1 Skills Competency Education for New PI Directors & Coordinators Session FourFebruary 28, 2007 Performance Reporting Sponsored by: The MT Rural Healthcare.

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Skills Competency Education for

New PI Directors & Coordinators

Session Four February 28, 2007

Performance Reporting

Sponsored by: The MT Rural Healthcare PI NetworkCo-Sponsored by: Mountain Pacific Quality Health

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Today’s Session Recap Session 3:

aggregation/assessment

Session 4 Performance Reporting Value and potential pitfalls 4 R’s of performance reporting Audiences Sample reports and tools

Questions

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Value: Why Report Performance

Pay for Reporting, Pay for Performance

Basis for objective decision-making

Provides leverage for improvement

Increases team knowledge & understanding Helps focus improvement efforts Encourages proactive response

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Value: Why Report Performance

Potential to improve organization culture Shared knowledge = shared power Unites individuals around common goals Fosters learning Encourages free exchange of ideas,

creativity Increases ownership of outcomes All celebrate successes and ‘good tries’ Can improve morale

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Potential Pitfalls

Reporting only for “regulatory compliance”

Introduction of bias into data collection and/or analysis

Rushing to decision-making

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Potential Pitfalls Different people like to receive

information in different ways

Potential for dysfunctional conflict Blaming with data Increasing resistance to change Triangulation Polarization of the organization

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Our Reporting Commitment Model the positive approach Report performance objectively Ensure the accuracy of the data Validate assessments &

recommendations Encourage full discussion, persevere Acknowledge, publicize and celebrate

successes Have some fun along the way

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4 R’s of Performance Reporting

Right InformationRight TimeRight Way

Right Audience

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The Right Information Is objective

Is relevant to the audience To their role in the organization To their span of control, scope To the decisions they have to make To the questions they have To the questions they have to answer

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The Right Time

When they can listen and receive it

In time to do something about the data

Length of report

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The Right Way

Attitude “process not people”; an opportunity

Style Format: the way they prefer to receive

info Language they can understand while

learning the vocabulary

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Audiences

Quality Management Team (QMT)ManagersMedical StaffGoverning BoardOthers: community

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Quality Management Team

Role Development and/or

implementation of strategic plan

Deploy operational work plan facility-wide

Monitor progress of PI teams

The Right Info Strategic plan

measures

Operations measures, facility wide

PI team performance

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Quality Management Team

Role Establish

improvement priorities

Allocate resources

Field questions from all levels of the facility and community

The Right Info Comparative info National, regional

trends, requirements

Costs, benefits

Solid understanding of issues, in-depth information as needed

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Quality Management Team

Right Way Objective

What’s going well What isn’t Why

Interactive Recommendations

Collaborative We’re all in this

together

Right Time Proactive Frequent reports Most

comprehensive data set reported

Long enough for full discussion of issues and questions; getting to consensus about actions

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QMT: Questions They Ask What’s on the horizon?

What are we doing to meet future challenges?

What new resources do we need?

What opportunities we can take advantage of?

What pitfalls do we need to beware of?

What weaknesses do we need to mitigate?

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QMT: Questions Asked of Them

Where are we now?

Where are we going?

Why are we going there?

What compelling reason can you give me for changing (ie, “What’s in it for me?”)

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The QMT Report High-level strategic and operational

measures where no identified problems/ops for improvement exist

Low-level, in-depth performance data where problems are identified or active improvement is underway (“drill down”)

Follow-up reporting each month

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Managers Role

Leaders Management

functions Decisions are

operational and strategic

Oversee one or more departments/services

Work with med staff Serve on PI teams

Right Information Overall

performance Management

functions Strategic and

operational data Department

specific data Relevant clinical

care data PI team data

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Managers Right Way

Format: help focus Style: not all are PI

experts Drill down when

warranted Collegial &

supportive Questions answered

or “I’ll find out”

Right Time Frequency: in time to

meet their performance requirements

Length: subset of the QMT measure set

Plenty of time for education

Plenty of time for questions

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Managers: Questions They Ask How is the organization doing?

How are the areas I’m responsible for doing?

Where are we going and why?

What’s coming down the road?

What’s in it for me and my staff to change?

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Managers: Questions Asked of Them

How is the organization doing?

How is our department doing?

Where are we going?

Why are we going there?

What’s in it for me to change?

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The Manager Report Small set of high-level strategic measures

Small set of management function operational measures

Low-level, in-depth data directly related to their areas of responsibility

Low-level, in-depth data where problems are identified or active improvement is underway (“drill down”)

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Medical Staff Role

Responsible for quality of diagnosis, treatment

Supervise allied health professionals

Supervise care provided by nursing and ancillary clinical services

The Right Info “Global” clinical data

(mortality, returns, etc) Quality of med records Patient safety Peer review Medication use Nosocomial infections Relevant clinical data

about ancillary services

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Medical Staff Role

Lead clinical PI

MS appointments

MS meetings & committees

Strategic planning

The Right Info Clinical PI team data Patient satisfaction Credentialing info Provider-specific

performance data Data collected for

committees (ER, OB, ICU, OR, LTC, Clinic)

Strategic measures

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Medical Staff Right Time

Hot issues: before MS meetings

General report: at MS meetings

Brief: 5-10 min ; “cut to the chase” unless ask questions

Right Way There to help them

get their work done faster, easier

Give them “heads up”

Suggest They are used to

asking the questions; watch defensiveness

Plenty of supportive literature

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Medical Staff Questions How do our clinical outcomes compare with

other, same-size, similar-practice facilities?

What are the diagnosis-specific performance measures for conditions we treat most often? How are we doing with them?

What can we reasonably do to adopt national diagnosis-specific practice guidelines to our unique rural/frontier healthcare delivery site?

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Medical Staff Questions How might my practice have to change to

do that?

Do patients really care?

What’s in it for me to change?

How might pay for reporting or pay for performance impact my practice?

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The Medical Staff Report Targeted clinical measure set to help them

move in the necessary direction Including publicly reported clinical measures

Small set of high-level, global measures they can use to benchmark with other facilities

Additional data as requested

Encourage them to lead clinical PI

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Governing Board Role

Full legal responsibility for the quality of care

Fiduciary Risk management

Accountable to community

Implement the strategic plan

The Right Info Highest level clinical

measures Patient safety Financial information Risk management data Publicly-reported

performance measures Patient satisfaction Strategic plan

measures

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Governing Board Role

Position for the future

Oversee CEO

Oversee medical staff Bylaws, Rules, Regs

Appoint medical staff

The Right Info What’s coming

He/she gives his/her own report

Work with med staff to do this

Credentialing, provider performance data

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Governing Board Right Time

At Board meetings

Brief: often only 5-10 minutes unless linked to strategy discussions

Right Way Give all they ask for Focus them on a few

key areas Inform them: long

time horizon Typically need lots of

education Encourage questions,

learning

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Board Questions What is the standard of care? Are we

meeting it? If not, what are we doing to change so that we consistently will?

Are we performing better today than we did last report period?

Are we making progress on our strategic plan? What new opportunities do we have?

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Board Questions Are our patients and community

satisfied with our services, facility?

What risks do we need to be aware of and plan to manage (internal, external)?

What’s going on at the national level that we need to prepare for?

What are we getting out of our investment in PI?

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The Board Report High level strategic and operational

performance measures: Clinical care Customer/patient/community satisfaction Hospital operations, including risk

management

CAH Annual Program Evaluation

Providing education, receiving direction

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SampleReports

“A Picture Speaks a Thousand Words”

Focusing your audience

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Sample Report “The 2nd quarter

mortality rate was 2.9. There were 9 ADEs, and 6 nosocomial infections. Overall, 80% of our patients were satisfied. 4 staff positions turned over.”

Strengths

Weaknesses

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Sample Report Strengths

Weaknesses

J F M Q1 A M J Q2

Mortal Rate

2.0

2.5

2.2

2.2

3.5

2.7

2.5

2.9

ADE’s1 1 2 2 3 2 4 3

NIR’s0 1 0

0.3

1 3 2 2

Cust Sat 85 86 85 85 82 79 80 80

Turn-over

0 1 00.3

3 2 01.3

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Sample Report Strengths

Weaknesses

J F M Q1 A M J Q2

Mortal Rate

2.0

2.5

2.2

2.2

3.5

2.7

2.5

2.9

ADE’s1 1 2 2 3 2 4 3

NIR’s0 1 0

0.3

1 3 2 2

Cust Sat 85 86 85 85 82 79 80 80

Turn-over

0 1 00.3

3 2 01.3

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Sample Report Strengths

Weaknesses

J F M Q1 A M J Q2

Mortal Rate

2.0

2.5

2.2

2.2

3.5

2.7

2.5

2.9

ADE’s1 3 2 2 3 2 4 3

NIR’s0 1 0

0.3

1 3 2 2

Cust Sat 85 86 85 85 82 79 80 80

Turn-over

0 1 00.3

3 2 01.3

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Sample Report Strengths

Weaknesses

0

1

2

3

4

J '06 F M A M J

Adverse Drug Events

Nosocomial Infections

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Sample Report

0

20

40

60

80

100

% C

om

ple

te

2nd Q 2006

HF Discharge Instructions

Activity DietDC Meds Follow up AptWeight Mon Symptoms

Strengths

Weaknesses

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Sample Report

QMT Report

June

2006

Assessment

Adverse Drug Events

4 Goal: </= 3 per 100 patient days. Increased in 2nd Q 2006. May be due to increased use locums nurses.

Nosocomial Infections

2 Goal: </= 1 per 100 patient days. Up overall in 2nd Q 2006. June NIRs down from previous months. Nursing staff stabilized in June.

Nursing staff turnover

0 Goal: 0-1. April and May turnover much greater than target; new per diem nurse staffing business opened locally.

Trending

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Sample Report (Spidergram)

Medical Records: % Documentation Completed

35%

45%

65%

38%

100%

100%

95%

98%

100%

98%

0%

20%

40%

60%

80%

100%Face sheet

Immunizations

Physician orders

H & P complete

Inf consents

Nursing assessment

Nursing care plan

Pt/family ed

Discharge planning

Discharge summary

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Sample Report

PIN MultiSt

Readmission within 30 days (12 mo rolling)    

Return to ER within 72 hours (12 mo rolling) 7.5% 7.5%

C-section rate (12 mo rolling)  

Mortality rate (12 mo rolling) 6.3% 6.3%

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Sample Report

Customer Satisfaction Q2

25

40

1522

6

40

36

8

45

13

48

35

24

77

33

81

448

0 20 40 60 80 100 120

Percent Satisfied

No Neutral Yes

My pain was well-controlled.

I would recommend this facility.

My call light was answered promptly.

I always knew my nurse's name.

My physician answered all of my questions.

Overall, I was satisfied w/ the quality of care I received.

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Sample Report

PI Prog 2005

2004 events

2005 events

$/eventCost Savings

Hip fx, fall

6 4 23,000 46,000

Nosocom Infects

20 11 8,000 72,000

Staff turnover

48 30 15,000 270,000

Total 388,000

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Electronic Support Tools Spreadsheet software

EXCEL (www.mtpin.org)

Lotus 1-2-3 Presentation software

Power Point (www.mtpin.org) Publication software

Front Page Page Maker

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Questions?

Next Time:

Quality Management Team Meetings

Wed, March 14, 1 pm