Exemplary Professional Practice QUALITY CARE MONITORING ... · Exemplary Professional Practice ....

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EP23EO Advocate BroMenn Medical Center 1 Exemplary Professional Practice QUALITY CARE MONITORING AND IMPROVEMENT EP23EO - Unit or clinic level patient satisfaction data (related to nursing care) outperform the mean or median of the national database used. Provide 8 quarters of inpatient, pediatric, and ambulatory/outpatient patient satisfaction data at the unit- or clinic-level collected within the previous 30 months before document submission. Advocate BroMenn Medical Center utilizes the vendor Press Ganey to obtain nationally benchmarked patient satisfaction data. Six survey tools are utilized to obtain feedback from patients served on inpatient and outpatient units/departments. The survey tools include: Inpatient Inpatient Behavioral Health Ambulatory Services Outpatient Services Emergency Department Medical Practice Random sampling methodology is used for all areas. The Pediatrics/Outpatient Infusion Unit has a small inpatient and outpatient pediatric volume and cares for adult and pediatric intravenous infusion patients. Patients from this unit are surveyed by either the Inpatient or Outpatient Services survey tool depending on which category they fit into. Due to the small pediatric population most quarters do not have a large enough n size to report the patient satisfaction data with the inpatient survey. The data listed below for this unit is from the Outpatient Services survey tool. DDCT Hospital Unit Name Courtesy and Respect (outperform) Responsive- ness (outperform) Patient Education (outperform) Pain (outperform) 6 West Surgical X X X X Medical Oncology Specialty Unit X X X Progressive Care Unit X X X X Intensive Care Unit n too low n too low n too low n too low Pediatrics/Outpatient Infusion (Outpatient Survey) X no cross walked survey question X no cross walked survey question

Transcript of Exemplary Professional Practice QUALITY CARE MONITORING ... · Exemplary Professional Practice ....

Page 1: Exemplary Professional Practice QUALITY CARE MONITORING ... · Exemplary Professional Practice . QUALITY CARE MONITORING AND IMPROVEMENT . EP23EO - Unit or clinic level patient satisfaction

EP23EO Advocate BroMenn Medical Center 1

Exemplary Professional Practice QUALITY CARE MONITORING AND IMPROVEMENT EP23EO - Unit or clinic level patient satisfaction data (related to nursing care) outperform the mean or median of the national database used. Provide 8 quarters of inpatient, pediatric, and ambulatory/outpatient patient satisfaction data at the unit- or clinic-level collected within the previous 30 months before document submission. Advocate BroMenn Medical Center utilizes the vendor Press Ganey to obtain nationally benchmarked patient satisfaction data. Six survey tools are utilized to obtain feedback from patients served on inpatient and outpatient units/departments. The survey tools include:

• Inpatient • Inpatient Behavioral Health • Ambulatory Services • Outpatient Services • Emergency Department • Medical Practice

Random sampling methodology is used for all areas. The Pediatrics/Outpatient Infusion Unit has a small inpatient and outpatient pediatric volume and cares for adult and pediatric intravenous infusion patients. Patients from this unit are surveyed by either the Inpatient or Outpatient Services survey tool depending on which category they fit into. Due to the small pediatric population most quarters do not have a large enough n size to report the patient satisfaction data with the inpatient survey. The data listed below for this unit is from the Outpatient Services survey tool.

DDCT Hospital Unit Name Courtesy

and Respect (outperform)

Responsive-ness

(outperform)

Patient Education

(outperform)

Pain (outperform)

6 West Surgical X X X X Medical Oncology Specialty Unit X X X Progressive Care Unit X X X X Intensive Care Unit n too low n too low n too low n too low

Pediatrics/Outpatient Infusion (Outpatient Survey) X

no cross walked survey

question X

no cross walked survey

question

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EP23EO Advocate BroMenn Medical Center 2

Operating Room No department specific patient satisfaction data collected by

vendor. Patients are not discharged from this area. Mental Health Unit X X X X Acute Rehabilitation Unit X X X Emergency Department X X X X

Cardiopulmonary Rehabilitation X

no cross walked survey

question X

no cross walked survey

question

Center for Wound Healing and Hyperbaric Medicine X

no cross walked survey

question

no cross walked survey

question X

Diabetic Education No department specific patient satisfaction data collected by

vendor

Cardiology -Invasive Cardiology X

no cross walked survey

question

no cross walked survey

question Non-Invasive Cardiology Reported as Cardiology with Invasive Cardiology above

Radiology X

no cross walked survey

question X

no cross walked survey

question

Post Anesthesia Care Unit No department specific patient satisfaction data collected by

vendor. Patients are not discharged from this area. Same Day Services X X X

Cardiovascular Care Unit X X X X

Pre-admission Testing No department specific patient satisfaction data collected by

vendor. Mother Baby Unit X X X X

Cardiovascular Service Line No department specific patient satisfaction data collected by

vendor Care Management Non-patient care area Clinical Documentation Improvement Non-patient care area Clinical Education Non-patient care area Clinical Informatics Non-patient care area

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EP23EO Advocate BroMenn Medical Center 3

Clinical Resource Unit No department specific patient satisfaction data collected by

vendor.

Magnet Non-patient care role

Nursing Directors Non-patient care roles Nursing Managers Non-patient care roles

Nursing Operations No department specific patient satisfaction data collected by

vendor.

Palliative Care No department specific patient satisfaction data collected by

vendor. Patient Safety Non-patient care area Quality Resource Management Non-patient care area Risk Management Non-patient care area

Wound/Ostomy No department specific patient satisfaction data collected by

vendor. Outperform majority of 8 Quarters 14 of 14 7 of 9 12 of 13 9 of 10

COURTESY AND RESPECT

The graph above demonstrates that the 6 West Surgical Unit outperformed the benchmark eight of eight quarters.

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EP23EO Advocate BroMenn Medical Center 4

The graph above demonstrates that the Medical Oncology Specialty Unit outperformed the benchmark five of eight quarters.

The graph above demonstrates that the Progressive Care Unit outperformed the benchmark eight of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

MOSU mean 91.2 95.1 91.7 94.7 92.6 95.0 93.5 93.5PG (All Respondents, Lg

PG DB) Mean 92.7 92.8 92.5 92.8 93.0 93.1 93.1 93.2

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Medical Oncology Specialty Unit, Med-Surg, Press Ganey,

Friendliness/courtesy of the nurses

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

PCU mean 96.9 95.5 95.2 95.6 95.6 96.3 94.4 96.4PG (All Respondents, Lg

PG DB) Mean 92.7 92.8 92.5 92.8 93.0 93.1 93.1 93.2

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Progressive Care Unit, Step Down, Press Ganey,

Friendliness/courtesy of the nurses

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EP23EO Advocate BroMenn Medical Center 5

The graph above demonstrates that the Intensive Care Unit did not have enough volume each quarter to have statistically meaningful data. The n size was too small for the vendor to provide data for the missing quarters.

The graph above demonstrates that Pediatrics/Outpatient Infusion outperformed the benchmark six of eight quarters. There is no department specific patient satisfaction data collected by the vendor for the Operating Room due to patients not being discharged from this unit.

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EP23EO Advocate BroMenn Medical Center 6

The graph above demonstrates that the Mental Health Unit outperformed the benchmark five of eight quarters.

The graph above demonstrates that the Acute Rehabilitation Unit outperformed the benchmark five of eight quarters.

3Q-

2014

4Q-

2014

Q1-

2015

Q2-

2015

3Q-

2015

4Q-

2015

1Q-

2016

2Q-

2016

Mental Health mean 100.0 95.5 94.9 97.5 97.1PG (All Respondents, All

Hosp DB) Mean 88.3 88.5 88.5 88.5 88.5

70

80

90

100

Mea

n Sc

ore

EP23EO Courtesy & Respect, Mental Health Unit, Psychiatric, Press Ganey, Friendliness/ courtesy of

the nurses

Survey began 3/1/15

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EP23EO Advocate BroMenn Medical Center 7

The graph above demonstrates that the Emergency Department outperformed the benchmark seven of eight quarters.

The graph above demonstrates that Cardiopulmonary Rehabilitation outperformed the benchmark five of eight quarters.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ED mean 88.6 91.3 91.9 89.3 88.7 87.9 91.0 91.6PG (All Respondents, Lg

PG DB) Mean 87.7 87.7 87.4 87.3 88.0 88.1 87.9 87.6

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Emergency Department, Emergency Department, Press Ganey,

Nurses' concern for your privacy

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Cardiopulmonary Rehabmean 95.0 94.8 97.6 94.8 97.2 97.7 97.1 98.5

PG (All Respondents, AllFacility DB) Mean 96.0 96.0 96.0 95.8 95.8 95.9 96.0 96.0

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Cardiopulmonary Rehabilitation, Specialty Practice, Press Ganey,

Friendliness/courtesy of the staff who provided your test or treatment

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EP23EO Advocate BroMenn Medical Center 8

The graph above demonstrates that the Center for Wound Healing and Hyperbaric Medicine outperformed the benchmark eight of eight quarters. Press Ganey does not collect department specific patient satisfaction data for Diabetic Education.

The graph above demonstrates that Cardiology outperformed the benchmark six of eight quarters. Cardiology includes both Invasive and Non-Invasive Cardiology.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

WHC mean 100.0 97.5 100.0 100.0 96.4 98.7 98.7 100.0PG Benchmark (All

Respondents, All Sites)Mean

93.7 93.8 93.9 93.8 93.8 93.9 94.1 94.2

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Center for Wound Healing & Hyperbaric Medicine, Specialty

Practice, Press Ganey, Friendliness/courtesy of the nurse/assistant

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Cardiology mean 91.0 90.8 95.1 96.0 93.8 95.6 95.1 93.8PG (All Respondents, All

Facility DB) Mean 93.3 93.4 93.3 93.2 93.2 93.3 93.4 93.5

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Cardiology (Invasive Cardiology & Non-Invasive

Cardiology), Specialty Practices, Press Ganey, Our concern for your privacy

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EP23EO Advocate BroMenn Medical Center 9

The graph above demonstrates that Radiology outperformed the benchmark eight of eight quarters. Patients are not discharged from the Post Anesthesia Care Unit, therefore the vendor does not survey these patients.

The graph above demonstrates that Same Day Services outperformed the benchmark six of eight quarters.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Radiology 96.4 96.4 97.1 96.1 97.0 97.1 97.6 96.6PG (All Respondents, All

Facility DB) Mean 96.0 96.0 96.0 95.8 95.8 95.9 96.0 96.0

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Radiology, Specialty Practice, Press Ganey, Friendliness/courtesy of the staff

who provided your test or treatment

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EP23EO Advocate BroMenn Medical Center 10

The graph above demonstrates that the Cardiovascular Care Unit outperformed the benchmark eight of eight quarters. Department specific data is not collected by the vendor for Pre-admission Testing.

The graph above demonstrates that the Mother Baby Unit outperformed the benchmark eight of eight quarters. Press Ganey does not collect department specific patient satisfaction data for the following roles and departments/units:

• Cardiovascular Service Line

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

CVCU mean 96.0 95.4 96.4 95.9 96.3 94.2 95.6 94.6PG (All Respondents, Lg

PG DB) Mean 92.7 92.8 92.5 92.8 93.0 93.1 93.1 93.2

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Courtesy & Respect, Cardiovascular Care Unit, Acuity Adaptable, Press Ganey,

Friendliness/courtesy of the nurses

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EP23EO Advocate BroMenn Medical Center 11

• Care Management • Clinical Documentation Improvement • Clinical Education • Clinical Informatics • Clinical Resource Unit • Magnet • Nursing Directors • Nursing Managers • Nursing Operations • Palliative Care • Patient Safety • Quality Resource Management • Risk Management • Wound/Ostomy

RESPONSIVENESS

The graph above demonstrates that the 6 West Surgical Unit outperformed the benchmark eight of eight quarters.

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EP23EO Advocate BroMenn Medical Center 12

The graph above demonstrates that the Medical Oncology Specialty Unit outperformed the benchmark five of eight quarters.

The graph above demonstrates that the Progressive Care Unit outperformed the benchmark eight of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

MOSU mean 80.9 88.3 83.8 87.0 89.7 90.0 86.8 85.3PG (All Respondents, Lg

PG DB) Mean 86.6 86.5 86.0 86.5 86.9 86.9 86.7 87.1

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Responsiveness, Medical Oncology Specialty Unit, Med-Surg, Press Ganey, Promptness in responding to call button

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

PCU mean 92.0 88.8 89.9 90.9 90.9 90.4 87.8 89.8PG (All Respondents, Lg

PG DB) Mean 86.6 86.5 86.0 86.5 86.9 86.9 86.7 87.1

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Responsiveness, Progressive Care Unit, Step Down, Press Ganey, Promptness in responding

to call button

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EP23EO Advocate BroMenn Medical Center 13

The graph above demonstrates that the Intensive Care Unit did not have enough volume each quarter to have statistically meaningful data. The n size was too small for the vendor to provide data for the missing quarters. There are no standard responsiveness cross walked questions on the Outpatient Services Press Ganey survey for Pediatrics/Outpatient Infusion.

There is no department specific patient satisfaction data collected by the vendor for the Operating Room due to patients not being discharged from this unit.

The graph above demonstrates that the Mental Health Unit outperformed the benchmark five of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ICU mean 90.6 85.0PG (All Respondents, Lg PG

DB) Mean 86.5 86.0

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Responsiveness, Intensive Care Unit, Critical Care, Press Ganey, Promptness in

responding to call button

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Mental Health mean 91.7 93.9 90.8 93.9 93.4PG (All Respondents, Lg

PG DB) Mean 84.1 84.2 84.2 84.3 84.3

70

80

90

100

Mea

n Sc

ore

EP23EO Responsiveness, Mental Health Unit, Psychiatric, Press Ganey, Promptness of nurses

responding to your requests

Survey began 3/1/15

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EP23EO Advocate BroMenn Medical Center 14

The graph above demonstrates that the Acute Rehabilitation Unit outperformed the benchmark four of eight quarters.

The graph above demonstrates that the Emergency Department outperformed the benchmark seven of eight quarters. There are no standard responsiveness cross walked questions on the Outpatient Services Press Ganey survey for Cardiopulmonary Rehabilitation or the Center for Wound Healing and Hyperbaric Medicine. Press Ganey does not collect department specific patient satisfaction data for Diabetic Education.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ED mean 88.2 91.2 90.8 88.3 88.3 86.1 89.7 89.3PG (All Respondents, Lg

PG DB) Mean 86.5 86.5 86.3 86.2 87.0 87.0 86.9 86.5

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Responsiveness, Emergency Department, Emergency Department, Press Ganey,

Nurses' attention to your needs

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EP23EO Advocate BroMenn Medical Center 15

There are no standard responsiveness cross walked questions on the Outpatient Services Press Ganey survey for Cardiology, which includes Invasive and Non-Invasive Cardiology or for Radiology. Patients are not discharged from the Post Anesthesia Care Unit, therefore the vendor does not survey these patients.

The graph above demonstrates that Same Day Services outperformed the benchmark three of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

CVCU mean 92.1 90.6 92.6 90.3 91.1 91.8 88.9 91.4PG (All Respondents, Lg

PG DB) Mean 86.6 86.5 86.0 86.5 86.9 86.9 86.7 87.1

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Responsiveness, Cardiovascular Care Unit, Acuity Adaptable, Press Ganey, Promptness in

responding to call button

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EP23EO Advocate BroMenn Medical Center 16

The graph above demonstrates that the Cardiovascular Care Unit outperformed the benchmark eight of eight quarters. Department specific data is not collected by the vendor for Pre-admission Testing.

The graph above demonstrates that the Mother Baby Unit outperformed the benchmark eight of eight quarters. Press Ganey does not collect department specific patient satisfaction data for the following roles and departments/units:

• Cardiovascular Service Line • Care Management • Clinical Documentation Improvement • Clinical Education • Clinical Informatics • Clinical Resource Unit • Magnet • Nursing Directors • Nursing Managers • Nursing Operations • Palliative Care • Patient Safety • Quality Resource Management • Risk Management • Wound/Ostomy

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EP23EO Advocate BroMenn Medical Center 17

PATIENT EDUCATION

The graph above demonstrates that the 6 West Surgical Unit outperformed the benchmark seven of eight quarters.

The graph above demonstrates that the Medical Oncology Specialty Unit outperformed the benchmark five of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

MOSU mean 83.0 85.7 87.4 89.8 87.0 90.1 89.8 89.7PG (All Respondents, Lg

PG DB) Mean 87.4 87.4 87.1 87.5 87.8 87.8 87.7 88.0

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Patient education, Medical Oncology Specialty Unit, Med-Surg, Press Ganey, Instructions

given about how to care for yourself at home

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EP23EO Advocate BroMenn Medical Center 18

The graph above demonstrates that the Progressive Care Unit outperformed the benchmark eight of eight quarters.

The graph above demonstrates that the Intensive Care Unit did not have enough volume each quarter to have statistically meaningful data. The n size was too small for the vendor to provide data for the missing quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

PCU mean 91.3 90.1 90.6 90.2 92.4 90.6 88.5 91.6PG (All Respondents,

Lg PG DB) Mean 87.4 87.4 87.1 87.5 87.8 87.8 87.7 88.0

70

80

90

100

Mea

n Sc

ore

EP23EO Patient education, Progressive Care Unit, Step Down, Press Ganey, Instructions given

about how to care for yourself at home

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ICU mean 90.6 88.9PG (All Respondents, Lg

PG DB) Mean 87.4 87.1

70

80

90

100

Mea

n Sc

ore

EP23EO Patient Education, Intensive Care Unit, Critical Care, Press Ganey, Instructions about how to

care for yourself at home

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EP23EO Advocate BroMenn Medical Center 19

The graph above demonstrates that Pediatrics/Outpatient Infusion outperformed the benchmark five of eight quarters. There is no department specific patient satisfaction data collected by the vendor for the Operating Room due to patients not being discharged from this unit.

The graph above demonstrates that the Mental Health Unit outperformed the benchmark five of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Mental Health mean 100.0 95.8 94.9 95.1 98.0PG (All Respondents,

Lg PG DB) Mean 85.7 85.8 85.9 86.0 85.7

70

80

90

100

Mea

n Sc

ore

EP23EO Patient Education, Mental Health Unit, Psychiatric, Press Ganey, Degree to which nurses

kept you informed about your medications

survey started3/1/15

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EP23EO Advocate BroMenn Medical Center 20

The graph above demonstrates that the Acute Rehabilitation Unit outperformed the benchmark six of eight quarters.

The graph above demonstrates that the Emergency Department outperformed the benchmark seven of eight quarters.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ED mean 83.7 88.4 87.7 86.5 85.3 84.6 85.2 84.8PG (All Respondents, Lg

PG DB) Mean 84.0 84.1 84.0 83.6 84.3 84.4 84.2 83.8

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Patient Education, Emergency Department, Emergency Department, Press Ganey,

Information you were given about caring for yourself at home

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EP23EO Advocate BroMenn Medical Center 21

The graph above demonstrates that Cardiopulmonary Rehabilitation outperformed the benchmark five of eight quarters. There are no standard responsiveness cross walked questions on the Medical Practice Press Ganey survey for the Center of Wound Healing and Hyperbaric Medicine. Press Ganey does not collect department specific patient satisfaction data for Diabetic Education.

The graph above demonstrates that the Cardiology outperformed the benchmark four of eight quarters. Cardiology includes both Invasive and Non-Invasive Cardiology.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Cardiopulmonary Rehabmean 94.2 96.8 96.9 94.3 95.6 97.7 93.8 91.2

PG (All Respondents, AllFacility DB) Mean 94.2 94.2 94.2 94.1 94.1 94.2 94.3 94.3

70

80

90

100

Mea

n Sc

ore

EP23EO Patient education, Cardiopulmonary Rehabilitation, Specialty Practice, Press Ganey,

Explanations regarding your test or treatment

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Cardiology mean 92.8 93.6 97.5 96.8 92.6 96.9 95.0 91.8PG (All Respondents,All Facility DB) Mean 94.2 94.2 94.2 94.1 94.1 94.2 94.3 94.3

70

80

90

100

Mea

n Sc

ore

EP23EO Patient Education, Cardiology (Invasive & Non-Invasive Cardiology), Specialty Practices,

Press Ganey, Explanations from the staff about what would happen during your test and treatment

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EP23EO Advocate BroMenn Medical Center 22

The graph above demonstrates that Radiology outperformed the benchmark seven of eight quarters. Patients are not discharged from the Post Anesthesia Care Unit, therefore the vendor does not survey these patients.

The graph above demonstrates that Same Day Services outperformed the benchmark seven of eight quarters.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Radiology 94.5 95.2 95.5 93.8 95.7 95.4 95.8 95.7PG (All Respondents,All Facility DB) Mean 94.2 94.2 94.2 94.1 94.1 94.2 94.3 94.3

70

80

90

100

Mea

n Sc

ore

EP23EO Patient Education, Radiology, Specialty Practice, Press Ganey, Explanations from the staff

about what would happen during your test and treatment

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EP23EO Advocate BroMenn Medical Center 23

The graph above demonstrates that the Cardiovascular Care Unit outperformed the benchmark seven of eight quarters. Department specific data is not collected by the vendor for Pre-admission Testing.

The graph above demonstrates that the Mother Baby Unit outperformed the benchmark eight of eight quarters. Press Ganey does not collect department specific patient satisfaction data for the following roles and departments/units:

• Cardiovascular Service Line

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

CVCU mean 89.3 89.1 91.1 91.2 90.5 90.7 91.0 86.5PG (All Respondents,

Lg PG DB) Mean 87.4 87.4 87.1 87.5 87.8 87.8 87.7 88.0

70

80

90

100

Mea

n Sc

ore

EP23EO Patient Education, Cardiovascular Care Unit, Acuity Adaptable, Press Ganey, Instructions

about how to care for yourself at home

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EP23EO Advocate BroMenn Medical Center 24

• Care Management • Clinical Documentation Improvement • Clinical Education • Clinical Informatics • Clinical Resource Unit • Magnet • Nursing Directors • Nursing Managers • Nursing Operations • Palliative Care • Patient Safety • Quality Resource Management • Risk Management • Wound/Ostomy

PAIN

The graph above demonstrates that the 6 West Surgical Unit outperformed the benchmark eight of eight quarters.

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EP23EO Advocate BroMenn Medical Center 25

The graph above demonstrates that the Medical Oncology Specialty Unit outperformed the benchmark four of eight quarters.

The graph above demonstrates that the Progressive Care Unit outperformed the benchmark seven of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

MOSU mean 85.1 87.5 85.2 88.9 85.8 89.6 86.0 90.8PG (All Respondents, Lg

PG DB) Mean 87.1 87.2 87.0 87.2 87.3 87.5 87.4 87.6

70

80

90

100

Mea

n Sc

ore

EP23EO Pain, Medical Oncology Specialty Unit, Med-Surg, Press Ganey, How well your pain was

controlled

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

PCU mean 90.7 88.2 89.4 87.5 90.7 87.8 86.4 89.2PG (All Respondents, Lg

PG DB) Mean 87.1 87.2 87.0 87.2 87.3 87.5 87.4 87.6

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Pain, Progressive Care Unit, Step Down, Press Ganey, How well your pain was controlled

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EP23EO Advocate BroMenn Medical Center 26

The graph above demonstrates that the Intensive Care Unit did not have enough volume each quarter to have statistically meaningful data. The n size was too small for the vendor to provide data for the missing quarters. There are no standard pain cross walked questions on the Outpatient Services Press Ganey survey for Pediatrics/Outpatient Infusion. There is no department specific patient satisfaction data collected by the vendor for the Operating Room due to patients not being discharged from this unit.

The graph above demonstrates that the Mental Health Unit outperformed the benchmark five of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ICU mean 87.5PG (All Respondents, Lg PG

DB) Mean 87.0

70

80

90

100

Mea

n Sc

ore

EP23EO Pain, Intensive Care Unit, Critical Care, Press Ganey, How well your pain was controlled

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

Mental Health mean 97.9 94.6 95.9 95.7 96.7PG (All Respondents, Lg

PG DB) Mean 84.7 84.7 84.8 84.8 84.7

70

80

90

100

Mea

n Sc

ore

EP23EO Pain, Mental Health Unit, Psychiatric, Press Ganey, Degree to which staff asked if you had

any physical pain

survey began 3/1/15

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EP23EO Advocate BroMenn Medical Center 27

The graph above demonstrates that the Acute Rehabilitation Unit outperformed the benchmark six of eight quarters.

The graph above demonstrates that the Emergency Department outperformed the benchmark seven of eight quarters. There are no standard pain cross walked questions on the Outpatient Services Press Ganey survey for Cardiopulmonary Rehabilitation.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

ED mean 80.4 84.5 95.3 81.8 81.7 79.5 82.4 80.4PG (All Respondents,

Lg PG DB) Mean 79.0 79.2 78.9 78.5 79.5 79.6 79.5 78.7

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Pain, Emergency Department, Emergency Department, Press Ganey, How well

your pain was controlled

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EP23EO Advocate BroMenn Medical Center 28

The graph above demonstrates that the Center for Wound Healing and Hyperbaric Medicine outperformed the benchmark eight of eight quarters. Press Ganey does not collect department specific patient satisfaction data for Diabetic Education. There are no standard pain cross walked questions on the Outpatient Services Press Ganey survey for Cardiology, which includes Invasive and Non-Invasive Cardiology or for Radiology. Patients are not discharged from the Post Anesthesia Care Unit, therefore the vendor does not survey these patients.

3Q-2014

4Q-2014

1Q-2015

2Q-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

WHC mean 93.2 92.7 97.5 96.4 96.2 92.2 94.1 93.8PG Benchmark (All

Respondents, All Sites)Mean

88.8 88.4 88.8 89.2 90.4 90.5 91.5 91.4

70

80

90

100

Mea

n Sc

ore

EP23EO Pain, Center for Wound Healing & Hyperbaric Medicine, Specialty Practice, Press

Ganey, How well your (the patient's) pain was controlled

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EP23EO Advocate BroMenn Medical Center 29

The graph above demonstrates that Same Day Services outperformed the benchmark five of eight quarters.

The graph above demonstrates that the Cardiovascular Care Unit outperformed the benchmark seven of eight quarters. Department specific data is not collected by the vendor for Pre-admission Testing.

The graph above demonstrates that the Mother Baby Unit outperformed the benchmark eight of eight quarters.

3Q-2014

4Q-2014

Q1-2015

Q2-2015

3Q-2015

4Q-2015

1Q-2016

2Q-2016

CVCU mean 90.6 88.2 91.1 92.3 89.9 89.3 88.6 87.0PG (All Respondents, Lg

PG DB) Mean 87.1 87.2 87.0 87.2 87.3 87.5 87.4 87.6

70.0

80.0

90.0

100.0

Mea

n Sc

ore

EP23EO Pain, Cardiovascular Care Unit, Acuity Adaptable, Press Ganey, How well your pain was

controlled

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EP23EO Advocate BroMenn Medical Center 30

Press Ganey does not collect department specific patient satisfaction data for the following roles and departments/units:

• Cardiovascular Service Line • Care Management • Clinical Documentation Improvement • Clinical Education • Clinical Informatics • Clinical Resource Unit • Magnet • Nursing Directors • Nursing Managers • Nursing Operations • Palliative Care • Patient Safety • Quality Resource Management • Risk Management • Wound/Ostomy

The graphs above demonstrate that Advocate BroMenn Medical Center outperformed the majority of the eight quarters in the categories of Courtesy and Respect, Responsiveness, Patient Education and Pain. 9.14.16 jlm