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Using HCAHPS data to improve the quality of patient care Tenet Healthcare Cindy Larkin, Senior Director Measurement Discussion Points Tenet Overview Transition to HCAHPS Service Strategy Measurement System Redesign Tenet by the numbers 60,000 + employees 1M + Admissions
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Cindy Larkin, Senior Director Measurement
18,149 licensed beds
64 free-standing outpatient centers
54 acute care
2 rehab hospitals
JCAHO issues Privacy and safety
High impact areas Teamwork and sensitivity to family needs
High use areas Patient Access
Outsourced areas Food and Nutritional Services
Adjusted sample to delete non-HCAHPS patients that would continue to be included in Tenet’s system; i.e., proxy interviews; non-medical, surgical, or OB patients; interviews conducted in non-HCAHPS approved languages. Unaccepted interviews need to be accounted for at each hospital to ensure we reach the minimum required sample size.
Changed the scoring methodology to include the mode adjustment.
While we cannot at this time mirror CMS results exactly, we modify our system when new guidelines are published.
Questions having a high correlation with overall satisfaction
All areas that will be publicly reported
Hourly RoundingWhite Boards
Five simple steps to make a positive first impression and to ensure continuous positive interaction throughout the patient’s experience
First step in forming a relationship with the patient. Be attentive to and greet your patient in a positive manner with a warm and friendly smile.
Upon introduction give the patient your name and the purpose for the encounter.
Manage the patients expectations by educating them about the length of time a particular procedure or request will take. Better to over-estimate than under-estimate.
Make sure the patients are knowledgeable and involved in their treatment. Use easily understood terms when providing information. Ask if they have any questions.
Thank patients for waiting, providing information, choosing your facility, etc.
PCAs round on the even hours
Licensed staff round on the odd hours
Documentation is kept on a clipboard outside of the room
Use the “Three P’s”
Emphasis throughout all initiatives is continuous, positive, caring communication with the patient, family members, and each other.
For example, rather than simply handing patients written instructions or brochures, tell them what they are for, what they include, what they should do with them, and ask if they have any questions.
HCAHPS area more than 5% below the norm
Begin by analyzing
the high-level results
to identify problems,
then drill down to pinpoint what specific area is driving the score
New System Goals
This is not just a Tenet program. We helped Field Research design it, but it is being offered to other clients
Starting with the general results, the home page of the reporting system provides an overview of hospital results including comparison to previous month, previous year, and Tenet Targets.
Internal Star rating system
Provides drill down to category, question, unit, and patient level to identify problem areas.
A white light bulb indicates the question scores at or above average, a red light indicates a problem area.
Easily creates an Excel file from any screen shot.
Clicking on a light bulb accesses the improvement suggestion section, “Ideas with Impact.”
Clicking on the links in the Additional Resources section accesses a toolkits or other resources they can use or refer to.
Links to a 103 page workbook describing exactly how to implement empathy training
Written by Wendy Leebov
Very Interactive. View any program, category, question, unit, by any time period selected with a click of a button.
Helps hospitals track the specific service initiatives they are working on.
Easily creates a PDF report to email or post.