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Abbott Northwestern Hospital’s Leadership and Delivery Research Paper

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Updated: Aug 14th, 2020


Abbott Northwestern Hospital (ABH) is an acute care hospital located in Minneapolis, Minnesota. The ABH’s overall HCAHPS rate is 4/5. Its scores on the 11 HCAHPS topics are as follows:

  1. Nurse communication – 81%
  2. Doctor communication – 84%
  3. Staff responsiveness – 70%
  4. Pain control – 74%
  5. Medication communication – 67%
  6. Clean room/bathroom – 73%
  7. Quiet room – 57%
  8. Discharge information – 89%
  9. Post-discharge care/care transition – 58%
  10. Hospital rating (9 or 10) – 79%
  11. Hospital recommendation – 84%

State and National Averages

A comparison table of the ABH’s HCAHPS scores to the Minnesota and national averages on the 11 measures are shown below.

HCAHPS Topic ABH State Average National Average
Nurse communication 81% 82% 80%
Doctor communication 84% 84% 82%
Staff responsiveness 70% 75% 68%
Pain control 74% 71% 71%
Medication communication 67% 67% 65%
Clean room 73% 79% 74%
Quiet room 57% 66% 62%
Discharge information 89% 89% 87%
Care transition 58% 55% 52%
Hospital rating (9 or 10) 79% 76% 72%
Hospital recommendation 84% 76% 72%

From the table, ABH ranks above the state average in HCAHPS scores related to pain control, post-discharge care knowledge, hospital rating, and hospital recommendation. Additionally, its scores exceed the national average in all HCAHPS topics except two, namely, clean room and quiet room.

Comparison to Other Hospitals

The other acute care hospitals near Minneapolis area include the Hennepin County Medical Center 1 and the Regions Hospital; their overall HCAHPS ratings are 2/5 and 3/5, respectively. A comparison table of the two hospitals’ HCAHPS scores relative to those of ABH is shown below.



Hennepin County Medical Center 1

Regions Hospital

Nurse communication 81%



Doctor communication 84%



Staff responsiveness 70%



Pain control 74%



Medication communication 67%



Clean room 73%



Quiet room 57%



Discharge information 89%



Knowledge of post-discharge care 58%



Hospital rating (9 or 10) 79%



Hospital recommendation 84%



A comparison of the HCAHPS survey results of the three hospitals indicates that ABH is a top-performing hospital in all patient satisfaction indicators except two, i.e., clean room and quiet room. In contrast, Regions Hospital excels in these two indicators (75% and 62%) compared to Hennepin County Medical Center 1 and ABH. Hennepin County Medical Center 1 has the lowest rating and performance in the 11 indicators among the three hospitals.

Survey Response Rates

ABH has the highest survey response rate of 39% and 1018 completed surveys. Regions Hospital and Hennepin County Medical Center 1 come in second and third with 579 and 561 completed surveys, representing a response rate of 31% and 14%, respectively.

Demographics and Services Provided

ABH offers a broad spectrum of primary health care services to the adult population through its Medicine Clinic. In particular, the hospital specializes in emergency services for chronic conditions, including diabetes and hypertension (Allina Health, 2016). It offers primary care services to people in the low-income bracket and non-English speakers. It also provides orthopedic and cardiovascular services. ABH has internal medicine residents who supplement physician care at the facility (Allina Health, 2016).

Cultural Dynamics

Improving HCAHPS scores requires nurse/doctor communication that is sensitive to the patient’s demographics, including cultural background and language. According to Weech-Maldonado et al. (2013), communication measures constitute a half of the HCAHPS indicators. As the patient population becomes more diverse, cultural competency at the staff level is required for better HCAHPS scores. Weech-Maldonado et al. (2013) found that hospitals with cultural competency programs record better HCAHPS results for racial minorities in relation to “nurse communication, staff responsiveness, quiet room, and pain control” (p. 51). Thus, staff cultural competence and communication has the potential of improving HCAHPS scores due to better inpatient experience for minorities.

Educational Dynamics

Implementing education and training programs can help build staff capacity and responsiveness to patient cultural needs (O’Leary, Darling, Rauworth, & Williams, 2013). Further, staff training could help build skills that enable the workforce to attain individual HCAHPS goals. For instance, skills in best practice patient rounding could improve clinical outcomes and inpatient experience. On the other hand, ongoing education or communication with the patient could improve his or her understanding of the medical care, leading to better HCAHPS scores.

Socioeconomic Dynamics

Socioeconomic factors have been shown to influence the HCAHPS response rate. Specifically, poverty has been linked to low response rates (Tighe, Fillingim, & Hurley, 2014.). The reason for this association is that poor or low-income households have low literacy/education levels that limit their comprehension of the HCAHPS instrument. Other factors such as anxiety over depressed income flows after a prolonged inpatient stay may contribute to low HCAHPS response rate. On the other hand, discharged full-time employees may be fully engaged to find time to complete the survey, leading to low response rates.

Financial Impact

HCAHPS scores are linked to hospital reimbursement under the CMS Value Based Purchasing (VBP) program. Fenton and Bertakis (2012) estimate that HCAHPS scores account for about one-third of 1% of the total hospital reimbursements. Improved patient experience scores calls for investment in critical areas, such as staff training to facilitate a cultural change and clinical process redesign. However, the hospital managers must make a business case for the return on investment (ROI) for the training programs and improvement initiatives (Marquis & Huston, 2015). Further, some aspects of ROI, such as staff output, can be evaluated in monetary terms, i.e., cost savings.

O’Leary et al. (2013) report that surgical cancellation rates in one hospital dropped by 3.3% after introducing “an online, interactive pre-surgical patient education” (p. 317). Therefore, a focus on HCAHPS can contribute to revenue growth through fewer procedure cancellations and malpractice suits. Besides, an improvement in patient experience also contributes to low re-hospitalization rates and higher patient retention, leading to better ROI in the long-term.

Impact on Quality

The patient experience is an important indicator of quality in clinical care. It is defined as the sum of clinical processes from admission, bedside care, to post-discharge care that determine patient perception of care (Fenton & Bertakis, 2012). Thus, HCAHPS scores reflect the patients’ perception of the quality of a hospital’s inpatient care. Patient satisfaction and patient safety intersect to determine quality. Fenton and Bertakis (2012) found a correlation between hospital HCAHPS scores and patient safety (lower medical errors). Therefore, improved nursing and physician communication translates into low medical error rates or fewer sentinel events. Further, patient experience reporting is an impetus for implementing quality initiatives to improve HCAHPS survey results.

Cause of Scores

The ABH’s HCAHPS survey results could be attributed to a range of quality initiatives implemented. The nursing department utilizes multidisciplinary rounds to accelerate care delivery (Dunn, 2011). It also uses aromatherapy as an intervention, contributing to high satisfaction rates. These initiatives contribute to improved nursing communication, a critical measure of HCAHPS. Moreover, AHB’s Kenny rehabilitation institute is staffed with a skilled to offer patient-centered rehabilitation services focused on pain management, resulting in improved patient experience. AHB provides quality cardiovascular and orthopedic care through its heart institute and orthopedic institute, respectively. The breadth of AHB’s inpatient care and accumulated expertise ensures comprehensive, patient-centered care that contributes to higher HCAHPS scores.

Organizational Change

Hospitals can improve their HCAHPS survey results by introducing changes that enhance patient involvement. A key driver of patient satisfaction is provider-patient communication. ABH should utilize varied modes of communication, including verbal and written instructions, to enhance patient recall. ABH should also use interpretation services to enable non-English speakers to understand medical information. Follow-up calls to seek feedback on post-discharge experience can also increase HCAHPS scores (Dunn, 2011). The feedback should then be used to improve particular drivers of satisfaction. Other strategies may include patient education on their condition and post-discharge self-care and staff training on patient satisfaction tactics.

Structure, Process, and Outcomes

‘Structure’ consists of the professional and institutional resources of a hospital (Tonges & Ray, 2011). The structure/framework of the strategic plan includes ABH’s technology resources, physician skills, and nursing staffing ratios that impact on patient satisfaction outcomes. ‘Process’ encompasses the actions taken in the whole continuum of health care delivery in a hospital (Tonges & Ray, 2011). The elements of ‘process’ included in this strategic plan are patient-centered care, the care delivery model, and the nursing process. Outcome describes the “states that result from the care process” (Tonges & Ray, 2011, p. 377). The process outcomes of this strategic plan will include HCAHPS scores on various patient experience measures.

Improving Organizational Quality

The organizational quality improvement would involve continuous quality improvement (CQI). Creating a cross-functional CQI committee in ABH’s units would help establish shared governance structures for capacity development and a culture of safety. Besides CQI initiatives, training ABH’s staff and management on patient experience drivers would facilitate the integration of evidence-based practices (EBPs) into clinical processes to enhance efficiency. The unit-level CQI committees would integrate shared governance and EBPs into the ABH’s organizational culture.

Shared Accountability

Three methods would help ABH meet its shared accountability goals. First, evidence-based medicine, patient satisfaction surveys, and clinical quality standards would ensure that providers and personnel deliver appropriate care to avoid medical errors. Second, patient engagement in wellness and disease prevention would make care affordable for patients and payers, i.e., Medicare and Medicaid. Third, aligning financial incentives with quality initiatives would enhance efficiency, reduce costs, and raise incentive payments.

Technology Trends

The integration of healthcare technology into clinical settings would require a patient safety focus. One of the methods health IT trends can be incorporated into clinical care is through vendor collaboration to develop customized, secure, and scalable EHRs. In addition, compliance with meaningful use principles prescribed in the HITECH act would ensure the hospital adheres to the requirements at each stage. Internal policy changes and security measures would promote the adoption of health IT in ordering, medication checks, and sharing of records.

Improve Care Delivery System

Improving the care delivery system would require a patient-centric culture. Seeking patient/family feedback would help identify and promote the drivers of quality. In addition, workforce training on HCAHPS indicators would create a culture centered on patient satisfaction. Adopting evidence-based medicine and CQI concepts, e.g., lean methodology, across the continuum of health care delivery would improve care quality and patient safety. Further, patient engagement/education coupled with clinical efficiency would reduce readmission rates and hospitalization costs.

Improve Financial Stability

Financial stability would be achieved through CQI councils to bolster clinical efficiency and HCAHPS scores. Better patient experience results would increase VBP incentives and referrals to ABH. In addition, follow-up plans would reduce readmission costs that decrease revenue. Evidence-based medicine would increase clinical outcomes and minimize costs associated with lawsuits due to medical errors.

Stakeholder Roles and Responsibilities

The stakeholders of this strategic plan include patients, professional staff, the community, local health networks, the department of health, and academic partners. Their specific roles and responsibilities include:

  1. Patients – patient expectations, needs, and satisfaction influences the nature and quality of health care provided.
  2. Professional staff/workforce – physicians and nurses deliver care and implement quality/safety interventions.
  3. Community – local community members have a leadership role in the hospital’s board.
  4. Local health networks – provide oversight, participate in health system planning, and support coordinated/accountable care delivery.
  5. Department of Health – coordinates hospital funding and participates in governance matters.
  6. Academic partners – coordinate student placements and medical rotations.

E2. Stakeholder Accountability

Stakeholder accountability and engagement would be achieved through building stakeholder capacity. Providing resources and competencies would ensure effective stakeholder engagement. In addition, identifying and addressing stakeholder concerns and risks would bolster accountability and improve performance. Establishing engagement guidelines would also ensure that the hospital is accountable to its stakeholders.

E3. Training

The staff would require training in patient satisfaction methods for a greater focus on patient experience. This would create a patient-centered culture to promote HCAHPS scores. Staff training on provider-patient communication and cultural competency would improve safety and care quality, translating into an increase in HCAHPS scores.

E4. Plan Implementation

Action Time
Create an organizational culture focused on patient experience Nov 2016
Implement structure, process, and outcomes to improve HCAHPS Dec 2016
Build EBPs and shared governance structures Jan 2017
Review 1 -compare HCAHPS scores to baseline
Build organizational quality Mar 2017
Develop shared accountability goals April 2017
Review 2 -compare HCAHPS scores to Review 1 score
Health IT integration May 2017
Improvement of the care delivery system Jun 2017
Improvement of financial stability Jul 2017
Review 3 – compare HCAHPS results to review 2

F. Evaluate the Strategic Plan’s Success

Method of Measurement that would be used

The post-implementation HCAHPS scores would be compared to baseline scores. An increase in HCAHPS survey results from the baseline data would be an indication of the strategic plan’s success.

Evaluation of the timeline

The evaluation of the progression of the strategic plan would involve a Gantt chart. The tool would guide the scheduling of meetings to review the progress made on a monthly basis.

Method of analysis

The HCAHPS measures (range between 1and 9) would be analyzed using quantitative methods to determine the percentage rating of each item.

Involvement of Stakeholders

Stakeholder involvement in the evaluation process would be achieved through status reports with HCAHPS scores. In addition, seeking the feedback of patients/families, healthcare staff, and community members at the pre-intervention stage, during implementation, and at the end of the plan through surveys would enhance stakeholder involvement. The survey should focus on clinical outcomes, patient safety, and patient experience.

Communication of Results

The evaluation results will be communicated internally to nurses and doctors through staff meetings, posters, and newsletters. Communication of the results to the patients/families will occur during shift rounds and during discharge. The results will be shared externally with the community and local networks through public events, newspapers, and press releases.


Allina Health. (2016). Web.

Dunn, L. (2011). Web.

Fenton J., & Bertakis K. (2012). The cost of satisfaction: A national study of patient satisfaction, healthcare utilization, expenditures, and mortality. Archives of Internal Medicine, 172(5), 201-212.

Marquis, B., & Huston, J. (2015). Leadership roles and management functions in nursing: Theory and application. Philadelphia, PA: Lippincott Williams.

O’Leary, J., Darling, A., Rauworth, J., & Williams, V. (2013). Impact of hospitalist communication-skills training on patient-satisfaction scores. Journal of Hospital Medicine, 8, 315-320.

Tighe, J., Fillingim, B., & Hurley, W. (2014). Geospatial analysis of HCAHPS pain management experience scores in US hospitals. Pain, 155, 1016-1026.

Tonges, M., & Ray, J. (2011). Translating caring theory into practice: The Carolina care model. The Journal of Nursing Administration, 41(9), 374-381.

Weech-Maldonado, R., Ellliott, N., Pradhan, R., Schiller, C., Hall, A., & Hays, D. (2013).

Can hospital cultural competency reduce disparities in patient experiences with care? Medical Care 50(9), 48-55.

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