HCAHPS Scores for Morris Hospital and Healthcare Center

HCAHPS Scores for Morris Hospital and Healthcare Center

Introduction

Morris Hospital and Healthcare Center is an acute care hospital that provides medical, surgical, and emergency services. Morris Hospital was founded in 1906 and located in the southwest of Chicago in Morris, Illinois. The healthcare institution is known for the compassionate care that provides to clients. Morris Hospital employs nearly 1,400 employees that include 300 Auxilians and over 200 physicians. The healthcare institution has a Board of Directors made up of 12 members responsible for governing it. Additionally, Morris Hospital also has an experienced Administrative team that is responsible for the day-to-day activities of the organization.

HCAHPS Scores for Morris Hospital and Healthcare Center

The overall star rating for Morris Hospital and Health Centre is 3 out of 5. In terms of communication between the patients and doctors and nurses, the hospital was rated at 81 and 82 percent, respectively. However, Morrison received a low rating of 56 percent when it came to ensuring that patients were not disturbed at night. Timely and effective care seemed to be a significant issue in the hospital as ratings on sepsis care, colonoscopy follow-up, and the use of medical imaging were low below the desired standards. Morris Hospital and Healthcare Centre also had low scores on complications and deaths associated with surgery, infections, and 30-day death rates revealing high levels of mortality and low levels of care effectiveness. Additionally, the rates of readmission after discharge from the hospital were rated at 15.3 percent with that for heart failure considerable high estimated at 21.6 percent.

Analysis of HCAHPS Scores

Most of the ratings of Morris Hospital and Healthcare Center were above Illinois’ average and also those of the national average specifically for patient experience, timely and effective care, and payment and value care. However, the ratings for complications and deaths and unplanned hospital visits were equal to those of the national average. However, the score for psychiatric unit service was missing for the hospital, so it could not be compared to the state or national average. Metrosouth Medical Center and Methodist Medical Center of Illinois are two other hospitals operating in the same region as Morris Hospital and Healthcare Centers. Although Morris was rated higher than Metrosouth, Methodist Medical proved to be better than the two. However, in timely and effective care, Metrosouth Medical Center received the highest ratings compared to both Morris Hospital, and Methodist Medical rated over 80 percent in all areas.

On the other hand, the three healthcare institutions recorded a rating that was equal to the national average in complications and deaths, related to surgical complications and 30-day death rates, and also unplanned hospital visits. In the psychiatric unit services, Methodist Medical received the highest rating, with most of the values being over 90 percent, such as in preventive care and screening and substance use and care. Survey response rates of Morris Hospital were better compared to Metrosouth and Methodist Hospitals. In terms of communication between patients and nurses and doctors, Morris was rated 82 and 81percent respectively, Metrosouth 80 and 79 percent, and Methodist 81 and 79 percent. Morris also had a higher rating in providing help to patients, explaining medicines, and providing information on what needs to be done during the recovery process compared to the other two hospitals. However, Metrosouth had a higher rating in maintaining silence for patients with a score of 63 percent with Morris and Methodist 56 and 61, respectively.

Morris Hospital serves explicitly the people of Grundy County and those residing in parts of Will, LaSalle, Livington, and Kendall counties. The population of the healthcare institution service area is estimated at 112, 742 with children and youths ranging from 0-19 making up 29.5 percent population, adults ages 20-64 making up 58.6 percent, and adults over 65 making 11.9 percent. Most of the people that the hospital serves is white, which makes up nearly 88 percent of its population. Hispanic/Latino are other races that the hospital serves who make up 7.8 percent of the population while African Americans and persons from other ethnicities make up 2 percent and 2.2 percent, respectively. Ninety-three percent of the patients that the hospital serves can speak English, while 4.5 percent speak Spanish.

Additionally, 28.2 percent of the patient population is low-income, with 8.5 percent of the total population living below the federal poverty level. The median household income of Morris’ patients estimated at $58, 638. The majority of the people that the hospital serves are patients further high school or college graduates.

Cultural Dynamics

Cultural dynamics have a significant impact on the HCAHPS scores of healthcare institutions. Communication, for example, is an essential tool that could be used to improve the HCAHPS scores by a hospital. There is a need for healthcare institutions to take into account the cultural differences that exist if they are to meet the expectations of patients. Healthcare institutions need to ensure that their staff is cultural competent enough to communicate with patients from different cultural backgrounds, specifically in areas such as the end of life. Healthcare institutions can only provide better care to patients if they have an understanding of a patient’s perspective. Cultural characteristics such as race, ethnicity, and preference of language have a direct impact on the perception that patients have regarding their experience and care provided. Reports also indicate that cultural and language barriers negatively impact on the relationships between patients and healthcare providers. Such barriers reduce the confidence and trust that patients have in healthcare institutions. Lack of such confidence and trust can result in low HCAHPS scores leading to low reimbursements. Additionally, healthcare institutions that incorporate cultural dynamics of their patients also encourage patient activation and engagement that are crucial for allowing patients to be able to navigate the healthcare system of a hospital satisfactorily. As a result, inequities within a hospital that can negatively impact the HCAHPS scores of a hospital.

Education Dynamics

Educational dynamics also have an impact on the HCAHPS scores of a healthcare provider. Hospitals need to understand the educational dynamics of their patient demographic population. Through such knowledge, healthcare providers can be able to improve patient education, which is crucial for medical adherence and understanding medication usage. However, healthcare providers that fail to consider the educational dynamics of their patient population are likely to have high rates of readmissions. Lack of healthcare providers understanding their patient’s educational dynamics is the primary reason for poor communication among providers regarding medication usage and adherence. Research also indicates that patient education has a direct impact on the satisfaction of patients, which has also has an impact on hospital reimbursement. Healthcare institutions with poor patient education have been attributed to poor patient satisfaction. Healthcare providers need to take into consideration the ages of patients, learning disabilities, and readiness, and motivation to learn. Taking into account such educational dynamics of patients can help healthcare providers to have a clear idea of the delivery methods that are appropriate for a patient’s learning style. Healthcare providers need to ensure that patients have the necessary knowledge and relevant information required to ensure that they are informed about them as providers and medication that can increase patient satisfaction, patient care, and hospital reimbursement.

Socioeconomic Dynamics

Patient priorities differ across socio-economic populations are healthcare providers need to understand the socio-economic dynamics of their patients. Healthcare providers can only cater to their patient’s preferences if they have a clear understanding of the socio-economic dynamics of their patient’s population. Having the ability to serve patients based on their socio-economic preferences is essential if healthcare providers are to increase their HCAHPS scores and funding levels. According to research, healthcare providers need to address the racial/ethnic disparities if they are to ensure patient satisfaction that can lead to higher reimbursement due to improved HCAHPS scores. Various socio-economic factors, such as income and education, influence the health outcomes of patients. Healthcare providers need to account for such factors when providing care to patients if they are to serve all groups of people, including the vulnerable ones. According to reports, the income associated burden of a disease is one of the significant causes of morbidity and mortality of patients in the United States. By understanding the socio-economic dynamics of its patients, healthcare providers can be able to easily strategize how they can provide better care at an affordable cost to patients. Providing quality care at an affordable price is one of the factors that is used to measure the HCAHPS scores of healthcare providers. Healthcare providers can, therefore, improve their scores and reimbursement if they can provide quality care at an affordable cost.

Financial and Quality Impacts and Potential Cause

Currently, the Centers for Medicare & Medical Services is tying hospital’s reimbursement to HCAHPS scores, which has an impact on the financial status of hospitals. Although the HCAHPS scores of Morris Hospital are encouraging, certain areas are below the national level, such as mortality and readmission. These outcomes reduce the reimbursement rate of the hospital that can lead to short-term financial impacts on the hospital. Lack of improvement in these areas can also lead to more errors and loss of clients that can, in the long run, ruin the financial status of the hospital. Apart from performing below national levels, Morris hospital also performs on the same level as the national average in areas such as efficient use of medical imaging and effectiveness of care, indicating a quality challenge. If scores for the hospital that are below and the same as the national level are not rectified, quality can deteriorate in the future due to the demanding nature of healthcare. The potential causes that might have led to high rates of readmission and mortality include inappropriate or incomplete treatment, poor social planning, and inappropriate handover from secondary to primary care. The reasons that might have led t excellent patient experience good communication between patients and staff, safety, and excellent patient-engagement.

Organizational Strategic Plan

Organizational Change, Structure, Process, and Outcomes

Organizational change can help to improve Morris’ HCAHPS scores to improve its reimbursement and financial status. The proposed plan is aimed at incorporating critical concepts in the processes and operations that can help to improve various outcome measures considered in HCAHPS. The framework of the strategic plan involves reducing the gap between the expectations of patients and the services provided as a way of maximizing experiences. The framework is based on seeking financial gains by encouraging patient-centered care that supports a culture of patient experience, patient-provider communication, transparency, and engagement. In the creation of a culture that promotes patient experience, specific job titles and training initiatives would be created aimed at enhancing staff-buy in, which is crucial for improving patient experience. Leadership would also be required to ensure that it instills and support a culture that prioritizes the experience of patients. To facilitate patient-provider communication, communication channels would be created to encourage interaction between customers and the staff, especially regarding service delivery and medical treatment. Clinical teams, physicians, nurses, and patients would be required to discuss and engage in active communication regarding procedures, medical treatments, care options, and treatment and service expectations. Information transparency is crucial for encouraging the involvement of patients in their care that can help to improve their experiences. To facilitate information transparency among patients and healthcare providers through the use of the internet that would allow nurses to be able to communicate relevant information to patients within and outside the provider’s walls. User-friendly websites would be created that would help to ensure that consumers have patient-specific data and that they are able to communicate with the healthcare provider easily. Patient engagement would be encouraged through ensuring that staff seeks the input of patients through surveys, focus groups, and face-to-face interactions. The outcomes of the strategic plan are focused on improving measures such as patient experience, care effectiveness, readmissions, and mortality.

Incorporation of Evidence-Based Practice

The integration of evidence-based practice would involve using the current best evidence, clinical expertise, and patient values to guide healthcare decisions. The process would involve taking steps that would encourage the identification and adoption of EBP to improve organizational quality. The first step would involve cultivating the spirit of inquiry within the organization where EBP and their application would be continuously questioned. The second procedure would involve searching and collecting relevant information on the best EBPs that fit the organization’s products and services. The third step would involve critically appraising the EBPs to determine their validity, reliability, and applicability to the organization. The third step would involve integrating EBPs with clinical expertise and preferences of patients, specifically in practice decision-making processes. The final step would involve evaluating the EBPs’ outcomes based on evidence where the consequences of an intervention would be evaluated.

Incorporating Shared Governance

Shared governance can be used to help organizations to promote optimal patient and nurse outcomes in healthcare institutions. The first step would be determining the preferred level of nurses involvement in decision-making processes, which would be the basis for incorporating shared governance. Unit councils would also be created who would be required to collaborate with staff nurses to determine shared opinions, ways of improving patient experiences, and participate in decisions concerned with process improvement. Hospital councils would also be held where nurses from different units would come together to discuss relevant issues that may be affecting their practices and patient care. Nursing leadership would be required to offer support to the staff nurses and act as intermediaries with the upper management. Also, themed councils would be regularly conducted that would be aimed to address various issues affecting the organization and the staff, such as quality, safety, and professional development. Through the approaches above, shared governance would be incorporated into the organization that would aid in improving quality leading to higher reimbursements and HCAHPS scores.

Methods to Incorporate Shared Accountability

Shared accountability involves utilizing key stakeholders such as patients, medical providers, payers, and personnel to improve care. The shared accountability approach in the strategic plan is built about various concepts that include evidence-based medicine, continuous quality improvement, and excellent health care as the responsibility of stakeholders. The shared accountability approach involves the utilization of clinical programs and services to create a robust mechanism that assists in delivering some of the most effective, appropriate, and evidence care. Patients would be encouraged to also engage in prevention and wellness programs and decisions that concern about their care. Additionally, a payment model will be developed that provides financial incentives to different stakeholders as a way of motivating them to seek high-value care.

Incorporating Technology Trends

Previously, healthcare providers stored medical records of patients manually. However, the current trend of storing information in healthcare is the use of electronic medical records. Through the utilization of electronic medical records, relevant information such as patient history, test results, and diagnosis would be able to be stored in an online location. The data would allow for more focused and accurate care in the organization that would further provide oversight for the health trends of individual patients. Mobile apps are also a new trend in healthcare that have been proved to be effective in improving accessibility. The strategic plan involves utilizing mobile software applications to assist patients and healthcare providers in managing health and wellbeing easily. The mobile apps are also intended to help healthcare professionals relevant information for improving quality of care, such as diseases, drugs, and education initiatives, among many more others. The use of Artificial Intelligence (AI) is another trend that is redesigning healthcare. The strategic plan involves utilizing AI algorithms in the organization for purposes such as mining medical records, designing treatment plans, and monitoring the treatment processes of patients.

Methods for Improving Care Delivery System

The strategic plan also involves improving the care delivery system in terms of quality, cost, access, and patient-centered care. The care delivery system would be centered on the whole person, where numerous stakeholders would be required to participate in the strategic plan. It encourages excellent levels of collaboration and aligning the system with the needs of the community, which are aimed at promoting quality and patient-centered care. The plan also urges service-based payment and bundled-based payments, which are meant to assist in reducing costs for the organization and patients. Technology use is also highly encouraged with the aim of making the hospital and its services assessable to patients at their convenience.

Improving Financial Stability

Ensuring staff satisfaction is one strategy that would be utilized in the strategic plan to promote financial stability in the organization. The morale of staff has a direct impact on turnover levels in an organization. Healthcare institutions with satisfied employees tend to encourage the morale of staff, leading to low turnover that encourages operation efficiency. Operation efficiency would help to reduce costs that can help to build financial stability. Staff satisfaction would be achieved by creating conducive working environments, competitive salaries, incentives, and supporting technologies. Another technique that would be used to improve financial stability in the strategic plan is the use of data to identify various opportunities for reducing the length of stay. Reducing the length of stay of patients can help to improve the financial and operational outcomes of hospitals. By reducing the length of stay of patients, costs of care for patients and staffing and premium pays can be able to be reduced in healthcare institutions that can lead to improved financial stability. Another strategy in the strategic plan for improving financial stability is developing an infrastructure for growth that would help to identify new sources that can help to increase revenue generation. By identifying new sources, more revenue can be generated that would ultimately lead to financial stability improvement. Relying on the current sources of revenue and being dormant when it comes to identifying and adopting new sources can put the healthcare institution at a disadvantage financially. Healthcare providers can only increase their revenue if they can come up with new sources that can help to increase revenue. Ultimately, adopting new sources of revenue would lead to financial stability improvement due to an increase in revenue.

Roles and Responsibilities of Stakeholders

Various stakeholders have a duty to play in the strategic plan if quality and patient safety are to be improved. The role of healthcare managers in the strategic plan is to foster an environment that supports quality care at maximum profit. They would be responsible for activities such as budgeting, administering of payrolls, benefits, and incentives, and also distributing regular communications about the HCAHPS scores and the impact of the organizational strategic plan. Nurses are other stakeholders who would be required to identify various challenges that they might be facing, especially those that relate to patient experience and satisfaction. Nurses are the staff that communicates mostly with patients and are, therefore, in a better position to identify the challenges and needs of patients to improve patient experience in the organization. The nursing staff would also be required to participate actively in decision-making processes, especially those that involve improving patient experience. Physicians are other stakeholders who would be required to work closely with employees in the organization to ensure employee satisfaction. Physicians would be required to continually keep communication lines open so that employees can easily communicate challenges and suggestions. Physicians would also be required to adopt shared decision-making processes. The physicians in the organization would be required to work with other stakeholders, especially nurses and patients, to make care decisions through leveraging experiences and input from the concerned groups. Patients and their families are other critical stakeholders who would have to play various roles in the organizational strategic plan. Patients would be required to participate in various programs that would be offered, learn about the changes that would be implemented, and regularly provide input on what works for them. Family members would be required to monitor and communicate the treatment progress of patients and report any concerns that they might have that may interfere with the recovery process.

Stakeholder Accountability and Involvement

Detailed performance objectives would be identified and communicated to all the concerned stakeholders. The stakeholders would be required to understand the importance of the performance objectives and how they would influence HCAHPS scores of the organization. Stakeholders who would fail to meet the performance objectives would be required to justify the failure and what they believe could be done to avoid such circumstances. All staff would also be required to report challenges that they might be having with the strategic plan to their respective leaders to identify areas for improvement. Leaders in the organization would also be held accountable for the performance of their junior. Regular meetings would be held where leaders from different departments would be required to express the grievances of their juniors and suggestions for improvement. Patients would also be required to participate actively and provide input regarding decisions that concern their health and treatment process. Family members and patients would be required to sign informed consent forms that prove that they were involved in the decision-making process and fully briefed about their condition and treatment alternatives.

Training of Staff

The strategic plan involves the adoption of various technologies that are shaping the healthcare industry. There would be a need to train various staff on how to use such technology effectively to prevent future errors and damage due to lack of knowledge. The staff would also be trained on how the technologies would improve patient outcomes and experiences and how they are transforming the healthcare industry. Communication is an essential tool for improving patient experience and outcomes. Providing staff with communication training would be crucial for the success of the strategic plan. Staff would need to be provided with training on various communications tools such as interhospital, intrahospital, bedside reporting, shift reporting, and handoff. The staff would also need to be provided with training on various communication tools that would be used in the strategic plan to convey relevant information to the stakeholders.

Timeline for Implementation of the Plan

The timeline for the implementation of the strategic plan is three years, and it includes periodic review checkpoints to measure its progress. The first year would involve preparing the staff and organization for the implementation of the strategic plan. In the first year, specific job titles would be created within the organization whose sole purpose is to come up with programs and training initiatives aimed at improving patient experience and HCAHPS scores in the organization. These specific job titles would be filled with senior and experienced staff from different departments while the training programs would be developed by personnel from the Human Resource Department. Periodic reviews during this year would be done every four months to check on the preparation progress. The second-year would involve putting the concepts of the strategic plan into action. The formulated positions would be filled, and training programs would be initiated to help the staff to acquire the necessary knowledge and skills. The proposed technologies, methods of improving care delivery, and approaches for strengthening financial stability would be adopted in the organization. Leadership from different departments would be required to carry out periodic reviews every three months to monitor the progress of the plan and determine whether any changes should be made. The final year would involve healthcare managers monitoring the impacts of the strategic plan and determining whether HCAHPS scores are improving. The final year would involve letting the staff independently applying what they have learned from the previous year regarding the strategic plan. Periodic reviews would be carried out by healthcare managers and improvements made to areas that have not been perfected.

Evaluation Process

Method of Measurement

The method of measurement that would be used to evaluate the strategic plan is the use of performance measures and quantifiable objectives. These measures and objectives include improved communication between all stakeholders, revenue increase, and improvements of various HCAHPS scores, specifically readmissions, patient experience, and timeliness of care. Based on the progress of these measures and objectives, it would able to be determined whether the implementation of the strategic plan is working at the benefit or not of the organization.

Evaluation of the Timeline

Evaluation of the timeline would be based on the milestones of the strategic plan. Evaluation of the timeline would be done annually, where it would be evaluated whether the required tasks in the strategic plan have been effectively completed. In the first year, the training, technology, specific job titles, and other methods would need to have been formulated and ready for implementation. The second-year would involve determining how effective the concepts and propositions of the strategic plan have been implemented and incorporated in the organization. Improvements are expected at the end of the second year throughout the organization. The final milestone is the third year, where the staff is expected to have acquired the necessary skills and knowledge to apply the concepts of the strategic plan competently.

Method of Analysis

The method of analysis that would be used to evaluate the strategic plan is SOAR, which stands for strengths, opportunities, aspirations, and results. SOAR was considered as the best method of analysis as it would help the organization to identify the strengths and opportunities during the implementation of the strategic plan that can be leveraged to ensure the desired outcomes are achieved. The method of analysis is also more action-oriented, focuses on meeting the desired aspirations, and can provide evidence and guidance on whether the organization is on the right track.

Involving Stakeholders in the Evaluation Process

Key stakeholders would also be involved in the evaluation process. The needs of the stakeholders would be represented throughout the evaluation process. Meetings would be held where key stakeholders such as nurses, physicians, HR personnel, and clinical teams would be briefed about the progress of the strategic plan and outcomes of the evaluation. The objective of these meetings would be to create a clear understanding of their interests, perceptions, and concerns regarding the strategic plan. The sessions would also be aimed at ensuring that all the concerned stakeholders have a clear understanding of their roles and responsibilities in the strategic plan. Other stakeholders, such as patients and their families, would be involved in the evaluation process through participatory evaluation. Patients and their families would be encouraged to give their honest feedback regarding the care they received and what they believe could be done to improve to ensure the best patient experience. Such active engagements would be vital in ensuring that a wide range of interests of various stakeholders are taken into consideration during the evaluation process that can lead to better outcomes.

Communication of Evaluation Results

The evaluation results of the strategic plan would be communicated both internally and externally. Memos and digital signage are the two tools that would be used to inform evaluation results to stakeholders in the organization. Memos would be posted on notice boards so that stakeholders can access the evaluation results of the strategic plans. Digital screens would be placed in strategic positions displaying the evaluation results to the stakeholders in the organization. Externally, the organization’s website would be used to communicate evaluation results. The evaluation results would be constantly updated on the company’s website where stakeholders can access it and view them. Emails would also be used to externally and internally communicate the evaluation results. Stakeholders would constantly be sent emails that provide updates on the evaluation process and results to keep them on the light regarding the progress of the strategic plan.