substantive questions

    • 4 screening questions

    • 5 demographic questions

Hcahps topics

  • CMS reports individual scores for:

    • Cleanliness

    • Quiet at night

    • Overall rating

    • Willingness to recommend

  • CMS reports composite scores for 6 topics:

    • Nurse Communication

    • Doctor Communication

    • Medication Communication

    • Responsiveness

    • Pain Management

    • Discharge Information

Patients see things differently than providers
Patients See Things Differently Than Providers

Source: Weingart SN et al. “Patient-Reported Safety and Quality of Care in Outpatient Oncology” Joint Commission Journal on Quality and Patient Safety; 33:2, 2007

22% of 193 patients reported a “recent unsafe episode”

More than 80% of the reported experiences were classified by reviewers as “service quality incidents”

  • 33% related to waits and delays

  • 21% related to poor communication and information for patients

  • 13% related to poor coordination of care among staff

The evidence is mounting
The Evidence is Mounting

HCAHPS Matters


Hcahps strategies implemented by 25 hospitals in learning network
HCAHPS Strategies Implemented by 25 Hospitals in Learning Network

Why hcahps matters

Why HCAHPS Matters:

Value-Based Purchasing Implications

Vbp overview
VBP Overview

  • DRG payments initially reduced by 1% in FY2013

    • reduction rises by 0.25% each year, ending with 2% reduction in FY2017

  • Payments adjusted based on performance on HCAHPS (30%) and clinical process measures (70%)

  • Hospitals may earn VBP points in two ways:

    • By achieving a certain level of performance or

    • By improving their performance

    • More points available for achievement than improvement

New york top priorities for improvement
New York Top Priorities for Improvement

Essential elements to consider
Essential Elements to Consider

  • Leadership Strategies

  • Strategies for Partnering with Patients and Families

  • Workforce Strategies

  • Data Use Strategies

  • Performance Improvement Strategies

Ideal scenario
Ideal Scenario

HCAHPS is viewed as a valuable tool to help organizations achieve multiple objectives

HCAHPS is part of a coordinated, comprehensive approach to partnering with patients and families

Everyone works together as a team to identify opportunities for improvement, innovate and implement strategies, and celebrate success

Improving communication through team training
Improving Communication through Team Training


  • A comprehensive evidence-based system to enhance teamwork and communication among healthcare professionals

  • HRET is the national training contractor

  • Free curriculum and tools available at http://teamstepps.ahrq.gov/index.htm