John Michael Weir – BBA, CHESP, REH

Wondering when your HCAHPS scores will be on the public reporting site? Here is the list for HCAHPS Public Reporting April 2011 through April 2012.

Presented here are the calendar quarters of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey results that will be publicly reported on Hospital Compare (www.hospitalcompare.hhs.gov) from April 2011 through April 2012.

Please note: The dates of preview and public reporting are estimates based on current timetables and thus are subject to change.

APRIL 2011 HCAHPS Public Reporting
QUARTERS INCLUDED: 3Q09, 4Q09, 1Q10, 2Q10
DATE RANGE: 7/1/2009 to 6/30/2010
DATE OF PREVIEW: January 2011
DATE OF PUBLIC REPORTING: April 2011

JULY 2011 HCAHPS Public Reporting
QUARTERS INCLUDED: 4Q09, 1Q10, 2Q10, 3Q10
DATE RANGE: 10/1/2009 to 9/30/2010
DATE OF PREVIEW: April 2011
DATE OF PUBLIC REPORTING: July 2011

OCTOBER 2011 HCAHPS Public Reporting
QUARTERS INCLUDED: 1Q10, 2Q10, 3Q10, 4Q10
DATE RANGE: 1/1/2010 to 12/31/2010
DATE OF PREVIEW: July 2011
DATE OF PUBLIC REPORTING: October 2011

JANUARY 2012 HCAHPS Public Reporting
QUARTERS INCLUDED: 2Q10, 3Q10, 4Q10, 1Q11
DATE RANGE: 4/1/2010 to 3/31/2011
DATE OF PREVIEW: October 2011
DATE OF PUBLIC REPORTING: January 2012

APRIL 2012 HCAHPS Public Reporting
QUARTERS INCLUDED: 3Q10, 4Q10, 1Q11, 2Q11
DATE RANGE: 7/1/2010 to 6/30/2011
DATE OF PREVIEW: January2012
DATE OF PUBLIC REPORTING: April 2012

At our hospital we are in year three of a Service Excellence Initiative. Partnering with Custom Learning Systems we have been been teaching all our staff hard and soft skills to improve customer service through service excellence. Being on the Service Excellence council has given me many opportunities to directly and indirectly influence the process and see first hand the cause and effect results of the program.

Here on my website I try to focus on Environmental Services related topics and the all important “room and restroom always clean” question.

Here are some initial steps for improving your HCAHPS scores:

Train and implement patient visits and staff rounding, utilizing HCAHPS scripting

Have regular, (daily or weekly) 15 minute stand up huddle with each shift to share HCAHPS scores, patient satisfaction and tips to continuously improve the patients experience

Create a regular report to share with your staff and direct reports recapping your scores, efforts and results

Pick one thing to focus on each month to increase your performance. Preferably something you can tie back into your HCAHPS questions.

On April 29, 2011 The Centers for Medicare & Medicaid Services today issued a final rule (42 CFR Parts 422 and 480) that sets forth its policies for the hospital value-based purchasing program. Under the Patient Protection and Affordable Care Act, the VBP program will pay hospitals based on their actual performance on quality measures, rather than just the reporting of those measures, beginning in fiscal year 2013. In the first year, the VBP program will include 12 clinical quality measures as well as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experiences with care survey.

The clinical measures will account for 70% of a hospital’s VBP score and the HCAHPS survey for 30%. For FY 2014, CMS will add the heart attack, heart failure and pneumonia mortality measures to the VBP program, as well as eight measures of hospital-acquired conditions and two composite patient safety and inpatient quality indicators developed by the Agency for Healthcare Research and Quality. The VBP program will apply to all acute-care prospective payment system hospitals with certain exceptions. For example, for the clinical process measures, CMS will exclude from hospitals’ scores any measures for which they report fewer than 10 cases and will exclude from the VBP program any hospitals for which fewer than four of the 12 proposed clinical process measures apply. CMS will also exclude from the VBP program any hospital that reports fewer than 100 HCAHPS surveys during the performance period.

For the FY 2013 incentive payments, CMS proposes that it will use data associated with hospital discharges from the third and fourth quarters of 2011 and the first quarter of FY 2012, as the “performance period” for the proposed clinical process of care and HCAHPS measures. So starting July 1, 2011 and running to March 31, 2012, our scores for “Room and restroom always clean” will be very, very important. All your hard work improving your scores will now be validated.

A hospital’s performance on each measure during the performance period will be compared with a “baseline period” from July 1, 2009 to March 31, 2010. Whether the hospital receives a value-based incentive payment, and the amount of such payment, will be based on either how well the hospital performs on the specified quality measures during the performance period or how much the hospital’s performance improves on the quality measures from its performance during the baseline period. The higher a hospital’s achievement or improvement during the performance period, the higher the hospital’s value-based incentive payment.

Do you know what your HCAHPS scores were July 1, 2009 to March 31, 2010? If you have been tracking and working on your performance good for you. If not, well, I’m sure you will be now. You should already have a spreadsheet setup for doing your own comparison and tracking.

In upcoming posts I will be writing about steps you can take to improve your scores and staff performance. Go HCAHPS!

What is Clostridium difficile?

Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). It accounts for 15-25% of all episodes of AAD.

Clostridium difficile is a bacterium that may develop due to the prolonged use of antibiotics during healthcare treatment. Clostridium difficile infections cause diarrhea and more serious intestinal conditions such as colitis. The CDC provides guidelines and tools to the healthcare community to help end clostridium difficile infections and resources to help the public understand these infections and take measures to safeguard their own health when possible.

C. difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulating when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur. The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients. However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients’ bathrooms (e.g., light switches) have been implicated as sources of infection.

How is Clostridium difficile transmitted?

Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.

Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. Standard isolation techniques intended to minimize enteric contamination of patients, health-care–workers’ hands, patient-care items, and environmental surfaces have been published. Hand washing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another.

What can I use to clean and disinfect surfaces and devices to help control Clostridium difficile?

Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC’s "Guidelines for Environmental Infection Control in Health-Care Facilities." [PDF 1.4 MB] Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with a sporicidal claim have been used with success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of Clostridium difficile. It is important to distinguish the need for a disinfectant with a sporicidal claim. Currently only specific bleach containing products have this registration. Bleach harms surfaces and is hazardous to the user. Normally, HAI’s can often be controlled with good cleaning practices and a non bleach disinfectant.

The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate. I recommend using microfiber towels and an accelerated hydrogen peroxide based disinfectant. There are now a few products with a C.difficile claim. One I have tried is Dispatch wipes. I found the odor to be acceptable for most of my staff but the film left after using is a significant and required a second cleaning to remove it for an acceptable appearance.

According to John L. Mason these are some of the qualities that make a
good leader.

. Leaders are always full of praise.

· Leaders learn to say "thank you" and "please" on the way to
the top.

· Leaders are always growing.

· Leaders are possessed with dreams.

· Leaders launch forth before success is certain.

· Leaders are not afraid of confrontation.

· Leaders talk about their own mistakes before they talk about someone
else’s.

· Leaders are people of honesty and integrity.

· Leaders have a good name.

· Leaders make others better.

· Leaders are quick to praise and encourage the smallest amount of
improvement.

· Leaders are genuinely interested in others.

· Leaders take others up with them.

· Leaders look for praise someone doing something right.

· Leaders respond to their failures before others have revealed them.

· Leaders never allow murmuring from themselves or others.

· Leaders hold others accountable.

· Leaders do what is right rather than what is popular.

· Leaders are servant.

"BUT" is a word that usually signals negative speech. For example, "Jason is a nice guy, BUT he can’t get his work done." or "Robin is a good cook BUT I can’t stand her taste in clothing." When we speak negatively about another person we try to excuse ourselves by asserting the truth of the negative fact we have expressed. After all, how can we be blamed for noticing such an obvious flaw in another person?

On the other hand, when the subject is ourselves, the word BUT is used as an excuse for our error in judgment or a flaw in our performance. "I would have taken care of it BUT I ran out of time…" or Yes I did that BUT it was because…"

A "complainer" is a person who sees the negative aspects in everyone and everything around them. This type of person cannot accept the good in his or her surroundings without the need to complain about what is not to their satisfaction. The type of person would be happy BUT…

A happy person will explain rather than complain. Looking for the good in others and for the best in every situation, this person says BUT when justifying the negatives in another. "She would be a better dresser if she came from a better home" or He would be a better student if he had the proper tutoring."

Make yourself and others around you happy. Train yourself to spend time explaining rather than complaining. Look for the good in others and talk about that. You can do it if you really try BUT maybe you have not tried yet.

We have our staff
We love them so
They scrub and clean
To make things glow

With smiles and cheer
They take each task
With hope their cleaning
Is going to last

They move the chairs
And gurneys to
Driving out dust bunnies
With determination and care

So to each one we do
Say with appreciation and pride
For everything you clean
We really thank you

We interrupt our regular update for this short video… Alternate title could be another day in the ER

Want to start making more progress toward your goals or business targets?  If you do, here is a simple process, which is guaranteed to work for you so long as you use it.  It’s based on a weekly, 3 step process of; reviewing, learning and taking action.  Although the focus is on weekly progress, by making each week an improvement on the previous week, you also make each month and year better too.

Here is how it works:

1. Do a review of last week

Start off by doing a review of last week.  Here are a few questions to ask yourself:

• Who did I connect with?
• What measurable progress did I make?
• What went less well for me?
• What ate into my time, with little return?
• Where did my best results come from?

Write your answers down and get them ready for the next step.

2. What did I learn from last week?

Reviewing your answers from the previous step, what lessons are there?

The way you invest your time, is directly linked to your success or otherwise.  This is why it’s important for you to identify the activities that sucked your time up, without providing you with some kind of measurable progress.  Equally, you need to determine what activities were most profitable for you.

Write down as many lessons from last week as you can.  Look for the gold dust and also the dross.

3. What will I do to make this week better?

If a commercial activity was not working for you last week, you need to either fix it or remove it from your work-flow.  Many small business owners repeat things that don’t work, purely because they are comfortable with them.  They hope that their results will “just get better”, yet as Einstein assured us:

Insanity is doing the same thing over and over, and expecting different results!

The week ahead can either be a chance for you to get a week better or a chance for you to relive the same frustrations again.  The reason most people simply get a year older each year, rather than a year better each year, is that they allow themselves to get into an unproductive rut.  They work hard, but mistake movement, for progress.

This final step is what separates the winners from the masses of frustrated business owners who make little if any progress.  Great intentions are not enough.  The world is full of people with great intentions, yet very few people action those great intentions.  You need to be smarter than that, if you want to make real, measurable progress.

Identify the changes you need to make and then motivate yourself to take the action required.  This is the cornerstone of all progress and the end to a life of frustration.

You’ve heard the saying….

“It’s not the size of the dog in the fight, it’s the size of the fight
in the dog.” – Mark Twain.

That Mark Twain saying, may seem kind of cliché… but think of it that
you are hearing it for the first time; It’s pretty powerful.

The quality of ‘fierceness’ (the fight) is really not what comes to my
mind when I hear that saying — For me it’s the ‘burning desire’ and
‘persistence’ of the small dog that impress me the most.

I hear regularly that we have our staff reduced, budgets cut and
additional space added…

…yes many are having tough times now. Things are not working out as
they planned, and some don’t feel they can achieve success.

People throw the word ‘success’ around as if it defines a certain
level of achievement. A certain HCAHPS score, Press Ganey rating, NRC
Picker Score.
Success can be small improvements and victories that you already make everyday.

For example…

If you are updating routines, writing down your your target results
and desired outcomes is your first step. A small but important step.

As you sit down to craft that new routine, you feel excited about the
possibilities of success.

You gather the excitement of this simple activity and you begin to
feel more positive.

When you finish updating your job routines and assignments, you feel
elated enough — one more task completed — but don’t feel successful…

…Why? Most often, success to us is that 99%tile, perfect score, no
complaints and other stuff.

But, if we think about success in ‘small increments’, more like little
victories — it’s less overwhelming, and it’s more fun that way.

Consider every small improvement that you make in your work a huge
victory. Do more of these small improvements and be persistent.

Persistence is key to feeling successful.

There are many qualities that help us in our work, but if I were to
pick one personal quality that stands out, it would have to be
‘Persistence’.

To your Persistent Success,

John

Far too many people spend more time planning their weekends than their lives. Then they suddenly realize that life has passed them by and they weren’t even aware it was happening. When you intently study what you most desire in life, you begin to focus your mind and concentrate your energy upon that which you wish to achieve. One of the great advantages of having a definite goal for your life is that it helps you prioritize your activities. When your major purpose is clear in your mind, it is unnecessary to analyze each individual situation. You know automatically whether your actions will move you toward your goal or away from it. You can then use all of your resources-time, money, and energy-to best advantage.

Having diverse strengths has always been a bonus, but in the past, you may have been able to get by with a fixed set of abilities or specialties more so than we can today. Those around you that you see as successful are employing everything from shrewd business acumen to honed writing skills and the soft, subtle world of human sociology and psychology to make their way in the world.

They’ve sharpened their instincts to know which skills are needed and when. In many ways it’s the age of the generalist rather than the specialist, and I think it can be explained pretty well by the traditional serenity prayer:

God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

Accepting the things you can’t change…

There are things – many things – that simply are what they are. We aren’t in control of the players, circumstances, or nature of these things, nor are we likely to be. So instead, the adaptable learn to maneuver within, around, or in spite of them, and continue along their own course.

It’s the ancient idea of being water around obstacles, or in this case, circumstances over which we have no control. Those that continually succeed largely do so because they’re able to identify the things that aren’t within their control and figure out how to incorporate or avoid them.

Changing the things you can…

Focusing your energy in the places where you can make a difference. Applying your knowledge, skills, or curiosity to those situations is always going to net you something more than pounding away at an immovable object.

Adaptability means that you not only aim to affect change, but that you’re patient enough to select the right tools, pace, and approach for the job.

Knowing the difference…

There is so much turmoil in humans that often we can’t tell a solvable problem from a fixed one.

We fight against immutable laws of human dynamics, instead of spending energy on forging relationships that matter to us. We judge other people for their perceived shortcomings rather than focusing on honing our own skills and exploring our own values.

This is a hard thing for us to accept sometimes. I’m guilty of it, too. But the more I observe, the more I think that those who are nimble, adaptable, and capable of improvising from a broad toolbox are the ones that will continue to thrive. Evolution keeps proving it over and over again.

Next time you’re frustrated or up against an obstacle, ask yourself whether or not you can change it, and if not, what you can do to work around it. You might just find yourself capable of solving more problems and making more progress than you might have imagined.

John

Not everyone wants to be a leader, but I think it is safe to say
everyone wants a leader. And not just any leader, but someone who
inspires, who creates, who energizes. What if you want to be a leader,
and you don’t know how. No problem, just hang around a leader you want
to be like.

By surrounding ourselves with leaders and through a process called
modeling, their leadership has a way of rubbing off on us.

Step one in developing as leaders is to realize your true potential to
lead and inspire others to take action. For some this can be tough due
to self-esteem and deserve issues. So get over it. One of the best
ways I know to combat this is to repeat to your self, “I am the leader
that people are looking for.” Say it over and over again. Write it on
post-it notes and stick them on your bathroom mirror if you have to.
Say or sing it in the shower and as you go through your daily
activities. This is guaranteed to get people looking at you if nothing
else.

Many people rob themselves of the opportunity to become leaders
because they are constantly dwelling on past events. The past is
history and only has the relevance we give it!! So forget about it.
Drop the drama and the self-esteem issues that hold you back and
realize that it serves NO ONE especially your self. Do this and you
will inspire others to take bigger actions by your example. See, you
are already a leader.

Leadership really is the greatest commodity on the planet and REAL
leadership is needed in the world now more than ever. It is extremely
marketable and there will always be a market for it. Companies and
people all over are desperate for real leaders.The one person who can
guide them silently through life.

Life really is one big game of follow the leader. The more you can be
the leader the more successful your life will be. Just remember one
thing, you must learn to follow before you can lead. True leaders are
humble. They lead not for recognition but because they are leaders and
that’s what leaders do!! They give generously. They lead by giving and
offering themselves where they are needed. They are the type of person
others flock to.

So there you go, just follow my directions and see what happens. If
you don’t see results right away, then go here and make this. It will
change your outlook…
http://www.cookingchanneltv.com/recipes/key-lime-habanero-cheesecake-recipe/i…

John

If you look around you will find there are three kinds of people, or
better put, three ways to look at “failure”. If you know me, then you
know I don’t like the word failure in the first place. I think people
need to be in the mindset that failure is just another word for try
again. What I recently learned is “try again” does nothing if you
don’t change your strategy. More on that in a moment.

The first way to look at failure is to say “I failed because I’m not
good enough” or “I failed because it was too difficult”. Then start
making excuses, blame anyone but yourself, complain and give up. These
people say it did not work, so lets forget about it. Then they go on
to something else. This makes me wonder why they try anything in the
first place. Reminds me of the guy I mentioned in a previous post
who never wants to try anything new. You can’t fail if you don’t try to do anything.

The second way to look at failure is to say you need to try harder. In
this group, you don’t think you fail because you are not good enough,
it is because you did not try hard enough. They try harder next time,
still don’t get results, so the try even harder the next time. They
try again and still don’t get the results they want, so what do they
do? You guessed it. Now eventually, if they target small goals, they
will hit them. However if they set high goals, it is rare that they
will reach those goals. They will improve by taking so much action but
they won’t hit the goals they really want. They never live the kind of
life they want. The reason is they keep on taking action but they
don’t change their strategy. In other words, if you keep on doing the
things you are doing today, you will reap the same results. After a
while, these people get really frustrated. I have seen many sales
people and network marketers fall into this category, and you will see
people in every business in this category. They work harder, see more
people, but more or less they stay in their comfort zone of doing the
same things the same old way. After a while they say “I’ve tried so
hard, I’ve tried everything” and they get cynical. They look at people
who have experienced success and think they are just lucky people.

So what is the answer? The third group of people respond to failure
very differently. In fact, they don’t even see failure as failure.
They say, “I did not fail. I just got feedback that I used the wrong
strategy.” By looking at not reaching their goals as just a sign to
change direction, to try something new, to change their strategy they
do not feel bad. They do not get demoralized, rejected, or depressed.
They still feel empowered, they still feel motivated. Without
realizing it, they use what is called reflective intelligence. They
are able to notice what went wrong with the strategy and they have the
ability to change their behavior and do whatever it takes to take
action again and again until they get the result they want.

So I hope you can take these examples of three ways to look at
“failure”, and make an effort to change your thinking. Decide that if
at first you don’t succeed, change your strategy and try again. Don’t
be defeated, don’t think you are not lucky, and by all means, don’t
just simply try again using the same methods that did not work in the
first place.

I have been studying behavioral based development strategies used by
individuals who are seeking to establish their legacy and bring their
life and leadership responsibilities into full harmony. Doing so, I
have found it easy to mirror those same strategies in my life. I often
wonder why so many people don’t do this, and remain stagnant, happy to
live mediocre lives, never making a difference in themselves or
others. Is this really going to make someone happy in life?

I remember a man telling me he was happy, his simple life, simple job,
did not want to make any more money, did not want to change anything.
I prompted him with questions like what if you need a new car? Answer:
I like my car, don’t need anything else. What if you want to go
somewhere, like during your next vacation time off? Answer: I don’t
want to go anywhere. I like this town just fine. After a short
conversation along these lines I gave up also. It was painfully
obvious to me that he gave up a long time ago and had no goals or
desires he would admit. That conversation was about three years ago,
and he has not gone back to school, or changed anything about his
life. Practically everything around him has changed, and he is one
decision away from unemployment, with no skills to support him.

It is clear to me, that while I want to grow, learn, stretch beyond my
current abilities, and help anyone I can along the way, not everyone
wants to. I find that sad, but certainly OK with me. If you think the
world will continue to cater to you, while you give nothing in return;
good luck with that. I can’t help anyone who does not want to help
themselves.

If you want to learn new and exciting things in 2011, then I certainly
am interested in helping you. So I will be changing the direction of
my writing to focus on methods and principles to improve your personal
and business success. Of course I will still write about cleaning, but
I will be writing more about cleaning up your life then cleaning up
your facility.

2010 was a great year. I helped several people grow and move up in
their careers. I watched many more improve greatly beyond their
beliefs that they could, and have taken a lot of notes. While I have
been absent online, I have gathered a wealth of material, I’ve been
testing it, and I’ve seen tremendous results. I am going to be sharing
all this with you here. You will learn how attitudes can be changed,
how to start and grow your own business, how you can turbo boost your
productivity at your current job, and how you can have anything you
want, if you are willing to help others along the way.

So starting today, I want you to tell yourself “I Am A Success!” ask
yourself, “What is My Next Move?” Then begin planning it. Don’t be
afraid, don’t hesitate, don’t put it off until tomorrow. Start today.

Tomorrow we begin to look at three ways people look at failure. Since
the more action we take, the more “failures” we have, looking at this
the right way will remove a stumbling block.