Patient Experience Strategies for FQHCs Financial, Clinical & Operational PerformanceApril 2014

Jay Duval Regional DirectorPress Ganey

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Abigail 11/07/08Abigail TodayReducing Suffering to Improve Performance

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Reducing Suffering to Improve Performance 2013 Press Ganey Associates, Inc.Prevent this suffering for patients:Provide evidence-based care. Prevent complications and errors.Ensure coordinated communication, demonstrate cooperation among staff.Reduce wait, show respect and value for the individual.Mitigate this suffering:Address symptoms, improve functioning, seek to cure, reduce pain and discomfort.Reduce anxiety and fear, educate and inform.Minimize the extent to which medical care disrupts normal life to the greatest extent possible.Provide distractions from the medical setting that provide respite to the anxious patient.Unavoidable Suffering Associated with Treatment Avoidable Suffering Arising from Defects in Care and ServiceUnavoidable Suffering Associated with DiagnosisPinpoint opportunities for FQHCs to reduce suffering and improve the care experience based on feedback from every patient, physician and employee.

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Increased Transparency & Accountability for Medical Practices on the HorizonPQRS Data Collection for Public ReportingPayment Modification for those Impacted by Physician VBP 2012 Press Ganey Associates, Inc.Physician Compare LaunchedCGCAHPSPCMH / CA / MNInitial launchPhysician Compare Public Reporting of PQRSInformation and time lines presented in this session are based upon Press Ganey's experience with other CMS CAHPS initiatives like Hospital and Home Health CAHPS.CMS Pioneer and MSSP ACO programs launch2012-2015

201220122013201420151Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q

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CMS CGCAHPS Survey Overview 2014 Press Ganey Associates, Inc.

THE FACTSCMS OFFICIAL CGCAHPS SURVEYWHOMandatory: Groups with 100 or more eligible professionals under one tax ID, submitting as a group through the GPRO web interfaceVoluntary: Groups with 25 or more eligible professional under one tax IDWHATStandard way to measure the patient experience CGCAHPS + Primary Care Themes6 month retrospective timeframe Access to SpecialistsHealth Promotion & EducationShared Decision-MakingCare CoordinationEducation about MedicationStewardship of Patient ResourcesBetween Visit Communication WHENONE time per year: January-MarchWHYImpacts at least 16.7% of payment as part of the value modifier (up to 4%)

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2013 Press Ganey Associates, Inc.Domain Weighting Changes2016Proposed

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Regulatory Administration

Survey Continuously for Improvement & to Achieve Higher Scores on the Regulatory Submission 2014 Press Ganey Associates, Inc.

Visit Specific Survey for Continuous Improvement of Patient Experience

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Quicker Feedback Through eSurvey 2013 Press Ganey Associates, Inc.Days LapsedPercent Returned

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Rapid-Cycle Improvement - Enabled by eSurveyUniversity of Utah reduced their improvement cycle time by 83%, from 12 weeks to 2 weeks.

We certainly reduced cycle time for change.

Having daily returns greatly enhanced Piedmonts ability to coach and to provide more valuable feedback.

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CGCAHPS questions, indicate the frequency of communication events in medical encountersFQHCs should add questions to yield actionable information on the quality of those events. Connecting CGCAHPS to Usable Data

In addition to knowing how often something is done, it is critical to understand how these things meet the patient expectations which allows for evaluation and improvement.

2013 Press Ganey Associates, Inc.

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2012 Press Ganey Associates, Inc.Always vs. UsuallyPatients reported how often their nurses communicated well with them during their stay. Communicated well means nurses explained things clearly, listened carefully to the patient, and treated the patient with courtesy and respect.

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Higher Employee Engagement, Better Patient Experience 2013 Press Ganey Associates, Inc.+ 62 percentile

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Higher Physician Alignment, Better Performance 2013 Press Ganey Associates, Inc.Comparison of CAHPS Performance Among Organizations with High- or Low- Physician Alignment

Chart1

6733

5942

Average National Percentile Rank

Morehead Alignment Data. CMS HCAHPS Data.

+40%

+103%

High Physician Alignment

Low Physician Alignment

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High Physician AlignmentLow Physician Alignment

Rate Hospital (0-10)6733

Recommend this Hospital5942

To resize chart data range, drag lower right corner of range.

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Rising Tide measure: Nurse CommunicationThis cluster of measures makes up 15% of a hospitals VBP score

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2012 Press Ganey Associates, Inc.CAHPS QuestionsDuring this hospital stay, how often did nurses treat you with courtesy and respect?NeverSometimesUsuallyAlwaysDuring this hospital stay, how often did nurses listen carefully to you?NeverSometimesUsuallyAlwaysDuring this hospital stay, how often did nurses explain things in a way you could understand?NeverSometimesUsuallyAlways

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Top Box Scores Based on Publicly Reported Data

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Press Ganey Data: National Scores Moved From 76% to 78% Since March 2011

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2012 Press Ganey Associates, Inc.Identify CausesIneffective communication: We think we communicated however the patients or their families did not understand. Example: Patients unaware of plan of care, and or do not understand plan of care from how it was communicated to them.

Inconsistent communication: Some people communicate better than others.Has to be every patient every encounter.

Substandard communication: Courtesy and respect not perceived by patient and family.

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Using CAHPS to Assess Service Reliability 2013 Press Ganey Associates, Inc.

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Standing Still is not an Option 2013 Press Ganey Associates, Inc.20082012Average market performance on CAHPS increased ~10% from Jan 2008 to Jan 2012.84th88th

Questions?

This presentation is intended to provide an overview of Press Ganeys contemporary business model that is helping healthcare organizations nationwide align their organization around delivering a reliable patient experience and as a result improve quality, reduce readmissions, enhance their brand and improve their financial performance.

The presentation includes three sections:An introduction to an evolutionary philosophy of how patients perceive care, how to use advanced analyses to understand that perception and improve performance;An overview of national trends in patient experience, how it affects quality, readmissions, and financial performance; andA review of Daughters of Charity performance trends, opportunities for improvement and high level strategies for improving patient experience and quality.

**There are three kinds of suffering for patients. Two of which are unavoidable related to their diagnosis or treatment. As healthcare providers, it is important to mitigate this suffering to the best of your ability. Minimize the effects on the patient to the greatest extent possible to reduce anxiety and fear.

The third kind of suffering is that which is caused by the healthcare system itself either due to defects in care or service. The most obvious example that gets attention would be medical errors. But there are more subtle kinds of avoidable suffering such as excessive waiting, poor communication, disrespect and lack of courtesy. All of these cause fear, anxiety and additional suffering for the patient.

In order to create a reliably positive experience for every patient, it is important to understand if there is avoidable suffering being caused. To understand that perspective, it is critical to provide EVERY patient an equal opportunity to voice their experience and then use that data to analyze the types of suffering present. Therefore, we at Press Ganey have built a new business model to afford our clients the ability to achieve that objective.*The Physician Compare website was launched in January 2012. CMS plans to add clinical quality data collected through the Physician Quality Reporting System to the website in 2013. The initial public reporting would be based on data collected during 2012.

States such as California and Minnesota and the NCQA Patient Centered Medical Home CGCAHPS are launching patient experience data collection in 2012

Providers reimbursement will be reduced by 1.5% in 2015 if they do not successfully participate in PQRS data collection.

Finally the Secretary must develop and implement a budget neutral VBP system for physicians based upon the quality of care and cost. The payment adjustments will begin with January 1, 2015 for specific physicians and groups determined by the Secretary. By January 1, 2017 a program should be in place for all physicians and groups of physicians.*AWB*Currently: Any CGCAHPS or CGCAHPS-like offering is under the CGCAHPS Insights Umbrella NamingMoving Forward: Only CGCAHPS Official Regulatory

We suggest all clients use a visit specific offering on a continuous basis and *Conversation with provider next day.**Today, Press Ganey continues to lead the patient experience industry. While remaining faithful to our founders mission, we continue to introduce innovative solutions and services designed to propel health care organizations forward on their journey to improving the patient experience. Nearly three decades ago, Press Ganey brought an unprecedented level of scientific rigor and understanding to the patient satisfaction industry. Now, we are again transforming health care as we redefine the patient experience and forge the path to allow the voice of every patient to be heard. Our integrated suite of solutions provides deeper data, advanced analytics, and strategic advisory and consulting services that deliver more powerful insights. Yesterday, we were helping clients improve the delivery of care. Today, we are helping clients drive targeted performance improvement and transform the patient experience.

*One of the pieces of data we wanted to share today we obtained from the hospital compare website. This table shows us what the national average is for each response category for the communication with nurses domain. What should jump out at you is how the bottom two categories, Sometimes and Never only account for 5% of responses nationally. However, 77% of responses fall in the Top Box category of Always and 18% fall into the next highest category of usually. As we know, Value Based Purchasing only looks at the Top Box percentage, so even if you had all 23% of your patient responses that werent always responding with Never it would be the same as if the other 23% of responses were usually. Its extremely important to create the types of experiences that have patients responding with that top category, and the fact that the second highest percentage of patient responses fall into the category just beneath the Top Box, it makes that improvement attainable.*There are many studies that support the concept that engaged employees lead to better patient experiences. Press Ganeys research supports improving patient experience and outcomes by improving organizational culture and ensuring all employees are engaged. If you compare the best places to work in the US according to their employees (green bars in the graph) with the least desirable places to work (the gray bars in the graph) the best places to work offer patient experiences that are significantly better than their counterparts. In fact their patient experience scores are 62 percentile points higher for overall rating top. Additionally, hospitals with highly engaged employees perform equal or better on 11 of 12 core measures. And while there are many factors that influence patient experience, this data demonstrates that providing an engaging culture for employees creates an environment where patients are much more likely to have reduced suffering and better experiences.

*Similarly, there are studies that support the concept that organizations that create an environment where physicians are aligned with the goals of the organization also have better patient experiences. Press Ganeys research supports improving patient experience and outcomes by improving physician alignment. If you compare the best places to practice in the US according to their physicians (green bars in the graph) with the least desirable places to practice (the gray bars in the graph) the organizations with high physician alignment offer patient experiences that are significantly better than their counterparts. In fact their patient experience scores are 103% higher on overall rating and 40% higher on likelihood to recommend the facility.

Alignment is a variable measuring the extent to which physicians feel a strong partnership/connection with the hospital/system. This is an environment where physicians can respond positively to the following items: I have confidence in Hospital Administrations leadership. Hospital Administration is responsive to feedback from physicians/providers. I can easily communicate any ideas/and or concerns I may have to Hospital Administration. I have adequate input into decisions that affect how I practice medicine. This hospital treats physicians with respect.

*But we shouldnt just get caught up in how everyone is performing on their communication with nurses domain, we should also take a step back to realize how important this particular aspect of the patient interaction is to the overall patient experience of care and Value Based Purchasing.

Rather than spending a long time speaking to the science behind the graphic on this slide, I want to speak to what this is essentially saying. The communication with nurses domain is a driving force in HCAHPS, particularly as it relates to Overall Hospital Rating.

The cluster of measures in green actually make up 15% of a hospitals VBP Score

However, the analysis uses only HCAHPS measures so it doesnt help you know what you could be missing, that could be an even bigger leading indicator.

*We feel it is very important to highlight the three specific questions that make up the Communication with Nurses Domain.

CMS through their Value Based Purchasing program is solely focused on those patients who report that the Nurses treated you with courtesy and respect ALWAYSListened carefully to what your patients have to say ALWAYSAndExplained things in a way that you could understand ALWAYSWe encourage you all to have copies of this blank survey to use as training tool with your staff, physicians and anyone who works in your organization.We often refer to the survey as an open book test! The questions help you know what is important to your patients from the time they are admitted to the day they are discharged, and everything that happens in between. The survey questions are the best tools to guide you toward what to focus on with your improvement initiatives Many improvement strategies that we will be discussing today are focused on increasing the consistency of the patient experience , in other words, expanding the times that we are at our best.

*As you can see from this graph taken out of an article from the Health Care Leader Action Guide to Effectively Using HCAHPS , published in March 2012, The communication with nurses domain is one of the top performing domains, with Doctor communication and Discharge communication scoring slightly higher when we look at the top box % of always responses from patients across the nation.

The top box % of always scores for the nursing communication domain was at 76% in March 2011

From this information you can now look at your own top box scores and see where you were at compared to the national % of top box scores.

*not only on how well facilities perform on the communication with nurses domain, but also speaking to the importance of data that is being viewed by staff, and making sure that data is timely so it will be much more meaningful. Our graph here points out the amount of movement weve seen in the communication with nurses domain since the last public report of patient data on the hospitalcompare website. Not only does this stress how well facilities are doing with this domain, but it also shows the amount of movement weve seen in just a year. Top box performance improving by 2% is a very important thing to know about! If you arent up to date on how everyone else is improving, you may think you are doing well by staying the same, when youre actually falling way behind! No one wants to be left behind in the world of Value Based Purchasing, its much too costly. However, with all that being said, we want to be sure you are looking at your data, whether that be through the Press Ganey Improvement Portal or through the Hospital Compare website, its important to realize how your performing and how those that your benchmarking against are performing.*Some of the causes that we have identified that can prevent our clients from communicating effectively are that we think we communicated however we did not validate that our patients understood what we said.If patients do not understand their plan of care, they are less likely to be compliant with the care plan. A patient who had hip surgery was told about the precautions she needed to take in getting up and moving around. Every care giver that came in reminded her of the precautions she needed to take. On the day of discharge the patient asked me what hip Percussions meant. She had not fully understood what the caregivers were talking about with this very important message after hip surgery to prevent a dislocation of the new hip!

Inconsistent communication is when we tell some patients everything but we are not consistent with our messaging to every patient, every family member, every time. Even as simple as introducing ourselves, our role and what we are going to be doing, should be consistent with everyone every time. If we are not consistent, there will be gaps in the care. As we are all aware, some of us communicate very easily, however in the hospital setting we are dealing with patients and family members that are often scared, anxious and do not understand all that is going on around them. The better we can create ways to communicate with all types of patients, the happier everyone will be. I often say to my clients that it is part of our job to bring peoples anxiety levels down through our clear, calm and professional communication.

Substandard communication results in our patients perceiving that we did not ALWAYS communicate with courtesy and respectWhen we are in a hurry, our tone of voice may convey that we either do not have time for the patient and their questions, or may come across that we are annoyed by all the questions our patients ask. I heard an ER nurse say to a patient, I already told you that! in response to the patient asking the nurse to clarify the discharge instructions.

Even if the care had been perfect up until that comment, I am pretty sure the patient would not give an always to the question of how often did we treat you with courtesy and respect.Transition: after carefully reviewing any and all causes that may be occurring within your organization and identifying where we can improve our communication we are now ready to move to step 3 in the 6 step improvement model*If we drill down into the National HCAHPS trend and look at each of the domains, the national average of all Press Ganey clients for each of the HCAHPS domains has increased year over year since 2008. Again reinforcing the need to continuously improve care for all patients.*As we look at national trends in HCAHPS performance, we see that attaining a high national percentile rank becomes more challenging each year. Thats because hospitals across the country are improving their performance not just the high performers but all facilities. For example, from Q1 2008 until Q1 2012, the AVERAGE performance on HCAHPS increased by approximately 10% (from 0.63 to 0.69) The entire distribution of scores shifted to the right (and the distribution became tighter). This means that you have to work harder just to maintain rank. The HCAHPS Overall Rating question provides a good example of how maintaining the same level of performance year over year is not sufficient in this HCAHPS age: In 2008 if 75% of responding patients rated your hospital a 9 or 10 (top box) on the HCAHPS overall rating question, your hospital would have been in the 88th percentile nationally whereas just 3 short years later, that same 75% would only get your hospital to the 78th percentile.

*This presentation is intended to provide an overview of Press Ganeys contemporary business model that is helping healthcare organizations nationwide align their organization around delivering a reliable patient experience and as a result improve quality, reduce readmissions, enhance their brand and improve their financial performance.

The presentation includes three sections:An introduction to an evolutionary philosophy of how patients perceive care, how to use advanced analyses to understand that perception and improve performance;An overview of national trends in patient experience, how it affects quality, readmissions, and financial performance; andA review of Daughters of Charity performance trends, opportunities for improvement and high level strategies for improving patient experience and quality.

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