Survey of Patients' Hospital Experience (HCAHPS)

Hospital Compare Data as of December 2016

(discharges from April 2015 through March 2016)

More recent data is also available reporting discharges from January to December 2016.

<<back to Quality Report Card home page

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. 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. ''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. 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.