Assessing Process and Audit Measures

1. Assessing Process and Audit Measures Armstrong Institute for Patient Safety and Quality Jill A. Marsteller, PhD, MPP Sept. 27, 2012

2. Learning Objectives • You will be able to: • Explain why measuring process is critical to success • Describe process measures planned for collection • Detail the planned collection process

3. Process Outcome Structure Donabedian Model How we organize care The results we achieve What we do during care delivery E.g., presence of policies or committees E.g., how often are evidence-based interventions performed E.g., how/ how many patients are harmed

4. Approaches to measuring process • Measures of perception • Accessible • Subject to bias • Regular process measures collection (audits) • More objective • Burdensome • Less frequent auditing • Less burdensome • Less reliable

5. Process measures you already collect • SCIP/STS • Abx selection • Abx timing • Abx stop w/in 48 hours • Glucose measure • Hair removal

6. New Measures/ Audit Topics • CLABSI: • Insertion (OR, ICU) • Maintenance (ICU, Floor) • CUSP: • Daily goals; AM Briefing; LFD (ICU, Floor, universal) • Briefing/debriefing ; Huddle; LFD (OR) • VAP process measures: • E.g., HOB elevation • E.g., sedation vacation • SSI: • Skin prep (type, appropriateness) • Antibiotic redosing

7. Timeline-OR

8. Timeline-ICU& Universal

9. Timeline-Floor

10. Audit data: “How To” • The timeline will tell you what to audit for the coming month • Collect data once a week and report at end of month • Methods: Observations; counts with measure/ count total eligible; answer Qs • When you enter web tool, it will tell you what audit data is due this month • Web-based data entry forms

11. Examples • Daily Goal Audit—Once weekly count the number of patients that had a Daily Goals sheet filled for them during interdisciplinary rounds; also count total number of patients. Report: DG patients and total • LFD Audit—Count number of defects worked on in last quarter; number resolved; number posted; number evaluated for effects • AM Briefing /Huddle/ OR Briefing/ Debriefing Audit—observe XX opportunities for briefings; Report: number of briefings conducted and number of opportunities

12. How process measurement helps you • Compliance is key to providing evidence-based practice • EBP allows you to meet your outcomes goals • Process measures provide a “map” to what’s working well and what’s not • Regular feedback on performance essential to performance and buy-in (transparency) • Use your data to inform, motivate, communicate laterally and upward

13. Example: Central Line Maintenance Audit Tool

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25. Action Items • Try out our new site! • Set up new members • Begin data entry for: • Rates • TCT • Audits Contact us at csts@jhmi.edu for support. Training for Surveys, VAP Daily Process Forms, Reports, and additional features are upcoming.