Before I start I would like to thank my preceptors for coming to this event.

Hello everyone! My name is Diana Katsereles. My case study was on

improvements for HCAHPs at Greater Baltimore Medical Center

(GBMC).

Does everyone know what GBMC is?........ For those of you who do not

know, GBMC is a 245 bed medical center located in Towson, MD. It is

about less than five minutes from here. GBMC is a private, not for

profit community medical center. Their vision phrase is to every patient

every time; we will provide care that we would want for our own loved

ones At GBMC all staff are encouraged to not only know what the

phrase but also to emphasize how work should be done it was for our

loved one.

I accepted an internship at Greater Baltimore Medical Center.

My internship was in the Nursing Administration Department of

GBMC. My preceptors were Dr. Porter and Ms. O’Connor Devlin. Dr.

Porter is the Chief Nursing Officer and Sr. VP of Patient Care Services.

Ms. O’Connor Devlin is the Administrative Director of Patient Flow and

Nursing Quality. Dr. Porter directs and facilitates the development of

hospital-wide patient care programs, implementing plans for nursing

care, and participates in quality improvement programs. Ms. O’Connor-

Devlin is a nursing leader who is responsible for the oversight of

HCAHPS initiatives for the inpatient units and for Partnership for

Patients (PFPs) initiatives measuring quality outcomes through evidence

based practices hospital-wide. She also manages patient flow. Ms.

O’Connor-Devlin also participates in multiple committees related to

patient safety and quality (Better Health/Better Care Committee, Patient

Safety, Quality and Safety, and Board Quality Committees).

HCAHPS stands for Hospital Consumer Assessment of Healthcare

Providers and Systems. It is the first national, standardized, publicly

reported survey of patient’s perception of hospital care. It was

developed by the Centers for Medicare and Medicaid (CMS) partnered

with the Agency for Healthcare Research and Quality (AHRQ) and the

Department of Health and Human Services. The first public report was

in 2008. The results were reported on the Hospital Compare website at

www.hospitalcompare.hhs.gov. According to CMS, the survey was

shaped by 3 goals:

Goal number one is to produce comparable data on patients’

perspectives of care so that consumers can make an informed decision

among hospitals.

Goal two is to create incentives for hospitals to improve their

quality of care.

Goal three is to enhance public accountability in healthcare by

increasing the transparency of the quality of hospital.

The HCAHPS surveys have a standard set of questions. The report

is randomly sent to a defined number of patients per month. The

surveys are available in English, Spanish, Chinese, Russian, and

Vietnamese and are sent via US mail. Surveys are also done by phone

or online. The patients who receive the survey are of all payer types.

They are required to be over the age of 18 at the time of admission; have

at least one overnight stay in the hospital as an inpatient; have a non-

psychiatric MS-DRG/principal diagnosis at the time of discharge; and be

alive at the time of discharge. There are twenty one questions that are

categorized into eight domain scores. The eight domains are the

considered significant aspects of the hospital experience. The domains

are Nurse Communication, Responsiveness of Staff, Medication

Communication, Cleanliness, Pain Management, Physician

Communication, Quietness, and Overall Hospital Experience. Of the

eight domains, three domains were chosen as a focus by nursing. These

were Nurse Communication, Responsiveness of Staff, and Medication

Communication.

The organizational strategy chart of GBMC shows the significance

of HCAHPS and who is involved (Appendix B). The Chief Operating

Officer leads the Better Health/Better Care Committee. Each Vice

President is responsible for a strategy and has an administrative director

who manages the processes with a performance improvement colleague.

They provide updates/reports to the senior executives. The HCAHPS

aspect is separated into the eight domains by domain leaders that are

specializing in that area. The domain leaders are usually nurse

managers. The domain leaders involve the physicians, ancillary

departments, and the front line staff when a new process is being

implemented. Front line staff would include the registered nurses (RNs)

and the nursing support technicians (NSTs).

The Nurse Communication domain is analyzed by plotting the

current HCAHPS score on a P chart over time. The responses to the

questions are measured using a scale of never, sometimes, usually, or

always. The graph shows the percentage of always responses. This is an

internal measurement tool and is publically reported on the GBMC

website. The percent always scores are also reported on the

hospitalcompare.gov website. The questions from the survey as listed in

the Studer reference are:

1) During this hospital stay, how often did nurses treat you with courtesy and respect?

2) During this hospital stay, how often did nurses listen carefully to you?

3) During this hospital stay, how often did the nurses explain things in a way you could understand? (43)

For the month of September 2014 the score for the overall Nursing

Communication was 79.04% (Appendix B). No special cause at this

time. P chart special causes are categorized by seven rules. Juan Negrin

personally communicated the seven rules:

1) 1 or more data points above/below the control limits. 

2) 2 of 3 consecutive data points above/below the 2 sigma line. 

3) 4 of 5 consecutive data points above/below the 1 sigma line. 

4) 8 or more data points in a row above/below the mean (known as a shift)

5) 6 data points or more all consecutively higher/lower than the preceding one, known as a trend. 

6) 15 data points or more hugging the mean. 

7) 14 data points or more alternating up and down (2014). 

After observing the scores for HCAHPS for each of the units, the

current processes were observed this was the 5 Phase Team

Communication process. The findings were from the team huddles, RN

to RN and NST to NST handoffs, and the RN to NST handoff. The

observation was to see how each unit performed the process and what

improved throughout the observations and the areas that need

improvement. The areas of improvement for team huddles included the

reduction of the duration of the huddle and to increase the attendance of

off going and oncoming staff. RN and NST handoffs were with five

minutes or less the majority of the time and always done in the patient

room. The RN to NST handoff was apparent on units that had been part

of the test project where the process was trialed. The opportunity for

improvement for the team huddles was the content of the information. It

was different on each unit. RN and NST handoffs lacked a standard

process and the handoff tools varied with the NSTs. RN to NST handoff

was not completed on some units. The units that had the handoff lacked

standardization.

The Responsiveness of Staff domain is analyzed by plotting the

current HCAHPS score on a P chart over time. The responses are

measured in the same fashion for each of the HCAHPS domains. The

percentage of always is publicly reported on the hospitalcompare.gov

website. From the Studer Group the questions from the survey are:

How often did you receive help getting to the bathroom or using the bed pan as soon as you wanted?

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted? (131)

For the month September 2014, the score for the overall Responsiveness

of Staff was 66.50% (Appendix D). No special cause at this time.

The current initiative for this domain is purposeful rounding by

using the four P’s (Pain, Possessions, Potty, and Pain). The leader

rounding tool is used to interview patients on the unit. A clinical care

coordinator or the nurse manager usually does this to measure if the staff

is being responsive to the patient needs. There were improvements with

unit observations. Staff is always courteous and purposeful rounding

was done every hour. The four P’s were asked when the RN did rounds.

Patient interviews improved (Appendix E) over a period of time. The

area of improvement observed is the variable response time to actually

respond to the patient’s needs. Units that had quicker response times

had the unit secretary call the RN or NST by phone. There is an

opportunity for improvement with this metric where the manager can

observe staff rounding to see if they are consistently reinforcing the 4

P’s with the patient on each interaction...

The Medication Communication domain is analyzed by plotting

the current HCAHPS score on a P chart over time. The responses are

measured in the same fashion for each of the HCAHPS domains. The

percentage of always responses is publicly reported on the

hospitalcompare.gov website. From the Studer Group the questions

from the survey are:

1. Before giving any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

2. Before giving you any new medicine, how often did staff tell you what the medicine was for? (183)

For the month September 2014, the score for the overall Medication

Communication was 61.74% (Appendix F). This is a trend which is a

type of special cause.

The current initiative for the domain is the Welcome Folder. On

all of the units the Welcome Folder has the same basic contents.

Information specific to specialty units is also included. When a new

medication is ordered the RN explains to the patient that this is

something new, what the medication is for, and what the most frequent

side effects might be. A medication education sheet is printed by the

staff and placed in the folder for the patient and family’s reference. The

sheet has more information about the medications the patient is taking.

A survey tool was developed for patient interviews (Appendix G).

Observations were also conducted on units to observe staff providing

this information. There is an area for improvement with the nursing

education and for follow-up during the patient interviews regarding

understanding the Welcome Folder (Appendix H). Over time there was

an increase with the Welcome Folder being present in the patient room.

Patients also could verbalize medications because the nurse

communicated the medications frequently as seen during observations.

The opportunities for improvements are the explanation of the new

medications and side effects, the process to explain the folder, and

engaging staff to print medication education sheets.

Overall findings from the three domains are: inconsistent practice,

lack of standard tools/practice, and lack of follow through. Inconsistent

practice was found with mixed reviews from patients about response

time and RN to NST handoffs. Lack of standard practice was found

with the NST handoff tools, content of huddles, and with the explanation

of the Welcome folder. Lack of follow through was found with

rounding on patients every day for feedback about response time and

medication education sheets.

From the findings, the following recommendations were made.

The solutions should be done all for current and future initiatives for

HCAHPS. This would include better leadership roles, accountability,

follow through, and standard work. Leadership should be from the

CUC. The CUC should be coaching, mentoring, and educating staff

about what the expectations are for the unit. If the CUC provides a good

leadership presence, the staff will be more involved with future

processes. There needs to be accountability for what those expectations

are of the staff. The nurse manager and the CUC should have the same

expectations and follow through with consistent counseling. Standard

work is important for better communication of information and to

decrease errors.

By using these recommendations, future initiatives could be better

organized and also achieve the opportunities for improvement. Projects

in progress for HCAHPS include introduction of a “No Pass Zone” as

outlined in the HCAHPS Handbook. When this is fully implemented no

staff member can pass a patient room where a call light is on without

answering it. This is used to improve the response time for patient needs

and should increase the domain of the Responsiveness of Staff score and

the Quietness domain score. In order for this to be effective all staff

must be accountable for answering the lights and either providing the

necessary care or by obtaining assistance from someone who can

address the patient’s needs. This would also be evaluated during

consistent leader rounding. The Medication Communication domain

would be addressing New Medications is being addressed by having the

resident physician educate the patient about new medications. This will

also help improve the Physician Communication domain. The outcomes

will be evaluated in the HCAHPS scores from both of the domains.

Finally the last new initiative is restructuring units by zones. This would

increase the Responsiveness of Staff since the team assigned to the area

can respond more quickly to patients needs.