Data Collec*on and Measurement in Quality Improvement Tanishah Nellom, MSPH Care Improvement Specialist, CCME January 2013
Quality Improvement in Healthcare The combined and unceasing efts of everyone healthcare professionals, pa;ents and their families, researchers, payers, planners and educators to make the changes that will lead to be>er pa;ent outcomes (health), be>er system permance (care) and be>er professional development. Quality Safety in Health Care. 2007 February; 16(1): 2 3.
How Data Drives Quality Improvement DATA
How Data Drives Quality Improvement cont d Iden;fica;on of the right problem (Root Cause Analysis) Implementa;on of applicable strategies and solu;ons Demonstrates the outcome of implemented interven;ons Data collec;on monitoring con;nued improvement
The Quality Improvement Process Physician generates discharge orders Source: NSW Health 2001, The Clinician s Toolkit Improving Pa;ent Care
Iden*fying the Problem (Example) It has come to the a>en;on of your organiza;on that customers are complaining of very long wait ;mes Intake process is very detailed and can take a while Two long- ;me employees have recently re;red All staff have not completed training on the new EHR system Recently, the organiza;on beefed up its print and television adver;sements
Iden*fying the Problem (Example) cont d Any or all of these issues could be the cause of the increased wait ;me but how can your organiza;on find out sure? Root Cause Analysis is a good way to iden;fy the true causes of the issue iden;fied
Things to Consider What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?
Why Use the Root Cause Analysis Process? Reduce ;me lost and money spent on solu;ons that will not be sustainable Discover that root causes can be within your four walls, outside, or a combina;on Iden;fy pa>erns of readmissions specific to your community Use results to guide targeted criteria and interven;on selec;on
Chart Audit/Abstrac*on Chart abstrac;on is necessary measuring and evalua;ng the quality of healthcare It is not suggested that chart reviews be done all pa;ents within a par;cular popula;on The data should be able to be extrapolated to the general popula;on
Chart Audit/Abstrac*on cont d Used at the diagnosis phase to iden;fy and quan;fy quality problems to establish baseline data prior to the interven;on Used at the impact phase to establish the effect of the interven;on Used at the sustainability phase to monitor sustained improvement
Chart Audit/Abstrac*on cont d Have a defined strategy selec;ng cases and the pa;ent popula;on Establish a data dic;onary Use a valida;on process Data must be organized and entered into a database Review provides clean, accurate data which will be used sta;s;cal analysis, repor;ng and easy access to inma;on Quality assurance is key to providing outcomes data to affect change or improvement in processes h>p://www.rx>m.com/pdfs/chart+abstrac;ons- Necessary+Evil.pdf
What Can Be Improved? Everything iden;fied as an area of concern cannot be improved at the same ;me Priori;ze iden;fied areas improvement Determine poten;al interven;ons the processes that require improvement Define permance measures Implement interven;ons Monitor the progress of improvement
Care Transi*ons Interven*ons Formal Programs BOOST ("Be>er Outcomes Older adults through Safe Transi;ons") toolkit BPIP (Best Prac;ces Interven;on Package) toolkit CTI (Care Transi;ons Interven;on) INTERACT ("Interven;ons to Reduce Acute Care Transfers ) POLST ("Physician Orders Life- sustaining Treatment ) RED ("Re- engineered Discharge") TTCAB ("Transming Care at the Bedside ) TCM ("Transi;onal Care Model") Mul*ple Drivers (Standalone/Homegrown) Advance care planning Bilingual, mul;- lingual materials Case management (Care Transi;ons- specific) CHF interven;on bundle Disease- specific interven;ons Medica;on reconcilia;on Plan of care, collabora;on with pa;ent/family
Care Transi*ons Interven*ons cont d Low Pa*ent Ac*va*on Ask Me 3" tool Coaching (non- CTI) Community Living Program Discharge planning checklist (CMS "Planning Your Discharge" ) Educa;on, pa;ent/family "Keeping Pa;ents at Home Pa;ent Emergency Care Plan (not BPIP- specific) Personal health record (not CTI- specific) Lack of Standard, Known Processes Alert system Assessment tools ACMs (Appropriate Care Measures) Audit, review or tracking Communica;on re- design (internal) Document standardiza;on Follow- up appointment (primary care) made at discharge Pa;ent mapping
Care Transi*ons Interven*ons Lack of Standard, Known Processes Pharmacy, inpa;ent (medica;ons filled at discharge) Pressure ulcer interven;on program Protocols and Pathways Referrals, enhanced Reports to providers (data, feedback) Risk assessment, readmission Staffing re- design Telehealth, telemedicine Inadequate Transfers of Inma*on Care coordina;on (general, non- specific) Communica;on re- design (external; cross- sekng) Discharge process, no;fica;on HIT (health inma;on technology), data sharing and transfer Provider support (cross- sekng) Beneficiary and community outreach SBAR ("Situa;on- Background- Assessment- Recommenda;on") h>p://www.cfmc.org/integra;ngcare/files/toolkit/interven;on/interven;ons_by_driver_031011.pdf
Measurement You ve selected an interven;on NOW WHAT? Iden;fy what data is needed to measure the problem and measure improvement Determine data sources and collec;on methods Determine data analysis techniques and storage requirements
Effec*ve Care, interven;on or ac;on achieves desired outcome. Clinical indicators PART: Quality Preven&ng Criteria Avoidable Readmissions Together Measures Benchmarking against other services/departments Morbidity and mortality mee;ngs/reports Appropriate Care/interven;on/ac;on provided is relevant to the client s needs and is based on established standards. Clinical indicators, Audits against interna;onal standards/evidence based guidelines Benchmarking against other services/departments, Service u;liza;on data Safe The avoidance or reduc;on to acceptable limits of actual or poten;al harm from health care management or the environment in which health care is delivered. Efficient Achieving desired results with the most cost- effec;ve use of resources. Responsive Service provides respect all and is client orientated. It includes respect dignity, confiden;ality, par;cipa;on in choices, promptness, quality of ameni;es, access to social support networks and choice of provider. Accessible Ability of people to obtain health care at the right place and right ;me irrespec;ve of income, physical loca;on and cultural background. Con*nuous Ability to provide uninterrupted, coordinated care or service across programs, prac;;oners, organiza;ons and levels over ;me. Capable An individual s or service s capacity to provide a health service based on skills and knowledge. Sustainable System or organiza;on's capacity to provide infrastructure such as workce, facili;es and equipment, and be innova;ve and respond to emerging needs (research, monitoring). Adverse events and incidents, Sen;nel events Clinical indicators, Benchmarking against other services/departments Morbidity and mortality mee;ngs/reports, Accredita;on reports Service u;liza;on data, Expenditure data Audits of equipment/resource usage, Customer complaints Wai;ng ;mes, Failure- to- a>end rates Service u;liza;on data Customer complaints Wai;ng ;mes Failure- to- a>end rates Accredita;on reports Service u;liza;on Customer complaints Wai;ng ;mes Failure- to- a>end rates Service mapping Clinician feedback Adverse events Wai;ng ;mes Adverse events Accredita;on reports Accredita;on reports Organiza;onal score boards Integra;on with data systems Business plans/resource alloca;on
Data Collec*on What sources of internal data are currently available? adverse events, incident reports and sen;nel events infec;on rates length of pa;ent stay clinical outcomes wai;ng ;mes surgery wai;ng ;mes the emergency department customer complaints expenditure reports State and na;onal data are also useful and readily available
Data Collec*on Methods Focus groups Surveys Interviews Brain storming Checklists Data collec;on ms
Data Collec*on Forms Project BOOST Cohort data collec;on m
Data Collec*on Forms cont d
Data Collec*on Forms cont d SNF Transfer Form To: Resident s Name: Allergies: DOB: BP: P: R: TEMP: O2 SAT: % FSBS: MG/DL PRECIPITATING FACTORS: REPORT GIVEN TO:, ER REPORTED BY: DATE: TIME:
Types of Data Administra*ve Data Helps define the popula;on of focus client demographics including age, gender Service delivery data frequency dura;on of client contacts; dates and ;mes of services Wai;ng ;mes Financial data, payer inma;on Readmission data Length of stay Clinical Data Relates to health needs of the popula;on and the impact of health services Mortality and morbidity rates Risk factors Adverse events Treatment prac;ces, including drug usage data Diagnos;c tests Infec;on rates.
Is the Data Good? Good data is reliable Repeated results with repeated measurements of the same variables A poorly designed tool may be completed differently by different people (inter- observer reliability) or differently by the same person at different ;mes (intra- observer reliability) Good data is valid The data tool measures what it is supposed to measure Seek out validated instruments to conduct your QI work Good data is unbiased Bias is created when a tool over measures or under measures the true result, leading to an invalid result. Data Dic*onary Standardized set of values that are applied to the data collec;on process to increase reliability and validity and decrease bias
Interpre*ng Data Aper data is collected and analyzed conclusions must be made from the results Involve stakeholders during this phase Seek input on the meaning of the data findings at each phase of the QI project Use the data findings at each phase to make decisions on the next phase of the QI project Present the results of the QI project to community
Interpre*ng Data cont d Quality Improvement Cycle 1. What is the problem or ques;on? 2.What can you improve? 3. How can you improve? 4.Have you achieved improvement? 5. Have we sustained improvement?
Presen*ng Results Include the original objec;ves A brief descrip;on of the data collec;on strategy, explana;on of the sample popula;on, exis;ng data sources, suppor;ng literature and data collec;on tools A brief descrip;on of your analysis strategy Any tables, graphs and sta;s;cs that describe your findings
h>p://www.cfmc.org/integra;ngcare/toolkit.htm
Care Transi&ons Collabora&ve Ques*ons And Discussion
Care Transi&ons Collabora&ve Tanishah Nellom, MSPH tnellom@scqio.sdps.org This material was reviewed by The Carolinas Center Medical Excellence, under contract with the Centers Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW- SC- C8-13- 4