Pre-Residency Study Set

According to the last Resolute Organizational Assessment Survey, how did the respondents (Directors and managers) respond to this question: Please list the top three things your organization does well and should continue to do.

1. Patient Experience 2. Employee Satisfaction 3. Quality

What do the Global Measures cover?

1. Patients' overall rating of the hospital. 2. If they would recommend it to family and friends.

How many directors and managers completed their organizational assessment survey?

11 out of about 30. Poor performance. Mark finds this unacceptable and is disappointed.

What are HCAHPS?

HCAHPS is a patient satisfaction survey required by CMS for ALL hospitals in the United States. It only applies to adult inpatients, excluding psychiatric patients. It measures patient's perceptions on their hospital experience. It provides a way to compare perceived hospital quality across the United States.

What does Resolute want to do with the electronic communication board concept found in the Pharmacy Dept. of Resolute?

Staff at resolute are choosing to be uninformed and not attend town hall meetings and other communication events. To counter this, Resolute leadership wants to take the electronic communication board found in Pharmacy and install them near the time clocks so staff are forced to see new messages.

What do HCAHPS specifically measure.

There are 10 HCAHPS measures. 6 - Composite measures, 2 - Individual items, and 2 - global items. All 11 of these measures are reported on Hospital Compare.

True or False, Brenna is Basic?

True, obviously.

What is the Mission Statement of Baptist Health System?

We help people achieve health for life through compassionate service inspired by faith.

Are HCAHPS adjusted to compare apples to apples when comparing one hospital s' HCAHP score to another?

Yes. To ensure that HCAHPS scores allow fair and accurate comparisons among hospitals, it is necessary to adjust for factors that are not directly related to hospital performance but which affect how patients answer survey items. CMS and the HCAHPS Project Team (HPT) apply adjustments that are intended to eliminate any advantage or disadvantage attributable to the mode of survey administration or characteristics of patients that are beyond a hospital's control.

What is a Glass Wall board?

All GEMBA boards feed into the Glass Wall board. There is only one Glass Wall board and it shows our current status across our five domains: (1) Cost, (2) Growth, (3) Quality, (4) Service, and (5) People.

What does RIF stand for? What is it?

Reduction In Force RIF = Layoffs.

What do the Individual Measures cover?

1. Cleanliness of patients' rooms 2. Quietness of patients' rooms

What are the Values (6) of the Baptist Health System?

-Compassion -Safety -Excellence -Accountability -Innovation -Faith

What are our Five pillars? Where does resolute rank on these five pillars?

1. Cost (Ranked 73 out of 74 Tenant hospitals - Bad) 2. Growth (Ranked 77 out of 77 Tenant hospitals - Bad) 3. Quality (Ranked 6 out of 73 Tenant hospitals - Good) 4. Service (Ranked 59 out of 77 Tenant hospitals - So so) 5. People (Ranked 75 out of 77 Tenant hospitals - Bad)

What do the Composite Measures cover?

1. How well RNs and MDs communicate with patients. 2. How responsive hospital staff are to patients' needs. 3. How well hospital staff help patients manage pain 4. How well the staff communicates with patients about new medicines. 5. Whether key information is provided at discharge. 6. How well patients understood the type of care they would need after discharge

According to the last Resolute Organizational Assessment Survey, how did the respondents (Directors and managers) respond to this question: What are the top three barriers/challenges you face that keep you from achieving your results in your area of responsibility at your organization?

1. Accountability 2. Time Management 3. Culture of Engagement

According to the last Resolute Organizational Assessment Survey, how did the respondents (Directors and managers) respond to this question: Please list the top three opportunities for improvement at your organization.

1. Business Strategy 2. Trust/Communication 3. Leadership Growth and Development

Why are HCAHPS important?

25% of our reimbursement is based on HCAHP results. Also, the 11 domains of HCAHP are summarized and displayed as the CMS Hospital Compare Star System (1-5 stars). Consumers may be picking which hospital to go to based on your CMS Star Rating (Derived from HCAHPS).

What does AIDET stand for?

A - Acknowledge I - Introduce D - Duration E - Explanation T - Thank you

What is a Stop Light Report?

A Stop Light Report is a report that shows staff suggestions. We use stop light reports to write down all the suggestions for improvement we hear and what we're going to do with them. Staff get to see this report to show we are listening to their suggestion and what we did with their suggestion and why it's either Green, Yellow, or Red. Green Column = We will implement the suggestion. Yellow Column = We are considering the suggestion Red Column = We will not implement the suggestion.

Who is the A-Team?

A-Team = Administration Team. The A-Team meets once a week. All directors are on the A-Team.

What is AIDET? Give an example.

AIDET is the correct way to enter a patient's room or initially interact with a patient or their family. Example of entering Mrs. Smith's room on the PCU: - RN: Hello Mrs. Smith, My name is Nurse ________. How are you feeling today? I'm here to help change your wound vac and this should take no more than ten minutes to do. Changing your dressing will allow us to see how you're healing up and see if we can't get some fresh dressing in place. *Changes wound vac dressing* Thank you Mrs. Smith! Before I go, is there anything else I can do for you? Have a great day and press your call light if you need anything.

_______________ from our workforce is key! Here, you must know _______________ measures like the back of your hand.

Productivity.

Who is Eric Shmacker?

Eric Shmacker is the President of Mission Trial Hospital. Eric graduated form West Point Military Academy and served 21 years in the Army. His son is going into High school and really likes playing basketball. Eric's son wants to go to play basketball in college in the North East somewhere. Eric is big on accountability.

True of False, If someone needs immediate medical attention in the therapy department or anywhere else in the Physician Offices' part of the Resolute Building, you can simply wheel them over to the Hospital portion of the building?

False. You have to dial 911 and wait for the ambulance/EMTs. Why: Legally speaking, Resolute Health Hospital and the Resolute Physician Offices' wing are two SEPERATE legal entities. Due to this fact, you must dial 911 first and can't just bring them over manually to the hospital part of the building.

What is the Leap Frog Survey?

Founded in 2000 by large employers and other purchasers, The Leapfrog Group is a national nonprofit organization driving a movement for giant leaps forward in the quality and safety of American health care. The flagship Leapfrog Hospital Survey collects and transparently reports hospital performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog's other main initiative, assigns letter grades (A, B, C, D, and F) to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents, and infections. Resolute Leapfrog Grade: B Mission Trail Leapfrog Grade: C

What is a GEMBA board?

GEMBA is a Lean initiative that was pioneered at Resolute and is being rolled out across Baptist All staff and leaders must update and use their Dept.'s GEMBA board. GEMBA is Japanese for "The real place." So, going to the gemba is going to the place where value is created, where the real work is taking place. The Spirit of GEMBA: Before proposing a solution to a problem, we should learn as much as possible about what is going on. GEMBA Boards usually have these four documents on them: Pareto Chart, Run Chart, S-Why Action Plan, and a Monthly Trend by Unit Report (Shows HCAHP domains).

When and how are HCAHPS collected?

HCAHPS are administered to a random sample of adult inpatients between 48 hours and six weeks after discharge. Patients admitted in the medical, surgical, and maternity care service lines are eligible for survey. HCAHPS are NOT restricted to Medicare patients. HCAHPS are collected in four survey modes: (1) Mail, (2) telephone, (3) mail with telephone follow-up, or (3) active interactive voice recognition (IVR). Hospitals must survey patients throughout each month of the year.

What is Hospital Compare and HCAHPS Star Ratings?

HCAHPS scores, based on four consecutive quarters of patient surveys, are publicly reported on the Hospital Compare Web site to help families decide where to go for quality care. In addition to this, HCAHPS Star Ratings summarize the results for each HCAHPS measure and present it in a format that is increasingly familiar to consumers, making it easier to use the information and spotlight excellence in healthcare quality. Twelve HCAHPS Star Ratings appear on Hospital Compare: one for each of the 11 publicly reported HCAHPS measures, plus a Summary Star Rating that combines all the HCAHPS Star Ratings.

What does HCAHPS stand for?

Hospital Consumer Assessment of Healthcare Providers and Systems.

Instead of a written news letter, how does Resolute Leadership communicate with staff? What about screen savers?

In lieu of a written new letter, Resolute is doing 1-2 minute VLOGs (Video news recordings) from Mark. VLOGS are really popular among staff and many are opening them up and watching and becoming informed. Mark also wants to change all our work computer screen savers to communicate organization news for staff to see.

What happened with our (Resolute Health's) Humana Contract?

Last Fall (Fall of 2016), Resolute Health did NOT renew their Humana Contract due to poor rate negotiations. The result of this was a significant loss in patient volume as we no longer accept Humana. Because of this, Resolute had to conduct a RIF (Layoffs) right before the holidays. Some staff are still uneasy about their job security and still anxious over the most recent RIF.

What is LDI?

Leadership Development Institute LDI is leadership development training for directors and executives only. It is held once a year.

What are Mark Bernard and Eric Shmacker both concerned about creating?

Leadership development and accountability among leaders/directors.

Who is Mark Bernard?

Mark Bernard is the President of Resolute Health Hospital. Mark worked for Methodist Health System for 18 years and worked 2 years in Houston, TX before becoming President of Resolute Health. Mark really likes hunting and fishing, and is originally from Fort Dodge, IA. Mark is big on accountability and leadership development.

What happened at our last town hall meeting?

Only 100 out of around 400 staff showed up. Poor turnout. Mark isn't happy.

What are two key focus areas that Resolute is focused on?

Patient experience and employee engagement.