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Data Office Hours

Data Office Hours. Title Block. January 2014 Dolores Hagan, RN, BSN K-HEN Education/Data Manager Debbie Campbell, RN-BC, MSN CCRN K-HEN Improvement Advisor. Agenda. Review of participation levels and requirements Discuss measure specifications Examine appropriate sampling techniques

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Data Office Hours

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  1. Data Office Hours Title Block January 2014 Dolores Hagan, RN, BSN K-HEN Education/Data Manager Debbie Campbell, RN-BC, MSN CCRN K-HEN Improvement Advisor

  2. Agenda • Review of participation levels and requirements • Discuss measure specifications • Examine appropriate sampling techniques • Demonstrate data collection tool • Harm Across the Board Template

  3. Commitment Letter • Background – CMS statement of work (SOW) • Continue the 40/20 reduction of harm goal • Ten focus areas with specific areas of focus defined • Includes • Patient and family engagement (PFE) • Leadership • Healthcare disparities • Teamwork and communication • Measurement

  4. Participation Levels • CMS scoring—HEN, State and Hospital level • Participation level • Improvement level • LOP (Z – 5) • K-HEN Participation requirements defined by the CMS scoring document • Minimum level yields minimum score • Full level yields maximum score

  5. K-HEN Incentive Plan • K-HEN defined • Not all states in the HRET HEN are doing this • Structured around • the level of participation • Timeliness of data submission

  6. Data Submission Schedule

  7. Measures by Area

  8. Measures by Area

  9. Measures By Area

  10. Measure Specifications • Most measures are nationally recognized standard measures • Follow the national specifications • May sample if the specification allows for it • Non-standard measures • State-wide specifications are under development • ADE Excessive Anticoagulation example

  11. Auditing Basics Deborah R. Campbell, RN-BC, MSN, CCRN Alumna K-HEN Quality Improvement Advisor Kentucky Hospital Association

  12. Sampling • A sample is: • A few of many • Part of a whole • A good sample is something else!

  13. Obtaining a meaningful sample • Common Errors: • Too small • Not representative • Representative samples allow us to make accurate statements about our population as a whole

  14. Obtaining a meaningful sample • IDEALLY, we would gather data on every instance of the intervention or outcome we are auditing • Example: Med Rec- 100% chart review- look at every patients admission paperwork • Barriers • Very large numbers • Limited resources

  15. Obtaining a meaningful sample • To be statistically relevant as a sample, it is accepted practice to gather at least 20 points of data monthly. • If the total population you are studying or measuring is < 20/month, each and every item should be audited. • If the population is larger, sampling techniques are appropriate.

  16. How to gather a GOOD sample • Avoiding Selection Bias • For items which are consecutive, use the auditing method of “Every “n”th item”. • Using the example of Med Rec again, one could design the process to audit every 10th admission (assuming there are enough admissions per month (>200) to provide 20 total audits for the month. If there are fewer than that, one could audit every 5th admission, etc.

  17. Cont’d • Avoiding Selection bias • For measure which require counts or observations, use the scheduling of days/times per month method. • Using for example CAUTI bundle compliance, one could design the process to audit: • All patients with a CVL every Monday, Wednesday and Friday. (or Q Monday) • Things to consider: differences among days of the week relative to census, staff, types of patients. Now what???

  18. Cont’d • Rotating audit schedule- more complicated, but may give you better information • Example 1 • Weeks 1 and 3: M, W, F • Weeks 2 and 4: Saturday and Sunday • Example 2 • Weeks1 and 3: M, W, F day shift • Weeks 2 and 4: M, W, F night shift (or Sat, Sun PM) • Example 3 • Weeks 1 and 2: Med-Surg Units • Weeks 3 and 4: ICUs

  19. Maintenance Takes a Village • Care team members other than primary RN • Supervisors, charge nurses • Nurses helping out (regular, floated, agency) • PCAs • Ward clerks • X-ray technicians • Respiratory therapists • Transporters • Family members • Patients themselves

  20. Questions? PLEASE let us help if this is new for you or you would just like a second opinion or advice from someone outside your everyday work flow!! Deb Campbell dcampbell@kyha.com 502-992-4383

  21. Data Collection Tool • Excel spreadsheet customized to your hospital • Numerators/Denominators • Process measures

  22. Harm Across the Board • New HAB template • NOT mandatory—but earns an extra incentive • K-HEN will help prepare as much as possible • New Improvement Calculator from HRET

  23. Open Discussion/Questions Complete Learning Activity Survey

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