Intalere Member Best Practice Spotlight: Montfort Jones Memorial Hospital – Community Hospital’s Journey for HCAHPS Excellence


We continue our series featuring members and their best practices. This one features Montfort Jones Memorial Hospital and its journey for HCAHPS excellence.


Montfort Jones Memorial Hospital’s (MJMH’s) inpatient satisfaction scores were among the lowest in Mississippi as well as nationwide. These scores were measured through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores which illustrate deficiencies in nine areas that are surveyed.


After the evaluation of MJMH’s 2013 HCAHPS scores, the performance improvement team developed the following plan for addressing the deficiencies in the scores:

  1. Implement daily leadership rounding.
  2. Perform post-discharge follow-up phone calls with involvement from case management.
  3. Encourage physician involvement and elect a physician champion.
  4. Train all staff on awareness of HCAHPS scores and importance of survey questions.
  5. Report monthly to Performance Improvement (PI), medical staff and department head committees on findings.
  6. Decrease the amount of overhead paging within the facility.
  7. Display to the community the achievements/awards on improvements made at MJMH in order to improve quality of care. 


Outcome data on the success of the project was monitored by reviewing monthly HCAHPS scores and comparing them to the state and national average scores. Both “overall rating” and “would you recommend the hospital” increased top box scores greater than 20 percent. Bottom box scores in these areas were decreased more than 46 percent. Cost reduction was obtained by improving discharge process and follow up as evidenced by a 20 percent reduction in readmissions. This along with HCAHPS scores is above the value-based purchasing threshold and will prevent a reduction of DRG payments or a penalty.

About Montfort Jones Memorial Hospital                            

Montfort Jones Memorial (MJMH) is a critical access hospital located in Kosciusko, Miss., licensed for 25 beds. MJMH is supported by an eight-member medical staff and offers services including an emergency department, inpatient med-surg floor, surgery department, laboratory, radiology, respiratory and rehabilitation.

Read more Intalere member success stories, including best practices now!


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