Transcript Document

HCAHPS
HFMA Annual Hot Topics Update
November 17, 2011
Presented by:
Wanda Koroniotis RN, BSN, MM
Director of Quality & Outcomes
What is HCAHPS?
Hospital Consumer Assessment of Healthcare
Providers and Systems
 National, standardized, publicly reported survey of
patient's perceptions of care
 Developed by CMS & AHRQ (Agency for
Healthcare Research & Quality).
 Hospitals must submit a minimum of 300 surveys
for each reporting period
 HCAHPS survey eligibility is any patient 18 years
of age or older discharged after an overnight stay,
not limited to MC beneficiaries
 Given to a random sample of patients between 48
hrs & 6 weeks after discharge
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HCAHPS GOALS
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Produces data about patients’ perspectives of
care that allow objective & meaningful
comparisons of hospitals on topics that are
important to consumers
Public reporting of the survey results creates
new incentives for hospitals to improve care
Public reporting serves to enhance
accountability in health care by increasing
transparency of the quality of hospital care
provided in return for the public investment
Questions Contributing to
HCAHPS Ratings
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Willingness to Recommend
Would you recommend this hospital to your
friends and family?
Communication with Nurses
During this hospital stay, how often did
nurses treat you with courtesy and respect?
During this hospital stay, how often did
nurses listen to you?
During this hospital stay, how often did
nurses explain things in a way you could
understand?
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Communication about Medications
Before giving you any new medicine, how often
did hospital staff tell you what the medicine
was for?
Before giving you any new medicine, how often
did hospital staff describe possible side effects
in a way you could understand?
Communication with Doctors
During this hospital stay, how often did doctors
treat you with courtesy and respect?
During this hospital stay, how often did doctors
listen carefully to you?
During this hospital stay, how often did doctors
explain things in a way you could understand?
 Pain Management
During this hospital stay, how often was your
pain well controlled?
During this hospital stay, how often did the
hospital staff do everything they could to help
you with your pain?
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Cleanliness of the Hospital Environment
During this hospital stay, how often were your
room and bathroom kept clean?
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Quietness of the Hospital Environment
During this hospital stay, how often was the area
around your room quiet at night?
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Responsiveness of Hospital Staff
During this hospital stay, after you pressed the call
button, how often did you get help as soon as you
wanted it?
How often did you get help in getting to the bathroom
or in using a bedpan as soon as you wanted?
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Discharge Information
During this hospital stay, did doctors, nurses or other
hospital staff talk with you about whether you would
have the help you needed when you left the hospital?
During your hospital stay, did you get information in
writing about what symptoms or health problems to
look out for after you left the hospital?
Strategic & Quality Goals
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HGB determined that we needed a clear quality
direction with an evolving vision that included not
only hospital quality, but also the communities
health & vitality.
We accomplished an in depth look at quality and
patient safety, by engaging a nurse consultant &
getting input from the trustees, C-suite, leadership
team, physicians and staff.
Ten teams consisting of leadership and frontline
staff were formed in 3Q10, one for each of the
objectives established. Their first task was to
collect baseline data for their goal by December
2010, and then develop PI plans, utilizing the PDCA
format to accomplish the goals.
Strategic & Quality Goals (con’t)
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A strategic planning approach included convening a Quality
Strategic Planning Team in March 2009 consisting of the
CEO, CNO, CFO, VP of Professional Services, Director of
Quality, a trustee, and physician; conducting an
organizational needs assessment between March – August
2009, completion of a SWOT analysis by members of the
Quality Council May 2009; quality surveys completed by
leadership team members and staff; provided joint
physician/board education; leadership team members
completed IHI’s on-line learning related to quality and
patient safety; and compiled and shared feedback from
board members, physicians, leadership team and
employees.
Strategic & Quality Goals (con’t)
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While the hospital’s previous strategic plan
had a quality component, the plan was
strengthened in the FY12 Strategic Plan to
include under the goal of Excellence: HGB will
promote an integrative approach and
maintain infrastructures that drive high level
of quality.
Strategic & Quality Goals (con’t)
 The Quality Strategic Planning Team crafted a
new quality vision: We are “Safe, Effective
and Well-prepared for You” with guidance
and input from Medical Staff, the Board of
Trustees, and Leadership throughout the
organization. The Quality Strategic Planning
Team established Ten (10) quality goals with
measurable objectives.
Quality Vision
We are Safe, Effective and Well Prepared for You
Safe
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Live a Culture of Safety
Achieve Quality and Safety Goals
Reduce Variation in Quality and Safety Processes
Effective
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Promote Health and Wellness
Achieve Evidenced Based and Best Practices
Improve Quality of Life through Disease Management
Well Prepared
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Demonstrate Operational and Clinical Competency
Enhance Emergency Preparedness
Be Organized
For You
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Develop an Exceptional Experience
Let’s All Take a Peek at
Our Data…..
http://www.hospitalcompare.hhs.gov
Then Along Comes a
Spider…. Value Based
Purchasing (VBP)
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The Hospital Value-based Purchasing Program,
beginning in FY 2013 applies to payments for
discharges occurring on or after October 1, 2012
CMS will make value-based incentive payments (1%
of MC reimbursement) to acute care hospitals,
based on:
 70% on how well the hospitals perform on certain
CMS quality measures
 30% based on patient experience scores called
HCAHPS
Proposed FY 2013 Domains
and Measures/Dimensions
Proposed Hospital VBP Measures
for FY 2014 (1 of 3)
Proposed Hospital -Acquired Condition Measures:
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Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III & IV
Falls and Trauma: includes Fracture, Dislocation,
Intracranial Injury, Crushing Injury, Burn, Electric
Shock
Vascular Catheter-Associated Infections
Catheter-Associated Urinary Tract Infection (UTI)
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Manifestations of Poor Glycemic Control
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Proposed Hospital VBP Measures
for FY 2014 (2 of 3)
Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Indicators (PSI), Inpatient Quality Indicators
(IQI), and Composite Measures:
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1.PSI 06 –Iatrogenic Pneumothorax, adult
2.PSI 11 –Post-Operative Respiratory Failure
3.PSI 12 –Post-Operative Pulmonary Emboli (PE) or Deep Vein Thrombosis
(DVT)
4.PSI 14 –Postoperative Wound Dehiscence
5.PSI 15 –Accidental Puncture or Laceration
6.IQI11 –Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate (with or
without volume)
7.IQI19 –Hip Fracture Mortality Rate
8.Complication/Patient Safety for Selected Indicators (composite)
9.Mortality for Selected Medical Conditions (composite)
Proposed Hospital VBP Measures
for FY 2014 (3 of 3)
Proposed Mortality Measures:
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MORT-30-AMI: Acute Myocardial Infarction
(AMI) 30-Day Mortality Rate
MORT-30-HF: Heart Failure (HF) 30-Day
Mortality Rate
MORT-30-PN: Pneumonia (PN) 30-Day
Mortality Rate
QUESTIONS?