Survey of Patients' Hospital Experience (HCAHPS) Compare Data as of July 2017

Survey of Patients' Hospital Experience (HCAHPS)

Hospital Compare Data as of July 2017

(discharges from October 2015 through September 2016)

More recent data is also available reporting discharges from July 2016 to June 2017.

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The customer service team is being
restructured. Nursing leader leadership will implement various measures to improve communication. Sharing Physician Scores with Medical Executive
Leadership Team, Working with Hospitalists to improve scores.  Assigned Hospitalist to units. A physician report card is prepared monthly and reviewed
by the head of the group on an individual basis.  Physician shadowing is ongoing. Expectations for performance scores
are built into physician contracts. Implementing shadowing for hospitalists and
communication of individual HCAHPS performance. Plan
for Patient Experience Coordinator to meet with Med Exec team and hospitalists to discuss/explain HCAHPS using PP presentation. Also,
a new initiative in place for hospitalists and all other MD’s on expectation for communication w/patients put in place
by hospital president and VPMA. Physician
shadowing program has been implemented. We are providing more data to our MDs surrounding patient interactions. Physician
engagement has been identified as a key performance indicator, with improvements being led by the Performance Improvement team
as a regional project. No Pass Zone has been implemented, meaning every
team member of the hospital is required to answer call lights. Hourly rounding has been implemented in which specific patient needs
like pain, plan of care, restroom, personal needs, and positioning are addressed. Staff communicates with patient about how
to use pain scale on white board and how to manage pain. Respond to patients as quickly as possible when there is a complaint of
pain. Staff to provide frequent updates if there is a delay in meds or options. Education is
being implemented and audits performed  with all nursing staff on  appropriate medication pass which includes providing the
name of all meds, purpose of meds, side effect of meds and providing printed material to patients regarding side effects of new medications. Working on scripting of team members to make
sure the patient is satified with the room cleaning. Also working with nursing team members to help decrease clutter in the patient room. Nursing Supervisors rounding on
night shift to measure noise levels and take appropriate action. Guidelines provided to Nursing
to help ensure more restful sleep for patients. Nurse Managers rounding on patients to ensure quiet
environment and to provide aids such as ear plugs. Care
coordination when possible; shutting doors, use of low voices, dimming lights. Limiting visitors after hours. Asking patients to use
earbuds after 9:00 p.m. Implemented
night-time quiet rounds, quiet times on unit 9pm-5am, quiet campaigns/ education. Patient Experience team has been assigned to work
on Quietness to improve scores. Refocusing on maintaining quiet; long-term: building more private rooms HCAHPS improvement projects are in place for floors with low scores
and high volume.  We are also scripting, coaching and documenting accountability results for all team members.  Ancillary
depts are coaching all staff on AIDET. Action plans are currently being implemented for each hospital
department requiring reporting on any/ALL best pactices that affect our Overall Rating ranking. Each manager reports their
action steps bi-monthly, their audit plan and the status for each best practice from their area. New leaders are now in place and the Customer Service Task
Force will be restructured under the guidance of senior leadership and Quality.   Patients rounds are done each day and any
problems reported to senior leadership. Managers review discharge folders daily. Care management
team is handing out new information card and discussing discharge plan with each patient.  Coordinators will verify that each patient
leaves with discharge folder upon checking out at nurse's station.

Survey of Patients' Hospital Experience (Hospital Compare Data
as of April 2017)