Transcript Slide 1

Skills Competency Education
for
New PI Directors & Coordinators
Session Two
Data Collection
January 31, 2007
Sponsored by: MT Rural Healthcare PI Network
Co-Sponsored by: Mountain Pacific Quality Health
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Today’s Session

Recap Session One: intro to PI

Data collection

Tools and Sample size
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Questions
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Data Collection
“Keep It Simple”
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Five ‘Keep It Simple” Steps
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Develop a list of potential data collections
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Use criteria to identify the “vital few”
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Define specific performance measures
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Clarify collection and reporting cycles
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Clarify responsibilities
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Step One:
Develop a list of potential systems or
processes to be monitored or
improved
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Potential Data Collection List
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What do we have to collect
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What should we collect
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What do we want to collect
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Data We Have To Collect
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Dept Public Health & Human Services
(DPHHS)
OSHA
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Life Safety Code
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Contracts, liability carriers
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Voluntary accreditation organizations
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Data We Have to Collect: CMS
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Compliance with federal, state and local laws
(C-150); includes EMTALA
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Staff licensing and certifications (C-154)
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Emergency Services (C-200)
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Blood use and therapeutic gases
Building and equipment maintenance (C-220)
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CMS Data We Have To Collect
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Emergency Preparedness (C-227)
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Life Safety (C-231)
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Physicians (C-251) and mid-levels (C-263)
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Medication Use (C-276)
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CMS Data We Have To Collect
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Adverse drug events (C-277)
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Nosocomial Infections (C-278)
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Dietary department and nutrition (C-279)
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Policies and Procedures review (C-280)
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Ancillary clinical services and staff
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CMS Data We Have To Collect
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Contracted services (C-285)
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Nursing services (C-294)
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Medical records (C-300)
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Surgery (C-320) and Anesthesia (C-322)
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CMS Data We Have To Collect
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Annual CAH Program evaluation (C-330)
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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)
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Quality of care improved (C-337)
Survey deficiencies corrected (C-342)
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CMS Data We Have To Collect
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Peer Review (C-339): quality and
appropriateness of diagnosis and treatment
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Organ Donation (C-344)
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Swing Bed Requirements (C-350 and on)
? Pay for Performance measures (P4P)
? Rural hospitals measure set
? HCAHPS & other new requirements
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Data We Should Collect
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Strategic and Operational Work Plans
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Customer needs and expectations
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Quality of clinical care
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Hospital Operations
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Data We Should Collect
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QNet Exchange using CART
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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
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Data We Want to Collect
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High risk patient care systems, processes
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High volume processes
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Problem prone processes
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“Drill down” data, active improvement
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Step Two: Use objective criteria
and a table to identify the “vital
few” data you will collect.
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Identify the Vital Few
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Criteria for identifying the vital few:
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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
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High-Risk Systems, Processes
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Emergency care, including transfer
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Obstetrics
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EMTALA
Emergency deliveries
Surgery/anesthesia (operative)
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Conscious sedation, use of reversal agents
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High-Risk Systems, Processes
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Non-operative but invasive procedures
IV’s and catheters
 Cautery, incisions
 Invasive gynecological procedures
 Echo, CT, MRI, thallium stress testing
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Medication Use
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High-Volume Processes
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Patient identification
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Medical Records
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Catheter use
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Medication use and special diets
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High-Volume Processes
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Patient admission, discharge and
transfer
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Billing, coding and insurance processing
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Orienting new staff
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Payroll
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Problem-Prone Processes
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Medical record documentation
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Medication administration
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Right diet to right patient every time
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Preventing nosocomial infections
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Problem-Prone Processes
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Preventing patient falls
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Preventing pressure sores
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Admissions, transfers and discharges
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Accurate coding, billing and days in
accounts receivable
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Practice: Identify the Vital Few
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Use a table (matrix) to evaluate each
possibility in terms of the vital few criteria
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List of possibilities down the left-hand side of
the page
Criteria listed in separate columns across the
top of the page
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Practice: “Vital Few” Table
CMS
Strateg High
Plan
Risk
High
Vol
Prob
Prone
Adverse Drug
Events
Nosocomial Inf
Dietary Dept
Nutrition
Pol/Proced
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Practice: “Vital Few” Table
CMS
Strateg
Plan
High
Risk
Adverse Drug
Events
X
X
Nosocomial Inf
X
X
Service Volume
X
Patient Satis
Med Records
X
X
X
High
Vol
Prob
Prone
X
X
X
X
X
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Practice: “Vital Few” Table
CMS
S Plan
High
Risk
ADEs
X
X
Noso Infect
X
X
Ser Volume
X
Pt Sat
MR
Prob
Prone
Total
X
3
2
1
X
X
High
Vol
X
X
X
X
2
X
5
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Practice: Identify the Vital Few
CMS
S Plan
High
Risk
High
Vol
Prob
Prone
Total
MR
X
X
X
X
X
5
ADEs
X
X
X
3
Noso Infect
X
X
Pt Sat
Ser Volume
X
X
2
X
2
1
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Practice: Identify the Vital Few
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In this practice example, the team might
agree to:
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focus most on medical records (score = 5)
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focus moderately on ADEs (score = 3)
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focus least on the other opportunities (score
< 3)
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Step Three:
Define Performance measures
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Define Performance Measures
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Pinpoint the exact process to be measured
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Medical records delinquency rate?
H & P completion within 24 hours?
Informed consents obtained?
Advance directives in record?
Verbal orders authenticated?
Etc…
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Define Performance Measures
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Decide when you will measure
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Prospective
Concurrent
Retrospective
Choose success rate or failure rate
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“82 % complete” vs “18% delinquent”
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Define Performance Measures
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Define Numerator and Denominator
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Clarify the desired performance level
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N: # CAH-MR complete w/in 30 days discharge
D: # CAH admissions
Benchmarks, thresholds, control limits
Clarify the Data source
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Medical record
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Step Four: Clarify data
collection and reporting cycles
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Collection & Reporting Cycles
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Factors to consider:
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Who is the end user
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How often do the end user(s) meet
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The ‘vital few’ score and priority
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Collection & Reporting Cycles
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How stable, or volatile, the process is
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How accessible the data is
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Additional costs to collect/report the
data (like patient satisfaction data)
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Collection & Reporting Cycles
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Common cycles
Weekly
 Monthly
 Quarterly
 Semi-annually
 Annually
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active improvement
high risk, active, strategic
moderate risk, strategic
low risk, stable
low risk, stable
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Collection & Reporting Cycles
Medical Records
Perf Measures
Provider arrives
in 30 minutes
Verbal orders
authenticated
MR Delinquency
eMR vendor
selection
Why
Collecting
Report
Cycle
Collect
Cycle
active imp
weekly
daily
survey def
quarterly
monthly
stable, CEO
semi-ann
semi-ann
strategic
quarterly
quarterly
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Step Five: Clarify responsibilities
for data collection and reporting
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Clarify Responsibilities
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Who has easy access to the data
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Administration
Department managers
Staff
Your role in the facility and time
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PI, risk management, infection control,
medical records, HIPAA, other duties.
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Clarify Responsibilities

Who is attending the end user’s
meetings
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Board, CEO, med staff, QMT, managers,
department meetings, staff, community
Your role as a leader, spokesperson for
PI in your facility
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Clarify Responsibilities
MR Perf
Measures
Who
Collects
Provider
arrival
ER staff
Verbal
orders
Nursing
Delinquency
Med Records
rate
eMR vendor
CFO, CEO
End User
QMT
Med Staff
Nursing
Med Staff
Med Staff
Board
all
Who
Reports
DON
DON
PI Coord
CFO, CEO
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Simple Data Collection Tools
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Data Collection Tools
www.mtpin.org
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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
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Dot Plot (Scattergram)
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Sample Size (Data Quality)
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30 data points
approximates the
normal curve
no less than 10
data points unless
it is 100%

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10% of a large
population
100% of a small
population
The data just needs to be valid and actionable
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Questions?
Next time
Data Aggregation and Assessment
Wed, Feb 14, 2007 1:00 pm
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Session Two References
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PIN Performance Improvement Manual,
rev. 1/06; www.mtpin.org
Risk Management Handbook, 3rd Edition,
ASHRM.
State Operations Manual, rev. May 2004.
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