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How Hospitals Can Raise Patient Satisfaction, CAHPS Scores

Sara Heath

Editor
sheath@xtelligentmedia.com

Improving patient satisfaction scores, such as CAHPS, is key for driving practice reputation and reimbursements.

Healthcare organizations with high patient satisfaction and CAHPS scores see a multitude of benefits. High patient satisfaction scores usually result in higher reimbursement payments from CMS, better patient retention rates, and the assurance for hospital staff that they fostered a positive experience for patients.

A May 2016 report from Vocera showed that patient satisfaction is the top-ranked priority at healthcare organizations. Due to the importance of ensuring favorable feedback from patients, the demand for patient experience officers and patient advocate executives is increasing, with these professionals pulling equal rank with other C-suite executives, the report said.

The primary measure for patient satisfaction is the Consumer Assessment of Healthcare Providers and Systems (CAHPS). The CAHPS survey is developed and funded by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS, and forms a component of some value-based reimbursement programs.

CMS also uses CAHPS scores to inform its star ratings, which are publicly available ratings about the quality of healthcare facilities.

Several types of CAHPS surveys are utilized throughout the care continuum, ranging from hospitals to nursing homes to health plans. However, the Hospital CAHPS (HCAHPS) and Clinician and Group CAHPS (CGCAHPS) are the most prominent and commonly used surveys.

Both surveys measure many of the same factors, including nurse care, doctor care, and facility environment.

The HCAHPS survey also includes questions about experiences within the hospital, including pain management, and continuity of care experiences.

CGCAHPS surveys target their questions to the general practitioner, asking questions about ease of healthcare access and how often the patient has been visiting the office.

Because HCAHPS and CGCAHPS are used for both reimbursement and patient rating purposes, it is important for healthcare organizations to improve their scores. Healthcare organizations can improve their CAHPS scores by understanding what is important to patients, what the surveys measure, and how to meet patient needs.

Improving Patient-Provider Communication

Provider Picture

The first two sets of HCAHPS questions pertain to nurse and physician communications with patients. These questions ask whether nurses and physicians communicated clearly with patients, and whether patients understood their diagnoses, prognoses, and treatment options.

Clear communication about healthcare information is integral to a positive healthcare experience, experts say. Hospitalization is often a stressful and worrying time for patients, and made even worse when clinicians do not adequately communicate what is going on and how they will treat a patient’s ailments.

In addition to allaying patient worry, providing meaningful explanations of conditions and treatments will help the patient taken ownership of her own health.

“Patients have a need for information,” explained Deirdre Mylod, PhD, Executive Director of the Institute for Innovation and Senior Vice President of Research and Analytics at Press Ganey.

“It’s not just making consumers happy to meet that need, but it’s also providing the right care. When you give people the right information, they can engage in care, they can be active participants, they’re better prepared to care for themselves at home, they’re less likely to be readmitted.”

Clear communication will require collaboration between the different members of the care team, added Mylod.

“As a patient, when one team member tells me one thing and somebody else tells me another, now I’m afraid and I’m thinking you’re not working together. Now I’m more scared than I need to be in a hospital,” she pointed out.

HCAHPS also asks patients whether nurses and physicians treated them with respect and empathy. Clinicians must tap into their interpersonal skills to provide compassionate care to their patients, while being mindful of cultural norms and barriers.

The healthcare industry might be falling short in this respect. A January 2017 survey conducted by Oliver Wyman and the Altarum Institute found that 40 percent of low-income patients have walked away from appointments feeling disrespected.

The survey, funded by the Robert Wood Johnson Foundation, showed that in addition to reducing patient satisfaction, lacking compassion also lowered quality of care. Patients who felt disrespected were three times less likely to trust their clinicians, and two times less likely to adhere to treatments.

Healthcare organizations should support their clinicians in pursuit of being more empathic. Organizations can host cultural sensitivity seminars, work with patients to continue to develop their interpersonal skills, and educate clinicians on evidence-based best practices for enhancing patient-provider communication.

Improving the Physical Hospital Environment

Hospital Setting

Two HCAHPS questions pertain to the hospital environment: hospital cleanliness and hospital noise levels.

In order to maintain an appropriately clean and sanitary facility, organizations must support their custodial staff and reinforce the importance of a healthcare facility being clean.

The American Hospital Association has long advocated for improving the hospital setting for patient satisfaction. In a 2016 guide, AHA listed the ways in which organizations can create environments more suitable for patient rest and recovery.

To create a quiet and peaceful environment, AHA says hospitals should implement and enforce rules about quiet hours and lights-out times.

“It makes sense that patients rate hospitals poorly when they cannot get good sleep or rest and have the additional stress of noise added to the already stressful situation of being unwell,” AHA wrote. “Data shows that noise in hospitals is the factor that scores lowest on HCAHPS scores nationwide.”

Healthcare organizations can take it a step further than HCAHPS mandates. Many hospitals are turning to their patients to inform room design that will facilitate a more comfortable experience.

When designing its new facilities in Delaware and Orlando, leaders at Nemours Children’s Health consulted with its patient and family advisory board to decide which features would best suit pediatric patient rooms.

“The parents came in and tested all of the furniture that they might be sleeping on in the rooms. They provided input into what we actually purchased,” recalled Nemours Chief Information Officer Bernie Rice.

“The children came in as well and helped pick colors and room layouts as far as if the counter was too high,” he continued. “They were very valuable and heavily influenced our construction and design to make sure it was a very family- and patient-friendly environment.”

Being Attentive and Reducing Unnecessary Discomfort

Improving Patient Discomfort

One highly-debated part of patient experience surveys is pain management. Amidst a raging opioid abuse epidemic, many experts question whether pain management should be a part of patient satisfaction scores that result in provider reimbursements. By tying payments to pain management, some clinicians may feel compelled to prescribe opioids when there could be other potentially less-risky forms of pain management.

In November 2016, CMS removed the pain management questions from the HCAHPS survey. However, the agency maintained that pain management is an important part of patient care and experience.

“CMS continues to believe that pain control is an appropriate part of routine patient care that hospitals should manage, and is an important concern for patients, their families, and their caregivers,” CMS said in a public statement. “CMS is continuing the development and field testing of alternative questions related to provider communications and pain, and will solicit comment on these alternatives in future rulemaking.”

While the pain management portions of the HCAHPS survey are currently under construction, clinicians should still work to reduce unnecessary patient discomfort.

Press Ganey is adopting this approach when consulting on patient experience, Mylod said.

“The way that we approach improvement for patient experience measures is to reframe it,” she explained. “The exercise is not to make consumers happy. The exercise is to reduce patient suffering.”

To boost scores in this realm, Mylod suggests clinicians – especially nurses – become even more attentive. This means not only answering call buttons, but also making regular rounds to hospital beds to ensure they meet all patient needs.

During these rounds, nurses can ask if the patient needs assistance using the restroom or if they need an object, such as a television remote, handed to them. Paying attention to these seemingly inconsequential needs could reduce adverse safety events, Mylod explained. If a patient gets up to retrieve a book, for example, he could fall and hurt himself, affecting the patient experience, increasing length of stay, or requiring additional expenses related to an injury.

Streamlining discharge processStreamlining the Discharge and Follow-up Process

HCAHPS asks patients about how doctors and nurses managed continuous care and the discharge process. The survey asks whether clinicians checked in on post-discharge care plans, made it clear which provider will follow-up with ongoing needs, and whether that care will be adequate for the patient’s condition.

At patient advocacy group Planetree, leaders have developed a hospital discharge plan to ensure clinicians meet patient needs.

The plan includes identifying a family care partner that will help take care of the patient following hospital discharge, said Planetree’s Director of Research Jill Harrison, PhD.

From there, clinicians check in with the patient and appointed caregiver to determine which functions they will need to learn for optimal at-home care.

“Planetree has a program that allows people to say that they want help with wound changes, or help ambulate their loved one, or help check a tracheotomy if the patient has one,” Harrison said. “Caregivers go through a training program with the nursing staff and learn how to provide that care so that when patients get out of the hospital setting their family members are ready to take that all on.”

Other key healthcare players are advocating for a similar strategy. AARP has been sponsoring a law in state legislatures across the country to support family caregiver engagement. The organization says caregiver engagement will help support continuity of care.

Research confirms that family caregiver engagement can reduce hospital readmissions by up to 25 percent.

Hospitals that implement family caregiver engagement and discharge plans may see not only increases in HCAHPS scores, but in quality of healthcare, as well.

The importance of improving patient satisfaction and CAHPS scores is well-founded. These scores help inform CMS value-based reimbursements and hospital ratings published on the CMS website. Many healthcare organizations also use these scores to inform their own internal practice improvement processes.

However, when it comes to improving patient satisfaction, it is also important for practice leaders to look beyond the survey. Improving patient satisfaction means understanding the facility’s unique patient population and its needs. What will please one group of patients may not satisfy another, and hospital leaders must bear that in mind.

While supporting initiatives specifically geared toward improving CAHPS scores, healthcare organizations should also consider projects that will serve their unique population.

Issuing practice-specific patient input surveys or consulting with a patient advisory council will help healthcare organizations move beyond surface-level satisfaction and find solutions that will be truly meaningful for patients.

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Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU

Serious about Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU

 Akron Children’s Hospital is serious about enhancing the patient experience, along with delivering quality healthcare in a timely, efficient manner. While the hospital formally established the Mark A. Watson Center for Operations Excellence in 2008, it has been performing quality improvement since its early beginnings 125 years ago. It’s no wonder the healthcare provider has consistently earned Best Children’s Hospitals rankings in 7 of the 10 specialties evaluated annually by U.S. News & World Report—including cancer, diabetes and endocrinology, pulmonology, neonatology, neurology and neurosurgery, and orthopedics.

The hospital encourages employees across all skill levels and departments to become involved in quality improvement, offering several levels of Lean Six Sigma training. As part of its green belt training and certification, employees learn to use Lean Six Sigma by leading and completing long-term projects with the guidance of experienced black belts.

One such green belt project, which began at the hospital’s Mahoning Valley, Ohio campus, had a goal to decrease one particular safety event—unplanned extubations in the hospital’s neonatal intensive care unit (NICU). To complete this project, the hospital improvement team relied on Lean Six Sigma tactics and the data analysis tools in Minitab Statistical Software.

The Challenge

Akron Children’s Hospital relies on Minitab Statistical Software to analyze their Lean Six Sigma project data. The hospital used Minitab to verify improvements made to the intubation process in the NICU.

An intubation is a medical procedure in which a breathing tube is placed into a patient’s trachea. This tube connects the patient to a machine called a ventilator, which helps the patient breathe. The procedure is common for both pediatric patients and adults in intensive care, but is most common for premature newborn babies residing in a hospital’s NICU. Babies born prematurely often have undeveloped lungs, which cause breathing problems and the need for the assistance of a ventilator.

Although this medical procedure is commonly performed, it is not without risk, and can cause trauma to or introduce an infection into the patient’s airway. Unplanned removal of the breathing tube, which is also known as an unplanned extubation, is a likely occurrence that can cause harm. Unplanned extubations are the fourth most common adverse event in NICUs across the U.S.

Akron Children’s Hospital’s Department of Respiratory Care had been collecting data on the rate of unplanned extubations in the Mahoning Valley NICU for well over a year, but had not had the capacity to investigate the occurrences further. Bonnie Powell, a Registered Respiratory Therapist and manager of respiratory services at Akron Children’s Hospital, was a green belt candidate during the time unplanned extubation data were collected. As part of her Lean Six Sigma training and certification, she set out to lead a project that would decrease the rate of unplanned extubations in the Mahoning Valley NICU.

“I knew this project was the perfect fit for me because as a respiratory therapist, I’ve been part of the frontline staff primarily responsible for intubating,” Powell says. “When you’re the one actually putting the tube into the patient, it just affects you more because you know the trauma that you could be causing to them.”

How Minitab Helped

While there’s not a true benchmark rate that NICUs should strive to stay below regarding unplanned extubations, the Vermont Oxford Network—a research collaboration of nearly 1,000 global NICUs including Akron Children’s—considers 2 in 100 intubated patient days to be the upper limit of acceptable. Previous data collected on the rate of unplanned extubations at the Mahoning Valley NICU revealed a rate of 3 in 100 intubated days.

“Any unplanned extubation has the potential to cause harm to the patient and negatively impact overall patient satisfaction,” says Powell. “We wanted to improve our performance on this metric.”

Powell’s Lean Six Sigma project team included a multidisciplinary group of nurses, respiratory therapists, a neonatal nurse practitioner, and a neonatologist.

The team began by using Lean Six Sigma tools to brainstorm reasons why unplanned extubations were occurring, as well as solutions for stopping them. “The fishbone diagram and cause maps were among the most helpful tools we used,” Powell says. “We looked at the highest impact solutions, as well as how easy they would be to implement, and prioritized solutions from there.

“This step helped us to organize and roll out our seven improvements into two phases,” she says.

Along with more frequent communication between nurses and respiratory therapists before, during, and after an intubation, as well as educational information distributed in meetings and via email, one improvement implemented was the “two to turn” rule. “Anytime an intubated patient is repositioned, one caregiver is turning the patient and another is holding the tube at the patient’s mouth,” Powell explains.

The team applied the improvements for several months, as collecting enough data to meet the required 100 intubated days for pre- and post-improvement comparison proved difficult for many reasons.

“There is a continuing trend in neonatal care to use devices such as masks and nasal prongs to connect the patient to the ventilator to help with breathing. When these devices are used, there is no need for a breathing tube, which reduces the number of intubated days and lengthened our post-improvement data collection period,” Powell says. “That, coupled with greater attention to our weaning protocol, which focused on shortening the time babies need ventilator support of their breathing, contributed to why we saw a reduced amount of intubated days.

“Of course, fewer intubated days was a good thing in this case, and supported the idea that our improvements were working,” adds Powell.

To compare unplanned extubations, pre- and post-improvement, the team visualized their data using control charts in Minitab Statistical Software.

Minitab graphs clearly reveal the impact of improvement efforts. This control chart displays the reduction in unplanned extubations after Lean Six Sigma improvements were implemented.

To verify their results statistically, the team ran a 2 proportions test in Minitab to see if their unplanned extubation rates decreased after improvements were put into place.

Hypothesis testing in Minitab makes it easy to determine if there is enough evidence in a sample of data to infer that a certain condition is true for an entire population.

The analysis showed the team that after improvements were implemented, the unplanned extubation rate had indeed decreased.

The team also used Minitab to perform process capability analysis both pre- and post-improvement. This tool provided another before-and-after comparison of unplanned extubation rates, and aided the project team in assessing whether the new process was capable and in statistical control.

“I have never taken a statistics course and have no background in this type of work,” Powell notes, “but Minitab, coupled with the instruction I received from the Center for Operations Excellence, made it easy for me to analyze and understand my data.”

Trauda Gilbert, deployment leader for the Center for Operations Excellence at Akron Children’s, echoes Powell. “To be able to use Minitab to visually demonstrate the before and after effect with a control chart, which you can then share with your team and champion is really valuable. Minitab also makes it easy for front-line staff to document that they have made a statistically significant difference. To be able to do that without having to interact with a biostatistician or one of the other very rarely found statistical resources in our organization, is very beneficial,” she notes.

“Healthcare quality is a little different than manufacturing because we can’t just run a DOE and tweak a process line,” says Gilbert. “Even though we’re different, Minitab still helps us out.”

Results

The data revealed a dramatic reduction in intubated days after the improvements were made, as well as a considerable reduction in the rate of unplanned extubations at the Mahoning Valley campus. The reductions brought their rates in line with the Vermont Oxford Network’s suggestion of 2 unplanned extubations in 100 intubated patient days.

“This project showed us that simple improvements can create real change,” says Powell. “The cultural change this project instilled in our team was exciting—the recognition that even they could make a difference is huge.”

Cost savings resulting from the reduction in supplies and staff time needed to care for unplanned extubations can be calculated, but the overall financial impacts are hard to quantify. “The larger costs of unplanned extubations—such as a longer NICU length of stay, ventilator-associated pneumonia, and other setbacks that the patient can experience from the event—can be difficult to tease out,” Powell says.

“Neonatal patients are some of our key customers here,” she continues. “Due to the fact that they were born early, they come back to our institution for care frequently, especially initially. Making sure they have a safe experience early is critical, because the results of good care at this stage can have exponential benefits for patients in the future.”

In addition to improving the patient experience, the project helped Powell obtain her Lean Six Sigma belt certification. “I did get my green belt as a result, and we’ve also rolled out selected improvements to the NICU at our Akron campus,” she says. “We’re in the process of collecting data there as well, so this project didn’t just stop in Mahoning Valley.”

Powell’s project is just one example of an estimated 300 documented projects that have been completed throughout the Akron Children’s organization. The total financial savings of the hospital’s operations excellence program is estimated to be more than $25 million since its official beginnings in 2008.

Learn more about lean six sigma in healthcare :  Six Sigma Master Class – Improving Healthcare Processes

Mapping the Healthcare Value Stream

Congratulations Vicki Chernoff on becoming Masters Certified in Continuous Healthcare Improvement!

1/07/2016 For Immediate Release – Phoenix, Arizona * United States

TPMG would like to congratulate Vicki Chernoff for successfully completing the Masters Certification for Continuous Healthcare Improvement program and earning her MCHI Certification!  Vicki successfully completed a rigorous 10 unit – 45 lesson online Masters Certification in Continuous Healthcare Improvement workshop by passing the certification examination with distinction.  This accomplishment acknowledges she has fulfilled the requirements for the MCHI program of study and, from this day forward, is certified as a MCHI professional.  By completing this distinctive course, she is qualified and authorized to implement Continuous Improvement and Performance Management systems.  Congratulations Vicki!

Vicki Chernoff is a Senior Clinical Data Analyst Mission Hospital.   She holds a BSN from Saddleback College, a Bachelor of Arts in Psychology from Concordia University Irvine, and a Masters Of Arts Degree in Research Psychology from San Fransisco State University.

The Performance Management Group’s Masters Certification for Continuous Healthcare Improvement program is specifically designed for professionals who work for healthcare clinics, hospitals and systems. TPMG has been certifying continuous improvement professionals for more than 15 years. The company provides training and certification on-site, online, and on-campus (at the University of Phoenix) nationwide. For more information regarding lean six sigma training, certification and consulting – contact TPMG llc at 623.643.9837 or logon to www.helpingmakeithappen.com.

How Healthcare Can Become Higher in Quality, Lower in Cost & Widely Accessible

Clay Christensen at the second Faculty Perspectives on Healthcare event.
February 8, 2012

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