HCAHPS News - Vanderbilt University Medical Center

March 26, 2013
HCAHPS News
As Value Based Purchasing (VBP) moves into the third performance period, the HCAHPS survey results will continue to
represent 30% of the total VBP calculation. If you work in the adult hospital, it is important that you are familiar with
the questions patients are asked about their stay.
Third Value Based Purchasing Period – Patient Experience Measures
January to December 2013 (performance) compared to January to December 2011 (baseline)
The patients surveyed for HCAHPS are not restricted to Medicare, but represent a sample of all patients discharged
from the adult hospital, excluding observation patients. Each domain (major category) is eligible to receive up to 10
points to contribute to the overall VBP score. It is vital that each unit become familiar with the HCAHPS survey and
focus improvement efforts on the questions within each of the domains.
Domains Include:
Overall Rating - Communication with Nurses - Communication with Doctors - Responsiveness of Hospital Staff
Hospital Environment (Quietness & Cleanliness) - Pain Management
Communication about Medications - Discharge Information
In 2013, VBP affected our Medicare reimbursement, and is the result of our scores from the first performance period,
July 2011 to March 2012 compared to the baseline period (July 2009 to March 2010). Below are the percentages of
our Medicare reimbursements at risk for being withheld by the Center for Medicaid and Medicare Services (CMS) for
the first three performance periods.
Performance Period
Medicare Reimbursement
withheld
First Performance Period (July 2011 to March 2012) 1.0%
Second Performance Period (April 2012 to December 2012) 1.25%
Third Performance Period (January 2013 to December 2013) 1.5%
To earn back the percentage of Medicare reimbursement, hospitals have to achieve a particular level of scoring by
improvement or achievement in clinical measures and HCAHPS scores. Due to this, it is extremely important that each
unit is focusing on the measures included in VBP. In this newsletter issue, we will focus on Hospital Environment
(Cleanliness and Quietness).
Monthly HCAHPS training courses including VBP: Log into the Learning Exchange
Questions and Assistance in understanding scores? Contact SMI@vanderbilt.edu or at (615) 936-6067.
Assistance in improving your unit scores: Contact Service Excellence Coaching and Consulting at (615) 343-1024 or
email cindy.wedel@vanderbilt.edu.

Quietness and Cleanliness… What Does It Mean to Your Patients?
As your patients are interviewed for the VUH patient satisfaction survey, they are given the opportunity to answer
open-ended questions to help us gain insight into the reasoning behind the rating. The comments are compiled into
Excel spreadsheets and can be exported from the EasyView website. You can view the Guide to Verbatim Comments to
learn how to access them.
We would like to highlight Quietness and Cleanliness, the two components of the Hospital Environment domain in Value
Based Purchasing. Included below is a sample of comments patients have given when they thought the unit was not
quiet or clean:
Quietness Comments
Cleanliness Comments
“A lot of noise at the nurse's station.” “Bathroom needed to be mopped.”
“I was right next to the nurse station. The nurses were very
loud at night and seemed to have no awareness that people
“The floor, the walls and picking up the debris. It was
were trying to sleep.”
so dirty that even my guests commented on it.”
“Other patients were making the noise.”
“The nurses talk loud, could hear alarms going off and the
lights I could see through the door were bothersome to me.”
“The way they entered the room instead of pushing the door
softly open.”
“In the first 36 hours, my floor was never swept.”
“The shower was (unsanitary) so I didn’t use it and
there was hair and dirt all over the floors.”
“Did not have housekeeping on a regular basis.”
“Up to 11:00 pm it was quiet, then when they either brought
“Laundry bag was not emptied, towels not picked
FY2013 Service Goals
Patient satisfaction surveying at Vanderbilt consists of two surveys: the PRC survey used for internal improvement, and
the HCAHPS survey that is part of Value Based Purchasing. The service goals for this fiscal year are based on our surveying
for internal improvement, or the PRC survey. If scores for this survey improve, we will see our HCAHPS results
improve as well. Your patients are currently being interviewed for the 3 rd quarter of FY2013. Two complete quarters
worth of data is now available to review and compare against the FY2013 Service Goals. The three metrics are Overall
Quality of Care, Overall Teamwork and Cleanliness. Click on the image below for a printable version of the goals.

Its’ Who We Are
The Service Measurement and Improvement (SMI) team directs and implements all patient satisfaction measurement
for VUMC including federally required surveys (HCAHPS). SMI’s work involves providing guidance to VUMC leaders in
accessing, understanding and improving scores. SMI strives to deliver meaningful and actionable patient feedback including
survey and website education. The department works together with leadership to uncover trends and provides
direction in prioritizing improvement efforts. SMI functions within the division of Patient Experience and Service to assist
in the creation of a better patient experience.
Denise Rabalais, Director
(615) 936-6066
Denise.rabalais@vanderbilt.edu
Meredith Speight, Consultant
(615) 936-6014
Meredith.speight@vanderbilt.edu
Denise Mitten, Administrative Assistant
(615) 936-6067
Denise.mitten@vanderbilt.edu