Patient Experience Data Self-Assessment
As a current or future health care executive leader, you are responsible for the patient’s experience in your health care organization. Whether you are overseeing a health system, hospital, clinic, or other health care organization, the patient’s experience will be one of your top three priorities (Institute for Healthcare Improvement, 2016). Understanding the data involved in measuring the patient experience is an important part of what you will be undertaking.
Interpreting patient experience data can quickly become overwhelming and confusing to anyone trying to use the data for improvement. The Patient Experience Data Self-Assessment challenges knowledge and common assumptions about what the data actually means. It can be used to expand your current knowledge on effectively using patient experience data.

Review the IHI patient experience data in the link provided.
Complete the IHI document by printing it, marking it manually, and then scanning it as a PDF document.
In a separate MS Word document, provide brief narrative justification for your responses to the six [6] questions.

Readings
Dempsey, C. (2016). The evolution of the patient experience. In The Society for Healthcare Strategy and Market Development of the American Hospital Association (Ed.), Futurescan healthcare trends and implications: 2016–2021 (pp. 6–10). Chicago, IL: Health Administration Press.

Groene, O., Arah, O.A., Klazinga, N.S., Wagner, C., Bartels, P.D., Kristensen, S., … Sunol, R. (2015). Patient experience shows little relationship with hospital quality management strategies. PLoS One, 10(7), 1-15.
Patient Experience Data Self-Assessment
1. What is a run chart?
A plot that shows patient experience values (e.g., willingness to recommend) in time order, with a median
reference line, is an example of a run chart. You can interpret the run chart with a set of rules. The rules
help you to detect patterns that may be signals that your system has improved or deteriorated.
? True
? False
? Not sure
2. The median of the HCAHPS Nursing Communications “top box” scores in the
accompanying chart…
a.
b.
c.
Is 78
Is 77
Can not be determined from the graph
82
Nursing Communications
81
Good
80
79
78
77
76
75
74
73
72
Sep-10
Oct-10
Nov-10
Dec-10
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Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
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3. Using the standard run chart rules for shift, trend, and “astronomical point,” examine
each chart for signs of improvement or degradation. The dashed line is the median
value to be used for reference. The first chart uses a median based on the first 12
months, also known as a “baseline reference” median.
A
Friendliness of nurses/ambulatory
100
95
per cent
90
85
80
75
70
65
60
Jan-10
Mar-10
May-10
Jul-10
B
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sep-11
Mar-11
May-11
Jul-11
Sep-11
Mar-11
May-11
Jul-11
Sep-11
Overall Quality of Care
80
75
per cent
70
65
60
55
50
45
40
Jan-10
100
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Did everything to help your pain
C
95
per cent
90
85
80
75
70
65
60
Jan-10
Mar-10
May-10
Jul-10
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Sep-10
Nov-10
Jan-11
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4. Interpreting a New Month’s Value
At your hospital, suppose the HCAHPS overall “top box” willingness to recommend* data shows an
average monthly performance of 80% for the past 12 months; the median monthly value is also 80%.
Now you get the latest month’s data — the value is 76%.
Circle “Yes” if the action is always justified as part of your reaction to this new month’s value of 76%.
a. Plot the 76% value on a run chart of “willingness to recommend” to see if
there is any signal over time according to the run chart rules.
Yes
No
Not
sure
b. Look at the “willingness to recommend” data in the context of the other
elements of the HCAHPS survey.
Yes
No
Not
sure
c. Re-iterate to staff the importance of continuous improvement and the
financial implications of a relatively poor score for “willingness to
recommend.”
Yes
No
Not
sure
d. Initiate an investigation to find out what changed in the most recent month
that caused the decrease as this month is below average.
Yes
No
Not
sure
e. Interpret the 76% value in terms of the number of patients surveyed.
Yes
No
Not
sure
*On average over the past 12 months, 80% of respondents have answered “Definitely yes” to the
HCAHPS question, “Would you recommend this hospital to your friends and family?”
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5. Interpreting HCAHPS Percentile Tables
Use the table below to answer the questions on the following page.
(source: http://www.hcahpsonline.org/files/January%202012%20HCAHPS%20Percentiles%20Table.pdf)
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Circle “T” for true, “F” for false, or “?” for Can’t tell from the Information provided. The questions pertain
to the hospitals described in the note marked by the red arrow.
a. If your hospital averaged 83 from April 2010 to March 2011 on the top box
Communications with Nurses composite, your hospital had a score lower
than more than 150 hospitals nationally.
T
F
?
b. If your hospital averaged 83 from April 2010 to March 2011 on the top box
Communications with Nurses composite, on average 17% of your hospital’s
patients who responded to the survey feel they did not experience “top
box” communications.
T
F
?
c. On the most recent HCAHPS monthly data report, your hospital scored 78
on the top box Recommend the Hospital. That means your hospital
outperformed more than 75% of the surveyed hospitals.
T
F
?
d. If Hospital A averaged a score of 6 points higher than Hospital B on top box
Overall Hospital Rating from April 2010 to March 2011, then in percentile
terms, Hospital A is at least 15% higher than Hospital B.
T
F
?
e. The national HCAHPS survey response rate for the period April 2010-March
2011 was 32%. This means that about 2 out of 3 patients contacted did
not complete the survey questions.
T
F
?
f. It always makes sense to compare ratings and percentiles of specific
departments or services (e.g. OB) rather than rely only on whole-hospital
summary measures.
T
F
?
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6. Correlations: Friend or Foe?
Use this table of national survey data for overall rating of inpatient experience to answer the questions
below. Circle “T” for true, “F” for false, or “?” for Can’t tell from the Information provided. The two digit
number in each row is the correlation between the overall rating and the rating of the item in the row,
e.g. the correlation between “Skill of physician” and “overall rating of inpatient experience” is 0.63.
Source: Press Ganey National database – through June 30, 2011
Questions
a.
The correlation value in each row can’t be any larger than 1 but could be
zero or even negative.
T
F
?
b.
If your aim is to improve the overall rating of in-patient experience at your
hospital, you should concentrate improvement on staff sensitivity to
inconvenience and staff actions to address emotional needs.
T
F
?
c.
If the national correlations align well with survey data at your hospital,
then reduction of noise level in and around room is not as likely to
improve your overall rating compared to staff including patients in
decisions re: treatment.
T
F
?
d.
The table implies that in terms of national summary data, room
cleanliness doesn’t really matter in terms of overall rating.
T
F
?
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