Avera Sacred Heart Hospital

Avera Sacred Heart Hospital


Switching to HealthStream’s telephone-based HCAHPS survey gave the organization rapid access to patient survey information, helping it to more quickly implement measures aimed at improving the patient experience and HCAHPS results. 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.


Avera Sacred Heart Hospital (ASHH) is the flagship of the Sacred Heart Region of the Avera Health System. It provides care for over 120,000 residents in a 15-county area of southeastern South Dakota and northeastern Nebraska. One of the biggest challenges that the 300-bed hospital experienced was how to make permanent the initiatives that were put in place as a result of findings from HCAHPS results. In a constantly changing healthcare environment they were challenged to make all necessary changes while improving key processes/systems and sustaining those positive initiatives.  


Avera transitioned to HealthStream in order to more quickly receive patient survey data on which to base decisions about improving the patient experience. At the organization, performance improvement teams lead HCAHPS and quality initiatives. These are multidisciplinary teams that review data, best practices or evidence-based care, and develop action plans to implement their own best practices. The many improvement efforts include communication efforts with all staff, patient communication best practices, hourly rounding, quiet time, communication boards in patient rooms, education on pain management for all nursing staff, Teach Back education, and department photo boards (including photos of caregivers in patient rooms). In addition, ASHH has been involved in national initiatives where they 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, Avera participated in IHI collaboratives, such as the 100K Lives Campaign and the 5 Million Lives Campaign. They are also currently participating in the CMS initiative—Partnership for Patients.


Avera employees provide exceptional care and are fully engaged in improvement efforts. For example, the Patient Care Services Council, made up of staff nurses from all of the acute care areas in the hospital, 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 above the 90th percentile. In addition, the organization regularly acts on comments from patient surveys, which drive improvement measures. They receive many comments that have led to specific initiatives, and Avera always incorporates their concerns as the organization addresses issues in their ongoing improvement efforts. ASHH also shares survey results and seeks input from physicians on improvement plans at monthly medical staff meetings. Medical staff is fully engaged in the improvement process and provides regular feedback.

HealthStream’s extensive best practices information has been a valuable resource for Avera, giving them the benefit of information gathered from organizations across the nation. In doing so, Avera has benefited from being challenged not to “accept” the status quo. ASHH started this journey committed to sharing data with frontline staff. They continue to be very transparent with performance data, which is always posted on the organization’s intranet so that everyone could see how they are doing in each unit in the hospital. Working with HealthStream gives them online web tools that schedule and “push” summary reports. As a result, staff receive reports on a schedule and can easily access and print out what they need when they need it.

According to Theresa Guenther, Director of Quality, “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.” 

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