Date of Graduation

Summer 8-13-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Problem: A hospice in the San Francisco Bay Area is being advised by The Joint Commission to increase their CAHPS scores. The monthly compliance report states communication with family as of February 2021 is 79%, getting timely help is 67%, and treating the patient with respect is at 95%. Each of these metrics has a goal to be at or above the 95% threshold. These Joint Commission findings require improvement for the next TJC audit.

Context: Priorities include identifying the root causes of low communication scores and implementing new strategies that leave patients and their families feeling that healthcare team members communicated with them effectively. A SWOT analysis was conducted to determine the strengths, weaknesses, opportunities, and threats of the implementation.

Interventions: The patient’s primary caregiver will receive a call within one month of admission. The purpose of this initial call is to assess how have they been since admission, do they know their care team, and do they have all of the supplies needed. The caller will focus on patient satisfaction, do they feel included in decisions with the care team, if they have experienced any difficulties contacting the team, and if there is anything else we can do for them at the moment. Calls will be documented on a patient survey call log and a patient note will be written stating what was discussed during the call and if any issues should be addressed.

Measures: The outcome measure is the score of communication with family with a goal of 95%. The process measures include the percentage of phone calls made to recently admitted patients (Daily Census Report) and the percentage of patients completing the CAHPS survey after discharge (Monthly Compliance Report).

Results: Post-implementation, communication CAHPS scores dropped by 1%. The current CAHPS score from July 2021 is 78%, which ranks the hospice as 22% in the nation.

Conclusions: Post-implementation, volunteers will continue calling patients and educating them about the CAHPS survey to increase survey response rates. The team remains confident that patient satisfaction phone calls will be successful in increasing CAHPS communication scores, but the implementation needs more time to take effect. Implications for practice include continuing research on how to best increase CAHPS scores. Although surveys do not fully capture the patient’s feedback, the CAHPS survey will continue being an integral benchmark for accreditation and improving the quality of care.