1. Innovation in Care Delivery Symposium
HCAHPS – Moving the Needle
October 29, 2013
Rick Evans, MA
Senior Director – Service Excellence

2. Objectives
At the completion of this session participants will:
1. Have a deeper understanding of patient experience
surveys, metrics and reimbursement implications
2. Learn about effective interventions that impact
HCAHPS results
3. Link selected interventions with service metric
outcomes
4. Describe how interventions can be implemented and
sustained
-2-

3. The Context for Improvement
Surveys, Metrics and Emerging
Reimbursement Structures
-3-

4. Our Goal – Improving the Patient Experience
• Focus
 Fostering Patient and Family Centered Care
 Integrating with quality and safety work
• Service is improved the same way that quality is
improved:
By planning
By using data to choose tactics and set achievable targets
By engaging the entire team in the plan
By being clear about everyone’s role in achieving
improvement
 By holding everyone accountable for tasks and deadlines
 By keeping the team updated on progress
 By celebrating success!





5. HCAHPS Survey Basics
• HCAHPS is an acronym for “Hospital Consumer
Assessment of Healthcare Providers & Systems”
• This survey measures patients perception of “how
often” they felt they received high quality clinical and
customer service
• Random sampling of adult inpatient discharges
• Excludes psychiatry, rehabilitation, and pediatric
discharges
• MGH administers through a vendor (QDM) by phone

6. HCAHPS: Questions
RATE HOSPITAL 0-10
HOSPITAL ENVIRONMENT
Rating Scale: 9-10
Rating Scale: Always
Room and bathroom kept clean
RECOMMEND THIS HOSPITAL
Rating Scale: Definitely yes
COMMUNICATION W/ NURSES
Rating Scale: Always
Nurses treat with courtesy/respect
Nurses listen carefully to you
Nurses explained things in way you understand
Area around room quiet at night
PAIN MANAGEMENT
Rating Scale: Always
Need medicine for pain
Pain well controlled
Staff do everything help with pain
RESPONSIVENESS OF HOSP STAFF
COMMUNICATION RE: MEDICINES
Rating Scale: Always
Rating Scale: Always
Never pressed call button
Given medicine had not taken before
Call button help soon as wanted it
Tell you what new medicine was for
Need help with bathroom/using bedpan
Staff describe medicine side effect
Help toileting soon as you wanted
COMMUNICATION W/ DOCTORS
Rating Scale: Always
Doctors treat with courtesy/respect
Doctors listen carefully to you
Doctors explained things in way you understand
DISCHARGE INFORMATION
Rating Scale: Yes
Left hospital- destination
Staff talk about help when you left
Info re: symptoms/problems to look for

7. A New Era in Patient Experience
Coming for
Outpatient,
Surgical and
Pediatrics and
other areas in the
future…..
Our Mission
Excellence Every Day
Patient Experience Metrics
Operational Strength
Healthcare Reform
& Reimbursement
Our Reputation
Public Reporting of
Data

8. Healthcare Reform Efforts Puts Hospital Dollars at Risk
Value-based Purchasing
Process of care & Patient experience
Begins FY2013, full 2% annual payment update at risk by FY2017
30-Day Readmissions
Up to 8 conditions targeted including AMI, HF, PNA
1% DRG payment penalty beginning FY2013, rising to 3% by FY2015
Hospital-Acquired Conditions
Up to 8 conditions targeted
1% DRG payment penalty for hospitals in worst quartile beginning FY2015
By FY2017, $6 out of every $100 Medicare DRG reimbursement potentially is at risk

9. Reimbursement Methodology
• Attainment – Score for how well
we perform compared to peers
Everyone
• Improvement – Score for
else is
improvement over our own
improving
performance baseline
too!
Reimbursed for each domain based
on which score is highest

10. Innovation Units
Implementing Effective Interventions
- 10 -

11. Innovation Units – Focus Areas and Desired Outcomes
Focus
1. New Culture through Relationship-Based Care
2. New Role of Attending Nurse; Domains of Practice
3. Standardized Processes
 Throughput and LOS Reduction
 Technology
 Controlling Variation
 Implementing Evidence-Based Practice
Outcomes
1. Patient Satisfaction: care is equitable and patient- and familyfocused
2. Clinical Quality: to improve quality and to make care safer
3. Unit Cost Reductions: to make care more cost effective
4. Staff Satisfaction: to remain a great place to practice
- 11 -

12. How do we achieve “ALWAYS?”
“ALWAYS” Demands Consistency
Consistency = Across shifts, team
members, services and locations…
Standardized Best Practices create consistency!
SUCCESS!!

13. Innovations in Care Delivery “Patient Journey” Framework –
Initial 15 Interventions
Patient stay; direct patient care;
tests; treatments; procedures;
clinical support;
operational support
Discharg
e process
Intervention
Admission
process: ED,
direct admits,
transfers
After
Intervention
Intervention
Preadmission
care
During
Intervention
Before
Postdischarge
care
Goal: High-performing, inter-disciplinary teams that deliver safe, effective,
timely, efficient, and equitable care that is patient- and family-centered
Discharge Planning:
-Est. discharge date
-Discharge disposition
Domains of Practice
Daily Interdisciplinary Team Rounds
Electronic Unit Whiteboards
In-Room Whiteboards
Smart Phones
Wireless laptop computers/tablets
Business cards
Hourly rounding
Quiet hours
Welcome Packet (notebook
and discharge envelope)
Relationship-based care
♦
The Attending Nurse role
Copyright MGH 2012
- 13 -
♦
Discharge
-Follow-up Call Program
Hand-Over Rounding Checklist

14. Intervention: Welcome Packet
GOALS:
• Engage Patients and Families
• Facilitate Questions
• Encourage Teaching
• Facilitate Discharge
HCAHPS Indicators Impacted:
• Nurse Communication
• Doctor Communication
• Pain Management
• Communication About
Medicines
• Discharge Information

15. Introducing the Innovation Units
• Introduces Innovation
Units
• Assures patients and
families of continued
quality care
• Invites participation

16. The Compact - Inviting Patients and Families to Engage
• Invites patient and family
to be our partner
• Outlines patient and
family responsibilities
• Communicates our
promise to care and sets
expectations
• Sets a tone
• Invites Relationship
Based Care

17. Introducing the Team
• Orients patients and
families
• Patient friendly role
descriptions
• Facilitates discussion
and questions
• Situates patients and
families “on the team”

18. Encouraging Questions and Teaching
• Prompts questions and
important themes
• Facilitates teaching
• Collects and supports
discharge readiness
• A place to
integrate/collect family
questions and concerns

19. Success Factors - The Notebook
It only works if it is used:
• Use to build relationship – with patients and with families
• Use the notebook in daily rounds
• Promote with all care team members as appropriate
•
•
•
•
Use when conducting patient education
Promote with families whenever appropriate
Use to start and document discussions
Integrate with white board information

20. Success Factors - The Envelope
• Use from first day to introduce going home checklist
• Review with patients AND families – identify challenging
issues early
• Issues with special populations (ICU’s, Psych)
• Take out everytime material is given to the patient to
take home
• Use to hold all patient education materials
• Use Key Words - connect dots with materials and self
care after discharge

21. Communication: In-Room White Boards








A “communication basic”
Supports knowledge of care team
Builds relationships
Articulates patient’s goal
Keeps an eye on discharge
Can be integrated with notebook
and other teaching tools
Keeping the board current is
critical
It’s only as good a resource as it
is used…
- 21 -

22. Intervention: Quiet Times
 Designated hours on inpatient
units where activity and
conversation is minimized to
allow patients to rest
 Most effective model is to have
a period in the afternoon and
during the night when quiet
hours are observed
- 22 -

23. What happens during Quiet Times?
•
•
•
•
•
•
•
•
Communicate Quiet Times with
patients
Where possible, turn down lights
across the unit and in patient rooms
Close doors where possible
Minimize conversations in nursing
stations and other areas
Encourage visitors to take breaks to
let their loved one rest
Where possible, TV’s and music are
allowed for patients only when
headphones are used
Phone conversations are allowed
only in designated areas away from
patient rooms
Clinical interventions are minimized
or eliminated

24. The Quietness Effort at MGH
• Quiet Times – implementation, training and education
• Collaboration with Buildings and Grounds
•
•
•
•
Doors
Pneumatic Tubes
Door alarms
“Addressographs”
• Collaboration with Facilities
• Rolling stock work
• Collaboration with Food and Nutrition
• Galley kitchens
• Food delivery
• Outreach to all disciplines

25. Intervention: Discharge Follow-up Calls
 100% of patients in the inpatient setting being discharged to home
will be asked to consent to receiving a discharge follow-up call.
 Calls are made within 24-48 hours
 We estimate 3-5 calls per day per nurse or attending nurse
 Average call time is 3-5 minutes
 Standard is two attempts to reach patient
 Scripts are utilized
- 25 -

26. Why make these calls?
Service Benefits:
 Communicate care and concern
 Opportunity to assess overall impression of hospital
performance
 Opportunity for quick service recovery, if needed
 Opportunity for staff recognition
Clinical Benefits:
 Assess patient’s compliance with discharge instructions
 Evaluate understanding of patient education provided
before discharge
 Identify opportunities for improvements in practice

27. The Studer Patient Call Manager Program (PCM)
• Automates post-discharge
calling process
• Daily download of
discharges
• Scripts for callers to use
• Data for accountability
•
•
•
•
Call rates
Connect rates
Interventions
Summarizes feedback
• Ability to interface with
EMR
• Recognition features

28. Discharge Phone Calls Implementation
Number of units live as of September: 36
Calls made to date: 10,984
Call Attempt Rate: 96%
Call Completion Rate: 66%
Average call length: 5 minutes (approx.)
Peak calling times: 11:00 AM – 3:00 PM
Percent of calls with clinical advice or
care coordination given: 22%
• Percent of patients with questions about
their discharge instructions: 11%
• Popular Themes for Reward/Recognition:
oNursing Care (45%), Doctors (12%)
•
•
•
•
•
•
•
*Data for Patients discharged 4/5/13 – 9/4/13 on units
live with PCM

29. Intervention: Hourly Rounds – The Four Ps
Evidence-based research indicates that hourly rounding increases
patient satisfaction, decreases fall rates, decreases skin
breakdown rates, and increases staff satisfaction.
The Four Ps
Presence: Establish personal connection at the beginning
and end of each shift and with each hourly round
Pain: Assess and address patient’s pain
Positioning: Patient’s physical position and comfort;
Positioning of needed items within reach
Personal Hygiene: Help with toileting
- 29 -

30. Implementation - Three Key Elements of the Best Practice
1. Strengthening Rounding – Using the 4 P’s:
 Training for all staff
 Hourly Rounds using our process and scripts
2. Documentation of rounds in the presence of the
patient and family
 Two methods
 Bedside Logs
 White Boards
3. Validation of rounds by the nurse leader
 Rounds on 5 patients per week using log
 Feedback to staff
 Monitoring of HCAHPS results
30

31. The “HOW” - Presence
 With new patients and at the beginning of each shift:
 Focus on making a personal connection
 When possible – sit next to the bed at eye level
 Learn about the patient’s priority for the day/your shift
 Introduce the practice of Hourly Rounds
 Communicate your knowledge of the clinical plan for the
day/shift
 With each hourly round:




Reinforce that you are conducting your Hourly Round
Address the patient by name
Assure needs are met before leaving
Assure that someone will be back within the hour

32. The “WHAT” – The Three P’s
 Pain
 Assess and address
 Positioning
 Patient’s physical position and comfort
 Positioning of needed items within reach
 Personal Hygiene
 Help with toileting
 Attending to these basics improves outcomes
AND achieves efficiency

33. Hourly Rounding – A Team Response
MGH Model includes others:
 PCA’s
 Alternating hours through the day
 Other disciplines trained
 Trained to address “P’s” when they are in the room

34. Documenting the Hourly Rounds
 Rounds should be documented in the presence
of the patient
 Two Options for MGH Units:
 Use of the White Board
 Logs at the bedside
 Why is this important?
 Assures the practice is happening
 Reinforces the practice with patients and family

35. Validation – A Key Component
Methods to validate Hourly Rounding is happening
will include:
 Nurse Leader Rounding on patients and families
 Explicit questions on hourly rounding
 HCAHPS Survey
 Ask patients if they experienced Hourly Rounding
 Data from these validation sources will be
shared with staff

36. Innovation - Involving Patient Advocates
 Led by Office of Patient Advocacy
 Advocates assigned to units
 Tracking of complaints or issues
 Conducting focus groups
 Gathering data through patient and family interviews
 Co-Led development of some interventions
 Links to Patient and Family Advisor Councils (PFACs)
- 36 -

37. Did the Needle Move?
Summary of Results to Date
- 37 -

38. HCAHPS Results – 2011 vs. 2012
MGH-wide vs. Phase 1 Innovation Units
MGH
2012
Survey Measure
Nurse Communication Composite
Doctor Communication Composite
Room Clean
Quiet at Night
Cleanliness/Quiet Composite
Staff Responsiveness Composite
Pain Management Composite
Communication About Meds Composite
Discharge Information Composite
Overall Rating
Likelihood to Recommend
•
•
81.0
81.6
72.9
48.5
60.7
64.9
71.9
64.0
91.2
80.1
90.5
HCAHPS Data for Innovation Units
includes 6 units for which data is available
– Bigelow 14, Blake 13, Ellison 16, Lunder
9, White 6 and White. Data not available
for ICU’s and Psych.
Date pull: 3.04.13
Change
(2011 - 2012)
+1.6
-0.3
+3.1
+3.3
+3.2
+1.3
+0.4
+1.3
+1.4
+1.0
+1.1
Innovation
Change
Units 2012 (2011 - 2012)
80.8
82.0
70.6
49.8
60.2
64.0
73.3
65.7
92.3
78.5
90.3
+4.5
+0.5
+4.2
+6.2
+5.2
+1.7
+3.7
+6.8
+2.7
+2.4
+2.4
KEY
2012 Score exceeds that of entire hospital
Rate of Improvement Exceeds that of the entire hospital
- 38 -

39. HCAHPS Results – Q2 YTD
MGH-wide vs. Phase 2 Innovation Units
2013 YTD
Survey Measure
2013 Quarter 2 YTD
MGH Overall Phase 2 Units MGH Overall Phase 2 Units
Nurse Communication Composite
Doctor Communication Composite
Room Clean
Quiet at Night
Cleanliness/Quiet Composite
Staff Responsiveness Composite
Pain Management Composite
Communication About Meds
Composite
Discharge Information Composite
Overall Rating
Likelihood to Recommend
•
•
80.6
81.7
74.2
50.1
62.1
63.5
71.1
80.4
81.5
74.6
50.3
62.4
62.8
72.2
81.3
82.1
75.6
52.3
63.9
65.0
71.9
65.1
65.1
68.0
81.5
81.8
77.0
53.2
65.1
64.6
74.2
69.4
91.3
80.1
90.4
90.8
79.8
90.2
92.5
80.1
91.3
92.1
80.5
92.2
* HCAHPS Data for Innovation Units
includes 22 units for which data is
available – Blake 6, Bigelow 6, 9,11,13,
Ellison 6,7,8,10,11,13,19, Lunder 7,8,10,
Philips House 20,21,22, White 8,9,10,11
Date pull: 6.26.13
KEY
Phase 2 Units Score exceeds that of entire
hospital
- 39 -

40. HCAHPS Indicator Results - Quiet at Night
How has Quiet at Night (Top Box %) been evolving over time?
Our patients
Upper/lower natural process limit
% of maximum achie vable score
52
50
48
46
Quiet
Times
Launched
44
42
Q3-2011
Q4-2011
Info Box
Organization: MGH
Survey: HCAHPSPlus
Date Range: Range: 7/1/2011~6/30/2013
Q2-2012
Cases Per Point
Cases Per Point
4
8
32
64
256
512
2048
4096
Q4-2012
16
128
1024
8192
Date Range
Date Range
By Month
By Quarter
By 6 Months
By Year
* Period incomplete
Q2-2013

41. HCAHPS Indicator Results - Nurse Communication
How has Nurse Communication (Top Box %) been evolving over time?
Our patients
Upper/lower natural process limit
% of maximum achievable score
84
82
80
78
76
Q3-2011
Q4-2011
Info Box
Organization: MGH
Survey: HCAHPSPlus
Date Range: Range: 7/1/2011~6/30/2013
Q2-2012
Cases Per Point
Cases Per Point
4
8
32
64
256
512
2048
4096
Q4-2012
16
128
1024
8192
Date Range
Date Range
By Month
By Quarter
By 6 Months
By Year
* Period incomplete
Q2-2013

42. HCAHPS Indicator Results - Discharge Information
How has Discharge Info (Top Box %) been evolving over time?
Our patients
Upper/lower natural process limit
% of maximum achievable score
94
93
92
91
90
89
88
Q3-2011
Q4-2011
Info Box
Organization: MGH
Survey: HCAHPSPlus
Date Range: Range: 7/1/2011~6/30/2013
Q2-2012
Cases Per Point
Cases Per Point
4
8
32
64
256
512
2048
4096
Q4-2012
16
128
1024
8192
Date Range
Date Range
By Month
By Quarter
By 6 Months
By Year
* Period incomplete
Q2-2013

43. What we know…
• Our chosen best practices
are evidence based
• They require commitment
to implement, but…
• These practices work!
• Phase one results are
compelling
• Phase two results show
similar promise
• Focus – sustaining
practices and
improvement

44. Anything else I can do for you?
Rick Evans
Senior Director – Service Excellence
Massachusetts General Hospital and Mass General
Physicians Organization
revans6@partners.org
617-724-2838