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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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using hcahps data to improve the quality of patient care

Using HCAHPS data to improve the quality of patient care

Tenet Healthcare

Cindy Larkin, Senior Director Measurement

discussion points
Discussion Points

Tenet OverviewTransition to HCAHPSService Strategy Measurement System Redesign

tenet by the numbers
Tenet by the numbers

60,000+ employees

1M+ Admissions

18,149 licensed beds

64 free-standing outpatient centers

12 states

54 acute care

2 rehab hospitals

tenet s patient satisfaction system
Tenet’s Patient Satisfaction System
  • Tenet has been conducting patient satisfaction surveys since 1982
  • Approximately 100,000 telephone surveys conducted annually by Field Research Corporation, founded in 1945
  • Programs:
    • Inpatient
    • Outpatient Surgery
    • Outpatient Services
    • Emergency Department
    • Inpatient Rehab
    • Outpatient Rehab
    • Mental Health
discussion points5
Discussion Points

Tenet OverviewTransition to HCAHPSService Strategy Measurement System Redesign

transition to hcahps
Transition to HCAHPS
  • Piloted the questionnaire at eight hospitals in the fall of 2004
  • Reviewed our system to ensure all CMS guidelines were met. Other than the questionnaire change, few modifications were necessary since Tenet’s system already met virtually all of CMS’s specifications
  • Participated in focus groups with the Agency for Healthcare Research and Quality (AHRQ)
  • In January 2005, transitioned to the HCAHPS questionnaire
communication is key
Communication is key
  • Selected one person from each hospital as the HCAHPS liaison, responsible for internal communication and training
  • Explained rationale for transition, which was to prepare for public reporting as soon as possible
  • Shared results of the pilot study to prepare hospitals that the scores would likely be lower due to question and scale changes rather than performance
  • Based on the pilot results, estimated the potential score impact for each hospital
  • Developed training materials to help hospitals understand the reasoning behind various guidelines, such as adjusting the results based on patient characteristics, etc.
questionnaire design
Questionnaire design
  • Transitioned entirely to HCAHPS rather than conducting two separate studies
  • Involved key hospital personnel in questionnaire design to obtain buy in
  • Selected custom questions to address issues not included in HCAHPS

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

  • Redesigned other questionnaires (OP Surgery, OP Services, and ED) to HCAHPS format
survey design changes
Survey design changes

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.

keep current with cms guidelines
Keep current with CMS guidelines

Composite/ Category


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.

discussion points11
Discussion Points

Tenet OverviewTransition to HCAHPSService Strategy Measurement System Redesign

service restructuring
Service restructuring
  • Added a corporate-based Service Team to:
    • Directly consult with hospitals
    • Collect the tools and resources hospitals were using
  • Changed priority focus
  • Adjusted “key words” used in initiatives
previous service focus
Previous service focus

Focus areas

Questions having a high correlation with overall satisfaction

current service focus
Current service focus

Focus areas

All areas that will be publicly reported

avoid trying to boil the ocean
Avoid trying to “Boil the Ocean”
  • Introduced initiatives that were broad in scope and would address several question areas
  • Hourly Rounding
  • Empathy Training
  • Focused on Discharge Information; the only area Tenet scored slightly below average compared to the HCAHPS Chartbook data
white boards
Some hospitals purchased eye-catching, customized white boards to reinforce initiatives such as:


Pain goals

Hourly Rounding

White 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.





Thank You

hourly rounding
Hourly Rounding

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”



Personal Needs


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.

discussion points22
Discussion Points

Tenet OverviewTransition to HCAHPSService Strategy Measurement System Redesign

used a back to basics approach to help hospitals systematically review hcahps results
Used a “back to basics” approach to help hospitals systematically review HCAHPS results

Overall Score


Category Average

Begin by analyzing

the high-level results

to identify problems,

then drill down to pinpoint what specific area is driving the score

Question Score

Unit Report

Patient Information



redesigned our reporting system to complement the approach and push the data into the hospital
Redesigned our reporting system to complement the approach and “push” the data into the hospital

New System Goals

  • Expand employee access
  • User-friendly (three screens to learn)
  • Link Measurement and Service
  • Reduce report turnaround time
  • Identify problem areas
  • Benchmark with high performers

This is not just a Tenet program. We helped Field Research design it, but it is being offered to other clients


Screen One

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


Screen Two

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


Screen Three

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.

contact information
Contact Information

Cindy Larkin

(469) 893-2444