Institute for Healthcare Improvement ● ihi.org Page 1

Patient Experience Data Self-Assessment

1. What is a run chart?

A plot that shows patient experience values (e.g., willingness to recommend) in time order, with a median

reference line, is an example of a run chart. You can interpret the run chart with a set of rules. The rules

help you to detect patterns that may be signals that your system has improved or deteriorated.

 True

 False

 Not sure

2. The median of the HCAHPS Nursing Communications “top box” scores in the

accompanying chart…

a. Is 78

b. Is 77

c. Can not be determined from the graph

72

73

74

75

76

77

78

79

80

81

82

Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11

Nursing Communications

Good

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3. Using the standard run chart rules for shift, trend, and “astronomical point,” examine

each chart for signs of improvement or degradation. The dashed line is the median

value to be used for reference. The first chart uses a median based on the first 12

months, also known as a “baseline reference” median.

60

65

70

75

80

85

90

95

100

Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11

p e

r c e

n t

Friendliness of nurses/ambulatory

40

45

50

55

60

65

70

75

80

Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11

p e

r c e

n t

Overall Quality of Care

60

65

70

75

80

85

90

95

100

Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11

p e

r c e

n t

Did everything to help your pain

B

A

C

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4. Interpreting a New Month’s Value

At your hospital, suppose the HCAHPS overall “top box” willingness to recommend* data shows an

average monthly performance of 80% for the past 12 months; the median monthly value is also 80%.

Now you get the latest month’s data — the value is 76%.

Circle “Yes” if the action is always justified as part of your reaction to this new month’s value of 76%.

a. Plot the 76% value on a run chart of “willingness to recommend” to see if

there is any signal over time according to the run chart rules.

Yes No Not

sure

b. Look at the “willingness to recommend” data in the context of the other

elements of the HCAHPS survey.

Yes No Not

sure

c. Re-iterate to staff the importance of continuous improvement and the

financial implications of a relatively poor score for “willingness to

recommend.”

Yes No Not

sure

d. Initiate an investigation to find out what changed in the most recent month

that caused the decrease as this month is below average.

Yes No Not

sure

e. Interpret the 76% value in terms of the number of patients surveyed. Yes No Not

sure

*On average over the past 12 months, 80% of respondents have answered “Definitely yes” to the

HCAHPS question, “Would you recommend this hospital to your friends and family?”

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5. Interpreting HCAHPS Percentile Tables

Use the table below to answer the questions on the following page.

(source: http://www.hcahpsonline.org/files/January%202012%20HCAHPS%20Percentiles%20Table.pdf)

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Circle “T” for true, “F” for false, or “?” for Can’t tell from the Information provided. The questions pertain

to the hospitals described in the note marked by the red arrow.

a. If your hospital averaged 83 from April 2010 to March 2011 on the top box

Communications with Nurses composite, your hospital had a score lower

than more than 150 hospitals nationally.

T F ?

b. If your hospital averaged 83 from April 2010 to March 2011 on the top box

Communications with Nurses composite, on average 17% of your hospital’s

patients who responded to the survey feel they did not experience “top

box” communications.

T F ?

c. On the most recent HCAHPS monthly data report, your hospital scored 78

on the top box Recommend the Hospital. That means your hospital

outperformed more than 75% of the surveyed hospitals.

T F ?

d. If Hospital A averaged a score of 6 points higher than Hospital B on top box

Overall Hospital Rating from April 2010 to March 2011, then in percentile

terms, Hospital A is at least 15% higher than Hospital B.

T F ?

e. The national HCAHPS survey response rate for the period April 2010-March

2011 was 32%. This means that about 2 out of 3 patients contacted did

not complete the survey questions.

T F ?

f. It always makes sense to compare ratings and percentiles of specific

departments or services (e.g. OB) rather than rely only on whole-hospital

summary measures.

T F ?

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6. Correlations: Friend or Foe? Use this table of national survey data for overall rating of inpatient experience to answer the questions

below. Circle “T” for true, “F” for false, or “?” for Can’t tell from the Information provided. The two digit

number in each row is the correlation between the overall rating and the rating of the item in the row,

e.g. the correlation between “Skill of physician” and “overall rating of inpatient experience” is 0.63.

Source: Press Ganey National database – through June 30, 2011

Questions

a. The correlation value in each row can’t be any larger than 1 but could be

zero or even negative.

T F ?

b. If your aim is to improve the overall rating of in-patient experience at your

hospital, you should concentrate improvement on staff sensitivity to

inconvenience and staff actions to address emotional needs.

T F ?

c. If the national correlations align well with survey data at your hospital,

then reduction of noise level in and around room is not as likely to

improve your overall rating compared to staff including patients in

decisions re: treatment.

T F ?

d. The table implies that in terms of national summary data, room

cleanliness doesn’t really matter in terms of overall rating.

T F ?

Week 2: Trends & Issues in Executive level Management for Health Administrators.

Patient Experience

The Beryl Institute (2016) defines the patient experience as, “The sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.”

No two health care organizations are exactly the same. While many health care organizations strive to provide health services that adhere to quality standards and promote patient safety, individual patient experiences may vary across different health care organizations.

Why might the patient experience be an important consideration when managing a health care organization? How might health care administration leaders determine whether their health care organization provides an excellent or high-quality patient experience?

This week, you explore the importance of patient experience for health care organizations. You examine different ways that patient experience data might inform how health services are offered in health care organizations, and you complete a patient experience data assessment for this week’s Assignment.

Learning Objectives

Students will:

· Assess patient experience in relation to patient data for health care organizations.

Learning Resources

This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below.

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Dempsey, C. (2016). The evolution of the patient experience. In the Society for Healthcare Strategy and Market Development of the American Hospital Association (Ed.), Futurescan healthcare trends and implications: 2016–2021 (pp. 6–10). Chicago, IL: Health Administration Press.

Groene, O., Arah, O.A., Klazinga, N.S., Wagner, C., Bartels, P.D., Kristensen, S., … Sunol, R. (2015). Patient experience shows little relationship with hospital quality management strategies. PLoS One, 10(7), 1-15.

Document: IHI Patient Experience Data Self-Assessment (PDF)

Assignment (APA 7th format) 3 pages.

Patient Experience Data Self-Assessment

As a current or future health care executive leader, you are responsible for the patient’s experience in your health care organization. Whether you are overseeing a health system, hospital, clinic, or other health care organization, the patient’s experience will be one of your top three priorities (Institute for Healthcare Improvement, 2016). Understanding the data involved in measuring the patient experience is an important part of what you will be undertaking.

Interpreting patient experience data can quickly become overwhelming and confusing to anyone trying to use the data for improvement. The Patient Experience Data Self-Assessment challenges knowledge and common assumptions about what the data actually means. It can be used to expand your current knowledge on effectively using patient experience data.

For this Assignment:

1. Review the IHI patient experience data in the link provided.

2. Complete the IHI document by printing it, marking it manually, and then scanning it as a PDF document.

3. In a separate MS Word document, provide brief narrative justification for your responses to the six [6] questions.

4. Upload both the PDF and Word documents into the Week 2 Assignment area.

5. Alternatively, if you have the Adobe program that allows you to type directly into the IHI document, you are free to do so and upload that one document.

The Assignment: (3 pages)

By Day 7

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK2Assgn+last name+first initial.(extension)” as the name.

Click the Week 2 Assignment Rubric to review the Grading Criteria for the Assignment.

Click the Week 2 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.

Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn+last name+first initial.(extension)” and click Open.

If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 2 Assignment Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 2 Assignment draft and review the originality report.

Submit Your Assignment by Day 7

To submit your Assignment: Week 2 Assignment