Issuu

White Paper THOUGHT LEADERSHIP

DESIGNING FOR RESULTS HOW AN EVIDENCE-BASED BUILT ENVIRONMENT IMPACTS SAFETY AND PATIENT PERCEPTION OF CARE AUGUST 23, 2012

W H I T E P A P E R | AUGUST 2012

table of contents 03

Introduction

Hospital Acquired Conditions & Built Environment

04 Evidence-Based Built Environment

05 Value Based Purchasing

06 HCAHPS Survey Questions

17 HCAHPS Improvement Grid

22 Project Team & Acknowledgements

23 Appendix

HCAHPS & the Built Environment

ÂŠ BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

AUGUST 2012 | W H I T E P A P E R

introduction Healthcare executives across the country are facing questions on how their organization can improve patient satisfaction and, as a result, scores on the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey. The importance of patient satisfaction results have evolved since the introduction of the Patient Protection and Affordable Care Act—better known as healthcare reform—which affects hospitals’ reimbursement partly based on scores they receive on the HCAHPS. Moreover, improving the patient experience and the environment for those who care for patients is simply the right thing to. How can you link the design of a patient room and related areas to improved patient satisfaction and patient outcomes? Healthcare facility planners and designers have the responsibility to create a physical environment that enables improved results. After all, creating an atmosphere in hospitals that is safe, clean and quiet makes patients more comfortable and more likely to heal. The ability to identify the design elements that contribute to a healthy and positive patient experience allows hospitals to institute operational plans and design solutions that improve the healing environment. The answer to improving patient satisfaction is a holistic one, encompassing PEOPLE – engaged caregivers; PROCESS – a systematic approach that drives efficiency and quality; and PLACE – a built environment that is an enabler to patient, family and staff satisfaction. Design solutions that respond to all three of the above elements allow the built environment to act as an enabler for positive staff interaction with patients.

Approach BSA LifeStructures has identified eight questions on the HCAHPS survey that can be impacted by the design of the built environment. Six of the 22 questions relate to the patient’s interaction with the staff, while two are directly associated with the built environment. The questions related to the built environment were analyzed and filtered through an improvement strategy process that identifies the impact of design, the recommendation for improvement and the expected outcome of that design solution. These design recommendations were then charted on the HCAHPS Improvement Grid to evaluate value relative to the capital cost of improvements and the potential for improvement. There are a number of planning and design processes that improve the components of a patient’s stay, from using noise reducing materials to creating rooms that limit opportunities for dirt and dust collection. Using this improvement process, each design is weighed against evidence-based design principles that evaluate improvement opportunities and related costs. Ultimately all the recommended solutions address the challenge of improving the patient’s experience and healing.

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evidence-based built environment: designing for results The process of implementing design solutions that measure outcomes starts with aligning goals, behaviors and processes. A coordinated approach to collaborative leadership and care will translate to results-driven design that addresses shared goals and objectives.

operational and facility planning driven design

Client Aligned Vision & Guiding Principles • Shared Vision & Strategy • Define Customer Experience

Aligned Goals

Benchmarks & Metrics • Core Measures • HCAHPS • Project Specific

Framework • Utilize Lean Healthcare Principles • Function Before Form

Performance Management • Thought Leadership • Aligned Professionals • Research & Best Practices

Aligned Behavior

Standardization • Process • Room • Unit Design

Accelerators • Prototypes • Simulation Modeling • Building Information Modeling

Aligned Process

SAFE

EFFECTIVE

EFFICIENT

TIMELY

PATIENT CENTERED AUGUST 2012 | W H I T E EQUITABLE (-)

value based PEOPLE purchasing An Engaged – Caregiver aligned goals

Hospital 0%Acquired

HOSPITAL ACQUIRED Condition CONDITION MEASURES • Falls • Infections • Readmissions

Measures

Under Value Based Purchasing Guidelines, total hospital reimbursement will include performance attainment and improvement against specific measures of the perception of care, process of care measures and quality outcomes. This approach to value-based purchasing puts the focus on outcomes and success measures. The built environment’s responsibility is to enable high performance in all the measures that drive success, particularly: patient experience, processes of care, outcomes of care and the prevention of hospital acquired conditions.

PA P E R

AFFORDABLE

25% (+/-)

25%Outcome Measure OUTCOME MEASURE (2014) (2014)

• Mortality for certain diseases within 30 days of discharge

PATIENT

PROCESS

PLACE

Systematic Approach for Quality

Built Environment that Enables Satisfaction

45%

CORE45% MEASURES (+/-) • Time to Cardiac Intervention for Acute MI Core • Collaborative, quiet & caregiver enabling Measures

30% (+/-)

30%Patient

PATIENTExperience EXPERIENCE MEASURES (HCAHPS)

Measures (HCAHPS)

• % Room Always Clean • % Always quiet around room at night

environment

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HCAHPS survey questions Your care from Nurses

Your experiences in this hospital

1. During this hospital stay, how often did nurses treat you with courtesy and respect?

10. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

18. After you left the hospital, did you go directly to your own home, to someone elseâ€™s home, or to another health facility?

2. During this hospital stay, how often did nurses listen carefully to you?

11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

3. During this hospital stay, how often did nurses explain things in a way you could understand?

12. During this hospital stay, did you need medicine for pain?

4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

13. During this hospital stay, how often was your pain well controlled?

5. During this hospital stay, how often did doctors treat you with courtesy and respect?

14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

6. During this hospital stay, how often did doctors listen carefully to you?

15. During this hospital stay, were you given any new medicine that you had not taken before?

7. During this hospital stay, how often did doctors explain things in a way you could understand?

16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

The hospital environment

When you left the hospital

20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Overall rating of hospital 21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? 22. Would you recommend this hospital to your friends and family?

17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

8. During this hospital stay, how often were your room and bathroom kept clean? 9. During this hospital stay, how often was the area around your room quiet at night? Source: Standard HCAHPS Survey. March 2012. Hospital Care Quality Information from the Consumer Perspective. 19 April 2012. <http://www.hcahpsonline.org/surveyinstrument.aspx>

ÂŠ BSA LifeStructures / Use of reprint not allowed without expressed consent from the author

AUGUST 2012 | W H I T E P A P E R

relationship between HCAHPS & the built environment Of the 22 questions used on the HCAHPS Survey, BSA LifeStructures identified eight questions that could be influenced by the built environment. Furthermore, these eight questions fall into two very distinct categories of influence. First, the hospital environment questions that directly ask about cleanliness and noise in and around the patient room. Second, the care composite questions where the caregiver interacts with the patient.

HOSPITAL ENVIRONMENT QUESTIONS (QUESTIONS 8 & 9)

During this hospital stay, how often were your room and bathroom kept clean? During this hospital stay, how often was the area around your room quiet at night?

CARE COMPOSITE QUESTIONS (QUESTIONS 1-3, 5-7)

Courtesy Respect Listen Explain

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W H I T E P A P E R | AUGUST 2012

QUESTION

BUILT ENVIRONMENT IMPACT design considerations

THE ENGAGED EMPLOYEE Respect, Courtesy, Listen, and Explain

Adequate caregiver space at the bedside

Off-stage collaboration areas to facilitate manager rounding and team communication

recommendations adequate caregiver space at the bedside

plan employee spaces with the same considerations as patient spaces

• Computer orientation, staff seating • Supplies at the bedside • Clear of Family Zone & path of travel to the bathroom • Collaborative areas at bedside

• • • •

off-stage team collaboration areas

provide flexible & adaptable options for caregiver documentation & workspaces

• Personal off-stage areas for manager rounding • Team collaboration areas to support multi-disciplinary rounding

• “Immersive” - place for quiet thought • Collaborative • Provide for standing and sitting at bedside and in caregiver documentation areas

caregiver support spaces

provide storage space at bedside for supplies used most often

Caregiver support spaces • • • • •

Natural light Healing environment Quiet Ergonomically

Staff lounges Entrance Respite areas Natural light Ergonomics

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QUESTION

BUILT ENVIRONMENT IMPACT

KEEPING THE PATIENT ROOM CLEAN – FINISHES design considerations

recommendations

flooring

THE HOSPITAL ENVIRONMENT

8. During this hospital stay, how often were your room and bathroom kept clean?

A clean room contributes to higher patient satisfaction

The Mohawk Group

Unclean room may contribute to negative perception Contaminated environment contributes to hospital acquired infections

• Choose products that are easy to clean • Choose products that look clean • Choose products with simple cleaning instructions

walls

MDC Wall

finishes & products • functionality • product selection

• utilize experience • first cost vs. long term cost

ceilings • maintenance • cleaning products

Armstrong

• Choose easy to clean paint products • Choose walls coverings that look clean • Choose products with simple cleaning instructions

• Choose easy to clean products • Choose products that look clean • Choose products with simple cleaning instructions

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QUESTION

BUILT ENVIRONMENT BUILT ENVIRONMENT RESPONSE TO CARE COMPOSITES IMPACT PATIENT ROOM RELATED ISSUES – DESIGN design considerations recommendations floor plan configuration • Avoid acute angles and corners 1

THE HOSPITAL ENVIRONMENT 8. During this hospital stay, how often were your room and bathroom kept clean?

A clean room contributes to higher patient satisfaction

Unclean room may contribute to negative perception

Contaminated environment contributes to hospital acquired infections

furniture location & placement • Avoid tight and compact areas which will be difficult to clean • Anticipate where furniture can be moved

furniture, casework, & built-ins • • • • •

Floor plan layouts Furniture locations Built-in casework locations Areas to collect dust Difficult areas to clean

areas that collect dust & dirt • Provide soffits above upper cabinets • Provide soffits for task down lighting • Provide sloped tops as an alternative to soffits

furniture location & design • Fixed vs. moveable • Snug fit vs. awkward voids • Cleaning products required

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QUESTION

BUILT ENVIRONMENT IMPACT

PATIENT ROOM NOISE – EXTERNAL design considerations

recommendations implement sound attenuation techniques • Sound masking at door • Sound insulation along corridor wall

THE HOSPITAL ENVIRONMENT 9. During this hospital stay, how often was the area around your room quiet at night?

Noise contributes to lower patient satisfaction

Noise contributes to slower recovery of the patient

Noise contributes to longer lengths of stay

implement caregivers/visitors “reduce voice volume” program external noise • Staff/physicians near patient room door • Caregivers/visitors in corridor • Equipment in corridor alcoves & storage • Decentralized nurse work stations

• Quiet zones • Provide sound recording devices in key locations (green, yellow, red) • Provide signage program

implement mitigation of external noise • Remove moveable items, carts & equipment • Sound insulation added at external sources • Study door locations to avoid door alignment

decentralized nurse work stations • Collaboration adds noise to the corridor • Work station adds noise at patient room entry • Corridors remain same width despite function change

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QUESTION

BUILT ENVIRONMENT IMPACT

PATIENT ROOM NOISE – INTERNAL design considerations

THE HOSPITAL ENVIRONMENT 9. During this hospital stay, how often was the area around your room quiet at night?

Noise contributes to lower patient satisfaction

Noise contributes to slower recovery of the patient

Noise contributes to longer lengths of stay

recommendations internal noise

implement sound attenuation techniques

• Toilet in adjacent patient room • Television in adjacent patient room • Adjacent mechanical rooms • Caregivers/visitors in adjacent patient room • Equipment in patient room • Caregivers/visitors in patient room

• Sound masking in room (white noise) • Sound insulation • Acoustical ceiling tiles

implement wall construction techniques • Increase wall thickness • Improve construction techniques • Sound insulation

implement same-handed patient room floor plan • Adjacent patient room noises reduced • No common headwall separate noise

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CONDITION

BUILT ENVIRONMENT HOSPITAL ACQUIRED CONDITIONS – PATIENT FALLS IMPACT PATIENT ROOM RELATED ISSUES – DESIGN design considerations

recommendations

preventing patient falls travel distance from bed to toilet using grab bars

HOSPITAL ACQUIRED CONDITION MEASURES

Patient falls in room & bathroom contribute to increased patient morbidity, mortality, LOS, & cost of care

exterior

19’5” 9’11”

6’7”

Clemson University Patient Room of the Future

4’10”

Patient falls in room and bathroom 3

Travel path to and from the patient bathroom are the most frequent contributors to falls Unobstructed pathways

preventing patient falls

corridor

toilet on footwall

toilet on headwall

distance from bed to toilet using grab bars • Consider that while rooms may be same-handed, patient will not be, and access to bathroom fro both sides of the bed should be considered. • Shorter travel distance from bed to toilet as much as possible • Hand rails are helpful in preventing patient falls, but not the complete solution

• Unobstructed path from bed to bathroom in few steps • Leafed double bathroom door • Handrails to bathroom and vertically outside bathroom door • Non-slip flooring • Lighted pathway from bed to bathroom • Visibility from corridor to bed or foot of bed • Toilet in center of bathroom to provide assistance from two caregivers

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CONDITION

BUILT ENVIRONMENT IMPACT

HOSPITAL ACQUIRED CONDITIONS – INFECTION PREVENTION design considerations

recommendations • Sink and hand sanitizers should be immediately available for access upon entry and exit to room

HOSPITAL ACQUIRED CONDITION MEASURES

• Sink should be visible to patient to observe staff handwashing 1

Infection Prevention 3

Location of sink and hand sanitizers

Personal protective equipment (PPE) location

Cleanability and surfaces

• Provide separate caregiver work surfaces away from sink to avoid splash contamination

infection prevention

• Personal Protective Equipment should be immediately available upon entry to the room

• Sink located at entry to patient room »» Features: height, depth, faucets, splash, visibility to patients • Cubicle curtains: cleanability, hand guards • Enclosed toilet in ICU • Decontamination and disinfection processes before design • Personal Protective Equipment location

• Limit cubicle curtains to only what is necessary for patient privacy between the door and bed. »» Provide cleanable hand pulls for curtains and keep them secured (tied back) so that they are only used when needed.

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CONDITION

HOSPITAL ACQUIRED CONDITION MEASURES Hospital acquired infections – during construction projects

BUILT ENVIRONMENT HOSPITAL ACQUIRED INFECTIONS - DURING CONSTRUCTION PROJECTS IMPACT PATIENT ROOM RELATED ISSUES – DESIGN design considerations recommendations

Infections lead to hospital readmissions

Infections contribute to lower patient satisfaction

Infections contribute to longer lengths of stay

negative pressure

construction

• Negative pressurization not maintained in construction zones leads to bad air infiltration in hospital • ICRA standards and requirements not met • Locations of required doors and exits not maintained leads to bad air infiltration in hospital • ILSM standards and requirements not met • Capping of relevant sheet metal during construction not completed

• Stricter enforcement of contractor requirements • Utilize camera and remote technology during construction • Financial penalties for contractors who do not meet requirements

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CONDITION

BUILT ENVIRONMENT IMPACT

HOSPITAL ACQUIRED INFECTIONS - DURING SCHEDULED MAINTENANCE

design considerations

HOSPITAL ACQUIRED CONDITION MEASURES Hospital acquired infections – during scheduled maintenance

Infections lead to hospital readmissions

Infections contribute to lower patient satisfaction

Infections contribute to longer lengths of stay

recommendations

AHU maintenance

maintenance

• Air handler maintenance (filters) is performed independent of operational functions and schedules • No specific maintenance protocols in place to coordinate with operational functions and schedules • Air handler maintenance (cooling coils) is performed independent of operational functions and schedules • No specific air handler running time protocol in place to ensure dirty particulates are transferred in hospital rooms and areas

• Develop maintenance protocols involving air handler maintenance • Utilize cameras and remote technology during air handler maintenance

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Based on the goal of improving HCAHPS Scores through facility modifications and changes, the Risk / Frequency Grid has been modified for this specific process improvement. Included on this page is the HCAHPS Improvement Grid which assists with strategic facility analysis and documentation. The grid includes the relative capital dollars required for an improvement compared to the effectiveness percentage of the improvement. This approach provides four quadrants for all of the proposed physical plant improvements to be categorized. This provides a relative value for the comparison in order to make evidence-based decisions.

HCAHPS & PATIENT SAFETY IMPROVEMENT

HCAHPS improvement grid

100%

75%

High Impact Low Cost

High Impact High Cost

Low Impact Low Cost

Low Impact High Cost

50%

25%

0% $

$$$

$$$$$

CAPITAL COST OF IMPROVEMENTS

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W H I T E P A P E R | AUGUST 2012

HCAHPS improvement grid

HCAHPS & PATIENT SAFETY IMPROVEMENT

100%

high impact/ low cost: High Impact Low Cost

75%

High Impact High Cost

50%

how to’s:

The High Impact – Low Cost quadrant focuses on those facility improvements which offer a high value and impact at a relative low cost. In addition, these elements can be implemented in short time frames due to their low cost nature.

• Lean process improvement • Utilize sound masking devices

Low Impact Low Cost

25%

• Improve cleaning products

Low Impact High Cost

• Remove noise generating equipment • Insulate noise generating equipment • Replace ceiling tiles

0% $

$$$

CAPITAL COST OF IMPROVEMENTS

$$$$$

• Add sloped top caps to exposed top caps • Modify areas difficult to clean • Clean cubicle curtains between patients

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HCAHPS improvement grid

HCAHPS & PATIENT SAFETY IMPROVEMENT

100%

high impact/ high cost: High Impact Low Cost

75%

High Impact High Cost

50%

how to’s:

The High Impact – High Cost quadrant focuses on those facility improvements which offer a high value and impact at a relative high cost. In addition, these elements require longer time frames to be implemented due to their relative high cost nature.

• Convert to all private rooms • Change countertops and horizontal surfaces

Low Impact Low Cost

25%

• Replace tired or broken furniture

Low Impact High Cost

• Consider built-in furniture • Add acoustical features at: »» Areas outside of patient room door

0% $

$$$

$$$$$

CAPITAL COST OF IMPROVEMENTS

»» Nurse work area out of patient room door • Decentralize collaboration stations away from patient rooms

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HCAHPS improvement grid

low impact/ low cost:

HCAHPS & PATIENT SAFETY IMPROVEMENT

100%

High Impact Low Cost

75%

High Impact High Cost

50%

how to’s:

The Low Impact – Low Cost quadrant focuses on those facility elements which offer less value and impact than others yet also requires a relative low cost. In addition, these elements can be implemented in short time frames due to their low cost nature.

• Eliminate inaccessible corners • Eliminate acute angles

Low Impact Low Cost

25%

• Relocate noise generating equipment

Low Impact High Cost

• Add sound insulation within toilet/shower walls • Replace flooring to improve cleaning and appearance

0% $

$$$

$$$$$

CAPITAL COST OF IMPROVEMENTS

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HCAHPS improvement grid

HCAHPS & PATIENT SAFETY IMPROVEMENT

100%

low impact/ high cost: High Impact Low Cost

75%

High Impact High Cost

50%

how to’s: Low Impact Low Cost

25%

The Low Impact – High Cost quadrant focuses on those facility improvements which offer less value and impact than others at a relative high cost. In addition, these elements require longer time frames to be implemented due to their relative high cost.

• Create same-handed patient rooms • Add sound insulation within patient room walls

Low Impact High Cost

• Improve lighting to simulate natural lighting • Healing gardens • Department greeting areas

0% $

$$$

$$$$$

CAPITAL COST OF IMPROVEMENTS

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project team & acknowledgements white paper co-authors:

Terry Thurston

RN, BSN, MBA Director of Healthcare Operations Planning phone | 317.674.2468 email | tthurston@bsalifestructures.com

BSA LifeStructres project team members:

Mike Castor Doug Fick Monte Hoover

@TerryThurston

Tara Kempf

Gary Vance AIA, FACHA, LEED AP Director of National Healthcare phone | 317.753.2819 email | gvance@bsalifestructures.com

Dan Miles Alex Miser Shawn Mulholland

@gmanvance

Keith Smith @LifeStructures

special thanks to:

BG Porter Chief Operating Officer

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appendix 24 HCAHPS: Patients’ Perspectives of Care Survey

27 HCAHPS Survey

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HCAHPS: Patients’ Perspectives of Care Survey HCAHPS Overview

HCAHPS Content and Administration

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. HCAHPS (pronounced “H-caps”), also known as the CAHPS® Hospital Survey, is a survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.

The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay. The survey contains 18 core questions about critical aspects of patients’ hospital experiences (communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital). The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports.

Three broad goals have shaped HCAHPS. First, the survey is designed to produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of the survey results creates new incentives for hospitals to improve quality of care. Third, public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the Centers for Medicare & Medicaid Services (CMS) and the HCAHPS Project Team have taken substantial steps to assure that the survey is credible, useful, and practical.

The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge; the survey is not restricted to Medicare beneficiaries. Hospitals may either use an approved survey vendor, or collect their own HCAHPS data (if approved by CMS to do so). HCAHPS can be implemented in four different survey modes: mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR). Hospitals can use the HCAHPS survey alone, or include additional questions after the core HCAHPS items. Hospitals must survey patients throughout each month of the year. The survey is available in official English, Spanish, Chinese, Russian and Vietnamese versions. The survey and its protocols for sampling, data collection and coding, and file submission can be found in the current HCAHPS Quality Assurance Guidelines, which is available on the official HCAHPS website, www.hcahpsonline.org.

Source: “HCAHPS: Patients’ Perspectives of Care Survey.” 2012. Centers for Medicare & Medicaid Services. 18 April 2012 <https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS. html>

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HCAHPS Development, Testing and Endorsement Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS survey. AHRQ carried out a rigorous scientific process, including a public call for measures; review of literature; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. During this process, CMS provided three opportunities for the public to comment on HCAHPS, and responded to well over one thousand comments. In May 2005, the HCAHPS survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS survey in October 2006, and the first public reporting of HCAHPS results occurred in March 2008. The survey, its methodology and the results it produces are in the public domain.

Hospitals implement HCAHPS under the auspices of the Hospital Quality Alliance (HQA), a private/public partnership that includes major hospital and medical associations, consumer groups, measurement and accrediting bodies, government, and other groups that share an interest in improving hospital quality. The HQA has endorsed HCAHPS. The enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions (“subsection (d) hospitals”) must collect and submit HCAHPS data in order to receive their full IPPS annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS survey, may receive an annual payment update that is reduced by 2.0 percentage points. Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS. The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012.

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HCAHPS and Public Reporting Publicly reported HCAHPS results are based on four consecutive quarters of patient surveys. CMS publishes participating hospitals’ HCAHPS results on the Hospital Compare website (www.hospitalcompare.hhs.gov) four times a year, with the oldest quarter of patient surveys rolling off as the most recent quarter rolls on. A downloadable version of HCAHPS results is also available through this website. Additional HCAHPS results can be found on HCAHPS On-Line, (www. hcahpsonline.org). To ensure that publicly reported HCAHPS scores allow fair and accurate comparisons across hospitals, it is necessary to adjust for factors that are not directly related to hospital performance but which affect how patients answer HCAHPS survey items. These adjustments eliminate any advantage or disadvantage in scores that might result from the survey mode employed or from characteristics of patients that are beyond a hospital’s control. In addition, the HCAHPS Project Team engages in a series of quality oversight activities, including inspection of survey administration procedures, statistical analyses of submitted data, and site visits of HCAHPS survey vendors and self-administering hospitals, to assure that the HCAHPS survey is being administered according to the protocols.

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YOUR CARE FROM DOCTORS

HCAHPS Survey 5.

SURVEY INSTRUCTIONS i i i

Never Sometimes 3 Usually 4 Always 1

You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.

Answer all the questions by checking the box to the left of your answer. You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this: ;

Yes No Î If No, Go to Question 1

Please note: Questions 1-22 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981

During this hospital stay, how often did nurses treat you with courtesy and respect?

Never 2 Sometimes 3 Usually 4 Always 1

During this hospital stay, how often did nurses listen carefully to you?

Never Sometimes 3 Usually 4 Always 1

During this hospital stay, how often did nurses explain things in a way you could understand?

Never Sometimes 3 Usually 4 Always 4.

Never Sometimes 3 Usually 4 Always 2

During this hospital stay, how often did doctors explain things in a way you could understand?

Yes No Î If No, Go to Question 12

11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? 1

12. During this hospital stay, did you need medicine for pain?

1 2

Yes No Î If No, Go to Question 15

13. During this hospital stay, how often was your pain well controlled?

Never Sometimes 3 Usually 4 Always 1

THE HOSPITAL ENVIRONMENT

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

During this hospital stay, how often were your room and bathroom kept clean?

Never Sometimes 3 Usually 4 Always 1

Never 2 Sometimes 3 Usually 4 Always 9 I never pressed the call button 1

March 2012

Never 2 Sometimes 3 Usually 4 Always

10. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

YOUR CARE FROM NURSES

During this hospital stay, how often did doctors listen carefully to you?

Never Sometimes 3 Usually 4 Always

You may notice a number on the survey. This number is used to let us know if you returned your survey so we don't have to send you reminders.

Please answer the questions in this survey about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

During this hospital stay, how often did doctors treat you with courtesy and respect?

YOUR EXPERIENCES IN THIS HOSPITAL

During this hospital stay, how often was the area around your room quiet at night? 1 Never 2 Sometimes 3 Usually 4 Always

14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

Never Sometimes 3 Usually 4 Always 1 2

March 2012

Source: http://www.hcahpsonline.org/surveyinstrument.aspx

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15. During this hospital stay, were you given any medicine that you had not taken before? 1 Yes 2 No Î If No, Go to Question 18 16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

Never Sometimes 3 Usually 4 Always 1 2

20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

1 2

17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

Never Sometimes 3 Usually 4 Always 1 2

WHEN YOU LEFT THE HOSPITAL 18. After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?

Own home Someone else’s home 3 Another health 1 2

facility Î

19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? 1 Yes 2 No

If Another, Go to Question 21

Yes No

OVERALL RATING OF HOSPITAL Please answer the following questions about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers. 21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

0 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 0

Worst hospital possible

March 2012

22. Would you recommend this hospital to your friends and family? 1 Definitely no 2 Probably no 3 Probably yes 4 Definitely yes

ABOUT YOU There are only a few remaining items left. 23. In general, how would you rate your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 24. What is the highest grade or level of school that you have completed? 1 8th grade or less 2 Some high school, but did not graduate 3 High school graduate or GED 4 Some college or 2-year degree 5 4-year college graduate 6 More than 4-year college degree

25. Are you of Spanish, Hispanic or Latino origin or descent? 1 No, not Spanish/Hispanic/Latino 2 Yes, Puerto Rican 3 Yes, Mexican, Mexican American, Chicano 4 Yes, Cuban 5 Yes, other Spanish/Hispanic/Latino 26. What is your race? Please choose one or more. 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or other Pacific Islander 5 American Indian or Alaska Native 27. What language do you mainly speak at home? 1 English 2 Spanish 3 Chinese 4 Russian 5 Vietnamese 6 Some other language (please print): _____________________

THANK YOU Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL] [RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Best hospital possible

March 2012

Source: http://www.hcahpsonline.org/surveyinstrument.aspx

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