Building a Quality Report Card. Angie Charlet ICAHN

Transcription

1 Building a Quality Report Card Angie Charlet ICAHN acharlet@icahn.org

2 Objectives Learn to define what a measurable quality metric entails Discover how to create meaningful dashboards that drive change Learn how to use Excel as your data collection friend

3 Why Are We Talking About Report Cards? National Standards Benchmarking Most of all.consumers are watching!

4 Quick Review

5 Driving Quality Metrics that Produce Results Think STEEEP IOM Six Domains of Health Care Quality

6 Safe Avoiding harm to patients from the care that is intended to help them

7 Timely Reducing waits and sometimes harmful delays for both those who receive and those who give care

8 Effective Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse)

9 Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy

10 Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status

11 Patient-centered Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuing that patient values guide all clinical decisions.

12 Three Types of Measures Structure Process Outcome

13 Structure Measure Evaluate the infrastructure of health care setting and ability to deliver care (clinics organization and resources) Staffing Staff skill and capabilities Policy & Procedures Availability of resources

14 Process Measure Used to determine the extent to which providers consistently give patients specific services that are evidence-based Think: did the patient receive the recommended care or not? Focused on areas of prevention and chronic disease management

15 Outcome Measures Evaluate patients health as a result of the care they have received. Looks at effects the care has had on their health, health status, and function. Can be more challenging to gather the data and hard to hold patients accountable to the recommended treatment

16 Enough About Definitions What makes a good quality metric A good measure drives change

17 Ongoing Climb: Always be asking, How can we do things better?

18 Making a Measure Work for You Is it meaningful? Does it make sense? Is it measurable? Do you have staff buy-in? What is the area of impact? Process? Outcome?

19 Where to Start? Problematic Area(s) Community needs Primary population Primary disease(s) Staff engagement Meaningful Baseline data

20 From Managers/Staff No time Not meaningful Cannot fix it Staff won t collect Late data No analysis No plan of action Staff cannot speak to the improvement

21 If someone came in and asked you what you do or have done for quality improvement.could you answer them?

22 First Impressions Ease of appointment scheduling? Same day appointments Same day nurse phone calls Wait times in waiting rooms/exam rooms First time patient experience

23 Rooming Complete questions Fall screening? Depression screening? Prevention screenings? Chart inclusive and ready for provider? Full medication reconciliation review? Any labs that should be on the chart? Referral/consult reports?

24 Physician Support Involve providers in the process of defining and selecting quality metrics Selecting metrics on the basis of medical evidence that proves a positive correlation with quality outcomes Holding providers accountable for quality measures that are reasonably within their control Streamlining the collection of data so as not to detract from the quality of the patient experience

25 Data Collection Tool Making Excel a Friend

26 Graph Selection

27 Types of Graphs Area Column Bar Line Pie

28 Common Elements of Graphs Colors Depth Axes Labels Title Legend

29 Benefits and Pitfalls Benefits Visually communicate results Analyze information from multiple periods, entities, sequences, etc. Patterns Pitfalls Data overload No conclusion Spreadsheets

30 Deceptive Graphs Emphasize or de-emphasize changes by affecting the axis Use different scales or starting points Use percentages to show growth Avoid trend lines Avoid displaying actual values Delivery

31 Deceptive view

32 IDEA PDCA Tool IDEA Improvement Opportunity Data Collection Methodology Explain Findings Action Steps PDCA/PDSA Plan Do Check/Sustain Act

33 Presenting the Data: In Dept.

34 Second half

35 Let s Break it Down

36 Where does the data go?

37 Data Points

38 The Reporting

39 Summary

40 PERFORMANCE IMPROVEMENT Dashboard Reporting

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42 Dashboards Simple Visual Relevant

43 Benefits of Dashboards Organize Summarize Focus Present Quick Easy to understand Interactive

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45 Keep it Simple

46 Reporting to Board/Committees: The Dashboard

47 Metrics and Data Build Your Dashboard

48 Metrics Build Your Dashboard

49 Core Measure 2nd Qtr. SCIP Results Top 10 % Cottage Sample Size National* Goal 2nd Qtr rd Qtr th Qtr st Qtr nd Qtr n / d SCIP SCIP # of patients Beta blocker in periop period if applicable 100.0% 100.0% 95.0% 93.0% 100.0% 100.0% 100.0% 27/27 Prophylactic Antibiotics within 1 hour prior 100.0% 100.0% 98.0% 100.0% 100.0% 100.0% 100.0% 43/43 Prophylactic Antibiotics Discontinued within 24 hours 100.0% 100.0% 98.0% 98.0% 97.0% 97.0% 98.0% 42/43 Appropriate Antibiotic selection for surgical pt % 100.0% 98.0% 100.0% 100.0% 100.0% 100.0% 43/43 Appropriate Hair Removal 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 65/65 Perioperative Temp. Management (this measure expanded from colon cases to all cases 4thQ2009) not available 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% 64/65 Urinary cath removed post op day 1 or 2 not available 100.0% 98.0% 98.0% 94.0% 100.0% 100.0% 40/40 Recommended VTE prophylaxis ordered 100.0% 100.0% 97.0% 96.0% 89.0% 97.0% 98.0% 57/58 Received appropriate VTE prophylaxis within 24 hours pre or post op 100.0% 100.0% 97.0% 100.0% 84.0% 97.0% 93.0% 54/58 AGGREGATE SCORE **(based on indicators used for CHS rankings)** GOAL: 100% 98.21% 98.63% 98.09% 99.07% 98.31% 699/711 Facility goals increased to 100% with 1st Qtr 2011 Green equals measures at 100% Red equals measures below 100%

50 Board Report Example

51 Our Data Collection Tool Summary Dashboard

52 Set Up What-If s in Excel To change red, yellow, green: Highlight the entire summary graph and then click on Conditional Formatting >Highlight Cell Rules.

53 Greater Than, Less Than, or Between Options Select the Greater Than, Less Than, or Between options. You will get a menu like the one below. Enter the % that you want and select Custom Format from the second drop down. First Time Set Up Requires Three Separate Formulas

54 Another Tool For You

55 Questions