quarterly educational webinar september 10, 2015 1:00 pm (cdt) sponsored by: finding the pulse of...

Quarterly Educational WebinarSeptember 10, 2015 1:00 pm (CDT)

Sponsored by:

Finding the pulse of your business

Thank you for joiningWe will begin at 1:00 PM CDT

Attendees are on ‘mute’Allow time for questions at the endClick on the ‘chat’ button

Housekeeping

Today’s ObjectivesAnalyze updated trends in HCAHPSGetting the most out of eMed surveysHCAHPS Observations and RecommendationsOutpatient and Ambulatory Services (OAS CAHPS)Emergency Department Patient Experience of Care

(ED PEC)Open for comments

HCAHPS Top Box ScoresOCT ‘13 – SEPT ‘14

Revised: July 15, 2015* www.hcahpsonline.org

50th

75th

90th

78% 78% 78%79% 79% 79% 79% 79%

81% 81%82% 82% 82% 82% 82% 82%

85% 85% 85% 85% 85%86% 86% 86%

74%

76%

78%

80%

82%

84%

86%

88%

Q4/11-Q3/12 Q1/12-Q4/12 Q2/12-Q1/13 Q3/12-Q2/13 Q4/12-Q3/13 Q1/13-Q4/13 Q3/13-Q2/14 Q4/13-Q3/14

NATIONAL HCAHPS TOP BOX SCORESNURSING COMMUNICATION

NURSING COMMUNICATION 50TH NURSING COMMUNICATION 75TH NURSING COMMUNICATION 90TH


Q4/11-Q3/12 Q1/12-Q4/12 Q2/12-Q1/13 Q3/12-Q2/13 Q4/12-Q3/13 Q1/13-Q4/13 Q3/13-Q2/14 Q4/13-Q3/1476%

78%

80%

82%

84%

86%

88%

90%

81% 81% 81%82% 82%

81% 81% 81%

85% 85% 85% 85% 85% 85% 85% 85%

88% 88% 88% 88%89% 89% 89% 89%

NATIONAL HCAHPS TOP BOX SCORESDOCTOR COMMUNICATION

DOCTORS COMMUNICATION 50TH DOCTORS COMMUNICATION 75TH DOCTORS COMMUNICATION 90TH



65%

70%

75%

80%

85%

67% 67% 67% 67%68%

67% 67% 67%

72% 72% 72% 72%73% 73% 73% 73%

78%79% 79% 79% 79%

80% 80% 80%

NATIONAL HCAHPS TOP BOX SCORESRESPONSIVENESS OF HOSPITAL STAFF

RESPONSIVENESS OF HOSP STAFF 50TH RESPONSIVENESS OF HOSP STAFF 75TH RESPONSIVENESS OF HOSP STAFF 90TH



68%

70%

72%

74%

76%

78%

80%

71% 71% 71%71% 71% 71% 71% 71%

73% 73% 73%74% 74% 74% 74% 74%

77% 77% 77% 77% 77%78% 78% 78%

NATIONAL HCAHPS TOP BOX SCORESPAIN MANAGEMENT

PAIN MANAGEMENT 50TH PAIN MANAGEMENT 75TH PAIN MANAGEMENT 90TH



60%

62%

64%

66%

68%

70%

72%

74%

76%

63% 64% 64% 64% 64% 64% 64% 64%

67% 67% 67% 67% 67%68% 68% 68%

71%72% 72% 72% 72% 72%

73%74%

NATIONAL HCAHPS TOP BOX SCORESCOMMUNICATION ABOUT MEDICATIONS

COMM. ABOUT MEDICATIONS 50TH COMM. ABOUT MEDICATIONS 75TH COMM. ABOUT MEDICATIONS 90TH



68%

70%

72%

74%

76%

78%

80%

82%

84%

86%

73% 73% 73% 73% 73% 73% 73% 73%

77%78% 78% 78% 78% 78% 78%

79%

83% 83% 83% 83%84% 84% 84% 84%

NATIONAL HCAHPS TOP BOX SCORESCLEANLINESS OF HOSPITAL

CLEANLINESS 50TH CLEANLINESS 75TH CLEANLINESS 90TH



55%

60%

65%

70%

75%

80%

60% 60% 61% 61% 61% 61% 61% 61%

66%67% 67% 67% 67%

68% 68% 68%

73% 73% 73%74% 74% 74%

75% 75%

NATIONAL HCAHPS TOP BOX SCORESQUIETNESS OF HOSPITAL

QUIETNESS 50TH QUIETNESS 75TH QUIETNESS 90TH


Only 4% gap between 50th and 90th


83%

85%

87%

89%

91%

93%

84% 85% 85% 85% 85%

86%

87% 87%87% 87%

88% 88% 88% 88%

89% 89%89%

90% 90% 90% 90%

91% 91% 91%

NATIONAL HCAHPS TOP BOX SCORESDISCHARGE INSTRUCTIONS

DISCHARGE INFORMATION 50TH DISCHARGE INFORMATION 75TH DISCHARGE INFORMATION 90TH



65%

70%

75%

80%

85%

70% 70% 70% 70%71% 71% 71% 71%

75% 75%76% 76% 76% 76% 76% 76%

81% 81% 81% 81%82% 82% 82% 82%

NATIONAL HCAHPS TOP BOX SCORESOVERALL RATING

OVERALL HOSPITAL RATING 50TH OVERALL HOSPITAL RATING 75TH OVERALL HOSPITAL RATING 90TH



67%

69%

71%

73%

75%

77%

79%

81%

83%

85%

71% 71% 71% 71% 71%72% 72% 72%

77%78%

77% 77%78% 78% 78% 78%

83% 83%82%

83% 83% 83% 83%84%

NATIONAL HCAHPS TOP BOX SCORESWOULD RECOMMEND

RECOMMEND THE HOSPITAL 50TH RECOMMEND THE HOSPITAL 75TH RECOMMEND THE HOSPITAL 90TH


Q1/13-Q4/13 Q3/13-Q2/14 Q4/13-Q3/1446%

48%

50%

52%

54%

56%

58%

60%

62%

51% 52% 52%55% 56% 56%

60% 60% 60%

NATIONAL HCAHPS TOP BOX SCORESCare Transition

CARE TRANSITION CARE TRANSITION CARE TRANSITION

* www.whynotthebest.org [retrieved 7/22/15]

HCAHPS “Highly Satisfied”July 13 – June 14

http://www.whynotthebest.org/

eMed Survey Reporting Tool

eMed Survey Reporting Tool*Provides snapshot regarding the patient’s experience for:

HCAHPS, Home Health, Emergency Department or Outpatient Services

Available in real-time upon completion of surveysAble to trend monthly, quarterly or annuallyQuery – Analyze multiple levels of data on demand

* JLM Proprietary Database

Getting the most out of eMed reporting1. Run high level reports to identify trends or areas for

improvement2. Utilize Top Box and Monthly reports to drill down

further to discover areas of concern3. Share information with staff and develop action plans

based on findings

Story of AnyHospital USAAnyHospital USA wants to evaluate their HCAHPS scores and see where there is room for improvementNeed to run reports and analyze the data on a number of levelsRun eMed survey reports to accomplish this

CMS HCAHPS National ComparisonData Summary (Trending)Top Box HCAHPS by AreaTop Box HCAHPS by Facility (System)Query for further analysis

Login to client site

https://www.emedsurvey.comClient Login:

1. Login to https://emedsurvey.com2. Enter Username and

Password (contact JLM if you do not have a username assigned.

https://emedsurvey.com/

Login to client site




3. From this page, you can decide to select “Reports” or run a query from the database.


Running Reports




3. From this page, you can decide to select “Reports” or run a query from the database.

4. Select type of report you want to run (CMS HCAHPS, HHCAHPS, Patient Satisfaction, etc)


Report Examples


CMS HCAHPS National Comparison

• 11 HCAHPS Composites • Compares your hospital

against the National Rankings (50th, 75th, 90th)

• CMS Mode adjusted• Color coded for easy

identification

Identified below national average in “Communication Medications” composite

Report Examples


Data Summary with Trending

• Displays individual measures for each composite

• Trend by: Decimal, Percent (Average) or Top Box format

• Trend up to 12 months

Report Examples


Data Summary with Trending (cont’d)

• Displays each measure individually

• Identifies Trends

Performing lower in “describing side effects”

Report Examples


Top BoxHCAHPS Areas

• Breaks down HCAHPS scores by unit or location

• Identify largest areas for improvement

• Top Box scoring

By area shows lower scores in Post Partum and 5th floor

Report Examples


Top BoxHCAHPS Facility Report

• Compare hospital scores across the system

• Specific to hospital or system

• Collaboration

A B C D E F

Report Examples


Weighted Response Summary

• Previously known as “Top Box” report

• Displays question percentage scores for each type of response• Very Poor• Poor• Fair• Good• Very Good

Works for Inpt, ER, Outp

Report Examples


Quarterly Benchmark

• Displays Quarterly Data compared to the JL Morgan DB

• Based on “weighted average” decimal scores• 1-5 scale

• Trends up to 4 quarters

Queries


Filter Data

• Select the question you want to drill down on further

• “Overall Rating”• Search for “7” or “8”

• “What prevented a “9” or “10”?

• Run Query• Analyze Results

Could this be a result of scoring poorly with “Response to call button”?

HCAHPS Observations

Opportunities for Improvement*Drill down on ‘missed opportunities’

Overall Rating – 7/8Would NOT recommend

Account for 10 – 15% decrease of overall HCAHPS scoresEvaluate “Usually” responses

Easier to move than “Sometimes” or “Never”

* Results may vary for your organization

Courtesy and respect?

Listen carefully

Explain Things

Call button

Help to bathroom

Pain controlled

Help with pain

Tell you what it was for

Describe side effects

Help you needed after leaving

Information in writing

Resp

onsiv

enes

s of S

taff

Com

mun

icati

on M

edic

ation

s

Common HCAHPS “Missed Opportunities”

Patient Satisfaction Drivers

ResponsivenessPain ManagementDischarge InstructionsDoctor / Nursing Comm.

Technology

Education Policies & Procedures

Tips for Improving Patient SatisfactionPatient Education

Educate patients on the purpose and possible side effects of taking their medicineEasy to understand – majority of patient’s surveyed only graduated high school

or less 4 years collegeLimit discharge instructions to one-page bulleted color page

Nursing / Staff EducationAddress patients and their family about their health care needs during dischargeReview response to call button policiesConstantly monitor patient’s pain controlEvaluate trends to move the ‘usually’ to ‘always’ responses

* www.hcahpsonline.org

Outpatient and Ambulatory Services (OAS) CAHPSJANUARY 2016

OAS CAHPSDesigned to measure the experiences of care for patients who visited a Medicare-certified hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) for a surgery or procedure. Produce comparable data on the patient’s perspective that allows objective and meaningful comparisons between HOPDs and free-standing ASCs on domains that are important to consumers. CMS plans to implement a voluntary national reporting program starting in January 2016.

Participation RequirementsCMS will provide guidelines for survey administration similar to those implemented on other CAHPS surveys.CMS-approved survey vendors will administer the survey on behalf of HOPDs and ASCs and submit the data to RTI International. RTI International will analyze the data; subsequently the results will be publicly reported on a CMS website.

About the SurveyAreas measured:

Communication and care provided by health care providers and office staff

Preparation for the surgery or procedurePost-surgical care coordinationPatient-reported outcomes

Three modes will be tested:Mail, telephone, mixed (mail / telephone f/u)

Next StepsJ. L. Morgan has applied to be a certified OAS CAHPS vendor (Oct15)

Continue to monitor JLM and OAS website for more information as it becomes available

More information: https://oascahps.org

https://oascahps.org/

Emergency Department Patient Experience of Care (EDPEC)UPDATED JULY 2015

ED PECFormerly EDCAHPS (Now Patient Experience of Care or EDPEC)Will provide patient experience data that enables comparison of EDs across the nation and promotes effective communication and coordination.CMS will undergo a feasibility test for the first quarter (Jan-Mar) 2016 discharges.

Test the impact on response rates of four novel data collection methods compared to standard data collection strategies.

There is no fee to participate in the test.

Survey InstrumentsDischarged to Community: 35 questions regarding ED experience, plus 18 questions regarding the respondent’s characteristics Admitted Stand Alone: 29 questions regarding ED experience, plus 18 questions regarding the respondent’s characteristics Admitted HCAHPS Add-on: 10 questions regarding ED experience that should be inserted into a full HCAHPS instrument, using the most recently available version of the instrument, immediately preceding the “About You”

Modes Tested An online surveyAn online survey with e-mail notification of survey availabilityEmail notification of an online survey with mail and phone follow-upAn in-ED distribution of a paper and pencil survey with option to complete and return by mail or to call in to complete the survey via telephone

ParticipationHospitals can NOT volunteer for field testOver the next several weeks, CMS will send out approximately 75 letters to hospitals notifying them that they have qualified for the feasibility testJ. L. Morgan & Associates will work with RAND to ensure all requirements for participation are metVisit https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ed.html for more information

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ed.html





Resources

www.hospitalcompare.hhs.govwww.hcahpsonline.org

www.whynotthebest.org

http://www.hospitalcompare.hhs.gov/

http://www.hcahpsonline.org/

http://www.whynotthebest.org/

* www.hcahpsonline.org/SummaryAnalysis

http://www.hcahpsonline.org/SummaryAnalysis

Contact Us:

J. L. Morgan & Associates7057 Meadowlark Drive| Birmingham, Al 35242

205-995-4226 | Fax: 205-995-7141www.Jlmorganandassociates.com

Jeff Morgan, President 205-408-8774 Office

[email protected]

Jay Bishop, MSHA, CPHQ, COO205-995-7108 Office

[email protected]

Tanya Harris-HaynesHCAHPS Manager

205-995-7144 [email protected]

Wendy DewPrograms Director

(Preventative Care / Pat Sat)205-995-7107 Office

[email protected]

Latrice LawsonData Manager

205-995-7139 [email protected]

http://www.jlmorganandassociates.com/

mailto:[email protected]





Thank you for your time!For more information, please visit www.jlmorganandassociates.com

http://www.jlmorganandassociates.com/

quarterly educational webinar september 10, 2015 1:00 pm (cdt) sponsored by: finding the pulse of...

Documents

q413q313q214q q411q312q112

medications50th q411q312q112

medications75th q411q312q112

medications90th q411q312q112

hosp staff75th q411q312q112

hosp staff90th q411q312q112

national hcahps

box scores communication