Introduction to HCAHPS October 22, 2015 Finding the pulse of your business Thank you for joining We will begin shortly

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  HCAHPS: Hospital Inpatients  HHCAHPS: Home Health Patients  CGCAHPS: Physician Clinic & Group Office Patients  EDCAHPS – Coming Soon *

HCAHPS Composite Measures Composite QuestionsResponses Communication with Nurses Communication with Doctors Staff Responsiveness Pain Management Communication about Medicines Cleanliness and Quietness Discharge Instructions Always Usually Sometime Never Overall Rating Rating from “0” (Poor) to “9/10” (Excellent) Would you recommend Definitely “Yes” Probably “Yes” No Care Transition (Reported Oct14) 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 *

HCAHPS Methodology  Phone methodology  Standardized script  Complex procedures  Begin calls at least 48 hours after discharge  1 st 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 1 st attempt  Callers can not leave voic *

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) *

HCAHPS Mix and Mode Adjustments (Phone Survey) HCAHPS Composite Mode Adjustment (Phone) Nursing Communication-4.0% Doctor Communication-1.3% Responsiveness-4.7% Pain Management-4.7% Communication Medications-3.9% Discharge Information-1.3% Cleanliness-5.3% Quietness-6.3% Would Recommend-4.4% Overall Rating-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 ScoreHCAHPS “Top Box” (Mix and Mode Adj) Patient Satisfaction “Overall Average” (No adjustments) Nursing Communication76%89%

Takeaway * Always compare your HCAHPS scores to the rest of the country (79% may actually be top in the nation!)

HCAHPS “Top-Box” Scores [Oct ’12 – Sept ’13] Measure DescriptionNATIONAL AVERAGE Patients who reported that their nurses "Always" communicated well79% Patients who reported that their doctors "Always" communicated well82% Patients who reported that they "Always" received help as soon as they wanted68% Patients who reported that their pain was "Always" well controlled71% Patients who reported that staff "Always" explained about medicines before giving it to them 64% Patients who reported that their room and bathroom were "Always" clean73% Patients who reported that the area around their room was "Always" quiet at night61% Patients who reported that YES, they were given information about what to do during their recovery at home 85% Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) 71% Patients who reported YES, they would definitely recommend the hospital71% Source: hospitalcompare.hhs.gov [Accessed: 8/28/14]

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) By end of third week, first week of discharges surveys begin* (Must span 8 days) COMPLETED

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” *

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 *

Scoring Methodology Example *

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. Run high level reports to identify trends or areas for improvement 2. Utilize Top Box and Monthly reports to drill down further to discover areas of concern 3. 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 Client Login: 1.Login to 2.Enter Username and Password (contact JLM if you do not have a username assigned.

Login to client site Client Login: 1.Login to 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.

Running Reports Client Login: 1.Login to 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)

Report Examples Client Login: CMS HCAHPS National Comparison 11 HCAHPS Composites Compares your hospital against the National Rankings (50 th, 75 th, 90 th ) CMS Mode adjusted Color coded for easy identification Identified below national average in “Communication Medications” composite

Report Examples Client Login: Data Summary with Trending Displays individual measures for each composite Trend by: Decimal, Percent (Average) or Top Box format Trend up to 12 months

Report Examples Client Login: Data Summary with Trending (cont’d) Displays each measure individually Identifies Trends Performing lower in “describing side effects”

Report Examples Client Login: Top Box HCAHPS Areas Breaks down HCAHPS scores by unit or location Identify largest areas for improvement Top Box scoring By area shows lower scores in Post Partum and 5 th floor

Report Examples Client Login: Top Box HCAHPS Facility Report Compare hospital scores across the system Specific to hospital or system Collaboration A B C D E F

Report Examples Client Login: 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

Report Examples Client Login: 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

Queries Client Login: 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 Could this be a result of scoring poorly with “Response to call button”?

Contact Us: J. L. Morgan & Associates 7057 Meadowlark Drive| Birmingham, Al | Fax: Jeff Morgan, President Office Jay Bishop, MSHA, CPHQ, COO Office Tanya Harris-Haynes HCAHPS Manager Office Wendy Dew Programs Director (Preventative Care / Pat Sat) Office Latrice Lawson Data Manager Office