Transcript HCAHPS - JL Morgan and Associates

Introduction to HCAHPS
October 22, 2015
Thank you for joining
We will begin shortly
Finding the pulse of your business
Today’s Objectives
Value Based Purchasing
Overview of HCAHPS
Sampling
“Top Box” Methodology
Life Cycle of a Survey
HCAHPS National Performance
HCAHPS Star Ratings
JLM eMed Survey Reports
Open for Q & A
Today’s Agenda
Value Based Purchasing 2017
Overview of HCAHPS
Sampling
“Top Box” Methodology
Life Cycle of a Survey
HCAHPS National Performance
HCAHPS Star Ratings
JLM eMed Survey Reports
Open for Q & A
Value Based Purchasing
FY 2017
What is CAHPS?
CAHPS
Consumer Assessment of Healthcare Providers and Systems
Developed by AHRQ to provide customers a standardized
survey of 27 questions evaluating their patient experience
Results are transparent
Can be used for comparisons
Help them make a better informed decision
* WWW.HCAHPSONLINE.ORG
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
Sometime
Never
Rating from “0” (Poor) to
“9/10” (Excellent)
Overall Rating
Definitely “Yes”
Probably “Yes”
No
Would you recommend
Care Transition (Reported Oct14)
* www.hcahpsonline.org
Responses
* WWW.HCAHPSONLINE.ORG
Strongly Agree
Agree
Disagree
Strongly Disagree
Bold=“Top Box”
Who Is Surveyed Under CMS Guidelines?
Eligible patients are:
Patients discharged from short-term, acute care hospitals
Age 18 or over
Non-Psychiatric DRG/principal diagnosis at discharge
At least one night stay
Excluded Patients
“No publicity” patients
Patients admitted to hospital from Police custody
Discharges with a foreign home address
Discharges to Hospice/Nursing Home/SNF
* WWW.HCAHPSONLINE.ORG
HCAHPS Methodology
Phone methodology
Standardized script
Complex procedures
Begin calls at least 48 hours after discharge
1st call made before 42 days after discharge
5 attempts for all randomly selected patients
Different times of the day
Different days of the week
Different weeks
Must span over
8 days
Last call completed 42 days after 1st attempt
Callers can not leave voicemail
* WWW.HCAHPSONLINE.ORG
HCAHPS Mix and Mode Adjustments
Before scores are published to the public, HCAHPS scores
are also mix and mode adjusted
 Patient Mix (Determined by patient populations, service line,
demographics, etc..)
 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
Pain Management
Communication Medications
Discharge Information
Cleanliness
Quietness
Would Recommend
Overall Rating
* WWW.HCAHPSONLINE.ORG
Mode Adjustment
(Phone)
-4.0%
-1.3%
-4.7%
-4.7%
-3.9%
-1.3%
-5.3%
-6.3%
-4.4%
-2.8%
HCAHPS vs. Patient Satisfaction Scores
 Because of the CMS methodologies, patient mix and mode adjustments,
HCAHPS scores should correlate, but will not match your internal scores
This 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 actually be top in the nation!)
* WWW.HCAHPSONLINE.ORG
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%
71%
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*
Life Cycle of a Survey (Preventive Care)
Pt D/C
Survey/Cmp
HCAHPS Star Ratings
Star Ratings
As 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
Easier for consumers to spotlight excellence in healthcare
quality
Will be based on the same HCAHPS questions
Star ratings for each composite plus new “HCAHPS
Summary Star Rating”
* WWW.HCAHPSONLINE.ORG
Scoring Methodology
Star ratings will NOT follow “Top Box” methodology
CMS employs all survey responses in the construction
of the HCAHPS Star Ratings
Each response assigned a score
Scores are calculated, assigned an average and rounded
up or down
Final scores will be patient mix and mode adjusted
* WWW.HCAHPSONLINE.ORG
Scoring Methodology Example
* WWW.HCAHPSONLINE.ORG
eMed Survey Reporting Tool
eMed Survey Reporting Tool*
Provides snapshot regarding the patient’s experience for:
HCAHPS, Home Health, Emergency Department or Outpatient Services
 Available in real-time upon completion of surveys
Able to trend monthly, quarterly or annually
Query – Analyze multiple levels of data on demand
* JLM Proprietary Database
Getting the most out of eMed 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 AnyHospital USA
AnyHospital USA wants to evaluate their HCAHPS scores and see
where there is room for improvement
Need to run reports and analyze the data on a number of levels
Run eMed survey reports to accomplish this
 CMS HCAHPS National Comparison
 Data Summary (Trending)
 Top Box HCAHPS by Area
 Top Box HCAHPS by Facility (System)
 Query for further analysis
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
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 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
against the National
Rankings (50th, 75th,
90th)
• 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
• 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 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 location
• Identify largest areas for
improvement
• Top Box scoring
Client Login:
https://www.emedsurvey.com
By area shows lower scores in Post Partum and 5th floor
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 question
percentage scores for
each type of response
• Very Poor
• 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
• 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
• “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
[email protected]
Tanya Harris-Haynes
HCAHPS Manager
205-995-7144 Office
[email protected]
Wendy Dew
Programs Director
(Preventative Care / Pat Sat)
205-995-7107 Office
[email protected]
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
[email protected]