1. Improving the Patient Experience: H-CAHPS Quality Improvement Project Invasive/Non Invasive Cardiology

2. Membership Cardiology Quality Council –Theresa Fortner -Nurse Manager Invasive Cardiology –Joelyn Niggel - Nurse Manager NI Cardiology –Karen McKenny - Nurse Educator –Julie Eastman - RN Invasive Cardiology –Kristin Pelkey - Cardiology Tech NI Cardiology –Kathy Getty - RN Invasive Cardiology –Judy Rent - RN Invasive Cardiology –Heidi Igneri - RN Invasive Cardiology –Melissa Lambert - Supervisor Cardiology Tech Dept. –Mike Socha - Supervisor Cardiac Ultrasound –Karen McKnight - Quality Consultant

3. What is the H-CAHPS Survey H ospital C onsumer A ssessment of H ealthcare P roviders & S ystems The survey and data collection methodology are mandated by the government. The survey, methodology and results are in the public domain. H-CAHPS is publicly reported on: www. hospitalcompare.hhs.gov www.hcahpsonline.org

4. Background Goals: H-CAPHS –Compare hospital perspective and patient perspective –Ensure the highest quality of patient care and understanding History: –2006 Voluntary collection began –2008 FAHC first participated –2010 Government regulated –2011 Value based purchasing rule finalized

5. Background –Not a satisfaction survey –Measures the behaviors of staff from the patients perspective –Patient Mix Adjusted (age, health, medicine, surgery, OBS) –Not limited to Medicare patients –Nursing and Physician based questions

6. Background Reimbursement –Government will hold 1% of Medicare payments –FAHC can earn back the 1% if we meet National Bench Mark Performance –Reimbursement is based on a % –This is expected to increase to 2% by 2017

7. Objectives Educate the staff regarding H-CAPHS Develop a Cardiology Code of Conduct for improving patient experience. Improve the patient experience in procedural areas. Distribute Thank You cards to all invasive outpatients post procedure

8. Methodology Education of Staff: –Presentations by content experts –Staff meetings in all departments addressing H-CAHPS and concerns regarding: communication, privacy, noise, and environment –Email Cardiology Quality Council to develop a Cardiology Code of Conduct based on staff feedback Redesign the current AIDET survey tool to meet the needs of a procedural area. Monthly auditing of all procedural areas Review results: H-CAHPS and Press Ganey Surveys

9. Implementation Cardiology Code of Conduct Staff Education Monthly Audits Thank You Note

10. Cardiology Code of Conduct Ways to impact the patient experience in a positive manner Communication: Cardiology Staff/Providers/Fellows –Communicate with patient and patient’s family of delays. Use “blameless apology” –Show concern for patient verbally as well as nonverbally –Introductions –Shows patient respect, courtesy, and confidence –Delays and updates Privacy –Maintain the patient’s physical privacy in the testing areas at all times.

11. Cardiology Code of Conduct Noise –In testing areas- pre and post procedure. Music Television Staff –Schedulers –Vendors –Monitor control room –Physician pagers during procedures Environment – Environmental Services

12. Action Plan/Next Steps Further revision of the AIDET tool –Forming it to fit the needs of the testing area –Clarifying aspects of AIDET Continued education for staff Education of auditing staff –How to use tool –Inter-rater reliability Continued monthly auditing Thank you cards: –Roll out to Non Invasive testing areas in 2012

13. Non Invasive Cardiology HCAHPS Staff Survey Totals

14. Invasive Cardiology HCAHPS Staff Survey Totals

15. H-CAHPS CARDIOLOGY

16. Displayed by Discharged Date

17. Cardiology M5 AugustSeptember SEPTEMBER AUGUST

18. Inpatient Cardiology – M5 Aug '11Sept '11 Friendliness/courtesy of the nurses96.797.0 Nurses kept you Informed91.992.7 Nurses checked ID97.596.1 Explanations happened during T&T92.293.3 Staff concerned for privacy91.791.9 Staff include decisions regarding treatments90.390.5

19. Outpatient Cardiology Testing Aug 2011Sept 2011 Facility Cleanliness of facility93.096.2 Std Test or Treatment Friendliness of staff97.496.2 Explanations given by staff91.795.2 Staff's concerns/questions worries91.594.2 Std Personal Issues Concern for privacy93.894.0 Response to concerns and complaints92.190.2