Introduction to HCAHPS Finding the pulse of your

  • Slides: 34
Download presentation
Introduction to HCAHPS Finding the pulse of your busines

Introduction to HCAHPS Finding the pulse of your busines

Objectives ØOverview of HCAHPS q. Sampling q“Top Box” Methodology q. Life Cycle of a

Objectives ØOverview of HCAHPS q. Sampling q“Top Box” Methodology q. Life Cycle of a Survey q. HCAHPS National Performance ØHCAHPS Star Ratings ØJLM Power BI Survey Reports

HCAHPS ØOverview of HCAHPS q. Sampling q“Top Box” Methodology q. Life Cycle of a

HCAHPS ØOverview of HCAHPS q. Sampling q“Top Box” Methodology q. Life Cycle of a Survey q. HCAHPS National Performance ØHCAHPS Star Ratings ØJLM Power BI Survey Reports

What is CAHPS? CAHPS Consumer Assessment of Healthcare Providers and Systems ØDeveloped by AHRQ

What is CAHPS? CAHPS Consumer Assessment of Healthcare Providers and Systems ØDeveloped by AHRQ to provide customers a standardized survey of 27 questions evaluating their patient experience q. Results are transparent q. Can be used for comparisons q. Help them make a better informed decision * WWW. HCAHPSONLINE. ORG

HCAHPS Composite Measures Composite Questions Communication with Nurses Communication with Doctors Staff Responsiveness Pain

HCAHPS Composite Measures Composite Questions Communication with Nurses Communication with Doctors Staff Responsiveness Pain Management Communication about Medicines Cleanliness and Quietness Discharge Instructions Always Usually Sometimes Never Rating from “ 0” (Poor) to “ 9/10” (Excellent) Overall Rating Definitely “Yes” Probably “Yes” No Would you recommend Care Transition (Reported Oct 14) * www. hcahpsonline. org Responses * WWW. HCAHPSONLINE. ORG Strongly Agree Disagree Strongly Disagree Bold=“Top Box”

Who Is Surveyed Under CMS Guidelines? ØEligible patients are: ØPatients discharged from short-term, acute

Who Is Surveyed Under CMS Guidelines? ØEligible patients are: ØPatients discharged from short-term, acute care hospitals ØAge 18 or over ØNon-Psychiatric DRG/principal diagnosis at discharge ØAt least one night stay ØExcluded Patients Ø“No publicity” patients ØPatients admitted to hospital from Police custody ØDischarges with a foreign home address ØDischarges to Hospice/Nursing Home/SNF * WWW. HCAHPSONLINE. ORG

HCAHPS Methodology ØPhone methodology ØStandardized script ØComplex procedures ØBegin calls at least 48 hours

HCAHPS Methodology ØPhone methodology ØStandardized script ØComplex procedures ØBegin calls at least 48 hours after discharge Ø 1 st call made before 42 days after discharge Ø 5 attempts for all randomly selected patients q. Different times of the day q. Different days of the week q. Different weeks q. Must span over 8 days ØLast call completed 42 days after 1 st attempt ØCallers can not leave voicemail * WWW. HCAHPSONLINE. ORG

HCAHPS Mix and Mode Adjustments ØBefore scores are published to the public, HCAHPS scores

HCAHPS Mix and Mode Adjustments ØBefore scores are published to the public, HCAHPS scores are also mix and mode adjusted q Patient Mix (Determined by patient populations, service line, demographics, etc. . ) q Mode Adjusted by Survey Type (Phone only, mixed, IVR) * WWW. HCAHPSONLINE. ORG

HCAHPS Mix and Mode Adjustments (Phone Survey) HCAHPS Composite Nursing Communication Doctor Communication Responsiveness

HCAHPS Mix and Mode Adjustments (Phone Survey) HCAHPS Composite Nursing Communication Doctor Communication Responsiveness Pain Management Communication Medications Discharge Information Cleanliness Quietness Would Recommend Overall Rating * WWW. HCAHPSONLINE. ORG Mode Adjustment (Phone) -4. 2% -2. 8% -0. 8% -3. 7% -1. 7% -2. 8% -8. 6% -3. 5% -2. 0%

HCAHPS vs. Patient Satisfaction Scores Ø Because of the CMS methodologies, patient mix and

HCAHPS vs. Patient Satisfaction Scores Ø Because of the CMS methodologies, patient mix and mode adjustments, HCAHPS scores should correlate, but will not match your internal scores ØThis explains why the HCAHPS national averages are currently at 75% to 80%. Example Composite Score HCAHPS “Top Box” (Mix and Mode Adj) Patient Satisfaction “Overall Average” (No adjustments) Nursing Communication 76% 89%

Takeaway Always compare your HCAHPS scores to the rest of the country (79% may

Takeaway Always compare your HCAHPS scores to the rest of the country (79% may actually be top in the nation!) * WWW. HCAHPSONLINE. ORG

HCAHPS “Top-Box” Scores [Oct ’ 12 – Sept ’ 13] Measure Description NATIONAL AVERAGE

HCAHPS “Top-Box” Scores [Oct ’ 12 – Sept ’ 13] Measure Description NATIONAL AVERAGE Patients who reported that their nurses "Always" communicated well 79% Patients who reported that their doctors "Always" communicated well 82% Patients who reported that they "Always" received help as soon as they wanted 68% Patients who reported that their pain was "Always" well controlled Patients who reported that staff "Always" explained about medicines before giving it to them Patients who reported that their room and bathroom were "Always" clean 71% Patients who reported that the area around their room was "Always" quiet at night Patients who reported that YES, they were given information about what to do during their recovery at home Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) Patients who reported YES, they would definitely recommend the hospital 61% Source: hospitalcompare. hhs. gov [Accessed: 8/28/14] 64% 73% 85% 71%

Life Cycle of a Survey (HCAHPS) Patient discharged from hospital Hospital assigns DRG and

Life Cycle of a Survey (HCAHPS) Patient discharged from hospital Hospital assigns DRG and upload to FTP site JLM receives file, scrubs data, survey (5 Calls) (Must span 8 days) COMPLETED By end of third week, first week of discharges surveys begin*

Outcome) Pt D/C Survey/Cmp

Outcome) Pt D/C Survey/Cmp

HCAHPS Star Ratings

HCAHPS Star Ratings

Star Ratings ØAs part of a new initiative to add five-star quality ratings to

Star Ratings ØAs part of a new initiative to add five-star quality ratings to its Compare Web sites, the Centers for Medicare & Medicaid Services (CMS) will add HCAHPS Star Ratings to the Hospital Compare Web sit q. Easier for consumers to spotlight excellence in healthcare quality q. Will be based on the same HCAHPS questions q. Star ratings for each composite plus new “HCAHPS Summary Star Rating” * WWW. HCAHPSONLINE. ORG

Scoring Methodology ØStar ratings will NOT follow “Top Box” methodology ØCMS employs all survey

Scoring Methodology ØStar ratings will NOT follow “Top Box” methodology ØCMS employs all survey responses in the construction of the HCAHPS Star Ratings q. Each response assigned a score q. Scores are calculated, assigned an average and rounded up or down q. Final scores will be patient mix and mode adjusted * WWW. HCAHPSONLINE. ORG

Scoring Methodology Example * WWW. HCAHPSONLINE. ORG

Scoring Methodology Example * WWW. HCAHPSONLINE. ORG

Power BI Survey Reporting Tool

Power BI Survey Reporting Tool

e. Med Survey Reporting Tool* ØProvides snapshot regarding the patient’s experience for: ØHCAHPS, Home

e. Med Survey Reporting Tool* ØProvides snapshot regarding the patient’s experience for: ØHCAHPS, Home Health, Emergency Department or Outpatient Services Ø Available in real-time upon completion of surveys ØAble to trend monthly, quarterly or annually ØQuery – Analyze multiple levels of data on demand * JLM Proprietary Database

Getting the most out of e. Med reporting 1. 2. 3. Run high level

Getting the most out of e. Med reporting 1. 2. 3. Run high level reports to identify trends or areas for improvement Utilize Top Box and Monthly reports to drill down further to discover areas of concern Share information with staff and develop action plans based on findings

Story of Any USA Hospital ØAny USA Hospital wants to evaluate their HCAHPS scores

Story of Any USA Hospital ØAny USA Hospital wants to evaluate their HCAHPS scores and see where there is room for improvement ØNeed to run reports and analyze the data on a number of levels ØRun e. Med survey reports to accomplish this Ø CMS HCAHPS National Comparison Ø Data Summary (Trending) Ø Top Box HCAHPS by Area Ø Top Box HCAHPS by Facility (System) Ø Query for further analysis

Login to client site 1. Login to https: //emedsurvey. com 2. Enter Username and

Login to client site 1. Login to https: //emedsurvey. com 2. Enter Username and Password (contact JLM if you do not have a username assigned. Client Login: https: //www. emedsurvey. com

Login to client site 1. Login to https: //emedsurvey. com 2. Enter Username and

Login to client site 1. Login to https: //emedsurvey. com 2. Enter Username and Password (contact JLM if you do not have a username assigned. 3. From this page, you can decide to select “Reports” or run a query from the database. Client Login: https: //www. emedsurvey. com

Running Reports 1. Login to https: //emedsurvey. com 2. Enter Username and Password (contact

Running Reports 1. Login to https: //emedsurvey. com 2. Enter Username and Password (contact JLM if you do not have a username assigned. 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) Client Login: https: //www. emedsurvey. com

Report Examples CMS HCAHPS National Comparison • 11 HCAHPS Composites • Compares your hospital

Report Examples CMS HCAHPS National Comparison • 11 HCAHPS Composites • Compares your hospital against the National Rankings (50 th, 75 th, 90 th) • CMS Mode adjusted • Color coded for easy identification Client Login: https: //www. emedsurvey. com Identified below national average in “Communication Medications” composite

Report Examples Data Summary with Trending • Displays individual measures for each 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 Client Login: https: //www. emedsurvey. com

Report Examples Data Summary with Trending (cont’d) • Displays each measure individually • Identifies

Report Examples Data Summary with Trending (cont’d) • Displays each measure individually • Identifies Trends Client Login: https: //www. emedsurvey. com Performing lower in “describing side effects”

Report Examples Top Box HCAHPS Areas • Breaks down HCAHPS scores by unit or

Report Examples Top Box HCAHPS Areas • Breaks down HCAHPS scores by unit or location • Identify largest areas for improvement • Top Box scoring Client Login: https: //www. emedsurvey. com By area shows lower scores in Post Partum and 5 th floor

Report Examples Top Box HCAHPS Facility Report • Compare hospital scores across the system

Report Examples Top Box HCAHPS Facility Report • Compare hospital scores across the system • Specific to hospital or system • Collaboration Client Login: https: //www. emedsurvey. com A B C D E F

Report Examples Weighted Response Summary • Previously known as “Top Box” report • Displays

Report Examples Weighted Response Summary • Previously known as “Top Box” report • Displays question percentage scores for each type of response • Very Poor • Fair • Good • Very Good Works for Inpt, ER, Outp Client Login: https: //www. emedsurvey. com

Report Examples Quarterly Benchmark • Displays Quarterly Data compared to the JL Morgan DB

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 Client Login: https: //www. emedsurvey. com

Queries Filter Data • Select the question you want to drill down on further

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 Client Login: https: //www. emedsurvey. com Could this be a result of scoring poorly with “Response to call button”?

Contact Us: Jeff Morgan, President 205 -408 -8774 Office Jeff. morgan@jlmassoc. com Tanya Harris-Haynes

Contact Us: Jeff Morgan, President 205 -408 -8774 Office Jeff. morgan@jlmassoc. com Tanya Harris-Haynes CAHPS Director 205 -995 -7144 Office tanya. harris@jlmassoc. com Kory Kasey, Research & Client Education 205 -739 -2314 Office Kory. Kasey@jlmassoc. com Wendy Dew HR/CAHPS Manager 205 -995 -7107 Office Wendy. dew@jlmassoc. com J. L. Morgan & Associates 7057 Meadowlark Drive| Birmingham, Al 35242 205 -995 -4226 | Fax: 205 -995 -7141 www. Jlmorganandassociates. com Latrice Lawson Data Manager 205 -995 -7139 Office Latrice. lawson@jlmassoc. com