OAS CAHPS Participant: Berger Health System Gets Ready for Mandatory Reporting

Added on Mar 16, 2017

OAS CAHPS Participant: Berger Health System Gets Ready for Mandatory Reporting
By Diana Mahoney
Industry Edge March 2017

Practice makes perfect. Or in the case of Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey adoption, practice makes ready, which is why Ohio-based Berger Health System joined Press Ganey’s Outpatient Ambulatory Surgery (OAS) CAHPS Voluntary Participant program last March.

The OAS CAHPS survey collects information about patients’ experiences of care in hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs). In 2016, the Centers for Medicare & Medicaid Services (CMS) initiated voluntary national implementation of the survey, which includes questions about communication and care provided by health care providers and office staff, preparation for the surgery or procedure, post-surgical care coordination and patient-reported outcomes.

Beginning in January 2018, OAS CAHPS participation will be mandatory for CMS-certified facilities that are required to submit quality data as part of the Outpatient Quality Reporting Program or the Ambulatory Surgical Center Quality Reporting Program.

“We knew that mandatory participation was coming down the pike, so we wanted to see what the questions were and where we might need to focus our efforts to get ahead of the game,” said Jennifer Hedges, manager of Services and Patient Experience for the full-service hospital and community health care system serving Ohio’s Pickaway County and surrounding communities.

“We didn’t want to wait until the program was mandatory to get started. We knew there would be a learning curve, and we wanted to get to the other side of it,” Hedges said. “We also wanted to have time to develop processes and practices that would help streamline the reporting and improvement cycle.”

The decision was a good one, as it allowed the organization time to educate the ambulatory surgery managers and staff and achieve buy-in.

“The survey was brand-new for this area, and it took us a few months to get the team on board. One challenge was explaining the discrepancy between performance scores and percentile ranking,” Hedges said. “Our mean performance scores were high, but our percentile rank, reflecting how we compare with other organizations, was low.”

Because staff initially were not happy with their scores, it was important to explain the potential magnitude of the effect between top-box and intermediate responses—for example, between an “always” response and a “usually” response—for items such as Communication with Nurses, Communication with Doctors and Responsiveness of Hospital Staff.

“Once we began talking about it with them and reviewing the feedback to identify improvement opportunities, we began to see a 180-degree turnaround in staff acceptance and attitudes, and this laid the groundwork for making necessary improvements,” Hedges said. “Most importantly, when our nurse manager began to understand the value of the survey feedback, he was able to communicate that to his staff, and this attitude shift was reflected quickly in our performance, particularly in the area of nurse communication.”

The nurse manager has become so aligned with the improvement mission, “he encourages patients to call him directly if they have issues or concerns,” Hedges said. Further, when patients submit negative feedback, he calls them as soon as he gets the report to try to resolve any issues.

In addition to staff buy-in, Hedges and her team are working to improve engagement among contracted professionals. “Our anesthesia providers are a contracted group, and sometimes there can be a lack of communication alignment and consistency, especially because they are an outside group,” she said. “When we get patient feedback that indicates an issue related to interaction with the anesthesiologist, we bring it to the anesthesiology director on-site so he can follow up on it. But we have less control than with our own staff, so it’s an ongoing effort, though we are seeing some improvement.”

The key to successful implementation, Hedges stressed, has been consistent communication with all survey stakeholders, including the nurse manager, the chief nursing officer, the medical director and the director of anesthesiology, to review the survey results and identify trends and improvement opportunities. “Before going live with the survey, we also set up weekly calls with our account manager to make sure we were on track and to have any questions answered. We were also going live with our Clinician and Group (CG) CAHPS survey at the same time, so it was a lot to wrap our heads around,” Hedges said.

Since implementing the survey, the Berger team has made some process changes to reflect the unique needs of the ambulatory/outpatient setting and lessons learned from early survey results.

“One thing we learned was that with the number of ambulatory surgery procedures coming in every day, patient registration could get delayed, so we reworked the registration process and introduced a service ambassador role to help streamline patient flow,” Hedges said. The service ambassador welcomes and logs in patients, and works closely with registrars to collect additional information if needed, inform patients of the status of their waiting time, and guide and inform them through the pre-surgical process.

Another change to the registration process is that the registration team “talks about the patient experience survey as soon as patients come in,” Hedges said. “We let patients know that they will be getting a survey and that their feedback is important to us.” This allows patients to realize that they have a voice in their care, and it helps build survey response rates that, in turn, provide robust samples to mine for improvement opportunities, she said.

The first few quarters after survey implementation, Berger’s ambulatory surgery percentile dropped, but it has since increased dramatically. “The turnaround paralleled the period when we were trying to get staff buy-in. When we achieved it our scores and ranking rose significantly,” said Hedges. “This is a good example of how staff and employee alignment are essential to successful survey and process improvement efforts.”

Now that the team’s performance is moving in the right direction, “we have established target goals so that we can sustain the improvement,” said Hedges. With all of the prep work behind them, “we feel like we are very ready for mandatory OAS CAHPS reporting. We are in a good position, and we are continuing to learn and make improvements based on our performance data.”

On Feb. 22, Press Ganey held a webinar, “Preparing for OAS CAHPS: Information You Need to Know,” which covered participation requirements, patient eligibility guidelines and other key aspects of the program. To learn more about how to prepare for OAS CAHPS, download the on-demand recording here.