Download Driving Performance Through Effective Data Management

Driving Performance Through
Effective Data Management
Kimberly Reints RN, BSN, PHN, CNOR
Objectives:
 1. Identify the difference between a proactive and a
reactive performance improvement study
 2. Describe at least three types of data that can be
captured in performance improvement studies
 3. Explain at least two methods of data collection
 4. Discuss one method to utilize results of a
performance improvement study.
Definitions of Proactive and Reactive
Performance Improvement Studies
 Proactive
 Reactive
Controlling a
situation by making
things happen or by
preparing for
possible future
problems.
Doing something in
response to a
problem or situation.
Reacting to problems
when they occur
instead of doing
something to prevent
them from
happening.
Proactive
Performance Improvement Studies
• Requires planning ahead and investigating
• Goal oriented
• Usually based on stakeholder motivations or quality
•
•
•
•
initiatives
An assessment of risks and vulnerabilities
Foresighted and visionary
Prioritizes data collection
Sets priorities (Prioritization Matrix)
Reactive
Performance Improvement Studies
• Something that “must be fixed”
• Response to an incident or near miss
• Response to unexpected or adverse patient outcomes
• Failed processes that were relied upon and trusted
• Breaches in acceptable standards of practice, standards of care
or regulatory requirements
• Puts future patients at risk for adverse outcomes
• Requires intensive analysis and cannot be ignored
• Focuses on the S – K - I
What is S-K-I?
• Systems or processes that are deficient or
defective
• Knowledge that is insufficient and
competency can be the issue
• Individual performance or behavior that is
inappropriate or non-compliant
Data, Information and
Knowledge
The D-R-I-P Concept:
D
Data
R
Rich
I
Information
P
Poor
• Data is comprised of facts
• Information is data that has become and is meaningful or
useful
• Knowledge involves managing and utilizing information to
predict and the control the future performance of processes
for optimal outcomes
Three Types of Data Captured in
Performance Improvement Studies
•
Internal benchmarks or current organizational standards
•
•
•
If organizational processes in control
•
•
•
•
What is the data telling us?
Where do we stand? What is our current baseline?
Are there small random variations in standards of care or documentation?
Are trends in data positive?
Is there compliance with CMS regulations and accreditation standards?
If organizational processes out of control
•
•
•
Are there major fluctuations or variations in standards or care or documentation?
Are trends in data negative?
Is there lack of compliance with CMS regulations and accreditation standards?
Prioritization of Performance
Improvement Studies by Standards
Three Types of Standards
•
•
•
The organizational standard
• Is our current organizational standard in line with current standards?
• What is our internal benchmark or compliance rate?
The empirical standard
• The external benchmark comparison
• The compliance rate compared with a regulation or evidence based
practice standard
The absolute or normative standard
• Usually determined by clinical trials typically referred to as evidence
based medicine
• Can be referred to as best practices
• Can include “Consensus Conference” which draws from health care
professional opinions – often referred to as the GOBSAT phenomenon
GOBSAT PHENOMENON
G – Good
O – Old
B – Boys
S – Sitting
A – Around
T - Talking
Reactive
Performance Improvement Sources
• Adverse Events (AE) – an incident resulting in harm to the
patient
• CMS Metrics
•
•
•
•
•
•
•
•
Falls
Burns
Hospital Transfers / Admissions
Wrongs –Wrong Site, Patient, Procedure or Implant
Health Care Acquired Infection
Medication Errors
Return to the operating room or procedure room
Breaches in cleaning and sterilization processes and/or high-level
disinfection process
Reactive
Performance Improvement Sources Cont’d
• Procedures or processes that place the patient at risk when
•
•
•
•
•
•
not performed
Procedures or processes performed when not indicated
Procedures or processes not performed when indicated
Problem prone procedures or processes such as procedures
with complications
High Cost Procedures
Patient injury of any kind
Safe Injection practices – one needle, one syringe, on patient,
one time (Immediately reportable by SA & AO)
Proactive
Performance Improvement Sources
• Patient Satisfaction Survey Results
• Corporate benchmarks
• Clinical Salaries per procedure
• Clinical Hours per procedure
• Drug Expenses per procedure
• Linen Expense per procedure
• Office supplies expense per procedure
• Salaries and benefits per procedure
• Maintenance costs of instrumentation
• Supply expense per procedure
Proactive
Performance Improvement Sources Cont’d
•
•
•
•
•
•
•
•
•
Retrospective chart audits
Medication tracers against written orders for medications
Verbal order tracers against medications given and authenticated
History and physical completion tracers
Increase in the number of procedures for a low volume problem prone
procedure
Narcotics signed out, used, documented & wasted with witness
The 5 moments of Hand Hygiene compliance
Pathology reports are not being sent to ASC or reviewed for abnormal
tissue in a timely manner
Near miss sharps injuries
Contributing Factors of
No-Harm Incidents
1.
2.
3.
4.
5.
6.
Team factors such as written and verbal communication issues or
confusion
Task factors such as the availability of facility protocols and/or the
availability and use of test results
Work environment factors such as the design, availability and
maintenance of equipment, staffing levels and skill mix of staff
Patient screening factors such as ASA 3’s and ASA 4’s
Individual factors such as staff knowledge, skills, physical and
mental health
Organizational and management factors such as structure, policies,
standards and goals of the organization
Methods of Data
Collection
100% of medical record audits of a specific documentation –
preoperative orders for eye medications and eye medications
documented as given.
2. Determine your sample size if 100% medical record review is not
possible – narrow the population or sample size by doctor, days of the
week, patient age, type of procedure, etc.
3. Asking patients and families if there was anything we could have done
better of different to improve their facility experience
4. Published evidence based practices in peer reviewed journals as
comparison to existing data like benchmarks
1.
How Do We Prioritize Our PI Projects?
Criteria for Performance
Improvement Prioritization
1.
2.
3.
4.
5.
IMPACT UPON:
Patient Outcomes
Patient Safety
Cost of Implementation
Staffing Efficiency
Cost reduction or savings
Criteria for Performance
Improvement Prioritization
1.
2.
3.
4.
APPLICABILITY TO:
Perceptions of patient, family and staff
High volume procedures
High risk procedures
Problem prone procedures
Criteria for Performance
Improvement Prioritization
1.
2.
3.
4.
REQUIREMENTS BY:
Required by regulations – CMS
Required by Accreditation Standard
Required by Process Control – internal
policy and procedure based on evidence
based standard
Quality Control required by manufacturer
PI Study Prioritization Matrix
Parameters
4
3
2
1
0
Impact: On patient outcomes
Important improve-ment in
patient care
Moderate improvement in patient
care
Little improvement in patient care
Questionable improvement in
patient care
No improvement in patient
care
Impact: On patient safety
Patient safety com- promised at
present
Patient safety at potential risk
Contributing factor to patient safety
risk
Minimal risk to patient safety
No risk to patient safety
Impact: On cost of
implementation
No cost for implementation
One time cost <5% of operating
budget
One time cost 5%-10% of op.
budget
One time cost >10% of
operating cost
Ongoing increased costs
Impact: On staffing or efficiency
Reduction of 1 FTE
Reduction of 0-1 FTE
Possible reduction in FTE
No impact on staffing or
efficiency
Increase in staffing costs
Impact: On cost reductions
Measureable reduction > 10%
5% to 10% measure-able
reduction
1% to 5% measureable reduction
No impact on cost of
implementation
Increase in operating costs
Applicability:
Perceptions of patient, family,
staff
Problems as indicated by
surveys, complaints or patient
grievances
Possible highly positive effect on
patient satisfaction
Possible moderate effect on patient
satisfaction and/or staff satisfaction
Possible minimal effect on
patient satisfaction or staff
satisfaction
No effect on patient, family,
visitor or staff satisfaction
Applicability:
High Volume
Affects 100% of patients
Affects 50% to 75% of patients
Affects 25% to 50% of patients
Affects 0 to 25% of patients
Does not affect patients
Applicability:
High Risk
May cause patient death
May cause per- manent serious
complication or injury to patient
May cause permanent minor /
temporary minor patient
complication
May cause temporary minor
complication to patient
No risk of complications to
the patient
Applicability:
Problem Prone
Process problems with
increased risk to patients/staff
Process problems with moderate
risk to patients or staff
Process problems with low risk to
patients/staff
Process problems with no risk
to patients/staff
No process problems noted
Requirements:
Regulatory or required standard
Required by CMS
Required by another regulatory
body
Required by accreditation standard
NA
Not required
Requirements: Process Control /
Quality control
Show significant variation in
process
Shows moderate variation in
process
Show minimal variation in process
NA
No variation noted
Total
Methods to Utilize the Results of a
Performance Improvement Study
1.
2.
3.
4.
5.
6.
7.
Report it to the Board and document it in the Board Minutes
Make certain that staff (rank and file) know the outcomes of the
study and the benefits to the center
Implement lasting change
Identify opportunities for staff in-services and staff competency
training if necessary
Utilize data to target other related issues to the original study
Utilize data to use for employee performance appraisals
At least one study must show improvement from a goal to
outcomes in practice - AAAHC