Avera Uses HealthStream to Improve HCAHPS Results
Success Story for HealthStream’s Patient Insights HCAHPS Survey
Submitted by Theresa Guenther -
Director of Quality
Avera Sacred Heart Hospital (ASHH)
Yankton, South Dakota
“Avera’s mission is to improve the health and lives of the people we serve by delivering high quality healthcare services. We view HealthStream as our
partner in that effort, as we seek to fulfill our mission every day.”
-Theresa Guenther, Director of Quality
Before selecting HealthStream the hospital’s top box % for the HCAHPS Overall Rating (0-10) score was 71%, which placed them in the 63rd percentile. This is the adjusted score for the overall rating of the hospital as reported by CMS. The most recent top box % for their HCAHPS Overall Rating (0-10) score is approximately 76%. The improvement from 71% to 76% is comparable to a 20 percentile point jump in the national rankings.
The Benedictine Sisters first opened their doors in 1897 and began providing care. Today, Avera Sacred Heart Hospital provides care for over 120,000 residents in a 15-county area of southeastern South Dakota and northeastern Nebraska. A 300-bed hospital located in Yankton, SD, Avera Sacred Heart Hospital is the flagship of the Sacred Heart Region of the Avera Health System. Avera switched to HealthStream’s telephone-based HCAHPS survey because the increased timeliness of data collection would enable them to have more timely information with which to work.
One of the biggest challenges at ASHH has been to “hardwire” the initiatives that are put in place as a result of findings from our HCAHPS results. That is, how do we ensure that every patient, every time receives the high quality, personal care that we are called to provide them? In a constantly changing healthcare environment we are challenged to make all necessary changes while hardwiring key processes/systems and sustaining those positive initiatives.
What specific steps have you taken to improve your
We have performance improvement teams that
lead our HCAHPS and quality initiatives. These are
multidisciplinary teams that review data, best practices
or evidenced based care, and develop action plans
to implement our own best practices. We have had
many improvement efforts. Specific things that we
have implemented include basics of communication
with all staff – AIDET, hourly rounding, Quiet
Time, communication board in the patient rooms,
department photo boards – photo of care givers with
patient rooms, education on pain for all nursing staff,
Teach Back education, etc. In addition, ASHH has been
involved in national initiatives where we collaborate
with facilities nationwide, sharing best practices and
processes to improve overall quality, such as the CMS
Demonstration project a few years ago and currently
the QUEST initiative. In addition, we participated in IHI
collaboratives, such as the 100K Lives Campaign and
the 5 Million Lives Campaign. We are also currently
participating in the CMS initiative, Partnership for
Which action in particular has been most instrumental
in bringing about your HCAHPS improvement?
Our employees are fantastic; they provide exceptional
care and are fully engaged in our improvement efforts.
For example, Avera Sacred Heart Hospital has a Patient
Care Services Council, made up of staff nurses from all of
the acute care areas in the hospital. This council works
continuously to improve the patient experience. In a
typical instance, they analyzed patient data and focused
on making improvements in discharge instructions.
Working as a team, they improved discharge instruction
scores from the 47th to over the 90th percentile.
In addition, we regularly act on comments from patient
surveys, which drives our improvement measures.
We receive many comments that have led to specific
initiatives, and we always incorporate their concerns as
we address issues in our ongoing improvement efforts.
We also share survey results and seek input from
physicians on improvement plans at monthly medical
staff meetings. Medical staff is fully engaged in the
improvement process and provides regular feedback.
What role has HealthStream staff played in helping
you improve your scores?
HealthStream shares its extensive best practices
information with us, giving us the benefit of information
gathered from organizations across the nation. In doing
so, they have assisted us by challenging us and others
not to “accept” the status quo. They collaborate with us
as we seek to continually improve.
What role have HealthStream’s reporting and online
web tools played in helping ASHH improve your
We started this journey committed to sharing data
with front line staff. We are very transparent with our
performance data. We have always posted our data on
our intranet so that everyone could see how we are
doing in each unit in the hospital. With our previous
vendor, we had to create our own cheat sheets. What
has been good about working with HealthStream is
that using online web tools we can schedule and “push”
summary reports. Our people receive reports on a
schedule and can easily access and print out what they
need when they need it.
What’s next in terms of HCAHPS for your
Currently we are working on employee rounding,
leadership development and accountability, and
hardwiring processes for improving our pain scores
and communication about medications. Our focus
improvement areas for quality include:
- Decreasing our overall readmissions
- Evaluating and implementing best practices to
reduce hospital harm
- Maximizing use of our electronic medical record
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