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Document Sample
The Monitor:
Making The Patient Satisfaction Survey
Part of Healthcare Decision-Making
Ms. Aletha Bullock, M3/5 PPM
Ms. Amy Smith, IMS Health
May 10, 2011
Outline
Background
PSS Reports to the CEB
Regions Quarterly Report Template
PSS Data Analysis
Satisfaction by Demographic Group
Mission Group Drill Down
Patients Comments
Issues Summary
Way Forward
FY10 PBB Response Rate Report
Best Practices
PSS in Enterprise Decision-Making
The Monitor System Training Guide
Questions and Answers
Backup Slides
2
Background
Navy Medicine Patient Satisfaction Survey (PSS) was
launched on 14 Mar 2007 to provide timely,
actionable data for health care decision-making
MTFs began incorporating PSS in Action Plans
during the 2009 business planning process
PSS added to the 2009 Strategic Goals process for
Patient Safety, Quality of Care, and Access to Care
Regions ownership of PSS reporting was established
by the Navy Medicine Corporate Executive Board
(CEB) in March 2010 to ensure enterprise-wide
accountability, and responsibility for achieving
Strategic Goals
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PSS Reports to the CEB
REPORT SCHEDULE BUMED REGION
Weekly Top 5 Providers by “B”
MEPRS Cost Code
Quarterly (Month 1) Peer Groups
(Jan., Apr., Jul., Oct.) Analysis
Quarterly (Month 2) Mission Groups
(Feb., May., Aug., Nov.) Drill-down
Quarterly (Month 3) Performance
(Mar., Jun., Sept., Dec.) Improvement Quarterly
Report
Annually Year-end Summary;
Private Sector
Healthcare Benchmarks;
Patients‟ Comments
Summary
4
Regions Quarterly Report
Template
Date:
Region:
Overall Response Rate:
Question(s) with Satisfaction below 80%:
Branch Clinics/MEPRS Cost Codes with Question(s) Satisfaction below 80%:
Corrective Actions Implemented: (Example: Increase FTEs, Staff training; Upgrades to
automated phone system; etc.)
Successes/Challenges Resulting From Previously Implemented Actions:
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PSS Data Analysis
Analyze data by question for Peer and Mission
Groups to determine where patient satisfaction falls
below 80%
Evaluate PSS data at the MEPRS code level; assess
demographic information to tailor corrective actions
to meet unique needs of customers
Monitor patients‟ comments for issues requiring
immediate attention
Implement region level corrective actions; report
results of those actions to the CEB on a quarterly
basis.
Share and implement best practices across Regions
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PSS Data Analysis
Go to Green
Regions corrective actions implemented to date
SOPs
Realignment of resources
Pharmacy process improvements
Staff training includes greater focus on patients‟ hot buttons
Other Benefits
Identified corrective actions needed to improve other Navy
Medicine data systems
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Satisfaction
by Demographic Group
Encounter Facility
Non-Enrolled TRICARE Prime Unknown Non-Enrolled TRICARE Prime Unknown
Age Group Female Male Female Male Female Male Age Group Female Male Female Male Female Male
0-4 100% 84% 87% 87% 86% 87% 0-4 88% 92% 88% 89% 87% 88%
5 - 14 87% 89% 89% 89% 88% 89% 5 - 14 91% 89% 90% 92% 90% 90%
18 - 24 85% 89% 85% 89% 81% 84% 18 - 24 88% 91% 90% 92% 86% 87%
25 - 34 85% 84% 84% 85% 84% 86% 25 - 34 87% 87% 86% 89% 87% 89%
35 – 44 86% 88% 86% 88% 86% 89% 35 - 44 90% 92% 90% 92% 90% 92%
45 – 64 91% 92% 91% 92% 89% 90% 45 - 64 93% 94% 94% 95% 92% 94%
65 + 94% 94% 94% 95% 93% 94% 65 + 97% 97% 96% 97% 95% 96%
Ancillary Access
Non-Enrolled TRICARE Prime Unknown Non-Enrolled TRICARE Prime Unknown
Age Group Female Male Female Male Female Male Age Group Female Male Female Male Female Male
0-4 83% 50% 67% 72% 72% 73% 0-4 91% 83% 75% 81% 77% 78%
5 - 14 77% 70% 74% 74% 77% 76% 5 - 14 81% 80% 80% 82% 81% 81%
18 - 24 78% 83% 77% 81% 76% 81% 18 - 24 80% 84% 80% 85% 74% 78%
25 - 34 76% 79% 74% 81% 77% 83% 25 - 34 77% 78% 76% 79% 77% 80%
35 - 44 81% 83% 79% 84% 81% 88% 35 - 44 81% 82% 80% 82% 81% 83%
45 – 64 87% 88% 85% 87% 87% 90% 45 - 64 87% 88% 87% 88% 86% 87%
65 + 92% 92% 90% 91% 92% 94% 65 + 92% 92% 92% 91% 90% 92%
Net Promoter
Non-Enrolled TRICARE Prime Unknown
Age Group Female Male Female Male Female Male • Based on Full Deployment
0-4 100% 100% 83% 86% 78% 79%
5 – 14 87% 84% 84% 84% 82% 83%
26 MTFs throughout Navy Medicine
18 – 24 82% 91% 85% 91% 75% 82%
25 – 34 75% 77% 72% 79% 77% 81% • Data source: “The Monitor,”
35 – 44 82% 85% 82% 84% 83% 87%
45 – 64 89% 92% 92% 94% 89% 89%
Navy Medicine Patient Satisfaction Survey 2010
65 + 96% 96% 96% 96% 95% 96%
Mission Group Drill-Down
Marine Corps Clinics
NH Camp Lejeune NH Beaufort
BMC Camp BMC Camp BMC Courthouse BMC Bldg 15 BMC French NBHC MCRD
Question
Geiger MCB Johnson MCB Bay MCB MCB Creek MCB Parris Island
Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10
Overall Satisfaction 80% 87% 79% 64% 70% 70% 82% 87% 72% 81% 82% 94%
Response Rate 1% 1% 1% 1% 3% 2% 1% 1% 2% 2% 1% 1%
Verified personal information 13% 25% 32% 40% 21% 38% 26% 29% 10% 18% 19% 31%
Provider listened 93% 100% 95% 80% 85% 88% 92% 93% 91% 94% 90% 92%
Explanation of treatment 93% 100% 82% 40% 85% 83% 96% 93% 88% 89% 88% 92%
Encounter
Explained study results 92% 75% 79% 75% 87% 60% 86% 83% 71% 67% 96% 100%
Explanation of follow up plan 86% 75% 81% 60% 69% 60% 91% 92% 81% 82% 97% 100%
Discussed medications 82% 50% 75% 50% 69% 50% 75% 78% 77% 77% 81% 83%
Management of your pain 67% 75% 81% 60% 67% 33% 71% 71% 67% 69% 91% 100%
Satisfied with care received 87% 100% 82% 60% 80% 75% 89% 86% 88% 89% 97% 100%
Case Management services 100% 100% 100% 100% 0% 0% 100% 100% 100% 100%
Phone service when scheduling 80% 50% 50% 67% 100% 100% 0% 100% 100%
Access
Ease of scheduling 100% 100% 83% 50% 80% 100% 100% 100% 60% 67% 80% 67%
Consideration of your schedule 100% 100% 80% 50% 60% 67% 100% 100% 60% 67% 100% 100%
See Provider(s) when needed 100% 100% 86% 50% 100% 100% 67% 50% 50% 67% 100% 100%
Pharmacy wait-time 100% 80% 50% 50% 0% 67% 50% 100% 100% 100% 100%
Ancillary Services
Pharmacy staff support 100% 100% 100% 75% 50% 75% 50% 83% 100% 100% 100%
Laboratory staff support 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100%
Laboratory visit 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 100%
Radiology staff support 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Radiology visit 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Coordination of services received 100% 100% 86% 50% 67% 33% 100% 100% 50% 50% 80% 67%
Facility
Needs and expectations met 100% 100% 86% 50% 67% 67% 83% 75% 67% 67% 67% 67%
Comfort of the facility 100% 100% 86% 50% 83% 67% 100% 100% 80% 67% 83% 100%
Cumulative FY10 Data Period: 16 Dec 2009 to 30 Sept 2010 9
Data Source: Monitor Questions with no 4 or 5 responses shown in GREY
Mission Group Drill-Down
Marine Corps Clinics
NH Camp Pendleton NMC San Diego
NH Twentynine
NHC Quantico BMC MCB BMC Camp Del BMC San BMC MCAS NHC Hawaii
Question Palms
CampPendleton Mar MCB Onofre MCB Miramar
Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10
Overall Satisfaction 88% 90% 77% 89% 75% 100% 78% 85% 85% 91% 83% 91% 86% 89%
Response Rate 10% 10% 4% 4% 2% 1% 3% 3% 12% 11% 8% 7% 9% 7%
Verified personal information 24% 17% 16% 27% 12% 14% 20% 24% 26% 32% 29% 34% 28% 16%
Provider listened 93% 93% 89% 89% 86% 100% 84% 85% 94% 93% 92% 96% 91% 92%
Explanation of treatment 93% 94% 91% 96% 91% 100% 91% 88% 93% 92% 92% 95% 91% 91%
Encounter
Explained study results 86% 83% 83% 86% 82% 100% 83% 81% 88% 86% 85% 88% 84% 84%
Explanation of follow up plan 90% 89% 88% 91% 84% 100% 84% 82% 90% 88% 90% 92% 86% 86%
Discussed medications 84% 82% 75% 72% 60% 100% 81% 77% 84% 83% 84% 85% 81% 82%
Management of your pain 86% 87% 85% 88% 72% 100% 86% 85% 87% 86% 83% 86% 82% 83%
Satisfied with care received 92% 93% 91% 93% 88% 100% 81% 81% 93% 92% 89% 92% 89% 90%
Case Management services 71% 100% 50% 100% 50% 83% 100% 93% 90% 87% 100% 84% 88%
Phone service when scheduling 83% 91% 50% 100% 100% 83% 100% 94% 91% 82% 83% 86% 94%
Access
Ease of scheduling 80% 88% 75% 100% 100% 100% 89% 100% 96% 97% 81% 83% 81% 93%
Consideration of your schedule 85% 95% 75% 100% 100% 100% 86% 100% 96% 95% 86% 94% 83% 94%
See Provider(s) when needed 72% 89% 75% 67% 100% 100% 100% 100% 93% 94% 82% 88% 62% 91%
Pharmacy wait-time 89% 70% 50% 100% 83% 50% 84% 84% 77% 72% 88% 86%
Ancillary Services
Pharmacy staff support 94% 93% 50% 100% 83% 50% 89% 85% 92% 93% 94% 92%
Laboratory staff support 93% 100% 100% 100% 88% 100% 96% 94% 95% 95% 96% 96%
Laboratory visit 93% 100% 100% 100% 88% 100% 98% 97% 95% 96% 94% 95%
Radiology staff support 89% 100% 100% 100% 100% 100% 98% 96% 96% 100% 92% 94%
Radiology visit 94% 100% 100% 100% 100% 100% 97% 96% 96% 100% 95% 93%
Coordination of services received 93% 97% 100% 100% 100% 100% 90% 100% 97% 97% 93% 95% 93% 93%
Facility
Needs and expectations met 90% 93% 100% 100% 100% 100% 82% 100% 96% 96% 93% 94% 95% 96%
Comfort of the facility 94% 98% 100% 100% 100% 100% 82% 100% 96% 98% 94% 95% 96% 98%
Cumulative FY10 Data Period: 16 Dec 2009 to 30 Sept 2010 10
Data Source: Monitor Questions with no 4 or 5 responses shown in GREY
Mission Group Drill-Down
Training Center Clinics
NHC Great Lakes NHC Annapolis NHC Quantico NMC San Diego
NBHC NCTC
NBHC NCTC NBHC NTC NBHC Bancroft BMC OCS NBHC The NBHC NTC
Question INPR Great
Great Lakes Great Lakes Hall Brown Field Basic School San Diego
Lakes
Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10 Sep 10 Mar 10
Overall Satisfaction 83% 91% 79% 89% 70% 80% 84% 96% 85% 96% 67% 81% 88% 92%
Response Rate 1% 1% 1% 1% 1% 1% 4% 3% 4% 5% 2% 2% 11% 10%
Verified personal information 79% 80% 26% 39% 8% 11% 17% 32% 24% 36% 11% 10% 39% 42%
Provider listened 86% 100% 85% 87% 83% 82% 95% 98% 98% 100% 85% 91% 94% 95%
Explanation of treatment 89% 100% 85% 85% 81% 79% 95% 98% 95% 100% 82% 91% 94% 95%
Encounter
Explained study results 83% 92% 80% 86% 72% 72% 89% 91% 88% 89% 78% 100% 90% 90%
Explanation of follow up plan 84% 93% 86% 90% 76% 76% 92% 96% 92% 94% 83% 89% 92% 92%
Discussed medications 86% 88% 81% 90% 63% 71% 95% 92% 79% 100% 53% 57% 87% 88%
Management of your pain 88% 92% 76% 86% 77% 76% 92% 100% 88% 94% 71% 71% 88% 87%
Satisfied with care received 87% 94% 86% 87% 78% 78% 95% 94% 95% 94% 78% 80% 94% 94%
Case Management services 69% 67% 100% 100% 100% 100% 100% 100% 75% 100% 91% 93%
Phone service when scheduling 54% 67% 100% 100% 100% 100% 95% 88% 88% 80% 94% 92%
Access
Ease of scheduling 87% 89% 92% 92% 100% 100% 96% 91% 100% 100% 93% 93%
Consideration of your schedule 80% 91% 92% 92% 100% 100% 96% 92% 100% 100% 92% 92%
See Provider(s) when needed 90% 100% 78% 88% 100% 100% 96% 91% 80% 100% 33% 89% 90%
Facility Ancillary Services
Pharmacy wait-time 88% 88% 93% 100% 100% 100% 100% 100% 100% 100% 50% 80% 78%
Pharmacy staff support 76% 90% 93% 100% 80% 100% 100% 100% 100% 100% 100% 100% 95% 95%
Laboratory staff support 79% 83% 82% 90% 100% 100% 100% 100% 100% 100% 95% 96%
Laboratory visit 74% 80% 78% 88% 100% 100% 100% 100% 100% 100% 96% 96%
Radiology staff support 77% 80% 100% 100% 100% 100% 100% 100% 100% 95% 97%
Radiology visit 80% 80% 100% 100% 100% 100% 100% 100% 100% 97% 97%
Coordination of services received 82% 92% 94% 93% 86% 100% 100% 100% 100% 100% 100% 100% 96% 94%
Needs and expectations met 88% 91% 84% 89% 88% 100% 96% 90% 88% 100% 75% 50% 96% 96%
Comfort of the facility 75% 92% 84% 89% 88% 100% 100% 100% 88% 100% 50% 100% 96% 97%
Cumulative FY10 Data Period: 16 Dec 2009 to 30 Sept 2010
Data Source: Monitor Questions with no 4 or 5 responses shown in 11
GREY
Patients’ Comments
8,000 500
6,853 441
7,000 450
400
6,000
5,209 Provider (Doctor) 350
5,000 Encounter/Appt
Facility and Staff 300
3,574 Provider (Doctor)
4,000 250
2,690 Encounter/Appt Facility and Staff
3,000 200
Access 119 114 Access
150
2,000 Appt Wait Time 85 68
100 Pharm Wait Time
1,000 50
90
0 0
FY10 Top 5 Positive Comments FY10 Top 5 Negative Comments
5,861
• Based on Full Deployment
26 MTFs throughout Navy Medicine
• Total Comments = 29,309
• Total Comments by Quarter: Total Negative
Q1 = 2,379 Total Positive
Q2 = 8,842
Q3 = 8,681
Q4 = 9,407 23,448
Issues Summary
Verifying personal information
Seeing provider when needed
Pharmacy wait time
Greater emphasis on services provided for
beneficiaries at Marine Corps and Training
Center Branch Clinics
Way Forward
Continue implementing strategies to address
drivers of patients’ concerns
Encourage maximum support and participation
of PSS
Implement strategy to incentivize commanders
support
FY10 PBB
Response Rate Report
Surveys Surveys Return Full Award Full Award PBB
Qtr
Sent Received Rate Weight Potential Award *
1 2,994 1,052 35.14% 5.6% $ 42,183 $ 41,620
NNMC 2 11,940 4,123 34.53% 5.7% $ 42,808 $ 41,926
Bethesda 3 13,723 4,812 35.07% 6.5% $ 48,612 $ 47,620
4 14,585 4,787 32.82% 6.0% $ 44,690 $ 43,902
1 2,386 400 16.76% 4.5% $ 33,617 $ 11,610
NH 2 12,858 2,129 16.56% 6.1% $ 46,099 $ 18,615
Pensacola 3 12,063 2,165 17.95% 5.7% $ 42,732 $ 18,739
4 15,442 2,614 16.93% 6.3% $ 47,316 $ 18,568
1 4,162 501 12.04% 7.8% $ 58,640 $ 183
NH Camp 2 11,896 1,487 12.50% 5.7% $ 42,650 $ 208
Pendleton 3 12,723 1,613 12.68% 6.0% $ 45,070 $ 138
4 15,794 1,961 12.42% 6.5% $ 48,394 $ 61
* Award value is sum of awards for individual branch clinics within Parent AOR
Best Practices
Addition of an appointment center
Addition of Pharmacy Check-in Window
Setting and monitoring performance metrics needing
improvement
Regional involvement with Commanders to ensure staff
training; one-on-one guidance
An automated system to announce prescription availability and
boards that list -“ready to pick-up” prescriptions
Initiate a “2-hour prescription drop-off” option via a check-in
kiosk
Prominently display PSS poster images on exam room doors
so it’s the last thing patients see on their way out
Display 8X10 images of posters at check in desks
PSS in Enterprise Decision-Making
PSS is a component of the NAVMED Patient and
Family Centered Care and Quality of Care Strategic
Goals
PSS Access metrics used to determine need for a
quality improvement Access to Care Action Plan in
MTF annual Business Plans
PSS results used to monitor Business Plan execution
in the achievement of targeted satisfaction goals
17
“The Monitor" System
Training Guide
https://navymedicinemonitor.med.navy.mil
19
https://navymedicinemonitor.med.navy.mil
Enter to access
Enter to access BUMED Dashboard &
Patient Surveys User Manager
Functions
Enter to access FAQs
Pending
completion of
Provider Survey
20
Account Roles and Access Levels
Branch MTF MTF Region Region
Roles Providers Director MTF Staff BUMED BUMED PM*
Clinic OIC CDR POC/Staff* CDR *POC/Staff
Access Clinic Clinic MTF MTF Region Region BUMED BUMED
Level Dashboard Dashboard Dashboard Dashboards Dashboard Dashboard Dashboard Dashboard
Provider Provider Clinics Clinics MTFs MTFs Region Region
Reports Reports Dashboard Dashboard Dashboards Dashboards Dashboard Dashboard
Provider Clinics Clinics MTFs MTFs
Reports Dashboard Dashboard Dashboards Dashboards
Clinics Clinic
Dashboard Dashboard
Provider
Reports
21
BUMED Login is located inside the Reports and Data module on The Monitor
Homepage. It allows users to:
1) Create accounts to gain access to special reports
2) Reset their password
3) View special reports
4) Also allows administrators to login to manage user accounts.
Click to create a
new account
Administrator‟s Login
22
After clicking the “Create Your User Name” link, the screen below allows the
user to create a username. The username has a minimum of 7 characters.
After the user enters their username, they click the „Next” button.
1. Enter your newly
created username
2. After creating
your username, click
the “Next” button
23
In the section below, the user must select a user role associated with their
assigned level of responsibility and the location of that role.
Drop Down
Menu
Select Region
Drop Down Menu for MTF in
Drop Down Clinic Menu in selected
selected Region
MTFs
Operations Manager role is for Provider ID as CHCS
individuals designated to analyze
data.
24
After the user creates a username, the user will see the profile information screen. The profile
information screen allows the user to input information that will determine their access level to the
BUMED Login (Reporting Module).
Select A Branch
of Service
Select Rank
Drop Down Menu
Input First and
Last Name Only
Office Phone Number 25
The third section of the profile information screen is called the “User UserID and Password”. In
this section, the user must create a password, enter their .mil email address and create a security
question and answer.
Enter a security question. This
The username is populated from the allows the user to reset their
“create Username Screen” password
Create a
password that
meets DoD
security standards
Enter your .mil
email address
Enter an answer to
your security question Click “Create User” button when all of
the information in the profile is
complete 26
The following screens will be seen once the user has confirmed that they would like to submit their
account request to the Administrators. The “Complete” screen will be seen first. This screen
notifies the user that their account has been successfully created. The next screen will be a
message from the Navy Medical Monitor Support Center.
1
2
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?
Question & Answer
Session
28
Back-Up Slides
FY11 PSS
Questionnaires
