Building a Quality Report Card Angie Charlet ICAHN acharlet@icahn.org
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
Why Are We Talking About Report Cards? National Standards Benchmarking Most of all.consumers are watching!
Quick Review
Driving Quality Metrics that Produce Results Think STEEEP IOM Six Domains of Health Care Quality
Safe Avoiding harm to patients from the care that is intended to help them
Timely Reducing waits and sometimes harmful delays for both those who receive and those who give care
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)
Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy
Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
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.
Three Types of Measures Structure Process Outcome
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
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
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
Enough About Definitions What makes a good quality metric A good measure drives change
Ongoing Climb: Always be asking, How can we do things better?
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?
Where to Start? Problematic Area(s) Community needs Primary population Primary disease(s) Staff engagement Meaningful Baseline data
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
If someone came in and asked you what you do or have done for quality improvement.could you answer them?
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
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?
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
Data Collection Tool Making Excel a Friend
Graph Selection
Types of Graphs Area Column Bar Line Pie
Common Elements of Graphs Colors Depth Axes Labels Title Legend
Benefits and Pitfalls Benefits Visually communicate results Analyze information from multiple periods, entities, sequences, etc. Patterns Pitfalls Data overload No conclusion Spreadsheets
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
Deceptive view
IDEA PDCA Tool IDEA Improvement Opportunity Data Collection Methodology Explain Findings Action Steps PDCA/PDSA Plan Do Check/Sustain Act
Presenting the Data: In Dept.
Second half
Let s Break it Down
Where does the data go?
Data Points
The Reporting
Summary
PERFORMANCE IMPROVEMENT Dashboard Reporting
Dashboards Simple Visual Relevant
Benefits of Dashboards Organize Summarize Focus Present Quick Easy to understand Interactive
Keep it Simple
Reporting to Board/Committees: The Dashboard
Metrics and Data Build Your Dashboard
Metrics Build Your Dashboard
Core Measure 2nd Qtr. SCIP Results Top 10 % Cottage Sample Size National* Goal 2nd Qtr. 2010 3rd Qtr. 2010 4th Qtr. 2010 1st Qtr. 2011 2nd Qtr. 2011 n / d SCIP SCIP # of patients 73 74 66 62 65 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% 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%
Board Report Example
Our Data Collection Tool Summary Dashboard
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.
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
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