January 28, 2013

Hospital Leaders Create The Culture of Always

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By Gabriel Perna
Whether its through better communication or simple amenities, even the most optimistic leader at a hospital will tell
you there is no perfect path to perfect patient satisfaction.
However, thanks to the Centers for Medicare & Medicaid Services (CMS) mandatory Value-Based Purchasing (VBP)
program, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) initiative, hospitals
across the country are certainly going to try to achieve that formula.
Of course, hospitals have been trying to achieve perfect patient satisfaction well before the term HCAHPS was
brought into existence. As Rhonda Scott, R.N., Ph.D., and chief nursing officer (CNO) at the Atlanta-based, 953-bed
Grady Memorial Hospital, says: Patient satisfaction isnt new. Whats new is the HCAHPS component from the
government as a way to compare apples-to-apples.
HCAHPS, a standardized 27-item survey distributed to a random selection of patients 48-hours to six weeks after
discharge, was developed as a way to compare hospitals through common metrics. It is tied to reimbursement from
the VBP program, accounting for 30 percent of a hospitals total performance score (TPS) for FY 2013. Overall, eight
measures are factored into the patient satisfaction part of the TPS: communication with nurses and doctors
(separately), staff responsiveness, pain management, communication about medicine, discharge, cleanliness and
quietness, and overall rating.
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CULTURE OF ALWAYS

Quint Studer, founder of the Gulf Breeze, Fla.-based Studer Group, a consultancy which partners with healthcare
organizations to help them improve HCAHPS scores, says organizations that do best on it put it in the clinical quality
realm. Furthermore, he says, theyre consistent.

Quint Studer
Healthcare has always been challenged by consistency, Studer says. Not only does HCAHPS measure whether
you are doing it period, it measures whether or not you are doing it consistently. In the past, other surveys would ask,
Was your pain managed? Today, it says, Was it managed always, often, sometimes, or never? All of sudden
organizations that may have looked pretty good on a patient satisfaction survey dont look good on an HCAHPS
feedback because of that missing consistency.
As Scott says, HCAHPS is a culture of always. And that culture is not longer just applicable to Medicare
reimbursement, says Katie Owens, practice leader at the Pensacola, Fla.-based consultancy firm, Baptist Leadership
Group. Owens says she has started to see commercial payers beginning to follow suit through accountability in
relation to HCAHPS scores.
NURSE COMMUNICATION

Hospitals like Grady have poured millions of dollars into improving patient satisfactionand ultimately, HCAHPS
scoresthrough various initiatives, as the first payment adjustments take effect this year from previous evaluations.
While Grady didnt do as well as it would have liked the first time around, Scott says she hopes it will be more than a
little better the next time.
One area of focus, for Grady Memorial and others is nursing communication. The hospital has invested in mobile
phones for nurses from Amcom (Eden Prairie, Minn.). According to Scott, through this system, patients can hit a
button and it sends a direct text message to their nurse with a specific request. The patient can also call that nurse,
and if he or she doesnt answer, the call will be sent to a different nurse. In the months since these phones have been
implemented, Gradys nurse communication scores have skyrocketed to the 96th percentile.
Other hospitals, such as Lafayette General Medical Center, a 353-bed acute-care facility in Lafayette, La., have
similarly focused on nursing communication. According to Lafayettes president and CEO, David Callecod, the
hospital has implemented daily active nurse rounding on every unit. At Cleveland Clinic, a non-profit academic
medical center in Cleveland, Ohio, James Merlino, who is chief experience officer and head of all patient experiencerelated initiatives, says hourly rounding from nurses has driven improvement in this area.

James Merlino
Why is there such emphasis on nurses? According to Scott, it goes back to consistency. First of all, if a patient is in
the hospital, its because they need round-the-clock nursing care. If it can be done in an outpatient center or a
physicians office, it would be done. Nurses are probably the only constant caregiver with the patient, she notes.
IMPROVING THROUGH IT

Gradys nursing mobile initiative isnt the only example where hospitals have invested in health IT to improve the
patient experience. According to Scott, Grady itself also has also invested in upgrading its Epic Systems Corporation
(Verona, Wis.) electronic medical record (EMR) and implemented a barcode scanning system for medication
administration. At Lafayette, Callecod says the hospital has upgraded its EMR from the Cerner Corporation (Kansas
City, Mo.) and joined a health information exchange.

Cleveland Clinics Merlino is a firm advocate of health information systems in improving the patient experience. He
says by collecting data on patients and merging it with healthcare IT data, the hospital can better understand how
different populations of patients react to their experience and then use it to improve processes.
Were able to do deep dives on extensive demographics to understand how patients rate their experience, Merlino
says. For instance, we know that sicker patients at hospitals have lower satisfaction. When you drill down on that
data, you realize they rank their experience that way because they require more robust communication. And so we
can focus on improving communication to challenged populations, because we know that will improve their
compliance, help them better understand their treatment, and reduce medication errors. Linking IT through the data
that has been collected has been revolutionary for us.
NOISE AND MORE

Across the landscape, hospitals have drummed up both obvious and unique ways to improve patient satisfaction
scores and the overall experience. At Grady, Scott says part of their $4 million renovation has included more
channels on the TV, better food options, and more private, high-tech friendly rooms. Changing the flow of the
operating room, allowing for a more streamlined process for patients, is an ongoing project at Lafayette General.
Noise is the big thing at Phoenixs Children Hospital, a 345-bed facility, where Deb Green, R.N., nurse manager for
the cardiovascular intensive care unit, has led the implementation of a number of strategies to reduce noise in the
ICU. This includes standard steps such as constructing noise-reducing walls and floors and more high-tech measures
such as working with Vocera (San Jose, Calif.) and Philips Healthcare (Andover, Mass.) to reduce the noise monitors
make by having a nurses handheld deviecs ring instead.
Noise is something you dont even think about often as a part of healing, Green says. You cant get a calm body
system if the noise level is so high its causing your heart rate to be elevated and your blood pressure to change.
THE RIGHT THING

The HCAHPS initiative and the governments culture of always are far from perfect in the eyes of many. For one, as
Scott says, what the patient wants 100 percent of the time might not always result in the best outcome. She says the
use of morphine to manage pain is an example where this could come into play. She also notes how unlike a
vacation or a restaurant, going to a hospital is not something patients plan on doing.
However despite some possible hesitation about HCAHPS, Scott and others, are adamant that focusing on the
patient experience is the right thing to do, not because of the incentive money tied to it, but because it should be a
part of what you do. At Cleveland Clinic, its become such an intricate part of the culture, they took the entire
workforce (43,000 in all) offline, sat them at tables of eight-to-10, and had them discuss how to best deliver the
hospitals patients first initiative.
There are incredible opportunities to improve and change the way we deliver medicine. Dont view this as a
mandate, and dont view it as something thats being forced upon you. View it as something thats right for patients
and use the opportunity to improve the way we deliver care, concludes Merlino.
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