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Concern over being slightly below the national average on emotional support after death led to a 12-month rolling monthly analysis and a focused improvement effort. Using PDSA methodology, the PI team aligned chaplain, nurse, and volunteer bereavement contact timing, standardized sympathy card practices, and expanded supportive engagement and bereavement service offerings. Results showed increased total contacts and improved CAHPS emotional support scores, culminating in Honors Elite for a sixth year.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":11,"@type":70,"position":76},"https://docshare.wps.com/template/presentations/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/improving-cahps-bereavement-survey-scores-formal-pi-project/382658/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/improving-cahps-bereavement-survey-scores-formal-pi-project/382658.png","ImageObject",442,249,{"name":88,"@type":89},"Riley","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-24",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What CAHPS performance issue prompted the improvement work?","Question",{"text":108,"@type":109},"Heartsway was slightly below the national average on the CAHPS question about receiving the right amount of emotional support in the weeks after death.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How was the improvement timeline determined for raising scores?",{"text":113,"@type":109},"Deyta’s honors list is based on the 12 months ending each September, so Heartsway tracked a 12-month rolling average monthly and increased scores above the national average by the end of September 2020.",{"name":115,"@type":106,"acceptedAnswer":116},"What were the key measurable outcomes from the PI project?",{"text":117,"@type":109},"Total bereavement contacts increased from roughly 300 per month to about 400 per month, and Heartsway went above the national average on the emotional support CAHPS question while receiving Honors Elite designations for six consecutive years.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},382658,1791747963,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":8,"category_name":11,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},1374391975076,"https://ap-avatar.wpscdn.com/avatar/14000253ca4ec9f6853?x-image-process=image/resize,m_fixed,w_180,h_180&k=1783305029341752051","Abstract  \nHeartsway uses Deyta as our CAHPS vendor for the family surveys. Once a year they select hospices that have excellent CAHPS survey scores and publish a list of Deyta Honors hospicesand Deyta Honors Elite Hospices. To qualify for Deyta Honors Elite you must exceed that national average on  all CAHPS survey questions. We have been named to the Honors Elite five years in a row. We are the  only Deyta client to be so honored.  \nWe are quite proud of this accomplishment and were concerned when we were slightly below the national average on one question: “Did you receive the right amount of emotional support in the weeks after death”?. We look at a 12-month rolling average of our CAHPS scores monthly. Deyta bases their list on the 12 months ending each September, so we still had several months to bring our average up and adopted increasing our scores to above the national average by the end of September 2020 as a formal PI project.  \nBereavement PI Project  \nHeartsway Hospice of Northeast Texas  \nIntroduction  \nWe have several disciplines who participate in bereavement care – chaplains, nurses, and volunteers so we selected a PI team that includes these disciplines plus the Bereavement Coordinator This was our first PI Project to utilize the PDSA methodology.  \n• Chaplains make a condolence call shortly after a death and make calls or visits at 1 , 2 , 3 , 6 , and 9 , months following a death.  \n• A nurse who is familiar with the patient/family makes phone calls at 2 , 4 8 and 12 weeks following a death.  \n• Volunteer write notes of condolence and encouragement at 1 , 2 , 3 . 6 and 9 months after a death.  \n• The Bereavement Coordinator also makes the routine chaplain calls and mails out a letter after 12 months offering additional bereavement services following a death (grief groups, memorial services, etc.) and includes a bereavement survey so the bereaved can evaluate our bereavement  \nprogram  \nPlan  \na.If the person who most needs bereavement services is different from the one getting the survey, add this second person to those receiving bereavement services based on post death bereavement assessment. The Bereavement Coordinator will maintain and distribute a list of any deceased patients who has more than one bereaved and the names of each.  \nb.For nursing, bereavement calls need to be scheduled and audited. In the event there are two active bereaved for a patient, note the names and phone numbers of each in a purple sticky.  \nc.Volunteer Coordinator needs MS Teams on his phone and join all the death groups.  \nd.We need to be consistent on sending a sympathy card signed by the patient’s care team shortly after a death.  \ne.Encourage staff or volunteer attendance at viewings and/or funerals or at least post supportive and relevant words to the funeral home’s web page for the deceased. The chaplain or other staff will communicate dates and times for visitations/funerals and will communicate viewing/funeral schedules, through a Teams text sent to “All”. This is optional depending on each staff member’s desires and work/life schedules. Code this activity as a bereavement visit. We will not track individual participation . We need to make it clear to all staff that while we encourage this, it is not a requirement. However, we have heard some very positive comments if a staff member attends and some very negative comments if they do not.  \nf.We will increase volunteer involvement in bereavement. Volunteers can make bereavement calls and may visit or attend the funeral/viewing in addition to cards at their discretion .  \nPDSA (Plan, Do, Study, Act)  \nStudy Results  \n| Percent Over/Under Deyta National Average |  |\n| --- | --- |\n| 5.0\u003Cbr>4.0\u003Cbr>3.0\u003Cbr>2.0\u003Cbr>1.0\u003Cbr>0.0\u003Cbr>-1.0\u003Cbr>-2.0\u003Cbr>-3.0 | 4.0\u003Cbr>3.8 3.1 2.8 0.9 1.2 1.0 1.3 1-Jan \u003Cbr>1-Feb 1-Mar 1-Apr 1-May \u003Cbr>1-Jun 1-Jul 1-Aug 1-Sep 1-Oct\u003Cbr>\u003Cbr>1-Nov -0.6 -0.7\u003Cbr>-1.3 -1.9\u003Cbr>|\n\nConclusion  \n• Total bereavement contacts increased from the 300 per month range to the ","cbCail8tQUaNCbx4","https://ap.wps.com/l/cbCail8tQUaNCbx4","pdf",313727,"English","# Bereavement PI Project\n## Introduction\n## Plan\n## PDSA (Plan, Do, Study, Act)\n## Study Results\n## Conclusion","[{\"question\":\"What CAHPS performance issue prompted the improvement work?\",\"answer\":\"Heartsway was slightly below the national average on the CAHPS question about receiving the right amount of emotional support in the weeks after death.\"},{\"question\":\"How was the improvement timeline determined for raising scores?\",\"answer\":\"Deyta’s honors list is based on the 12 months ending each September, so Heartsway tracked a 12-month rolling average monthly and increased scores above the national average by the end of September 2020.\"},{\"question\":\"What were the key measurable outcomes from the PI project?\",\"answer\":\"Total bereavement contacts increased from roughly 300 per month to about 400 per month, and Heartsway went above the national average on the emotional support CAHPS question while receiving Honors Elite designations for six consecutive years.\"}]","Improving CAHPS Bereavement Survey Scores - formal PI project | PDF",1790251542]