HCAHPS score analysis and strategic planning for University of Alabama Hospital

Healthcare System Survey Data

Healthcare System's Survey Data

This report uses the HCAHPS "(Hospital Consumer Assessment of Healthcare Providers and Systems)" scores (Medicare Gov, 2014 p1) to develop the strategic plan for the University of Alabama Hospital. The objective of analyzing the HCAHPS scores of the organization is to enhance an improvement for the hospital. The essence of the NCAHPS is to use the scores of the organization and compare them with hospitals that enroll for the Medicare. The results allow consumer to make objective and fair comparison about the hospital, and evaluate importance care received compared to the national or state standard.

Objective of this document is to use the HCAHPS scores of the University of Alabama Hospital to make the strategy plan and improve the entire organization. The outcomes of the document is to assist the hospital board to make a detailed strategic plan for the organization in order to incorporate quality improvement, care delivery model, share accountability, technology and financial stability. The document also presents the timeline to complete the proposal.

A. Analysis of the HCAHPS score of the University of Alabama Hospital

The study uses the HCAHPS scores of the "Inpatient Psychiatric Facility Quality Reporting Program Facility" (Medicare Gov, 2014 p1) to analyze the University of Alabama Hospital. The Appendix 1 provides the HCAHPS scores for the University of Alabama Hospital. "The inpatient Psychiatric facility program" (Medicare Gov, 2014 p1) allows consumer to compare the quality of the hospital with other hospitals dealing with inpatient psychiatric services. (Medicare Gov, 2014 p1) The paper uses the following variables to evaluate the quality of the facility of the hospital:

HBIPS 2, - "Hours of physical restraint use"

HBIPS 3-" Hours of seclusion use"

HBIPS 6 -- "Post discharge continuing care plan" and HBIPS 7-"Post discharge continuing care plan transmitted to next level of care provider upon discharge." (Medicare Gov, 2014 p1).

B1.Comparing University of Alabama Hospital Score to the State average and National average

The paper collects the HCAHPS scores of the University of Alabama Hospital between 01 October 2012 and 31 March 2013. Comparative analysis of the University of Alabama hospital to the national average and state average on the quality of facility for the Inpatient Psychiatric unit reveals that the University of Alabama hospital performs below national average and state average with reference to HBIPS-2. For example, the number of hours that the hospital use in the physical retrain of inpatient (HBIPS-2) is 1.75-hour, while the state average is 0.54 and the national average is 0.39.

Moreover, the total number of hours that the hospital holds all psychiatric inpatients in seclusion (HBIPS 3) is below the state average. The hospital scores 0.28-hour, while the state average hour is 0.11-hour. However, University of Alabama hospital performance on HBIPS-3 is better that national average that scores 0.35. The paper also evaluates the hospital based on the post continuing care plan after patients have been discharged (HBIPS 6) from the hospital. The results reveal that the hospital performs below the state average and national average. While the University of Alabama Hospital scored 28.56, the score for the state average is 80.22 and the national average is 73.52.

The University of Alabama Hospital scores zero for the "Post discharge continuing care plan transmitted to next level of care provider upon discharge." (HBIPS 7) ." (Medicare Gov, 2014 p1). While the score for the state average is 73.98 and the score of the national level is 62.74.

2. Comparing University of Alabama Hospital Scores to Trinity Medical Center and St. Vincent's East Care

The paper compares the score of the University of Alabama Hospital with the Trinity Medical Center in Alabama. The results reveal that the University of Alabama Hospital performs better than the Trinity Medical Center for the (HBIPS-2) because the Trinity Medical Center scores 3.85 hours on the number of hours that the hospital use in maintaining physical retrain of patient while the University of Alabama score 1.75-hour.

The total number of hours that the Trinity Medical Center holds all psychiatric inpatients in seclusion (HBIPS 3) is 0-hour, which is better than the University of Alabama Hospital score of 0.28-hour

Moreover, the Trinity Medical Center performs better than the University of Alabama Hospital on the post continuing care plan after patients have been discharged. (HBIPS 6) because the hospital scores 100 compared to the University of Alabama Hospital that scores 28.56.

On the other hand, St. Vincent's East Care in Alabama performs better than the University Of Alabama Hospital in HBIPS-2 because its score is 0.03 hours compared to the University of Alabama that scores 1.75-hour. In HBIPS 3 (hour of seclusion), the St. Vincent's East Care scores 0.2 hours compared to the University of Alabama that scores 0.28-hour. In HBIPS 6 ("Post discharge continuing care plan"), the St. Vincent's East Care scores 88.64 while the University of Alabama that scores 28.56.

3. Comparing the survey response rates to the Sparks Regional Medical Center and Baptist Medical Center

The survey response of the University of Alabama is very good and above average because virtually all the survey results for the HBIPS 2, HBIPS 3, HBIPS 6 and HBIPS 7 have been recorded and displayed at the NCAHPS website. However, the response rate for the Baptist Medical Center in Alabama is poor because its response scores for the HBIPS 2, HBIPS 3 are not available. Although, the hospital records a response scores for HBIPS 6 because it score 94, overall, the University of Alabama Hospital response rate is better than the Baptist Medical Center response rates. Moreover, the University of Alabama Hospital response rate is better than the response rate of the Sparks Regional Medical Center because Sparks Regional Medical does not have the scores for the HBIPS 2, and HBIPS 3. Although, the hospital records a response scores for the HBIPS 6 because it score 100, overall, the University of Alabama Hospital response rates are better than the response rates of Sparks Regional Medical Center and Baptist Medical Center response rates.

4. University of Alabama Hospital Demographic of Patient population & Services

The demographic of the patient for the University of Alabama Hospital is presented in the table below:

Admissions

72,212

Inpatient surgeries

22,144

Outpatient visit

422,609

Emergency room visits

83,433

Births

1,146

Number of Beds

1,062

Moreover, the hospital delivers the following services:

Services Delivered by the University of Alabama Hospital

Inpatient

Birthing room

Burn care

Heart catheterization (diagnostic child)

Heart catheterization (diagnostic adult)

End-of-life services (Palliative care & Pain management )

Neonatal intensive care

Neonatal intermediate care

Infection isolation room

Heart surgery (adult)

Heart surgery (pediatric)

Heart catheterization (treatment adult)

Heart catheterization (treatment child)

Cancer services

Psychiatric care & Psychiatric emergency services

Outpatient

Certified trauma center

Dental services

Chemotherapy

Chiropractic services

Alzheimer center

Arthritis center

Bariatric and weight control services

Heart catheterization (diagnostic adult)

Breast cancer screening and mammograms

Heart catheterization (diagnostic child)

Genetic testing/counseling

Geriatric services

Fitness center

HIV-AIDS services

Home health services

Heart catheterization (treatment adult)

Heart catheterization (treatment child)

Kidney dialysis

Chemotherapy

Physical rehabilitation

Psychiatric services (Consultation, Child & adolescent services, Geriatric services and Outpatient care)

Sleep center

Urgent-care center

Women's health center

Stop-smoking program

Sports medicine

Substance-abuse programs

Wound management services

Patient and Family Support Services

Chaplaincy

pastoral care services

Cancer services

Alzheimer center

Help with government services

Patient support groups

Patient representative ombusdman

Transportation for elderly Transportation for handicapped

Translation services

Diagnostic & Therapeutic and Community Imaging Outreach

Services

Ultrasound

CT scanner

Diagnostic radioisotope facility

Health fairs

MRI (Magnetic resonance imaging )

Multislice spiral CT

Health screenings

Single photon emission CT

6. Potential Short- and Long-term Financial Impact

The HCAHPS scores can affect both short-term and long-term financial goals of the hospital because the hospital derives part of its income from the Medicare program. The Medicare is a federal government program that delivers social and health insurance to older people aged above 65. Thus, the in income that the hospital will earn from the federal government on Medicare will depend on the number of Medicare patients seeking for the medical services from the University of Alabama Hospital. If the number of patients declines based on the HCAHPS scores the results will have short and long financial impact on the hospital because there will be a decline in both quarterly revenue and accumulated revenue at the end of the fiscal year. Moreover, the federal government will reduce the cumulated payment per year for the hospitals that do not meet the 2.0%.

6a. Potential Impact on Hospital Quality Outcomes

Potential impact of the hospital quality outcome is that the quality of health delivered by the hospital will be reduced because a decline in revenue will lead high worker's turnover rate. Moreover, the hospital will not be able to retain highly skilled and experience staff. The impact will make the hospital to be short of health materials, which could consequently affect the future HCAHPS scores for the hospital.

Reference

Medicare Gov. (2014). Inpatient Psychiatric Facility Quality Reporting Program. Retrieved 19 October From http://www.medicare.gov/hospitalcompare/psych-measures.html#stateQQ

Appendices

Appendix 1: NCAHPS Scores for the University of Alabama Hospital

NCAHPS Scores for the University of Alabama Hospital

Start_Date

10/01/2012

End_Date

03/31/2013

State Average

National Average

HBIPS-2_Measure_Description

"Hours of physical-restraint use" (Medicare Gov, 2014 p1)

"Hours of physical-restraint use" (Medicare Gov, 2014 p1)

"Hours of physical-restraint use" (Medicare Gov. 2014 p1)

HBIPS-2_

Overall_ Rate _ Per_ 1000

1.75

0.54

0.39

HBIPS-2_Overall_Num

230992.31

HBIPS-2_Overall_Den

15732

216692

24426778

HBIPS-2_1-12_Rate_Per_1000

0.00

0.63

0.28

HBIPS-2_1-12_Num

0.00

81.83

HBIPS-2_1-12_Den

96

5,455

694887

HBIPS-2_13-17_Rate_Per_1000

8.70

1.8

0.26

HBIPS-2_13-17_Num

107798.6

HBIPS-2_13-17_Den

14470

17501590

HBIPS-2_18-64_Rate_Per_1000

0.35

0.48

1.01

HBIPS-2_18-64_Num

96.15

106935.02

HBIPS-2_18-64_Den

11452

110556

4415221

HBIPS-2_ 65_ Over_ Rate_ Per_1000

0.06

0.41

0.20

HBIPS-2_

65_Over_Num

1.97

113600.29

HBIPS-2_65_Over_Den

86201

24100261

HBIPS-3_Measure_Description

Hours of seclusion Use

Hours of seclusion Use

"Patients discharged on multiple antipsychotic medications" Medicare Gov. (2014)

"Patients discharged on multiple antipsychotic medications" Medicare Gov. (2014)

"Patients Discharged on Multiple Antipsychotic Medications" Medicare Gov. (2014)

HBIPS-4_Overall_Footnote

4

HBIPS-4_1-12_Footnote

4

HBIPS-4_13-17_Footnote

4

HBIPS-4_18-64_Footnote

4

HBIPS-4_65_Over_Footnote

4

HBIPS-5_Measure_Description

"Patients discharged on multiple antipsychotic medications with appropriate justification" Medicare Gov. (2014)

"Patients discharged on multiple antipsychotic medications with appropriate justification Medicare Gov. (2014)

"Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification" Medicare Gov. (2014)

HBIPS-5_Overall_Footnote

4

HBIPS-5_1-12_Footnote

4

HBIPS-5_13-17_Footnote

4

HBIPS-5_18-64_Footnote

4

HBIPS-5_65_Over_Footnote

4

HBIPS-6_Measure_Description

"Post-discharge continuing care plan created" (Medicare Gov, 2014)

"Patients Discharged from a Hospital-based Inpatient Psychiatric Setting with a Continuing Care Plan Created" (Medicare Gov, 2014)

"Patients Discharged from a Hospital-based Inpatient Psychiatric Setting with a Continuing Care Plan Created"

(Medicare Gov, 2014)

HBIPS-6_Overall_%_of_Total

26.56

80.22

73.52

HBIPS-6_Overall_Num

98

324983

HBIPS-6_Overall_Den

442049

HBIPS-6_1-12_Footnote

1

HBIPS-6_13-17_%_of_Total

26.14

81.55

85.69

HBIPS-6_13-17_Num

23

41981

HBIPS-6_13-17_Den

88

48990

HBIPS-6_18-64_%_of_Total

22.51

80.02

73.23

HBIPS-6_18-64_Num

43

204220

HBIPS-6_18-64_Den

278872

HBIPS-6_65_Over_%_of_Total

35.90

78.91

64.23

HBIPS-6_65_Over_Num

28

58562

HBIPS-6_65_Over_Den

78

91176

HBIPS-7_Measure_Description

"Post-discharge continuing care plan transmitted to the next level of care provider upon discharge" (Medicare Gov, 2014)

"Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge" (Medicare Gov, 2014)

"Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge" (Medicare Gov, 2014)

HBIPS-7_Overall_%_of_Total

0.00

73.98

62.74

HBIPS-7_Overall_Num

0

277244

HBIPS-7_Overall_Den

441868

HBIPS-7_13-17_Den

88

36269

HBIPS-7_18-64_%_of_Total

0.00

71.98

61.78

HBIPS-7_18-64_Num

0

2.918

172210

HBIPS-7_18-64_Den

278725

HBIPS-7_65_Over_%_of_Total

0.00

73.77

56.18

HBIPS-7_65_Over_Num

0

51205

HBIPS-7_65_Over_Den