BE THE VOICE-BE THE CHANGE February 10, ICH CAHPS INTRODUCTION 2017 WEBINAR
OBJECTIVES Introduction to Network 14 ICH CAHPS QI Team Explain linkage of ICH CAHPS with QIP and Dialysis Facility Compare, and Patient Centered Care Review project background/selection of focus facilities Describe project components Patient Survey Toolkit Root Cause Analysis Patient Engagement Facility Patient Representative (FPR) Home Therapies Discussion Groups Facility Intervention Sustainability Review Project Timeline Explain CMS Watch List Wrap-up
STAFF Kelly Shipley, RHIA, QI Director* kshipley@nw14.esrd.net (469) 916-3803 Maryam Alabood, Administrative Assistant Javoszia Sterling, BA, Outreach Coordinator *denotes project lead
WHERE TO FIND PROJECT INFORMATION INCLUDING THIS WEBINAR http://www.esrdnetwork.org/
WHERE TO FIND PROJECT INFORMATION
CMS ICH CAHPS Consumer Assessment of Healthcare Providers and Systems In-Center Hemodialysis Survey
WHAT IS PATIENT- AND FAMILY- CENTERED CARE (PCC OR PFCC)? Build patient/family knowledge, beliefs, culture Dig ignity ity & & resp spect ect into plan of care. Listen to, honor choices. Share complete, unbiased, timely info. Know In Infor ormati mation on patients’ health literacy and act accordingly. sh sharing aring Par articipati icipation on Support patient involvement at the level they choose. This level may change over time. Col olla laborati boration on Patients/families/care team work together on policy development, implementation, evaluation. Institute for Patient - and Family- Centered Care
WHAT IS ICH CAHPS? • A set of questions asked of in-center hemodialysis patients via a third-party vendor which elicit valuations of care rather than satisfaction per se • Asks how often en positi itive e or negati ative e aspect cts s of care occurred such as: − How often did the Dr. spend enough time with you? − How often were you treated with courtesy & respect? • Asks whethe ether and how often en patients have specific experiences − Requires more items − Reports are less subjective (than many satisfaction survey instruments) − Are easier to interpret and more useful to providers Administered twice a year (once in spring, once in fall) •
PY 2019 QIP CLINICAL MEASURE ICH CAHPS SURVEY Desc script ption on Percentage of patient responses to multiple testing tools. Composite Score: The proportion of respondents answering each response option by item, summed across all items within a composite. Composites include: Nephrologists’ Communication and Caring, Quality of Dialysis Center Care and Operations, and Providing Information to Patients, Overall Rating: a summation of responses to the rating items grouped into 3 levels NQF #0258 Exclus usion ons s 1.Facility attests that it treated fewer than 30 eligible in-center hemodialysis adult patients during the “eligibility period,” which is defined as the year prior to the performance period 2.Facilities that treat 30 or more eligible in-center hemodialysis adult patients during the “eligibility period,” but are unable to obtain at least 30 completed surveys during the performance period 3.Facilities with a CCN open date on or after January 1, 2017 4.Facilities not offering In-Center Hemodialysis 5.The following patients are excluded in the count of 30 eligible patients: a)Patients less than 18 years on the last day of the sampling window for the semiannual survey b)Patients receiving hemodialysis from their current facility for less than 90 days c)Patients receiving hospice care d)Patients currently residing in an institution, such as a residential nursing home or other long-term care facility, or a jail or prison Data ta Sour ource( e(s) s) 1.ICH CAHPS 2.REMIS, CROWNWeb, Enrollment Data Base (EDB), and other CMS ESRD administrative data (form 2744 to obtain certification date and facility type)
DIALYSIS FACILITY COMPARE WEBSITE
DIALYSIS FACILITY COMPARE WEBSITE
2016 PROJECT RESULTS Be the Voic ice, e, Be The Change e ICH CA CAHPS HPS QIA Percent of Patient Respondents who Answered Yes to Question #39 Goal: 5% RI (<=37.3%) by September 30,2016 80.0 71.9 70.8 70.5 70.5 70.0 67.6 60.0 57.7 % Respondents 50.0 40.0 Rate Goal 34.0 30.0 20.0 10.0 Q#39: In the last 12 months, did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis? 0.0 Baseline Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 n=25 Project Facilities
CMS REQUIREMENTS ICH CAHPS QIA Network chooses the “worst” scored question to improve Select lowest performers (facilities with the worst scores for the selected question) Minimum of 20 facilities 5% patient impact Administer the survey to 1/8 of the patients monthly over an eight month period beginning in February 2017 and ending in September 2017 Patient Subject Matter Experts will be utilized for development of interventions Goal: Achieve a 5% relative improvement from baseline Not an explicit requirement, but seeking good response rates. Bottom Line: Patients’ perspectives on experiences of care matters. Providers, Networks and CMS are listening and will collaborate with patients to make their experience of care better.
SELECTION ICH CAHPS • Spring 2016 ICH CAHPS Results Q#39 1 • 532 ICH Dialysis Facilities in Texas % Positive Responses • Worst Scored Question Analysis Network 14 Avg.= • Q#39: : Perit itonea neal l dialysis alysis is dialysis alysis given ven through ugh the e belly lly and is 56.6 usually ually done ne at home me . In the e las ast 12 mont nths hs, , did d either her your r kidn dney 2 doct ctors or dialy lysis is cent nter er staf aff f talk lk to you about ut perit itonea neal l dialys alysis is? Focus Facility Avg.= 33.9% • Facility with poorest scores to Q39 (>59% patients answered negatively and response rates >20%); sorted by census • 26 focus facilities (6 over minimum requirement for attrition) 3 • 2,121 patients (5.1% Network scope)
PROJECT OUTLINE Webinars 1. Project Introduction – 2/10/17 2. Wrap-Up – by 8/28/17 Facility Root Cause Analysis to examine reasons behind poor scores for Q39 3. Survey Monkey – 3/27/17 Surveys 4. Monthly patient survey distribution x 8 months (February, March April, May, June, July, August, and September) & send to Network Patient Engagement 5. Facility Patient Representative 6. Home Therapies Group Discussions in May – 6/7/17 7. Implement interventions June to July – 7/31/17 Sustainability 8. Sustainability Plan - 9/13/17
ROOT CAUSE ANALYSIS (RCA) By 3/27/17 facilities will complete a series of questions online via survey monkey to determine causes for HIGH negative patient responses to ICH CAHPS Q39 in their facility Human Resource Factors Staffing Kidney doctors Patient-Related Factors Health literacy Memory Survey responses Process Factors Patient education Patient teaching QAPI processes Equipment/Material Factors National shortage of PD dialysate Survey vendors
Root Causes for Negative Patient Scores on ICH CAHPS Q#39 70 60 50 40 #1 30 #2 #3 20 10 0 Human Resource Patient Related Process Factors Equip/Material Factors
PATIENT SURVEYS Patient Survey STARTER Kit Facility Instructions * Patient Surveys and Return Envelopes • Facility allotted number for 8 months plus 4-5 extra surveys Large Print Survey * Facility-specific Monthly Patient Checklist – do not send this back to Network; this is for facility use only Response Drop-Off Box UPS Ground Envelopes addressed to the Network • One per month for 8 months to be used to return the completed, sealed patient survey envelopes to the Network Survey Calendar * • Survey Month and corresponding monthly date to mail completed surveys back to Network * available on website
PATIENT SURVEYS Spanish on other side
PATIENT SURVEYS RESPONSE DROP-OFF BOX
PATIENT SURVEYS RESPONSE DROP-OFF BOX TAB A Insert TAB A in the slot with directional arrows labeled TAB A behind the survey response opening
SURVEY CALENDAR – DUE DATES SURVEY CALENDAR Distribute patient surveys during Mail surveys (via UPS in enveloped this month: provided) to Network by: February 2017 Wednesday – March 1, 2017 March 2017 Monday – April 3, 2017 April 2017 Monday - May 1, 2017 May 2017 Thursday - June 1, 2017 June 2017 Monday - July 3, 2017 July 2017 Tuesday - August 1, 2017 August 2017 Friday - September 1, 2017 September 2017 Thursday – September 28, 2017
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