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A top performer keeps on climbing
In 2006, leaders at Tahoe Forest Hospital were in the midst of the application process for the Malcolm Baldrige National Quality Award. Baldrige, an integrated approach to organizational performance management, pushes applicants to use hard data and measurable benchmarks to track progress. As they defined their operations through the Baldrige criteria, Tahoe Forest Hospital’s leaders, who have always recognized patient satisfaction as a market differentiator for the organization, realized they needed a stronger mechanism for data analysis and benchmarking for patient satisfaction.
Tahoe Forest Hospital is one of the two hospitals in Tahoe Forest Hospital District (TFHD), a not-for-profit, special district, patient-centered health care system. The health system includes two rural critical-access hospitals, outpatient service facilities, specialized care centers and satellite locations that serve six counties in two states spread over approximately 3,500 square miles in the Sierra Nevada Mountains.
At TFHD, “Service – The Best Place to be Cared For,” is one of five Foundations of Excellence, which are the basis for strategic objectives toward achieving the district’s organizational vision of being the best mountain community health system in the nation. Complementary to the service foundation is “People – The Best Place to Work and Practice.” Without the dedication and compassion of its workforce, TFHD could not achieve any level of success.
Tahoe Forest Hospital District was founded by the local community to provide top quality care for its residents and those visiting the region. Delivering quality care and maintaining exemplary patient satisfaction are an ongoing priority for the leadership, physicians and staff.
To that end, patient satisfaction is a standing theme in the annual strategic planning process. Engaging with physicians and employees, who are central to creating a high-performing organization where patients can receive the best care available, and understanding the factors that underlie their job satisfaction are key components of achieving that overarching goal.
“Our performance excellence journey reinforced our need to listen to the voice of the customer, and thus we selected Press Ganey to help us collect, analyze and benchmark our patient satisfaction. We also utilized Press Ganey to deploy our employee and physician satisfaction surveys,” says Virginia Razo, TFHD’s chief operating officer. “It's been a continuous learning process on behalf of the administration about how to use satisfaction data to inform improvement plans and then keep rechecking it to make sure we are focusing on the right things. I must say, Press Ganey has made it really easy for us.”
As a result of a strategic initiative that utilizes quality improvement techniques to target customer service, the facility routinely scores above the 90th percentile for its integrated HCAHPS inpatient survey and for emergency department satisfaction. It also has solid scores for outpatient and ambulatory surgery.
In 2008, Tahoe Forest Hospital created an outpatient satisfaction improvement group titled the WOW team (Working on Wonderful) made up of managers and front-line staff. This team was charged with improving customer service in the outpatient areas. The team’s leader was enthusiastic as she taught the team how to interpret the information provided by Press Ganey and work toward common goals that were identified on the priority list. Since that team’s inception, all of the managers have been trained how to access and interpret their information; goals are aligned and incorporated into 90-day action plans that are reviewed by administrators. “Our management team really understands the linkage between implementing patient satisfaction performance improvement initiatives and the corresponding results, because they own the data; they don’t depend on somebody else to analyze and report it to them,” Razo says. “Management can research and analyze data for themselves and share the information effectively, particularly with our key stakeholders – our physicians and employees.”
All managers whose departments touch on patient satisfaction issues have been trained on Press Ganey Online and eCompass. Many managers and directors have created regularly scheduled custom reports and run them at least quarterly. The managers share not only response data but also the Priority Index questions with staff. Tahoe Forest Hospital has performance excellence boards posted in each department so employees can see their progress on patient satisfaction, clinical, operational and financial performance.
Patient satisfaction reports are compiled quarterly from data for each of the surveyed care areas (inpatient, outpatient, ambulatory surgery and emergency department) and are shared with the medical staff and publicly elected board of directors, which has strongly supported improvement initiatives surrounding building customer loyalty.
Tahoe Forest has made a point of focusing on HCAHPS Top Box scores, particularly on how it rates with comparable facilities in its region on the Press Ganey database. “We do score at the high end of the Press Ganey database, and we want to avoid creating an environment of complacency,” Razo says. “We stay focused on building customer loyalty by working as a team to understand how we can move those threes and fours to fives. Equally important is to ensure that the causes of any ones and twos never happen to our patients again.”
Razo appreciates the value of the integrated Press Ganey survey over the HCAHPS instrument. “The HCAHPS survey alone lacks sufficient data to gain a clear perspective of the satisfaction performance of the entire facility. The HCAHPS survey only measures patients’ perspectives during a hospitalization; however a large part of our business takes place in the outpatient areas, such as the emergency department and in our ambulatory surgery department. There is also a breadth of services that Press Ganey provides that far outpaces what simply using the HCAHPS survey provides.”
Physicians are on board
Tahoe Forest Hospital District’s Board of Directors’ focus on customer service has paved the way for physicians to buy into customer satisfaction, Razo says. She adds, “Physicians like data, and the nice thing about Press Ganey is that the data are statistically analyzed and clearly displayed, making it easy to understand and take action on.”
Through the use of Press Ganey’s Priority List the organization learned that patients didn’t feel as if they were able to spend enough time with physicians or that physicians were sufficiently concerned about their questions or worries. The physicians helped identify barriers that could be contributing to their feelings and suggested chairs be placed in the room, allowing physicians the ability to sit while discussing patient’s concerns. When results didn’t improve as expected, hospital staff members utilized Press Ganey’s Solutions Starters and benchmarked what other organizations had done to address their patient’s concerns. They learned that placing pads and pens in the room marked, “Questions for your doctor or nurse” may help patients remember what questions they had during their stay. “We continue to seek ways to eliminate all of the factors that complicate communications,” Razo says.
The Priority Index also helps to precisely target improvement initiatives. For example, in the ED there is a reoccurring issue of pain management/patient pain control. ED nurses and physicians determined that while they can’t eliminate pain prior to surgery or other treatments, they can use scripting to let patients know that caregivers’ primary concern is their comfort and care, and that if there is anything they can do to reduce pain, they will. “We can’t get them from 10 to 0 (on rating of pain), but we work with the patients to find out what is an acceptable level of pain, so the patients’ expectations are met,” Razo says.
Continuous food quality improvement
Perhaps the clearest example of Tahoe Forest’s improvement success has come in food service. In 2007, the dietary department was stunned to learn that the hospital’s inpatient food service ranked at the 17th percentile nationwide on the Press Ganey database. The hospital was already in the process of building a new café to replace its old cafeteria for patients and employees, and it decided to expand the project to include a continuous quality improvement initiative.
Focus groups were conducted with patients, employees, physicians and the community to identify issues of importance. The department also looked at benchmarks set by other hospital food service operations.
The needed improvements identified included:
- Meeting the food requirements of hospital patients and residents of the Extended Care Center.
- Meeting the food needs of night staff.
- Providing a catering service internally and externally to the community.
- Ensuring that food served was fresh through a work flow that ensured preparation took place just before food was served.
A new executive chef was hired. The chef, Matt Pierz, planned an entirely new menu and taught the staff how to develop flavorful selections that also met the various dietary needs of patients and residents. He also implemented a “sample table” process that brought in a variety of staff to evaluate food for taste, texture and other attributes before serving.
“The sample table is our best example of a quality improvement process,” says Margaret Holmes, director of dietary and environmental services. “Initially, we modified our regular menu, but then we looked at the low-sodium food and realized it didn’t taste that great, so we made changes to the recipe to improve the flavor without compromising the nutritional need. Then we looked at purees and grinds (for special diets), and now we have looked at the salads. So, for each step, we test one more thing to make sure the whole tray is improved, and not just the center of the plate.”
The sample table is an example of a systematic process that is well-deployed. Every taster documents his or her recommendations; the comments are reviewed once a week and recipes are changed to reflect them. Not only is learning inherent in the process of refining food, but there is also assessment and improvement of the system based on the feedback.
Tahoe Forest Hospital’s inpatient dietary department now ranks above the 90th percentile in the all-facility database and serves as a national benchmark for Press Ganey. Additionally, the team was recognized by receiving the Achievement Award for the Most Sustainable Improvement in Quality and Excellence at the 2009 “Good to Best” Annual Healthcare Food Service Industry Conference.
“The dietary department’s success is a great example of one of our directors who has used data to inform decisions that are paying off in spades,” Razo said. “Margaret learned how to set up the Press Ganey dashboard; she reviews and shares the results regularly with her staff and she recognizes the team for their accomplishments.”
Not satisfied with its success and understanding that quality and customer service are constantly evolving dynamics, Tahoe Forest Hospital District continues its focus on patient satisfaction and utilizes Press Ganey as a performance excellence improvement tool. It is now looking to achieve the same results at its second hospital – Incline Village (Nev.) Community Hospital – that it does at Tahoe Forest Hospital; it is committed to that quest.
Todd Sloane, Senior Writer, Press Ganey Associates
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