Working to Improve the

Patient Experience

March 12, 2013 2 – 3:30pm

Arizona Critical Access Hospital Quality Network

Arizona Rural Hospital Flexibility Program

AZ-CAH Quality Network

CAH Participants

Benson Hospital Teresa Vincifora Ora Goodman

Carondelet Holy Cross Hospital Karen Nestor Marilyn Majalca

Cobre Valley Community Hospital Kara Holcomb

Copper Queen Community Hospital Claudia Romo Sadie Maestas

Hopi Health Care Center TBD

Hu Hu Kam Memorial Hospital Sarah Wolterman

Little Colorado Medical Center Sonia Ybarra Leslie Fusaro

Northern Cochise Community Hospital Susan Cazaux

Page Hospital Michelle McCabe

Parker Indian Health Center Sherry Killingsworth Lily Shimahara

Sage Memorial Hospital Christi El-Meligi

Southeast Arizona Medical Center Annie Benson Robi Berry

White Mountain Regional Medical Center Cherie Passalacqua

Wickenburg Community Hospital Linda Brockwell Judy Carroll

Purpose of Today’s Webinar

• Strengthen the AZ-CAH Quality Network

• Support hospitals in selecting QI project to improve patient satisfaction

• Discuss process for sharing HCAHPS Scores

• Introduce MBQIP / Hospital Compare Reports

• Identify next steps

I. Welcome and Introductions

II. HCAHPS Update

III. Pt. Satisfaction QI Projects

a. Discussion with members

b. Cobre Valley Regional Medical Center – Pain Management

IV. Next Steps

V. Medicare Beneficiary Quality Improvement Project (MBQIP) Quality Reports

VI. Summary & Evaluation

Agenda

HCAHPS Reported by Hospitals

Established New to HCAHPS Not currently

Carondelet Holy Cross Benson Hospital Hopi Health Care Center

Cobre Valley Reg. Medical Ctr. Hu Hu Kam Memorial Hospital Little Colorado Medical Center

Copper Queen Comm. Hospital Northern Cochise Comm. Hospital Parker Indian Health Center

Page Hospital White Mountain Reg. Med. Ctr. Sage Memorial Hospital

Wickenburg Comm. Hospital Southeast Arizona Medical Ctr.

• How are you receiving HCAHPS data? – What frequency? – What format? – What kinds of reports?

• How are you using HCAHPS information? – Who receives reports? – What hospital areas

• Are you satisfied? – Examples of use – Suggestions for improvement?

• What questions do you have?

Discussion

Sample HCAHPS Vendor Report

• Track performance over time

Sample Healthstream HCAHPS Benchmarking Report

Pt. Satisfaction - QI Project Ideas

Category/HCAHP Proposed QI Projects

Staff Responsiveness Close the loop of patient falls

Pain Management

We have initiated a Pain Management policy, completed staff education regarding the policy and pain

assessment, and have initiated chart audits to monitor that pain is being addressed, and re-evaluated.

Nursing care areas are using educational tools to assist in developing a pain management plan with

patients. Nurses are also required to reassess pain after a pain medication has been given and document

it in the medical record. If the reassessed pain score is above the patient’s pain goal, the nurse is required

to intervene (call physician for additional orders, teach relation techniques, etc.). Compliance is

monitored and reported monthly at Quality Council.

Hospital Environment

Quiet at night initiative to raise awareness of needed rest for healing and dedicating quiet time on units

Physician communication to increase transparency of reporting scores

Top Tactics-Purposeful Patient Rounding, Leading Rounding

ED Waiting Times

Reduce no show rate

Tracking the time it takes from Doctors order to transfer-to-floor

Communication Physician communication to increase transparency of reporting scores

Discharge

Follow up phone calls to patients when discharged

Making appointments for follow up when patients leave the hospital

Emergency Room patient discharge follow up phone calls

Other Need to choose an HCAHPs vendor and then will pick a project.

• How did you select the project

• What data did you use?

• Who was / is involved?

• How will QI project information be monitored?

• How does it fit into existing hospital QI projects

• Is there an Aim Statement?

QI Projects Presentations

Cobre Valley Regional Medical Center

HCAHPS Improvement Project: Pain Management

AZ-CAH Example

Patient Experience: OB

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Pain Controlled

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Pain Assessed Every Hour

Patient Experience: OB

QI Project Selection

Staff

Hospital Data Patients & Families

Patient Communication

Lower HCAHPS Scores

Leadership Team

Incident Reports

Family Communication

Direct Reporting to Quality

Selection of QI Project

HCAHPS Survey: Pain Management (Q12-14)

Abstracted from Hospital Compare (December 2012, Bullock) * Fewer than 100 patients completed the HCAHPS survey. Use scores with caution, as number of surveys may be too low to reliably assess hospital performance. ** There were discrepancies in the data collection process.

HCAHPS Survey: Medication Management (Q15-17)

0 20 40 60 80 100

Cobre Valley Regional Medical Center **

Copper Queen Community Hospital *

Carondelet Holy Cross

Page Hospital

Arizona Average

% Patients who reported that staff "Always" explained about medicines before giving it to them.

Abstracted from Hospital Compare (December 2012, Bullock) * Fewer than 100 patients completed the HCAHPS survey. Use scores with caution, as number of surveys may be too low to reliably assess hospital performance. ** There were discrepancies in the data collection process.

kk Best Practices: Pain Management

Patients who reported that their pain was "Always" well controlled

Tactics that make “Always” responses more likely 1. Use Individualized Patient Care to Manage

Patient Perception of Pain 2. Conduct Hourly Rounding to Consistently

Address Pain 3. Pain Poster

Source: The HCAHPS Handbook, Studor (2010)

Next Steps

• Communication – develop project ideas - Flex staff and AZ-CAH Quality Network peers

- Situational analyses with your hospital teams

• Identify QI projects - Aim Statements

• AZ-CAH Quality Network webinar

• Attend AZ-CAH workshop

• Technical Assistance available

• Share HCAHPS data

Answer the question, “What are we trying to accomplish”?

Communicate expectations

Are time specific

Are measureable

Define the specific population or populations affected

Are clear and unambiguous

Can be used in your elevator speech

They aim BIG

Source: Dr. Andrea Silvey, HSAG, adopted from Institute for Healthcare Innovation

Effective Aim Statements

• Flex Guidance (May 2) • Team STEPPS training (April 9-10) • AZ-CAH Quality Network webinar (April) • AZ-CAH Quality Network workshop (May or June)

– Location (tbd) – Date (tbd)

• Quality Programs in the IHS, Dorothy Dupree. (April 16) – Arizona Telemedicine Program Grand Rounds – CME available – Live Stream details forthcoming

• Billing and Coding Boot Camp, (April 22-24), Phoenix – Certification – Preparation webinar (Date tbd)

• Computerized Physician Order Entry (CPOE), Peter Catinella, MD & Clint Hinman,PhD – Arizona Telemedicine Program Grand Rounds – CME available – Live Stream details forthcoming

Upcoming Events

Date / location for face-to-face

• Poll

• Please send HCAHPS scores / reports

• Develop your QI projects

• Communicate TA service needs

• AZ-CAH Workshop (May / June) – Aims Statement

– Needs assessment / situation diagnosis

– Share quality reports

– Strategies to improve pt. satisfaction

– Strategies to analyze data

Homework

Medicare Beneficiary Quality Improvement Program (MBQIP)

• Participation Agreements signed – 11 AZ-CAHs – 1,139 National CAHs

• Encourage participation in Hospital Compare / HCAHPS – Phase 01 Measures (Pneumonia / HF) – Phase 02 Measures (HCAHPS, Outpatient) – Phase 03 Measures (ED & Pharmacy, Sept 2013)

• AZ-Flex working in collaboration with HSAG • First MBQIP report release (Dec. 2012)

– Data Aggregated for four quarters to increase #s

• Second Data release (expected May 2013)

MBQIP Report: One Year Aggregate Data (Q4, 2011 – Q3, 2012)

Four Quarter Aggregate Current Quarter

Quality Measure

A H G K F B D All

Reporting

AZ-CAHs

State

Avg.

National

Avg.

Discharge Instructions 30% 67% N/A 100% N/A 33% 80% 47% 67% 83%

Evaluation of LVS

Function 78% 73% N/A 50% N/A 33% 100% 70% 43% 85%

ACEI or ARB for LVSD 100% 100% N/A 100% N/A N/A 100% 100% 100% 87%

Blood Cultures

Performed in ED Prior

to Initial Antibiotic

100% 90% N/A 0% 95% 67% 89% 90% 77% 95%

Initial Antibiotic

Selection for

Community-Acquired

Pneumonia in

Immunocompetent

Patients

85% 88% N/A 0% 100% N/A 100% 100% 89% 89%

Source: Teligen, HRSA Office of Rural Health Policy, Dec. 2012 * ACEI or ARB for LVSD: Heart failure patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge.

MBQIP “Take Home” Messages

• Report to Hospital Compare (even small numbers)

• Health Services Advisory Group Resources

– Hospital Compare & QualityNet –

• cchapin@hsag.com or sgerhart@hsag.com

• Flex (and SHIP) funding being tied to MBQIP

• Emphasis on healthcare quality & value

Thank You!

Arizona Rural Hospital Flexibility Program This webinar is made possible through funding provided by the Health Resources and Service

Administration, Office of Rural Health Policy, Medicare Rural Hospital Flexibility Program

Please call us / your peers with any

related thoughts / feedback