Driving Practice Improvement Using Dashboards

1. Driving Practice Improvement Using Dashboards Nancy Donaldson RN, DNSc., FAAN UCSF Stanford Center for Research & Innovation in Pt. Care

2. The Context Nursing Practice The Strategic Goal To reduce the cost of healthcare delivery while improving the quality, effectiveness and safety of patient care

3. Era of Performance Accountability • Administrators • Stockholders • Payers • Purchasers • Consumers • Legislators • Regulators • Policy Makers

4. Components of Care Delivery

5. Quality “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” IOM (1994)

6. Quality of Care Re-Defined • By Structure--Continuous shifting of skill mix and hours of care based on acuity AND pressure to reduce costs in new market place • By Processes--Safety; comfort; disaster avoidance; risk vs. complication prevention • By Outcomes--Cost per case; patient satisfaction; functional status; adherence; clinical status and quality of life.

7. Examples of Popular Press Headlines

8. Quality of Care Concerns • Use of unnecessary or inappropriate care • Underuse of needed, effective and appropriate care • Shortcomings in technical and interpersonal aspects of care • Patient safety—errors & omissions IOM (1994 & 1999)

9. November 1999--IOM Panel Reports--Medical mistakes cost $29 Billion (NY Times & CNN)

10. Medical Error Defined “...an unintended act (by omission or commission) or one that does not achieve its intended outcome.” Lucien Leape, MD, Agency for Health Care Policy and Research from Reducing Errors in Health Care Research in Action Fact Sheet. Agency for Health Care Policy and Research Pub. No. 98-P018, Sept. 1998 http://www.ahrq.gov/research/errors.htm.

11. Diagnostic (delay/ failure to use or act on test) Invasive diagnostic procedure Surgical procedure Anesthesia Prevention Drug (dose, interaction, allergy, wrong drug) Equipment failure Diet (eg, salt-free) Nosocomial infection Nursing procedures Blood transfusion safety Types of Healthcare Errors

12. How Errors Occur • Medication errors • Diagnostic inaccuracies • Inaccurate information recall • System failures from Reducing Errors in Health Care Research in Action Fact Sheet. Agency for Health Care Policy and Research Pub. No. 98-P018, Sept. 1998 http://www.ahrq.gov/research/errors.htm.

13. Institute of Medicine Report Four-tiered approach to reducing medical errors Establish national focus on patient safety Identify and learn from medical errors through mandatory and voluntary reporting systems Raise standards and expectations for improvement through oversight, group purchasers, professional groups Implement safe practices at the delivery level PUBLIC - PRIVATE PARTNERSHIP!

14. Improving Patient Safety • Computerized ADE monitoring • Computerized MD order entry (CPOE) • Computer-generated reminders for follow-up testing • Standardized protocols • Computer-assisted decision-making • Understanding relationships between factors, i.e., nursing staffing and adverse events. from Reducing Errors in Health Care Research in Action Fact Sheet. Agency for Health Care Policy and Research Pub. No. 98-P018, Sept. 1998 http://www.ahrq.gov/research/errors.htm.

15. Types of Healthcare Errors • Diagnostic error • Equipment failure • Infections • Blood transfusions • Misinterpretation of other medical orders from Medical Errors: The Scope of the Problem. Fact sheet, Pub. No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville MD. http://www.ahrq.gov/clinic/errback.htm

16. Errors are Preventable !Studies of Medical Records Show Promise • A landmark study indicated: --70% of adverse events were preventable --6% were potentially preventable --only 24% were not preventable • A 1999 study showed 54% of surgical errors were preventable from Reducing Errors in Health Care Research in Action Fact Sheet. Agency for Health Care Policy and Research Pub. No. 98-P018, Sept. 1998 http://www.ahrq.gov/research/errors.htm.

17. The Best Offense Is a Good Defense Against Medical Errors John M. Eisenberg, MD, Director Agency for Healthcare Research and Quality The Best Offense Is a Good Defense Against Medical Errors: Putting the Full-Court Press on Medical Errors. John M. Eisenberg, MD, Director, Agency for Healthcare Research and Quality, at the Duke University Clinical Research Institute, Jan. 20, 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/spch012000.htm

18. The role of measurement in perpetual practice improvement

19. “Managing a company by means of the monthly report is like trying to drive a car by watching the yellow line in the rear-view mirror”. Myron Tribus (Wheeler, 1996)

20. Diverse Sources of Quality Data • Centralized Public/Private/Professional databases • Unusual occurrence database • Adverse event database • Payer claims data • Clinical information systems • Financial/billing systems • Surveys • Drill down charts/logs/records review (c) Nancy E. Donaldson DNSc., RN (1997)

21. JCAHO Screening Indicators –www.jcaho.org (What’s new!) 1. Overtime 11. Staff injuries on the job 2. Family complaints 12. Injuries to patients 3. Patient complaints 13. Skin breakdown 4. Staff vacancy rate 14. On-call per diem use 5. Staff satisfaction 15. Sick time 6. Patient falls 16. Pneumonia 7. Adverse drug event 17. Postoperative infection Staff turnover rate 18. Urinary tract infection 9. Understaffing as compared 19. Upper GI Bleed to organization’s staffing plan 20. Shock/cardiac arrest 10. Nursing care hours per 21. Length of stay patient day

22. Limitations for Current Reporting Strategies Monthly & Quarterly Reports difficult to interpret retrospective & delayed data impossible to explore relationships between data elements difficult to understand variation poor integration and standardization

23. Impact on Performance • Decisions lack 3-dimensional perspective • Decisions now based on data then • Data is not integral to strategic business • Data is not source of information

24. Current Tools Common process improvement analytic strategies: Root Cause Analysis Focused Data Queries Benchmarking Quality Studies Process Control Charts

25. The Ultimate Challenge--Converting Data into Information and Information into KNOWLEDGE

26. Data Dashboard—Healthcare Instrument Panel

27. Imagine the Dashboard • One page summary of all critical measures needed to guide business & practice • Actionable information • Early warning of emerging issues/problems • Current data • Integrated data systems/sources

28. Variation In Health Care • Significant treatment variation is associated with suboptimal costs, quality & outcomes • Wide clinical diversity associated with suboptimal outcomes • Common Cause vs. Special Cause • Reducing variation generally increases quality

29. Statistical Process Control Chart • Documents performance or outcomes over time • Upper and lower control limits allow special cause variation and common cause variation to be discriminated • Aim is to eliminate special cause variation (stabilize process) and then focus efforts on reducing common cause variation

31. Evidence-based Outcomes Improvement

32. Innovation A change in nursing practice that is perceived as new by those adopting it, and that represents a significant alteration in the status quo.

33. Catalysts to Innovation Action Suboptimal performance (processes or outcomes) Strategic imperative (grow market/margins) Customer feedback Important new knowledge/technology Grass roots identification of recurring problem Retrofitting solution to a lesser problem c. Nancy Donaldson RN, DNSc.

34. Sources of Innovation • Invention • Borrowing - - Benchmarking • Enhancing Processes • Transfer of new knowledge • Adoption of new technology • Vision c. Nancy Donaldson RN, DNSc.

35. Using Evidence-based Clinical Innovations • The Research Utilization Process • The CQI Process • Organizational Adoption Process

36. Role Activities of the Nursing Research Consumer • Evaluation • Translation • Interpretation • Dissemination • Application and/or utilization

37. CalNOC Partners for Quality TRIP to Reduce Hospital FallsYEAR 1Nancy E. Donaldson RN, DNSc., FAAN—PIPat McFarland RN, MS—Project DirectorCo-Investigators: Drs. Brown, Burnes Bolton, Aydin, Dunton, Rutledge, PravikoffSupported By Grant #1U18HS1370401

38. The CalNOC Partners to Reduce Patient Falls Project builds on the infrastructure of the California Nursing Outcomes Coalition Database Project, a joint venture of ANA\California & the Association of California Nurse Leaders (ACNL) California Nursing Outcomes Coalition Database Project

39. CalNOC Database ProjectOverview The California Nursing Outcomes Coalition (CalNOC) Database Project is a collaborative initiative engaging a diverse team of staff nurses, advanced practice clinicians, educators, researchers, administrators and leaders in nursing in attaining a shared vision of designing, systematically implementing, and evaluating a statewide nursing outcomes database.

40. CalNOC Mission CalNOC advances improvements in patient care quality, safety, and effectiveness by... • Building and sustaining a valid and reliable statewide outcomes database • Conducting research to advance evidence-based interventions to achieve quality • Synthesizing and disseminating data to shape public policy, practice, and education

41. CalNOC Indicators Structural Indicators • Hours per Patient Day • Skill Mix • Ratios • Use of Contract Staff • Nurse Education--highest degree

42. CalNOC Indicators Process Indicators • Falls--Risk and Consequential • Pressure Ulcers (prevalence) • Restraint Use (prevalence)

43. CalNOC Partners TRIP to Reduce Patient Falls ProjectThe primary aim of this 4 year quality improvement demonstration project is to reduce the incidence of patient falls and severity of fall related injury in 100 medical surgical patient care units in CalNOC hospitals through evidence-based coaching, education and consultation; through improving falls risk assessment and prevention intervention clinical effectiveness.

44. CalNOC Hospitals

45. Trip to Reduce Falls Intervention • Institutional baseline self-assessment • Individualized falls related drill down data analysis report and facilitated presentation • Coaching for performance improvement • Linker role development • CE for key staff related to falls reduction • Strategic resources • Networking, benchmarking & synergy

46. Important Web Sites • CHIPP.CAHWNET.gov • ahcpr.gov • hcqualitycommission.gov • nih.gov or ninr.gov • amhpi.com/eyeonpatients (Picker Institute) • ncqa.org. (HEDIS) • jcaho.org • nursingworld.org (ANA)