Survey of Patients' Hospital Experience (HCAHPS)

Hospital Compare Data as of October 2017

(discharges from January - December 2016)

More recent data is also available reporting discharges from October 2016 to September 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. 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. Quiet time implemented 2 hours during the day as well as during the night shift. Quiet rounds are done to offer patients ear buds, ear phones for TVs for semi private rooms. Refocusing on maintaining quiet; long-term: building more private rooms 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.

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