Skills Competency Education for New PI Directors & Coordinators

1. Skills Competency Education forNew PI Directors & Coordinators Session Two Data Collection January 31, 2007 Sponsored by: MT Rural Healthcare PI Network Co-Sponsored by: Mountain Pacific Quality Health

2. Today’s Session • Recap Session One: intro to PI • Data collection • Tools and Sample size • Questions

3. Data Collection “Keep It Simple”

4. Five ‘Keep It Simple” Steps • Develop a list of potential data collections • Use criteria to identify the “vital few” • Define specific performance measures • Clarify collection and reporting cycles • Clarify responsibilities

5. Step One:Develop a list of potential systems or processes to be monitored or improved

6. Potential Data Collection List • What do we have to collect • What should we collect • What do we want to collect

7. Data We Have To Collect • Dept Public Health & Human Services (DPHHS) • OSHA • Life Safety Code • Contracts, liability carriers • Voluntary accreditation organizations

8. Data We Have to Collect: CMS • Compliance with federal, state and local laws (C-150); includes EMTALA • Staff licensing and certifications (C-154) • Emergency Services (C-200) • Blood use and therapeutic gases • Building and equipment maintenance (C-220)

9. CMS Data We Have To Collect • Emergency Preparedness (C-227) • Life Safety (C-231) • Physicians (C-251) and mid-levels (C-263) • Medication Use (C-276)

10. CMS Data We Have To Collect • Adverse drug events (C-277) • Nosocomial Infections (C-278) • Dietary department and nutrition (C-279) • Policies and Procedures review (C-280) • Ancillary clinical services and staff

11. CMS Data We Have To Collect • Contracted services (C-285) • Nursing services (C-294) • Medical records (C-300) • Surgery (C-320) and Anesthesia (C-322)

12. CMS Data We Have To Collect • Annual CAH Program evaluation (C-330) • CAH practice reflects policies, procedures, laws • Utilization of services • 10% of active (open) and closed medical records • Health care policies • QA/PI Program (C-336) • Quality of care improved (C-337) • Survey deficiencies corrected (C-342)

13. CMS Data We Have To Collect • Peer Review (C-339): quality and appropriateness of diagnosis and treatment • Organ Donation (C-344) • Swing Bed Requirements (C-350 and on) ? Pay for Performance measures (P4P) ? Rural hospitals measure set ? HCAHPS & other new requirements

14. Data We Should Collect • Strategic and Operational Work Plans • Customer needs and expectations • Quality of clinical care • Hospital Operations

15. Data We Should Collect • QNet Exchange using CART • Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Community-Acquired Pneumonia (CAP) • Pneumonia vaccinations (Immunizations) • Surgical Care Infection Prevention (SCIP) ** HCAHPS, rural, and other new measures

16. Data We Want to Collect • High risk patient care systems, processes • High volume processes • Problem prone processes • “Drill down” data, active improvement

17. Step Two: Use objective criteria and a table to identify the “vital few” data you will collect.

18. Identify the Vital Few • Criteria for identifying the vital few: • Specifically required by a regulator • Specifically identified in the strategic plan • High risk patient care systems, processes • High volume patient care systems, processes • Problem-prone patient care systems, processes • Current focus for active improvement

19. High-Risk Systems, Processes • Emergency care, including transfer • EMTALA • Obstetrics • Emergency deliveries • Surgery/anesthesia (operative) • Conscious sedation, use of reversal agents

20. High-Risk Systems, Processes • Non-operative but invasive procedures • IV’s and catheters • Cautery, incisions • Invasive gynecological procedures • Echo, CT, MRI, thallium stress testing • Medication Use

21. High-Volume Processes • Patient identification • Medical Records • Catheter use • Medication use and special diets

22. High-Volume Processes • Patient admission, discharge and transfer • Billing, coding and insurance processing • Orienting new staff • Payroll

23. Problem-Prone Processes • Medical record documentation • Medication administration • Right diet to right patient every time • Preventing nosocomial infections

24. Problem-Prone Processes • Preventing patient falls • Preventing pressure sores • Admissions, transfers and discharges • Accurate coding, billing and days in accounts receivable

25. Practice: Identify the Vital Few • Use a table (matrix) to evaluate each possibility in terms of the vital few criteria • List of possibilities down the left-hand side of the page • Criteria listed in separate columns across the top of the page

26. Practice: “Vital Few” Table

27. Practice: “Vital Few” Table

28. Practice: “Vital Few” Table

29. Practice: Identify the Vital Few

30. Practice: Identify the Vital Few • In this practice example, the team might agree to: • focus most on medical records (score = 5) • focus moderately on ADEs (score = 3) • focus least on the other opportunities (score < 3)

31. Step Three:Define Performance measures

32. Define Performance Measures • Pinpoint the exact process to be measured • Medical records delinquency rate? • H & P completion within 24 hours? • Informed consents obtained? • Advance directives in record? • Verbal orders authenticated? • Etc…

33. Define Performance Measures • Decide when you will measure • Prospective • Concurrent • Retrospective • Choose success rate or failure rate • “82 % complete” vs “18% delinquent”

34. Define Performance Measures • Define Numerator and Denominator • N: # CAH-MR complete w/in 30 days discharge • D: # CAH admissions • Clarify the desired performance level • Benchmarks, thresholds, control limits • Clarify the Data source • Medical record

35. Step Four: Clarify data collection and reporting cycles

36. Collection & Reporting Cycles • Factors to consider: • Who is the end user • How often do the end user(s) meet • The ‘vital few’ score and priority

37. Collection & Reporting Cycles • How stable, or volatile, the process is • How accessible the data is • Additional costs to collect/report the data (like patient satisfaction data)

38. Collection & Reporting Cycles • Common cycles • Weekly active improvement • Monthly high risk, active, strategic • Quarterly moderate risk, strategic • Semi-annually low risk, stable • Annually low risk, stable

39. Collection & Reporting Cycles

40. Step Five: Clarify responsibilities for data collection and reporting

41. Clarify Responsibilities • Who has easy access to the data • Administration • Department managers • Staff • Your role in the facility and time • PI, risk management, infection control, medical records, HIPAA, other duties.

42. Clarify Responsibilities • Who is attending the end user’s meetings • Board, CEO, med staff, QMT, managers, department meetings, staff, community • Your role as a leader, spokesperson for PI in your facility

43. Clarify Responsibilities

44. Simple Data Collection Tools

45. Data Collection Toolswww.mtpin.org • Log sheets fastest and easiest • Table (matrix) easy, great for QA, more efficient than several log sheets if collecting data on related measures from same source • Dot Plots great for collecting same data over a long period of time • Surveys satisfaction, needs, opinions • www.surveymonkey.com

46. Dot Plot (Scattergram)

47. 30 data points approximates the normal curve no less than 10 data points unless it is 100% 10% of a large population 100% of a small population Sample Size (Data Quality) The data just needs to be valid and actionable

48. Questions? Next time Data Aggregation and Assessment Wed, Feb 14, 2007 1:00 pm

49. Session Two References • PIN Performance Improvement Manual, rev. 1/06; www.mtpin.org • Risk Management Handbook, 3rd Edition, ASHRM. • State Operations Manual, rev. May 2004.