Finding and Evaluating Events, Developing an Action Plan 9:55-10:15AM

Transcription

1 Session: (GS05) Statistics: Common Core Saturday, July 22, :00 AM 10:15 AM Finding and Evaluating Events, Developing an Action Plan 9:55-10:15AM Bruce L. Hall, MD, PhD, MBA Professor of Surgery, Professor of Healthcare Management, Fellow-Center for Health Policy Washington University in Saint Louis Vice President and Chief Quality Officer, BJC Healthcare, St Louis, MO

2 Disclosures I am Consulting Director for the ACS NSQIP and am an active advocate for the ACS and the NSQIP.

3 BJC Healthcare, Washington University Saint Louis, American College of Surgeons Hospital Surgeon Champion Surgical Clinical Reviewer Barnes-Jewish Hospital Bruce Hall, MD, PhD, MBA Mitzi Hirbe, RHIA, CPHQ Carmina Jackson, RN, BSN Joann Batten, BS, RHIT Liz Pratt, DNP, RN, ACNS-BC: ISCR Barnes-Jewish Saint Peters Hospital Kenneth Hacker, MD Elizabeth O Neil-Greiner, MHA, RN Barnes-Jewish West County Hospital Sam Bhayani, MD Sheena Moreland, RHIT Boone Health Center Susie Early, MD Paula Kempf, RN Christian Hospital Darren Kest, MD Janet Adams RHIA, BS Missouri Baptist Medical Center David Robson, MD Sarah McNutt, RN, BSN Stacey Braning, RN, BSN Missouri Baptist Sullivan Hospital Jarislaw Michalik, MD Julie Stowe, RN, BSN Parkland Health Center Jeff Swinarski, MD Julie Stowe, RN, BSN Progress West Hospital Colleen Glisson, MD Elizabeth O Neil-Greiner MHA, RN Saint Louis Children s Hospital Jackie Saito, MD Jeanne Cullen, RN, BA, RRT BJC Health System Kate Gase, MPH, CIC, FAPIC, Manager Marty Antal RN, BSN (Supervisor) ACS Quality and Safety Conference New York City, July 2017

4 Finding and Classifying Events Basic Action Planning

5 Finding and Classifying Events Basic Action Planning

6 To understand God s thoughts, We must study statistics, For these are the measure of his purpose. - b Florence, Tuscany

7 Finding and Classifying Events What Do You Need? SAR Definitions (matching data period) A Friend (your SCR or your SC!) Access to NSQIP Platform/ Workstation Medical Records

8 Finding and Classifying Events What Do You Need?- SAR Data Portal Resource Portal

9 Finding and Classifying Events What Do You Need? Definitions (matching data period)

10 Finding and Classifying Events What Do You Need? Definitions (matching data period)

11 Finding and Classifying Events Where to start? Institutional Imperatives Worrisome Trends over Time Government / Payer Priorities Outliers Deciles (8, 9, 10) Raw Event Rate Baseline It really doesn t matter where you start!...

12 Finding and Classifying Events SAR Grab your most recent report. Pick any model (category of population & events you want to consider) (I don't care whether you are labeled an outlier or not).

13 Finding and Classifying Events SAR Use your report to identify the actual cases that were flagged as events- Pick a model, and go to your Case Occurrences Report

14 Finding and Classifying Events Case Occurrences Report (Resource Portal)

15 Finding and Classifying Events Case Occurrences Report Select Model

16 Finding and Classifying Events Case Occurrences Report Select Model View Cases

17 Finding and Classifying Events Case Occurrences Report Select Model View Cases

18 Finding and Classifying Events Medical Record Review Go to the medical record for your cases (assign some to a friend!) Put each event case into one of THREE CATEGORIES: A. Error- should not have been coded according to the NSQIP definition. B. True case by NSQIP definition, but clinically insignificant. C. True case by definition and clinically significant.

19 Finding and Classifying Events Three Categories A. Error- should not have been coded according to NSQIP definition. Error was made in classification. Actions: Check all sources- check with SCR for guidance on data sources. SC/SCR Team Review Consider educational audit Inter Rater Reliability (IRR) Audit Educate the surgeons (if underlying documentation issues contributed) Team review and education SC / SCR. Monitor for continued errors in the near future. Inform ACS Clinical Support if you think def n / clinical guidance contributed to the error.

20 Finding and Classifying Events Three Categories B. True case by NSQIP definition, but clinically insignificant. Actions: Educate the surgeons (if documentation improvement can help) Inform ACS Clinical Support if you think specification or guidance can be improved. (Clinical Support considers context and feedback over time.) Inform surgeons this can be considered a false positive.

21 Finding and Classifying Events Three Categories C. True case by NSQIP definition, and clinically significant. Actions: Review with providers to determine whether any changes in care processes could change this outcome in the future. Evidence review, best practices review, expert discussion. This is the category everyone wants to pay attention to... ACTION PLAN, Continued Monitoring

22 Finding and Classifying Events Categories Drive Actions A. Data Coding Error B. True case, insignificant. C. True case, significant.

23 Finding and Classifying Events Basic Action Planning

24 Basic Action Planning What Do You Need? Create a Plan- One Pager / Elevator Speech Purpose or Aim- What do you plan to do? Rationale- Why this project this way? Specific Aims- Detailed, granular actions or learnings Outcomes- What will be different, How will we know? Sometimes we use an SBAR - Situation, Background, Analysis, Recommendations

25 Basic Action Planning What Do You Need? Create a Process Cycle PDSA Initial review to support your draft PLAN Detailed review Review current processes Identify gaps to best practice to attack! Root Out those gaps!- why there, what s driving? What is known about such gaps and interventions? How big is the problem? Where is the problem? Do we have lagging or leading indicators? Organizational Forces for good, and not

26 Basic Action Planning What Do You Need? Create a Process Cycle Initial review Detailed review identify gaps Include multi-disciplinary experts, Identify champion(s), Engage leadership, Build team PDSA

27 Basic Action Planning What Do You Need? Create a Process Cycle PDSA Initial review Detailed review identify gaps in care processes to attack! Include multi-disciplinary experts, Identify champion(s), Engage leadership, Build team Leadership sponsor Team leader Clinician champion Staff representatives Additional stakeholders Implementation Experts

28 Basic Action Planning What Do You Need? Create a Process Cycle PDSA Initial review Detailed review identify gaps in care processes to attack! Include multi-disciplinary experts, Identify champion(s), Engage leadership, Build team Plan intervention and measurement Charter/Scope? Start with low resource plan (if possible) Data: Leverage EMR- collect baseline data, lagging/leading? Plan for Change Management of thought and work Feasibility and Politics

29 Basic Action Planning What Do You Need? Create a Process Cycle PDSA Initial review Detailed review identify gaps in care processes to attack! Include multi-disciplinary experts, Identify champion(s), Engage leadership, Build team Plan intervention and measurement Define tasks Charter/Scope? Define Levels of responsibility and accountability Start with low Define resource Timelines plan (if and possible) Milestones Data: Leverage Plan EMR- for group collect & baseline outside data communications Plan for Change Plan Management necessary education of thought and work Feasibility and Plan Politics to Track progress and problems

30 Basic Action Planning Plan What Do You Need? Create a Process Cycle Initial review Detailed review identify gaps in care processes to attack! Include multi-disciplinary experts, Identify champion(s), Engage leadership, Build team Plan intervention and measurement 3 mos.? Charter/Scope? Start with low resource plan Leverage EMR- collect baseline data Plan for Change Management Define tasks PDSA Define Levels of responsibility and accountability Define Timelines and Milestones Plan for group & outside communications Plan necessary education Plan to Track progress and problems

31 Basic Action Planning Plan What Do You Need? Do Study Act Create a Process Cycle Initial review Detailed review identify gaps Build team Plan intervention and measurement Implement (0-3 months?) Measure Evaluate Revise Iterate Share Successes Tell Stories Share Knowledge! PDSA

32 Basic Action Planning P D S A What Do You Need? Create a Process Cycle Initial review Detailed review identify gaps Build team Plan intervention and measurement Implement Measure Evaluate (6-12 months?) Revise Iterate Share Successes Tell Stories Share Knowledge! PDSA

33 Basic Action Planning P D S A What Do You Need? Create a Process Cycle Initial review Detailed review identify gaps Build team Plan intervention and measurement Implement Measure Evaluate Revise Iterate Share Successes Tell Stories PDSA Were aims achieved? Do metrics reflect success? Were there success factors? Were there obstacles & headwinds? What do we know now? Lessons learned What should we do next? Revise, Iterate, Close? How do we communicate & Share?

34 Basic Action Planning P D S A What Do You Need? Create a Process Cycle Initial review Detailed review identify gaps Build team Plan intervention and measurement Implement Measure Evaluate Revise Iterate Share Successes Tell Stories 3 months 3 months 6 months PDSA 1 year Be better than this!

35 Finding and Evaluating Events, Developing an Action Plan Thank You! ACS Quality and Safety Conference New York City, July 2017