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	James L. Holly, M.D.

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Letters - July 30, 2013 First Iteration of the COGNOS HCAHPS Audit

This is the format for SETMA’s HCAHPS Internal Audit. The following principles apply:

Every patient SETMA discharges from the hospital receives a follow-up call the day following. In the past 4.5 years, SETMA has discharged over 20,000 patients from the hospital. In that time the Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan (Since 2010, this has been SETMA’s name for the Discharge Summary). In that time, 98.7% of the time, this document has been completed before the patient leaves the hospital.
The HCAHPS question are now part of that call.
Added to the audit displayed below will be how many patients declined to participate in the survey and why.
Under each hospitals name, SETMA’s Providers who regularly attend at those hospitals will appear, with their HCAHPS Scores
The audit is de-indentified data; SETMA’s Care Coordination Team makes the calls and completes the HCAHPS template. The template and the process can be reviewed on our website at: http://jameslhollymd.com/epm-tools/SETMAs-Internal-HCAHPS-Survey-Tutorial
When a response is substandard, that identified information is sent to the provider so that they can personally review their performance and develop a personal plan for improvement.
Each hospital will have a vendor conducted HCAHPS Survey which is a sample of 5-8% of the patients discharged from the hospital. SETMA’s Survey includes all patients discharged from the hospital.

We think this process will enable us to improve our HCAHPS performance. We are still compelled by the time of a 2011 white paper which is The HCAPHS Imperative for Creating A Patient-Centered Experience.

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Related Reports

	SETMA’s Internal HCAHPS Audit for 2013 SETMA’s Internal HCAHPS Audit for month of August SETMA’s Internal HCAHPS Audit for the month of September

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