NEPI/IHI HCAHPS Project Work Plan 1 Introduction to Project - - PDF document

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NEPI/IHI HCAHPS Project Work Plan

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Introduction to Project

Background: The New England Performance Improvement (NEPI) network was developed in 2004 as collaboration among the Rural Hospital Flexibility (Flex) programs in Maine, New Hampshire, Vermont and Massachusetts. The network, coordinated through the New England Rural Health RoundTable (NERHRT), has partnered with the Institute for Healthcare Improvement (IHI) to design and implement a rural hospital-specific Performance Improvement project. Project Purpose: To assist New England rural hospitals with the implementation of best practices for patient engagement and satisfaction. Improvement Topic: The 2011 NEPI Project will involve one Performance Improvement area (“Expedition”), “Advanced Techniques to Improve Your HCAHPS Score”. Cost: Free – Each state’s Rural Hospital Flexibility (Flex) program has committed funds for IHI Passport(s), webinars and technical assistance Timing: The project will start with the first national IHI HCAHPS Expedition webinar in March 2011 and will last approximately 3 months, comprised of six (6) national webinars and six (6) NEPI rural hospital-specific webinars. Resources: Participating hospitals will have access to the following services/programming:

• 1. Regularly scheduled IHI nationwide HCAHPS Expedition webinars
• 2. NEPI rural hospital-specific extended learning through customized

webinars

• 3. IHI materials on HCAHPS best practices
• 4. Networking among New England rural hospital Performance Improvement

professionals

• 5. Individual consultations through existing state networks may be available
• 6. Performance monitoring and benchmarking among participating NEPI

rural hospitals (optional project component)

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What Hospitals Need to Know

Estimated Time Commitment: Participating hospitals will be asked to attend each of the national IHI HCAHPS webinars (hosted by IHI using WebEx technologies) as well as the NEPI rural-specific extended learning webinars (using similar web-based technologies but as a separate session) held after the national webinars. Each webinar will last approximately 60 minutes. It is anticipated that IHI will hold six (6) national and six (6) NEPI rural webinars. MINIMUM TIME COMMITMENT PER CAH:

• 1. Participation in IHI National Calls (6 calls at ~60 minutes each)
• 2. Participation in NEPI/CAH Specific Calls (6 calls at ~60 minutes each)
• 3. Project communication/coordination within each facility (30 minutes per

month) Data Collection and Benchmarking Data collection and benchmarking is optional

• Data Source and Type: Hardcopy quarterly HCAHPS reports from survey

vendors (but encouraged) for participating

• hospitals. As part of the project, hospitals will have an opportunity to submit

quarterly HCAHPS data to the NERHT. The NERHRT will aggregate HCAHPS data and create regional benchmark reports that will be used to compare performance across participating hospitals and identify variances/performance

• gaps. This analysis will inform the IHI programming and provide for more

targeted technical assistance. Hospitals electing to submit data to NERHRT will

• nly need to send already-available HCAHPS reports for a specified period of

time to support the project; there will be no duplication of data entry or any additional burden placed on hospital staff. Benchmark reports will be blinded and be made available only to participating hospitals, state partners/consultants and IHI.

• Submission Process: Mail hardcopies to PMI using address below
• Specifications: Reports should include quarterly scores for all core

HCAHPS questions

• Aggregation and Reporting: Done by PMI, Benchmark reports made

available to CAHs

• Policy: Reports will be blinded unless hospitals/state networks indicate
• therwise
• Duration: We request quarterly reports starting 1st
• Extended Period: Project may request additional periods after project

completion to facilitate a study of performance impact(s) Quarter CY2009 through current

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About the Conveners

The New England Rural Health RoundTable (NERHRT) is a non-profit, membership-driven organization composed of a diverse group of individuals and organizations committed to improving health and health care throughout the rural New England communities. The RoundTable was established in 1997 with funding from the National Rural Health Association (NRHA) and serves as a regional rural health advocate for Connecticut, Massachusetts, Rhode Island, Maine, New Hampshire and Vermont. Our Board of Directors includes State Office of Rural Health Directors, Flex Grant Coordinators and other rural stakeholders from each of these states. The Institute for Healthcare Improvement (IHI) is an independent not-for- profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action

Advanced Techniques to Improve Your HCAHPS Score Timeline

Session One National IHI Call, Thursday, March 3, 2011 1-2:30 PM EST

• HCAHPS and You! What is HCAHPS, how it measures the patients

experience and why it is so important to your bottom line

• Assignment - pick one or more HCAHPS measure that you want to

address

• Thursday, March 10th

1:00 – 2:00 New England rural hospital extended learning call Session Two National IHI Call: Thursday, March 17, 2011 1-2 PM EST

• Patient and Family Shadowing: Uncovering Opportunities to Deliver

Exceptional Patient and Family Care Experiences Overview of Shadowing, focusing on Steps 1-3. Report from teams: On their assignment—what HCAHPS measure did they pick and why

• Assignment- Read Shadowing Guide and complete Steps 1-3
• Thursday, March 24th

1:00-2:00 New England rural hospital extended learning call Session Three National IHI Call: Thursday, March 31, 2011 1-2 PM EST

• Go Shadow! Review Steps 4 and 5 Report from teams: Details on

steps 1 through 3

• Assignment- Complete a shadowing experience related to an HCAHPS

measure that you identified, from execution to review and planning next steps

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• Thursday, April 7th

1:00-2:00 New England rural hospital extended learning call Session Four National IHI Call: Thursday, April 14, 2011 1-2 PM EST

• Reporting–Step Six Review, how to report and use your findings

Report from teams: Shadowing experience from 2-4 teams including what saw differently by seeing through the eyes of the patient and family.

• Assignment- Create a Care Experience Flow Map and Observation Report
• Thursday, April 21st

1:00-2:00 New England rural hospital extended learning call Session Five National IHI Call: Thursday, April 28, 2011 1-2 PM EST

• Changing the view for your Patient and Family – what projects can

you develop form these findings? How to build PFCC HCAHPS Project Teams to find solutions. Report from teams: On results of Care Flow Mapping and Observation Reports for 2-4 teams

• Assignment- Develop a project team that will work together to improve the

patient and family experience.

• Thursday, May 5th

1:00-2:00 New England call Session Six National IHI Call: Thursday, May 12, 2011 1-2:30 PM EST

• Using PFS as a Introduction the PFCC Methodology and Practice

Report on the changes selected and anticipated results of your PFC HCAHPS Project Teams

• Thursday, May 19th

1:00-2:00 New England rural hospital extended learning call

Evaluation of National and NE project

• Post IHI HCAHPS Expedition webinar survey. IHI have given permission

for the NE Flex coordinators to review the responses to this survey from the NE participants. Results will be discussed at the FLEX workshop

• Post NEPI rural hospital-specific webinars project survey to all NE
• participants. Results will be discussed at the FLEX workshop
• The data collection and benchmarking was optional (but encouraged) for

the NE participating hospitals and individual states were given the unblended option within their state with the collective NE data blinded. Hospitals were expected to conduct a project over the 6 week educational session (please see lessons learned for further information on the impact

• f this)* and as a result hospitals started projects at different times. It was

decided to extend the reporting period for HCAHPS scores to 2012 to allow for the variation in project dates and for the delay in seeing any changes in HCAPHS scores as a result of timeline of individual project

• activities. All the NE state offices are continuing monthly conference calls

6 with state hospitals to discuss individual projects, lessons learned and review of data reports over the extended reporting period.

• At the NERHRT Symposium in Oct 27-28th

@ Inn at Mills Falls Meredith, NH there will be a presentation on this project by NEPI with one hospital/state presenting on their individual project. Feedback from Flex Coordinators; Lessons Learned

• The first IHI project was a learning experience which will allow future

participants to have a better understanding of how the process works.

• The initial coordination needs to be very clear with the process, time

commitment, participants who would benefit, potential projects, etc.

• Have a clearer understanding of the IHI expectations from hospitals before

the program begins i.e. most hospitals were not prepared to do a project and did not have one decided on, see session one; Assignment - pick

• ne or more HCAHPS measure that you want to address. The NE

specific calls were designed to be the forum for rural hospitals to discuss issues with implementing an IHI project in their facilities and to get support and feedback from colleagues and IHI faculty. *Both Flex coordinators and hospitals were unclear of the expectation from IHI that they should start a project immediately so as a result there was not a lot of input until projects got started. This was a valuable lesson around communication. .

• Having a point person to assist hospitals when they had questions – felt

this worked well.

• Important to have a commitment from the hospital and consistency in the

participants.

• Many hospitals would not be able to afford this type of education if not for

the financial support from the ORHPC

• Need to be mindful that hospitals are extremely stretched with few extra

financial resources, and look for opportunities that add value – this project addressed how hospitals could use an inexpensive process to improve their HCAHPS scores.