Featured Case Study:
A Playbook for Winning on HCAHPS
(Baton Rouge, La.)
Our Lady of the Lake Regional Medical Center (OLOLRMC) is a 720-bed facility in Baton Rouge, La. One of the largest private medical centers in Louisiana, it treats more than 35,000 patients in the hospital and serves more than 350,000 people through outpatient locations with the assistance of more than 1,000 physicians and 4,000 employees. A Magnet-designated facility, it was the hospital of the year for 2008 and 2010 (Louisiana State Nurses Association) and recipient of the Louisiana Performance Excellence award (Louisiana Quality Foundation) in 2008 and 2010.
The first posting of publicly reported data from HCAHPS in 2008 shocked hospital leaders. With the knowledge that before long those scores would have an impact on Medicare reimbursement, the hospital went to work.
The hospital uses Press Ganey HCAHPS InsightsSM survey tool to guide decision making. After a hospital-wide review, OLOLRMC adopted a potent combination of process changes, shared decision-making and a new organizational structure around service excellence.
Performance and Outcomes
"We were at the bottom of the barrel," says Deborah Ford, RN, MSN, vice president of patient care services of OLOLRMC's first publicly posted HCAHPS scores. "Here we were a Magnet-designated hospital, the hospital of the year for 2008 and 2010 (Louisiana State Nurses Association) and recipient of the Louisiana Performance Excellence award (Louisiana Quality Foundation) in 2008 and 2010. With all those awards, we wondered why we were having challenges."
The review of processes revealed that caregivers tended to define quality and patient satisfaction through the success rate for completing tasks in a complex health care environment. "I am a nurse myself," Ford says. "I knew I could put in a catheter with sterile technique, with no resulting infection. I could start my IV on the first try, and nobody feels anything. But that isn't what satisfaction is about. Patients expect care to be good. What they remember is that the nurse cared about them as a person. That is not a lesson I learned easily, nor do others."
Lynda Suhrer-Roussel, PhD, quality analyst at OLOLRMC, says: "HCAHPS looks at perception of, 'were these things always taken care of,' vs. the quality of the experience and the care on the standard inpatient survey. The tools are there for both surveys, but there is richer information on the integrated survey."
The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay, including core questions about critical aspects of patients' hospital experiences. Press Ganey research on national HCAHPS data has found that the nurse communication section of the survey has the highest correlation with overall rating and likelihood to recommend. However, looking only at HCAHPS questions means missing many patient-centered issues that are at the heart of patient perceptions of care. For example, 15 Press Ganey HCAHPS Insights survey questions are more highly correlated with HCAHPS "recommend" than the most highly correlated HCAHPS survey question, “staff do everything to help with pain.”
The hospital undergoes an annual strategic review to assign all objectives for the year. Each leader has a group that has certain deliverables and aligned action plans that are reviewed regularly. The hospital's chief operating officer holds a monthly patient satisfaction meeting attended by satisfaction team leaders.
The improvement effort focused initially on a few HCAHPS domains: communication with nurses, noise reduction, pain management, discharge instructions and medication education (later, venipuncture and responsiveness of hospital staff were added).
On each unit, there is shared responsibility for the patient satisfaction initiative. "Our model of shared decision-making sets the tone for nurses and other team members to become engaged in the patient satisfaction and premier service strategies," Ford says. Two leaders are assigned to each domain team to create a cross-functional approach that fosters diversity and creativity. For example, the "communication with nurses" domain team is led by a medicine division leader and an emergency room division leader.
It was decided early on that to build awareness of the project, ensure consistency of effort and provide easy reference, an HCAHPS manual was needed.
Barbara J. Griffin, BSN, NE-BC, divisional director of nursing, who was in charge of the communication with nurses section, came up with the name and the theme of the manual. It is called the HCAHPS Playbook, in honor of a local high school football star who was treated at OLOLRMC following a serious auto accident. "He was used to having a playbook for football, so we thought, why not a playbook for HCAHPS?" Griffin says.
The book contains a "play" for each domain. For example, the communications with nurses play focuses on hourly rounding, with nurses making hourly visits to each patient room. A nurse manager also rounds and audits how often nurses visit each room and what the call bell response has been. (A 10-minute or less response is the expectation.)
In each patient room is a "communications center," a white board that must be rigorously maintained, with names of nurses and the visits they make, as well as the patient's plan for that day.
As a result of the efforts, there has been a 7% increase in the nurse communication score for the percent of survey respondents who said nurses "always" communicate effectively.
There have been even larger improvements in other domains: A 19% bump for pain management, a 24% increase on noise and a 26% increase for medication instruction.
One of the most impressive results is that OLOLRMC's "always" rating for the overall rating on HCAHPS question has improved 21% since 2007, while the "recommend" score rose 14%.
Perhaps the most telling detail of the OLOLRMC patient experience is its "Thinking of You" card.
When a patient is admitted, the card, which reads, "Sending you warm thoughts for a quick recovery," is attached to the chart.
Everybody who touches the patient – from the physicians to nurses to social workers and radiologic techs – signs it with a personal touch. A day or two after the patient gets home, the card arrives in the mail, reinforcing the staff's concern.
"Patients really like it. It has been a big hit," Griffin says.