Survey of Patients' Hospital Experience (HCAHPS)

(December 2017 reporting is based on discharges from April 2016 - March 2017)

More recent data is also available reporting discharges from January-December 2017.

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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. 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  Action plans are 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. 1) HCAHPS improvement projects were implemented for units with low scores. 2) All managers report progress to leadership on a monthly basis. 3) We are coaching and documenting accountability results for all team members. 4) Ancillary departments are coaching all staff on AIDET. 5) Nurse managers and charge nurses are rounding with patients to ensure best practices are in place. 6) Care management is working closely with all discharged patients to ensure communication about follow up care is appropriate and ensuring all patients have what they need when they leave the hospital. 7) Care management team also assisting RN’s to ensure discharging patients understand their plan of care.

Care Managers will: 1) verify all communication boards are being utilized and filled out correctly. 2) distribute