2012 User Group. 22 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Convert Your Data into Action June 20, 2012 1:30-2:45 Melinda Cotton Julie.

2012 User Group2012 User Group

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Convert Your Data into Action

June 20, 20121:30-2:45

Melinda CottonJulie Standerfer

Joyce Rutherford-Donner

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Quality Improvement and eHealth Data Solutions

• eHealth Data Solutions believes in using data for decisions, so we have designed our products to help you convert data to action and support quality improvement.

• CareWatch uses the hundreds of data points found on the Minimum Data Set to populate Watch pages for quality and provides Statistical Process Control charts to help you interpret changes over time.

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5 Elements of Quality Assessment/Process Improvement

• Element 1: Design and Scope• Element 2: Governance and Leadership• Element 3: Feedback, Data Systems and

Monitoring• Element 4: Performance Improvement Projects

(PIPs)• Element 5: Systematic Analysis and Systemic

Action

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Interdisciplinary Team

• Administration• Medical Director• Nursing leadership• Pharmacy• Activities• Social Services• MDS Coordinator• Nursing Assistant• Dietary• Environmental Services

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Plan – Do – Study – ActThree Fundamental Questions

• What are we trying to accomplish

• What changes can we make that will result in an improvement

• How will we know that a change is an improvement

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FOCUS PDSA

• Find a process that needs improvement

• Organize a TEAM that knows the process

• Clarify current knowledge of the process

• Understand causes of process variation

• Select the process improvement

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FOCUS PDSA

• Plan the improvement process

• Do the new process and collect data

• Study the results of the new process

• Act to hold gains and improve further

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Quality Measures

Enhancing the Quality Measure Benchmarks

Surveyor Quality Measures

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Using Benchmark Data Successfully

• Check related QM indicators to avoid working in silos› ADL Decline with weight loss and depression› In-dwelling Catheter with UTI and high risk PU› High Risk PU with weight loss and depression› Pain Management and Pressure Ulcers (short

stay)• Drill down into the Watch pages

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Surveyor QMs

• ONLY in Casper Reports• Were used prior to the 3.0• Are all long stay measures• Surveyors thought they were too good to leave out

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Percentage of Residents Who Have Had a Fall During Their Episode of Care

• Numerator› One or more look-back assessments where

J1800=1

• Denominator› All long stay nursing home residents with one or

more look-back assessments

• Exclusions› Look-back assessments where J1800= -

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Psychoactive Drugs

• Percentage of Residents Who Are Receiving Psychoactive Drugs But Do Not Have Evidence of Psychotic or Related Conditions

• Numerator› Prior to 4/1/2012 N0400A=1› 4/1/2012 or later N0410A=1,2,3,4,5,6,7

• Denominator› All long stay residents with a selected target

assessment

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Psychoactive Drugs

• Exclusions: › Resident did not qualify for the numerator and

any of the following is true: Assessment with target dates on or before3/31/2012: N0400A= - Assessment with target dates on or after 4/1/2012: N0410= -

› Any of the following related conditions are present on the target assessment Schizophrenia Psychotic disorder Manic depression (bipolar disease) Tourette’s Syndrome on the prior assessment if this item is not

active on the target assessment and if a prior assessment is available

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Psychoactive Drugs

• More Exceptions› Tourette’s Syndrome› Huntington’s Disease› Hallucinations› Delusions

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Prevalence of Antianxiety/Hypnotic Use

• Numerator› Assessments with target date on or before 3/31

N0400B=1 or N0400D=1

› Assessments with target date on or after 4/1 N0410B=1,2,3,4,5,6,7 or No410D= 1,2,3,4,5,6,7

• Denominator› All long stay residents with a selected target

assessment

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• Exceptions› Pre 4/1 N0400B, N0400D equal –› 4/1 and post N0410B, N0400D equal –› Any of the following conditions are present on

the target assessment Schizophrenia, Psychotic disorder Manic depression Tourette’s Syndrome Tourette’s on the prior assessment if this item is not active on the

target assessment and if a prior assessment is available

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• More exceptions› Huntington’s disease› Hallucinations› Delusions› Anxiety disorder› Post traumatic stress disorder› Post traumatic stress disorder on the prior

assessment if this item is not active on the target assessment and if a prior assessment is available.

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Prevalence of Behavior Symptoms Affecting Others

• Numerator› Presence of physical behavioral symptoms

directed towards others: E0200A=1,2,3 or› Presence of verbal behavioral symptoms

directed towards others: E0200B=1,2,3 or› Presence of other behavioral symptoms directed

towards others: E0200C=1,2,3 or› Rejection of care:E0800=1,2,3 or› Wandering: E0900=1,2,3

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Prevalence of Behavior Symptoms Affecting Others

• Denominator› All residents with a selected target assessment

except those with exclusions

• Exceptions› Target assessment is a discharge:

A0310F=10,11› E0200A,B,C is equal to - ^› E0800 is equal to - ^› E0900 is equal to - ^

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How to Find This Information in CareWatch

• Prevalence of Falls› Reports/MDS 3.0 Details

Set date range back for a year Go to Section J: Falls Sort for J1800

• Other three QMs› Tasks/MDS 3.0 Details Definition

Write out how you want the report to look first Follow the Help to create

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Statistical Process Control Charts (SPC)

• SPC Charts tell a story about performance that should not be ignored.

• Selection of a QM to “correct” from a single point in time QM report could cause a facility to spend time on something that may not be a problem and could actually cause more problems for the facility.

• It is desired that the minimum 12-15 points of data (months or quarters) is used.

• Trend is 5 or more points in a row in which the measure increases, decreases, or is above or below a benchmark.

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Questions and Discussion

2012 User Group. 22 | 10/11/2014 | © eHealth Data Solutions 2012 User Group Convert Your Data into Action June 20, 2012 1:30-2:45 Melinda Cotton Julie.

Documents

user group slide

data study

benchmark data

data systems

user group quality improvement

user group plan

user group quality measures

user group focus pdsa