209174 Challenges/lessons learned: Implementation of hospital consumer assessment of

Tuesday, November 10, 2009

Consuelo Dungca, EdD, RN , Quality Management and Clinical Affairs, NYC Health & Hospitals Corporation, New York, NY
Juliet G. Gaengan, RN, MSA , NYC Health and Hospitals Corporation, New York, NY
Sue Lee, MPA, RN , Quality Management, New York City Health and Hospitals Corporation, New York, NY
NYC Health and Hospitals Corporation (HHC) is a public health corporation of 11 hospitals, 4 nursing homes, 6 diagnostic/treatment centers, home and healthcare agency and managed care agencies w/over 80 clinics in the five boroughs. HHC provides services to a very diverse population, many immigrants and serves 1.3 million New Yorkers. HHC is relentlessly working to achieve one of its goal to be the provider of choice by the communities it serves, by embarking on a system-wide approach to improve its Culture not only on Quality and Safety but also on patient satisfaction. HHC's Quality Assurance Committee (QAC) of the Board of Directors noted significant improvement in management of diseases such as heart failure, myocardial infarction and pneumonia as evidenced by results of clinical indicators monitored for years. However, the QAC members concluded that quality of care as perceived by patients cannot be measured by these indicators, hence in 2007, HHC participated w/CMS HCAHPS survey program (Hospital Consumer Assessment of Healthcare Providers and Systems). Using principles of quality improvement, QAC of the board sanctioned a task force comprised of representatives from 11 hospitals who met regularly and brainstormed on successfully complying w/CMS strict HCAHPS criteria. Consensus decision to hire a vendor was endorsed and a request for proposal was published and a vendor was selected. HHC dry run from January to June 2007 was conducted in preparation for CMS mandatory participation in July 2007. Initial results were unfavorable and in mid-2008 decision was made to expand areas surveyed to include four hospitals ED/OPD and two Diagnostic and Treatment Centers. Results were regularly reported to QAC of the Board and facilities discussed their action plans called, “Moments of Truth”. Members Survey tool was expanded to include “Patients' Voice” which enables facilities to hear patients' response to “Thinking of this hospital admission, what one thing could the hospital have done better?” To date, each facility has a Champion driving the program to ensure Vendor's database are viewed weekly, responses analyzed and improvement opportunities implemented. Results are improving and clinicians are driving the program, not relying on Customer Relations department. Included in the HHC HCAHPS initiative is addressing the Joint Commission standard on employee disruptive behavior. HHC believes that unhappy employees will result in unhappy patients.

Learning Objectives:
a) Identify challenges in implementing a standard approach in measuring patient perception of care in a large scale system b) Discuss quality improvement principles in identifying opportunities for improvement and arrive at a successful outcome

Keywords: Patient Satisfaction, Quality Improvement

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I manage the Corporate Quality Management program, including HCAHPS
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.