Being the Best

How PI is changing Press Ganey scores at CCHC

The culture of Process Improvement is becoming established throughout Cape Cod Healthcare and some notable progress has been made at the two hospitals. The latest success stories revolve around patient satisfaction, which is a key part of the five pillars of the CCHC Process Improvement plan: People, Service, Quality, Finance and Growth.

At Falmouth Hospital, Press Ganey patient satisfaction scores in the area of Ambulatory Surgery and Endoscopy have improved dramatically since the first of the year. In Ambulatory Surgery and Endoscopy, the scores soared from the 10th percentile in the first quarter of 2010 to the 50th percentile in the third quarter.

The Ambulatory Surgery and Endoscopy staff found ways to improve after seeing the first quarter results, said Charge Nurse Caryn White, RN.

“We were in disbelief. Our staff are all seasoned, compassionate, caring nurses who work in these departments. But once we got over the initial shock, we realized it wasn’t a care issue,” she said.

The staff came to understand that two things were needed to improve patients’ experiences; shorter arrival time and better communication and attention to patients and family needs. Surgical patients’ arrival time was decreased from two hours to 1 1⁄2 hours, and Endoscopy patients arrival time was decreased to one hour prior to the procedure, rather than two hours. Physicians bought into the changes and it has worked out well, said Endoscopy Charge Nurse Carol McAlvin, RN. Both charge nurses agreed they will continue to identify ongoing opportunities for service recovery from patients’ arrival to next day follow-up phone calls.

Pamela Kendrick, Director of Quality Improvement at FH, credited staff for stepping up throughout the hospital to find ways to improve service.

“We all recognize that our outpatient is really where our patients can make choices about where they go. Radiology, Physical Therapy, Pulmonary Therapy, etc., are all areas where people have choices,” she said. “That’s why we want to be the best.”

The latest Process Improvement initiatives at Cape Cod Hospital are in the area of Outpatient, Ambulatory Surgery and patient privacy. Press Ganey scores for Outpatient and Ambulatory Surgery are improving, and the staff and department heads are working hard to make sure the trend continues, said Cathy Bachert, Director of Quality Improvement at CCH.

Process Improvement improves quality and we remain true to the Cape Cod Healthcare motto, “World Class Care Right Here,” she said.

Staff and managers in the three target areas at CCH have been focused on several key issues.

The top areas of focus for Ambulatory Services:

  • Room comfort, cleanliness and décor
  • Patient information, i.e., letting patients know what to expect
  • Maintaining patient privacy throughout the process


Top areas of focus for Outpatient:

  • Staff sensitivity to the needs of patients
  • Response to concerns/complaints


Top themes for improvements in the area of Privacy:

  • Identifying ways to show patients and families we are concerned about their privacy
  • Using key words at key times during the interview process


A second tier to these areas of focus is to standardize how we prepare patients for their experience with us, Bachert said. Expectations for everything from where to park, where to go and what is going to happen when they get there should be clearly spelled out for patients, she said.

Both hospitals are committed to being the best hospitals in the nation, and improving process is essential to achieving that goal.

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