PIMC Semiannual Report Patient Experience JanuaryJune 2017 FISCAL

PIMC Semiannual Report. Patient Experience January-June 2017

FISCAL YEAR END Patient Experience (7/1/16 -6/30/17) 7/11/2017 PIMC Target / Goal Description Press Ganey Inpatient Overall composite mean score Quarterly score meets Peace. Health FY 17 Care. Together target Press Ganey Inpatient Room section Quarterly score meets Press Ganey mean score 50 th percentile (as of Aug 2016) Less than or Greater Target/Goal than FY 2017 Frequency Threshold for Corrective Action Q 1 Q 2 Q 3 Q 4 FYTD Percent Rank FYTD ≥ 86. 4% Quarterly 85. 9% 91. 5% 97. 5% 90. 0% 87. 9% 90. 3% 83 ≥ 84. 3% Quarterly 82. 4% 90. 6% 100. 0% 84. 6% 88. 0% 79 Press Ganey Inpatient Pain Well Controlled question mean score Quarterly score meets Press Ganey 50 th percentile (as of Aug 2016) ≥ 87. 7% Quarterly 86. 3% 80. 0% 100. 0% 96. 4% 100. 0% 92. 2% 95 HCAHPS WOULD YOU RECOMMEND Quarterly score goal TBD in FY 18 ≥ 70% Quarterly 68. 0% 88. 9% 100. 0% 72. 7% 66. 7% 77. 8% 67 HCAHPS RN Communication Dimension Quarterly score meets Nursing Top Box Score Strategic Plan FY 17 Target ≥ 80. 6% Quarterly 71. 5% 66. 7% 100. 0% 94. 4% 84. 0% 81 ≥ 65. 1% Quarterly 57. 1% 68. 9% 100. 0% 81. 8% 73. 3% 74. 0% 81 ≥ 65. 6% Quarterly 54. 9% 66. 7% 100. 0% 80. 0% 76. 0% 94 HCAHPS Responsiveness of Staff Dimension Top Box Score HCAHPS Quiet at Nigjht Question Top Box Score Quarterly score meets FFY 18 (CY 16) VBP Achievement Threshold RN Leader Rounding Percent of Patients that recall being visited by a RN Leader ≥ 80. 0% Quarterly 60. 0% 75. 0% 100. 0% 70. 0% 100. 0% 77. 0% Hourly Rounding Percent of Patients that state they were checked on hourly by RN Team during the day ≥ 80. 0% Quarterly 60. 0% 44. 0% 100. 0% 55. 0% 60. 0% 54. 0% Press Ganey ED Overall Composite Mean Score Press Ganey ED Nurse Section Mean Score Quarterly score meets Strategic Plan FY 17 Target ≥ 96. 2% Quarterly 84. 3% 96. 2% 94. 4% 95. 5% 94. 5% 95. 3% 98 ≥ 96. 0% Quarterly 84. 4% 96. 5% 94. 6% 95. 8% 96. 7% 95. 9% 97 Press Ganey ED Doctor Section Mean Score Quarterly score meets Provider Contracts FY 17 Target ≥ 96. 0% Quarterly 84. 4% 98. 5% 94. 7% 94. 2% 93. 7% 95. 7% 99 Inpatient Nsize ED Nsize 9 137 1 99 11 88 6 78 27 402

Emergency Department Overview (January-June 2017) • Despite a small dip in scores, PIMC has been able to sustain it’s top box performance for several quarters. • In all of the Emergency Service Key Driver sections of care, PIMC remains above the 95 th percentile for the nation. (This means that PIMC scores above and beyond 95% of hospitals in the nations on all the key indicators that make up the Emergency Department care experience. These totals are based on patient feedback on post Emergency Dept. visit surveys) ALL PG DB= All Emergency Services client surveys returned for all hospitals in the entire Press Ganey Database. n=Number of surveys returned Mean = Average

Inpatient Experience Overview (January-June 2017) The biggest challenge in improving the care experience for admitted patients is that we don’t have a large enough admitted patient volume to be able to adequately measure how we are doing at providing care to our admitted patients. Between January 1 st and June 30 th we only received 17 inpatient surveys. We need at least 30 returned surveys to be able to validate the data as statistically significant. ALL PG DB= All Inpatient Hospital client surveys returned for all hospitals in the entire Press Ganey Database. n=Number of surveys returned Mean = Average

Outpatient Ambulatory Surgery (OAS) Overview (January-June 2017) • We are above the 50 th percentile in all but 2 sections of the survey. • We did see a small dip Jan-March. • Opportunities focus around our Registration process and information patients about delays and wait times. ALL PG DB= All OAS client surveys returned for all hospitals in the entire Press Ganey Database. n=Number of surveys returned Mean = Average

Patient/Family Comments Everyone was helpful & friendly. The sedation worked well & I felt no discomfort during the procedure, & had no recollection of it! I felt I wasn't priority because I only had a sprain knee. I was not given an in. DEPTH explanation initially, but when I asked for detail it was very readily supplied. Significant lag time between the nurse's work up and when MD actually arrived. A+ experience overall. I was very impressed with the team and the facility. I am so thankful to be able to have this service on island! I could not make the follow up appointment because doctor isn't at our hospital after enough. Peace Health ER in Friday Harbor, WA was the best possible experience a bloody cyclist could ask for! Warm, compassionate & highly skilled. Everyone was extremely helpful to my husband I. Assisted with lodging ideas and other needs including food and phone chargers! The Peace Island medical center is just a few minutes' drive from my home, which makes it VERY convenient when you live on an island. I felt that the nurses and doctor worked carefully and professionally with me before and during the procedure Nurse was concerned with my comfort & made sure I was out of pain before I left. All the doctors, I think the hospital should & nurses all came by to check on provide sleep masks for overnight me & wish me a fast recovery stays if wanted by patient. I was before I left. I especially hard to sleep! appreciated the "get well" and I received in the mail signed by all the nurses & tech. Very thoughtful. Tendency to NOT introduce self & name badges were turned over; left for extended periods without knowing what was happening; asked for glass of water - male RN asked if I had been given anything for pain yes - after a bit, RN came back with injection but forgot water. Had to wait til next staff person came in - *Dr. Sullivan was AMAZING!! (We didn't want to leave!! He was very informative. ) *Dr. Perez was outstanding! Very clear regarding treatment outcome and next steps. Did an excellent job of balancing my needs and the needs of other patients. Excellent communicator, explained fully why my treatment needed to be delayed.