“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

Impact

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.

Background

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.

Challenge

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.

Solution

What specific steps have you taken to improve your scores?

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 Patients.

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 scores?

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 organization?

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 system

To find out more about partnering with HealthStream, please fill out the form on the right side of the page