1. Patient Experience Body of Knowledge Policy & Regulatory Domain Team www.theberylinstitute.org September, 2012

2. Policy & Regulatory Domain Team Introductions NameRoleOrganization Mary Owen (Team Leader) Assistant Director, Patient ExperienceUniversity of California, Irvine Health Nicki AndersenDirectorFirst Health Sue CollierVice President, Patient-Family ExperienceVidant Health Caryn EstenDirector, Planning & Strategic SupportFroedtert Health Sandra TomsCustomer Service ManagerDenton Regional Medical Center

3. Reminder: Process/Our Role June 2012 PX Body of Knowledge Domain Teams Identified Volunteers confirmed Team Chairs Identified July – Sept 2012 Content Framing Domain teams will meet virtually to brainstorm content central to their topic Outcome is content outline that could support a 3-4 hour learning module Content development will be supported by “cross-pollination” by team chairs who will meet monthly to update one another on progress. All content suggestions will also be made available for comment to participants Modules will be revisited for priority order to support course development Oct – Dec 2012 Course Development Course development will begin in order of priority determined Courses will be designed, piloted and rolled-out once available Alternative venues for delivery will be determined and implemented With course development initial testing frameworks will be formed for certification, this will include requirements, tests, recertification requirements and grandfathering 2013 Course Roll-out and Certification Planning Course development will continue as needed in early 2013 Continued development of certification test development Full complement of courses available by end of Q1 2013 Initial offering/Pilot of Certification exam targeted for Fall 2013 3 www.theberylinstitute.org

4. POLICY & REGULATORY ISSUES Understanding of the policy and regulatory issues that influence or impact patient experience efforts. Summary of Content Suggestions from Beryl Membership  Understanding of governing bodies (Joint Commission / CMS).  Public Reporting (Understand process and impact). o CAHPS Surveys- Hospital, Clinic, Home Health. o Value-Based Purchasing.  Hospital Compare.  Healthcare Reform Knowledge.  National Patient Safety Initiative.  Cultural initiatives (CLAS Standards).  State policies/practices.  Grievance Processes and Management.  Other public reporting measures (such as third party commercial payors) and the potential for contract penalties/incentives.  Hospital Reporting Sites such as: Health Grades, and US News and World Report – understanding Criteria and measurement.  Understanding Magnet, LeapFrog and other designations.  NCQA and other regulatory agencies for medical groups and health plans.  Grievance process (also part of service recovery above).  Directory of important resources (CMS, JC, etc.)  Provide simplified documents outlining CAHPS and VBP, Patient Rights as defined by CMS, etc.  Understanding who obtains this information and keeps up with new regulations. Who to contact when need arises.  Collaboration with Quality.  Understanding of privacy implications; information security issues.

5. Policy & Regulatory Domain Development Concepts & Key Learnings Sections Learning Objectives Objective Regulatory History SectionsConcepts Mandates versus Recommendations SectionsConcepts Translating Policy Into Practice SectionsConcepts July – Sept 2012 Content Framing Domain teams will meet virtually to brainstorm content central to their topic Outcome is content outline that could support a 3-4 hour learning modules Content development will be supported by “cross-pollination” by team chairs who will meet monthly to update one another on progress. All content suggestions will also be made available for comment to participants Modules will be revisited for priority order to support course development Understanding of the policy and regulatory issues that influence or impact patient experience efforts.

6. Sections Regulatory History Mandates Versus Recommendations Healthcare Reformation 1.What is the history?1.What is mandated? 2.What is recommended by agencies as best practices? 1.What is the impact of healthcare reform on the development of patient experience in healthcare today?

7. Regulatory History Learning Objective: Understand how the driving forces behind improving patient experience impact regulation and policy development. Sections/ConceptsLearning Objectives / Take Aways What is the history? What has driven focus on patient experience and healthcare? What have been the phases of patient experience development? -IOM (safety focus) Affordable Care Act (reimbursement focus) - Understand the difference between federal, state, and local levels of policy development impacting patient experience. What has been the response as an industry to these changes?

8. Mandates Versus Recommendations Sections/ConceptsLearning Objectives / Take Aways What is the difference between mandates and recommendations?Understand the differences. What are the current mandates? What are the current drivers of patient experience and healthcare? -consumer drivers (informed and engaged, responsible citizens) -provider drivers (VBP) What are the current recommendations? What is the future projected vision for patient experience development? -timelines for / evolution of CAPHS Movement of reactive TJC survey process where provider drives outcome versus consumer driven voice with CAPHS What has been the response as an industry to these changes?Tail wagging the dog versus dog wagging the tail Learning Objective: Identify differences between mandated versus recommended reporting requirements and how each influence regulation & policy development.

9. Translating Policy Into Practice Learning Objective: Develop skills to monitor and respond effectively to changes in healthcare and patient experience policy. Sections/ConceptsLearning Objectives / Take Aways How do we become efficient and effective healthcare leaders? -proactive -prepared -positioned How do we prepare to become effective healthcare leaders? How can healthcare leaders position their organization for success?

10. Metrics and Measurement Domain Development Concepts & Key Learnings Sections Learning Objectives Objective Understanding the components of an effective measurement process, including the identification of key metrics and the use of data. Data Elements 7 Sections 19 Concepts Data Sources 4 Sections 15 Concepts Analyzing Data 6 Sections 15 Concepts Applying Data 4 Sections 11 Concepts Sharing Data 5 Sections 18 Concepts July – Sept 2012 Content Framing Domain teams will meet virtually to brainstorm content central to their topic Outcome is content outline that could support a 3-4 hour learning module Content development will be supported by “cross-pollination” by team chairs who will meet monthly to update one another on progress. All content suggestions will also be made available for comment to participants Modules will be revisited for priority order to support course development Example from another domain team…thank you John Murray!

11. Sections Data ElementsData SourcesAnalyzing DataApplying DataSharing Data 1.Why do we need data? 2.Types of data (qualitative v quantitative) 3.How to use data for improvement 4.Basic Statistical Concepts (variation, std deviation, statistical significance, central tendency) 5.Patient Experience data ( Scales used, mean score, Top Box, Percentile Rank) 6.Data limitations (small sample size) 7.Understanding measurement of inputs (actions/activity) and outcomes (survey scores) 1.Survey Collection modes (phone, mail, online) 2.Internal sources of information (surveys, rounding logs, post discharge callbacks, grievances/complaint s, focus groups) 3.External sources (Hospital Compare, Why Not the Best) 4.Research Articles – best practices 1.Aggregating data from multiple sources (how to pull data and bring it together) 2.Types of information collected (HCAHPS v vendor survey, Kano model) 3.Finding useful/actionable information (correlation, vendor analysis on key drivers) 4.Statistical Analysis (regression, modeling etc. examples where used and relevant) 5.Looking for trends 6.Understanding VBP performance calculations (contribution of HCAHPS) 1.Using data for performance improvement 2.Tracking and trending qualitative data (survey comments, complaints) 3.Analysis of HCAHPS scores and application to VBP 4.Performance Improvement Analysis Tools (Radar charts, affinity diagrams) 1.Transparency 2.Dashboards and Report Cards (format, detail level, process and frequency, audience specific) 3.How to display data (trends, control charts etc.) 4.Helping others to understand what data is telling us 5.Hardwiring distribution and discussion of metrics (push or pull or mix of both) Example from another domain team…

12. Data Elements Sections/ConceptsLearning Objectives/Take Aways 1.Why do we need data? Value of Evidence-based practice Research Philosophy/Methodology Why data is important 2.Types of data how the data can (or cannot) be used (Nominal Data, Ordinal Data, Continuous Data) qualitative (patient comments and stories) quantitative To understand uses and limitations of data (the right tool for the right job) 3.Ways to look at data Baseline data (starting point) Trending (your performance over time) Benchmarking (how you compare to others) What the data is telling you 4.Basic Statistical Concepts populations and sampling (N/n) normal variation (within groups-between groups) regression to the mean/data smoothing extraneous variable/confounds (lack of controls) std deviation statistical significance (power, error) central tendency (mean, median, mode) Understanding of basic statistics and how to apply them 5.Patient Experience data Understanding Scales: Mean score, Top Box, Percentile Rank, Likert scale, clustering towards top of scale Net Promoter score (where useful and where not) Understanding of how data is used and applied in our particular environment 6.Understanding measurement of inputs actions/activity outcomes (survey scores) Predictive Indicators (activities aimed at driving the score – e.g. response to call light, rounding, bedside shift report, employee engagement) Outcomes Measures (survey returns) Measuring both process (inputs) and outcomes (scores) Example from another domain team…

13. Next Steps June 2012 PX Body of Knowledge Domain Teams Identified Volunteers confirmed Team Chairs Identified July – Sept 2012 Content Framing Domain teams will meet virtually to brainstorm content central to their topic Outcome is content outline that could support a 3-4 hour learning module Content development will be supported by “cross-pollination” by team chairs who will meet monthly to update one another on progress. All content suggestions will also be made available for comment to participants Modules will be revisited for priority order to support course development Oct – Dec 2012 Course Development Course development will begin in order of priority determined Courses will be designed, piloted and rolled-out once available Alternative venues for delivery will be determined and implemented With course development initial testing frameworks will be formed for certification, this will include requirements, tests, recertification requirements and grandfathering 2013 Course Roll-out and Certification Planning Course development will continue as needed in early 2013 Continued development of certification test development Full complement of courses available by end of Q1 2013 Initial offering/Pilot of Certification exam targeted for Fall 2013 13 www.theberylinstitute.org

14. QUESTIONS? Thank you team!