Basic Skills Competencies for New QI/PI Coordinators Performance Improvement Basic... · Web viewOur work ranges from meeting and exceeding the needs and expectations of customers,

Table of Contents

I. Getting Organized....Abbreviations, Acronyms and DefinitionsHistory and Philosophy4 Step Improvement Cycle: Plan Do Study ActRoles and ResponsibilitiesPI Program Policy/PlanDrafting Policies and Procedures

II. Working with Departments/ServicesTask FunctionInterpersonal FunctionTips for Managing Conflict

II. Data Collection, Aggregation and Assessment

IV. Performance Reporting

V. Tips for Surviving Regulatory Surveys

VI. CAH Annual Evaluation

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Getting Organized...... Introduction

I. Abbreviations, Acronyms and Definitions

Refer to the appendix at the back of this manual for a list of commonly encountered abbreviations, acronyms and the definitions of commonly used terms in quality/performance improvement.

II. Brief History and Philosophy of Continuous Quality and Performance Improvement

1950’s Dr. W. Edwards Deming, statistician, and post-WWII reconstruction in JapanQuality = results of work

total cost

1965-1979 P.B. Crosby: “zero defects” at ITT

1980’s Outcomes-based management: achieving desired outcomes

1980’s Quality Assurance: achieving an acceptable failure rate

1990’s Total Quality Management (TQM): build quality into processes and systems“Quality, after all, is not an end in itself, but the strategic method that the hospital uses to effectively and efficiently perform its mission.”

“Total Quality Management in a Hospital”, Wm J. McCabe; QRB April 1992. p 140.

Quality Improvement, JCAHO: continuous cycles of improvement

Performance Improvement, JCAHO: performance is more objectively measured than quality

Six Sigma: reduce the failure rate to less than 3.4 defects in a million opportunities

2000 Value of healthcare = quality cost

2005 Institute of Medicine, Crossing the Quality Chasm: safe, effective, patient-centered, timely, efficient, equitable

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What is “Quality”?

Mar 2007 Secretary Leavitt, HHS: “right treatment to the right patient at the right time, every time”

The Distilled Quality/Performance Improvement Philosophy:

The performance of any organization can and must be continuously improved;

The quality of decision-making improves when it is based on objective information;

Top leadership support is fundamental to success;

Team work and cooperation are essential; To settle for anything less is an unacceptable management position.

... to settle for anything less in healthcare now is an unacceptable national position....

Getting Organized...... The 4 Step Improvement Cycle

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Quality is _____________________________________________________

_____________________________________________________________

And the purest motivation for embracing performance improvement:

It’s the right thing to do for the patients who come and entrust their lives, or the lives of their loved ones, into our hands.

Is it Plan, Do, Check, Act (PDCA)......... or Plan, Do, Study, Act (PDSA)?

Practice Scenario

1. Review of occurrence/incident reports reveals you have 15 falls in one month in your facility.Is this acceptable performance, or do you have an opportunity for improvement?

2. What next steps do you take in planning for improvement?

3. What actions will you take to trial your improvement plan?

4. How will you know whether or not improvement has been achieved?

5. Is the improvement you achieved ‘enough’?

6. What steps will you take to permanently implement the improvement actions?

Getting Organized...... The Scope of our Work

Our work ranges from meeting and exceeding the needs and expectations of customers, to improving patient care process and systems and, indeed, to improving all of the hospital’s operations.

I. Customers

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1. Internal Customers are the direct recipients of work. In healthcare, patients and their families, staff (including per diem staff and students), medical staff and Board members are all internal customers.

2. External Customers are the indirect recipients of work. In healthcare, regulatory surveyors (CMS, OSHA), insurance carriers, product vendors and members of the community can be external customers.

II. Patient Care Processes and Systems

The term quality improvement comes from the philosophy that health care workers should always be improving the quality of patient care.

A patient care process is ______________________________________________________.

A patient care system is ______________________________________________________.

Improving the quality of patient care processes and systems, then, can include:

Improving clinical care delivery and clinical care support services Acquiring new patient care or testing technology Reducing the risk to a patient in the healthcare environment Identifying new health care markets and developing the ability to serve them

III. Hospital Operations

There are other processes and systems in the hospital which we don’t often think of as impacting patient care, but they do, and they also need continuous improvement. Because of this and the difficulty people were having defining quality, the terminology was broadened to ‘performance improvement’ and improvement efforts were realigned to evaluate for improvement non-clinical hospital departments, including:

Financial performance (including billing practices) Building/Environment of Care (EOC) Human Resources Information Management (including electronic medical or personal health records) Materials Management (supply) Marketing/Community Relations

IV. The National Quality Agenda

1. Institute of Medicine (IOM): the care we deliver should be.....

Safe – we do no harm Effective – we achieve the desired outcome Timely – without delay Efficient – without waste, without error

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Patient-centered – individualized Equitable - same for all patients

Crossing the Quality Chasm (2001

2. Centers for Medicare and Medicaid Services (CMS) http://www.cms.hhs.gov

“... the right care for every person every time.” Jan 2007, CMS vision statement,HHS Sec Leavitt

a) Congressional mandates Omnibus Reconciliation Acts Tax Relief and Health Care Act of 2006

b) State Operations Manual (SOM) and the Medicare Conditions of Participation (CoP) http://www.cms.hhs.gov/manuals/downloads/som107ap_w_cah.pdf , 2009

c) CART & public hospital performance reporting; voluntary participation for CAHs Acute myocardial infarction Heart Failure Pneumonia Surgical Care Improvement Project

d) Hospital and Nursing Home Compare: performance data websites

hospitals: www.hospitalcompare.hhs.gov

nursing homes: http://www.medicare.gov/NHCompare

e) HCAHPS: Hospital- Comprehensive Assessment of Healthcare Providers SurveyFor PPS hospitals only, at this time www.hcahpsonline.org

f) Value-based Purchasing: for PPS hospitals, only at this time

g) Outpatient Performance Measures, “Rural Measures” - see attachedhttp://www.qualitynet.org/dcs/ContentServer?cid=1191255879384&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page (Quality Net Exchange)

3. Institute for Healthcare Improvement (IHI) www.ihi.org

100,000 Lives Campaign (Jan 2005 – June 2006)

o Deploy rapid response teamso Deliver reliable, evidence-based care for AMIo Prevent adverse drug eventso Prevent central line infectionso Prevent surgical site infectionso Prevent ventilator-associated pneumonia

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5 Million Lives Campaign (Dec 2006- Dec 2008) http://www.ihi.org/IHI/Programs/Campaign/

o All of the 100,000 Lives interventions (see above)o Prevent harm from high-alert medicationso Reduce surgical complicationso Prevent pressure ulcerso Reduce MRSA infectiono Deliver reliable, evidence-based care for congestive heart failureo Get Boards on Board

4. National Patient Safety Goals for Critical Access Hospitals (Joint Commission)

Patient identification Communication Safe medication use Reduce risk of healthcare-associated infections Unanticipated death or major permanent loss of function Reduce harm from falls Encourage patient and family to report safety concerns Improve recognition and response to changes in patient condition

http://www.jointcommission.org/NR/rdonlyres/6B00286D-DB29-4237-98D5-0D57CF807098/0/CAH_2010_NPSG.pdf

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Getting Organized...... Roles and Responsibilities

I. The Organization Chart Clarifies Roles and Responsibilities

A. Governing Board/Board of Directors Role

“ The CAH has a governing body that assumes full legal responsibility to provide quality health care in a safe environment.” Tag C-0241, Condition § 485.627(a)

According to the State Operations Manual for Medicare providers, the specific duties of the Board in Quality/Performance improvement include:

Determine the eligibility of candidates for medical staff and appointment qualified providers

Review and approve Medical Staff Bylaws Ensure the organization is in compliance with State and Federal laws, and the Medicare

Conditions of Participation (CoP)The Board also has a legally-recognized duty to the community to make decisions for them in trust (“fiduciary duty”), i.e., in their best interest. In order to make sound decisions on behalf of the community, the Board works to ensure there is a plan for how to go forward into the future (strategic plan). The plan always includes financial management plans, but also typically includes goals for improving:

How the organization meets and exceeds its customer needs & expectations How to improve patient care systems How to improve hospital operations

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How are you supposed to be able to get your arms around all of this?!!

You can’t do it alone.... you need others to work with you...

Board of DirectorsGoverning Board

Chief Executive OfficerAdministrator

Medical StaffChief/Director

DepartmentsServices

Quality ManagementPerformance Improvement

Board members, in the course of meeting their trust obligations, should discuss and come to agreement about the need for the organization to continuously improve its performance. They will need to monitor the implementation of the strategic plan to ensure the organization is moving forward. Their monitoring should include routinely reviewing key objective measures of hospital-wide performance. The key measures are often presented in a dashboard report format for easy identification of areas where performance targets are being met, and where adjustments need to be made to reach performance goals.

B. Chief Executive Office/Administrator and other Senior Leaders Role

The role of senior leadership in a successful quality/performance improvement program cannot be overstated. Without leadership support within the facility, the program is doomed to a continuous cycle of collecting and reporting meaningless numbers. The data collected is meant to support informed, objective decision-making within the organization, at every level, in order to support the organization’s ability to achieve the specific strategic objectives established by the Board, and thereby attain its mission, continuing to provide necessary healthcare services to the community well into the future.

There are several specific actions senior leaders are responsible for which support these goals:

Demonstrate commitment to the strategic objectives and QI/PI through its actions and decisions

Convert the Board’s strategic objectives into measurable, short-term, operational goals (these are often called a work plan or initiatives). The short-term goals will clearly link back to the strategic objectives and focus in some way on improving:

o Meeting and exceeding internal and external customer needs and expectationso Patient care systemso Hospital operations

Communicating established goals throughout the organization

Providing education for staff and medical staff about quality/performance improvemento This includes sharing learning from QI/PI projects, publishing and celebrating

successes and “good tries”

Supporting the QI/PI Coordinator and working cooperatively with that person to achieve real, significant improvement

Providing through the budget system the needed resources to do QI/PI wello Human resourceso Access to necessary information and datao Technologyo Time to work through the improvement cycleo Financial resources

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o Environment

C. Medical Staff Role

“ The doctor of medicine or osteopathy provides medical direction for the CAH’s health care activities and consultation for, and medical supervision of, the health care staff.” Tag C-0257

According to the State Operations Manual, it is the responsibility of the medical director to perform the following QI/PI functions:

Evaluate and improve the quality of patient diagnosis, treatment and patient outcomes. At a minimum, this includes:

o All patient care serviceso Nosocomial infectionso Medication therapy (see tag C-0337)

Evaluate and improve the quality of patient care provided by other members of the medical staff

Evaluate and improve the quality of other patient care services and service providers (these services include dietary, the therapies, lab and blood utilization, radiology or imaging, anesthesia, etc)

Evaluate and improve the quality of the medical record Evaluate and approve contracted patient care services

The medical staff’s work will include the peer review, utilization review and mortality review functions, as well as evaluating applicant and current provider applications for medical staff membership and privileges, and making recommendations to the Board about action on those requests.

Nothing makes life easier for a QI/PI Coordinator than a medical provider who understands and is engaged in the QI/PI program actively. A couple of words of caution, however: time really is a physician’s most valuable resource- spend it wisely. Focus your providers on the issues that are relevant to their work, and if possible, in areas where they have a personal interest.

Role Assessment Worksheet

Going Well Needs to be Worked On

Board and CEO/Administrator

____________________________________ __________________________________

____________________________________ __________________________________

____________________________________ __________________________________

____________________________________ __________________________________

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Medical Staff

____________________________________ __________________________________

____________________________________ __________________________________

Quality Management Team

____________________________________ __________________________________

____________________________________ __________________________________

____________________________________ __________________________________

QI/PI Coordinator/Director

____________________________________ __________________________________

____________________________________ __________________________________

____________________________________ __________________________________

Dept/Service Leaders/Managers

____________________________________ __________________________________

____________________________________ __________________________________

____________________________________ __________________________________

D. The Quality Management Team and QI/PI Coordinator

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Quality Management

Customer Needs and Expectations Patient Care Systems Hospital Operations

Patients, families, visitors

Satisfaction, complaints

Staff and Medical Staff

Satisfaction surveys

CommunityNeeds assessment

surveys

RegulatorsRegulatory surveys

By Service Site &/or Dept

Diagnosis SpecificAMI, HF, CAP, SCIP

UR, Peer ReviewCase Management

Patient SafetyMed Use, IC, Falls,

Litigation

Risk ManagementOccurrences, claims

Financial Performancestatements

Building, SafetyEnvironment of Care

(EOC)

Human ResourcesStaff quals & competency

Info and MaterialsManagement (Med

Records)

Marketing, Foundation

The Quality Management Team (QMT)

If you have ever attempted to single-handedly change a process or system in your organization based on your well-intentioned desire to do so, but without the support of others in your organization, you understand the truth of what Dr. McCabe is saying in the quote above. Your authority to make changes unilaterally goes as far as your office or work space door. And without authority, it is grossly unfair to have delegated to you the responsibility to make needed changes.

So, how is the change needed to make improvement accomplished? Back to Dr. Deming’s 14 Points for Management- teamwork. You need to be able to meet and work with others in the organization to accomplish the necessary changes to propel your organization forward. One team is of primary importance- the team that will coordinate and support all of the different improvement efforts going on in the organization, whether the effort is to prepare for a regulatory survey, correct deficiencies, or develop a safer way to pass patient medications. That team, which we refer to as the Quality Management Team, is also sometimes called the Quality Council, or Performance Improvement Council, or similar such names.

The Quality Management Team varies in composition from organization to organization, usually based on the organization’s size, the complexity of services offered, and the extent to which QI/PI is integrated into the organization’s culture. Please note that the word “team” simply means more than one person is involved. You are one; if the only other person you work with on quality issues in your facility is your CEO, your team has 2 permanent members. It is still a team at that point. Other members of your Quality Management Team might include:

Senior organization leaders Department/service heads Other QI/PI staff, if any Medical staff representative Governing Board member Line staff Community member

The first and foremost essential function of the Quality Management Team is to conduct the independent assessment of objective evidence concerning the hospital’s overall quality management system. Key characteristics of this assessment are that it:

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“…It is extremely important that quality management is not assigned solely to this department...” (or individual)...” which has neither the authority nor the resources to change the system… it should not assume, or have delegated to it, the line’s responsibility for managing quality.”

“Total Quality Management in a Hospital”, Wm J. McCabe; QRB April 1992

Is prevention-oriented and proactive. This team does not meet to ‘fight fires’.

Is fact-based: hard data is the basis of assessment whenever possible

Is independent, meaning that it is not constrained by organization structure and reporting relationships, but requires the entirely unbiased collection of relevant objective data from the entire organization about:

o Critical system, process & outcome measures related to strategic and operational goals

o The work of all interdisciplinary QI/PI teams

o Department and/or service-level PI activities

Uses continuous assessment and improvement cycles to improve all aspects of the organization’s performance. This team uses the same improvement cycle (PDCA/PDSA) to monitor, assess, improve and implement improvements as any other improvement team in the organization.

Always ends with decision-making about current performance and a plan for moving forward if indicated.

In addition to independently assessing the organization’s performance, the Quality Management Team will:

Coordinate resource utilization and allocation for PI activities

Eliminate organization barriers to improvement

Make decisions based on team member consensus rather than position/hierarchy to the maximum extent possible

Manage conflict within the team typical of competing needs and desires arising in a proactive, constructive manner; this team pays attention to group dynamics to maximize its own effectiveness

Provide the organization staff education about PI; team members all understand PI well enough to be able to actively participate in providing this education

Educate the community about the organization’s efforts to improve performance; may provide performance information in an annual community report

Periodically evaluate the overall soundness of the organization’s approach to quality management by conducting an annual progress or QI/PI program evaluation

Quality/Performance Improvement Manager, Director, or Coordinator

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We seem to have lots of different titles, and to have many different kinds of job duties assigned to us, based on the size and complexity of our organizations. But, when it comes to quality and performance improvement functions, our roles are often very similar, and usually include many of the following duties:

Supports the organization’s long-range strategic plano May provide data for strategic plan development to senior leaders, as requested

Supports the organization’s short-range operation work plano Provides data for operational work plan development, as requested

Provides leadership and guidance for the Quality Management Team (QMT)o Often serves as chairperson of this team

Leads or assists the QMT in developing the organization-wide approach to performance improvement (the “QI/PI Plan”)

Leads or assists the QMT in the development and definition of relevant measures of organization performance

o Customerso Patient care systems and processeso Hospital operations

Independently collects and analyzes objective data for use by the QMT in assessing performance

o Resolves data quality issues

Independently prepares and provides written and verbal performance reports for various audiences, as appropriate

Supports and facilitates medical staff, department, service and/or PI team efforts to improve performance

Provides PI education and training

Identifies and requests needed resources to support, promote, advance the program

E. Department and Services Managers, Directors or Coordinators

You should be able to expect your department or service leaders to actively support and participate in your organization’s QI/PI Program. These leaders need to:

Commit to the philosophy of continuous improvement

Support the organization’s strategic plan

Obtain education about performance measurement and improvement

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o Gain competence and confidence in the use of PI toolso Learn how to analyze the processes and systems of their departments and the

organization

Participate in data collection, assessment and reporting

Work cooperatively with senior leaders, including the QI/PI Coordinator, to identify and implement relevant annual goals and performance measures for their department:

o General goals might need to be converted into specific projects and/or targetso New or additional resources might need to be requestedo A time frame for project completion or goal achievement is clearly establishedo Responsibility for achieving goals and/or completing projects is clearly assignedo Relevant measures of performance are developed and defined for each important

goal and/or projecto Responsibility for regularly reporting performance is clearly assigned

Work cooperatively with other departments, services and staff to improve performance

o Serves on the Quality Management Team and other interdisciplinary improvement teams as needed

Discuss progress and performance data with other leaders regularly

Discuss progress and performance data with department staff regularly

Educate their staff about PI

Increase their staff’s skill and confidence in using PI methods and tools

Identify and remove department or service barriers to improvement

Celebrate successes and “great tries”; learn from every project

Getting Organized...... The QI/PI Program Policy or Plan

One written document in the organization’s administrative manual is expected to pull all of the pieces above into one neat little package. Surveyors will read this document prior to visiting with you in order to gain an understanding of how the PI program in your organization works.As with all organization policies, your PI Policy/Plan will have three major components:

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A policy statement answers the question, “What is the official position of the organization on this subject or about this program?”

One or more purpose statement(s) of the program, and answers the question, “Why does this program/process exist? Why is the organization doing what it is doing?”

The procedure, or approach, for implementing the policy and making it real in the organization; tells how the work will get done or how the policy will be implemented.

I. QI/PI Policy Statement: what is the official position of the organization on this subject?

a) Identify some key-word clues from the State Operations Manual, App W, Tags C336-343:

____________ ___________ _____________ ____________

____________ ___________ _____________ ____________

b) Write a full sentence, using the most important key words, about the organization’s position of this subject (hint: you are telling others what you will or will not do with this statement)

XXX Hospital/Medical Center will _________________________________________________

______________________________________________________________________________

II. Purpose Statement(s): tell others why you are going to do or not do what you said in the policy statement. (hint: Purpose statements usually begin with the work “to”, or “in order to”, or some variation of that phrase.)

a) Refer to the tags again, and look for key purpose words or phrases. They often clearly identify the few, critical functions of a program from the surveyor’s perspective.

Some examples:o “To evaluate the quality and appropriateness of diagnosis and treatment, and treatment

outcomes”o “To identify and resolve patient care, health and/or safety problems”o “To proactively identify and resolve patient care and/or safety problems or concerns”o “To improve effective resource utilization”o “To ensure appropriate remedial action is taken to address deficiencies”o “To improve patient, family and community satisfaction with XXX’s services”

b) Write a bulleted sentence, using the most important key words or phrases you identified about why the organization is taking the policy position it has chosen.

XXX Hospital/Medical Center will implement this policy.....( fill in the blanks below):

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When writing policies/procedures, always check the SOM tags and interpretive guidelines to see what CMS says a certain program, person, group or service is supposed to do. Be sure to include each element CMS mentions somewhere in your policy/procedure. They will read your policy/procedure and the SOM side by side during a survey, and if anything is missing the organization will receive a deficiency at that tag or CoP.

o ______________________________________________________________

o ______________________________________________________________

o ______________________________________________________________

o ______________________________________________________________

PRACTICE: read the statements below. Are they policy or purpose statements?

A. “XXX Hospital will maintain an effective quality assurance program to continuously evaluate and improve the quality and appropriateness of the diagnosis and treatment furnished in the

CAH and of the treatment outcomes.”

B. “XXX Hospital will maintain an effective performance improvement program throughout the organization to continuously evaluate and improve the quality and appropriateness of diagnosis and treatment, and other services affecting patient health and safety.”

III. Procedure: describes in detail how the policy will be implemented or the program works.

a) The level of detail in the procedure is sufficient so that someone who is unfamiliar with the program can identify their role “do it” correctly.

b) Describes the policy/program scope, i.e., who and/or what is affected by it?

o Who: some staff? all staff? medical staff? Executives? Board members?o What: some services? all services? hospital? clinic? nursing home?

c) Describes specific roles and responsibilities of the individuals involved. (hint: sometimes it is easiest to start at the top and work your way down the org chart; or vice versa. Also, check the regs again- they often provide information about roles from the surveyor’s perspective).

o Individuals ultimately responsible for the quality of care provided (Board)o Who implements the PI program on behalf of the Board (CEO or Administrator)o Who is responsible for directing and improving medical care (Medical staff)o What the PI Director/Coordinator doeso What the Quality Management Team doeso What Department/Service Directors doo What all staff do

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d) The PI Program Policy/Procedure also describes the kinds of data that will be collected:

Regulatory requirements, for example:o “All patient cares services and services affecting patient health and safety”o Nosocomial infections and medication therapyo Medical recordso Diagnosis and treatment

PI teams underway and their work Patient satisfaction Strategic and operational work plan objectives

e) Describes the methods of improvement the organization will use and when to use each:

Plan, Do, Study, Act / Plan, Do, Check, Act (for interdisciplinary teams, complex issues) Six-Sigma (when there is no margin for error) Rapid Cycle Improvement (when you need to make rapid interdisciplinary improvement) Quick fixes (often appropriate for individual departments to use)

f) Describes how data is collected, aggregated, assessed and performance is reported

In my organization, data is collected, aggregated, assessed and reported by _______________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

g) Describes how priorities for improvement are selected

In my organization, ____________________________________ establish(es) the priorities for improvement.

h) Describes how interdisciplinary PI teams are requested, authorized and monitored

In my organization, interdisciplinary PI teams can be requested by _______________________

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Heads up! Surveyors frequently ask staff about the approach to improvement the organization uses to see if they are familiar with it, have been trained in using it and can comfortably describe a time they used it.

_____________________________________________________________________________.

In my organization, interdisciplinary PI teams are authorized and monitored by ____________

_____________________________________________________________________________.

i) Describes how the organization defines and responds to sentinel events.

In my organization, sentinel events are defined by _____________________________________

_____________________________________________________________________________.

In my organization, _____________________________ reports sentinel events to___________

_____________________________within (specify time frame)__________________________.

In my organization, ______________________________________ investigates sentinel events

and reports the findings of the investigation to ______________________________________

____________________________________________________________________________

In my organization, _____________________________ reports a verified sentinel event

to the appropriate State agency or other regulatory body within (specify time frame)

____________________________________________________________________________.

j) Describes how the effectiveness of the PI Program will be evaluated and improved

In my organization, the effectiveness of this program is evaluated by _____________________

_________________ at least ( how often the program is evaluated) ______________________.

k) Describes how an annual evaluation of the CAH Program will be conducted

In my organization, the annual evaluation of the CAH Program is conducted by ____________

___________________. The results of the eval are reported to the medical staff by __________

___________________ and to the Board of Directors by _______________________________.

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The QI/PI Coordinator/Director role in the annual evaluation is to _______________________.A review of the utilization of services will be accomplished by____________________________

______________________________________________________________________________

A review of at least 10% of open and closed medical records will be accomplished by________

______________________________________________________________________________

A review of the clinical policies will be accomplished by________________________________

______________________________________________________________________________

The determination of whether or not utilization was appropriate, policies were followed and what, if any changes are needed, will be made by _____________________________________.

IV. Tips for Writing Policies and Procedures (P/P)from Michelle A. Williams, J.D. and Gary McClanahan, J.D.

Alston and Bird LLP, November 2003

A. Policies and Procedures have intended uses. How the organization uses them:

To teach people how to approach and do a particular task

To ensure consistent communication across the organization

To minimize “hand me down” education, i.e., cheat sheets and sticky notes

To decrease the opportunity for deviation from legal requirements

To decrease the opportunity for error (cheat sheets, sticky notes)

To demonstrate compliance with the law:

o P/P are the first thing surveyors request regardless of the Agency they represent

o Are looking to see if they reflect current law- DPHHS for hospital licensure- CMS for EMTALA compliance- OIG for Medicare billing- OSHA for worker safety

o Any regulatory statement that reads, “The organization should have…” means the regulator expects you to have a P/P to address that issue.

To document and defend organization practice (contracts, agreements, in surveys or court)

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o Hospital-based Physician Agreements- Medical Staff Bylaws: “The applicant agrees to abide by the Bylaws...”

o Transfer Agreements: who will do whato Corporate Integrity Agreements (a government-mandated agreement

between the facility and government to eliminate fraud)

Other Voluntary Reasons

o Regulatory “Guidance” Statements- Interpretive Guidelines- OIG Hospital Compliance Guidelines- HIPAA Compliance Guidelines

o Hospital accreditation: P/P are voluntarily submitted for review- Joint Commission or ISO 9000

B. Policies and Procedures get used in unintended ways:

In Discovery

o During regulatory surveys of all typeso Legal defense, because:

- They define the standard of care provided- They define the patient/provider relationship- They define the employer/employee relationship- They define patient, visitor, staff expectations

C. Tips for Managing Policies and Procedures

1. Inventory, i.e., make a complete list of all of your p/p: when several versions of a policy exist, the odds that the versions will be inconsistent with each other increases, resulting in:

Increased opportunity for facility not to be in compliance with current law Increased opportunity for inconsistent implementation, and therefore, error Increased liability risk due to decreased defensibility in court- which is the ‘correct’

version?

a) P/P Manuals to look for:

Facility Level Manuals Department Level Manuals

Administration NursingHuman Resources PharmacyHIPAA, privacy DietaryCorporate Compliance Medical RecordsSafety Radiology

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Infection Control LaboratoryPerformance Improvement SurgeryOthers Others

b) “Policy Manual-Like Documents”

Bylaws, Plans, Handbooks- Governing Board and Medical Staff Bylaws, Rules and Regulations- Employee Handbooks

Based on a particular subject matter- Corporate Compliance or HIPAA Compliance Plans- Emergency/Disaster Response Plan

Affect either the entire facility or a specific group in the facility

2. Evaluate whether or not P/Ps are put into daily practice (part of the CAH Annual Eval requirements)

3. Draft Policies You Need: Alston & Byrd Recommended Process

a) Identify criteria for when a p/p is needed When need to reinforce verbal instructions Same questions are asked by staff repeatedly Task/process/policy is critical and must be error-free Task occurs rarely, and no one remembers how to do it

b) Review the existing manuals and policy-like documents to see if already have one.

c) Develop a draft p/p: clearly mark this document as “DRAFT”

d) Conduct a trial reading (reading out loud will help you identify and clarify confusing acronyms, sentences or gaps in the procedure)

e) Obtain approvals of the draft as necessary and/or appropriate for your organization Committee and/or Department level

- don’t forget the CAH Policy Review Committee for all patient care policies (C-258, 263, 272, 334)

Administration, CEO/Administrator Medical Staff when clinical Board

f) Publish the draft to the proper user group

g) In-service the staff who will use it and trial the policy/procedure for a specific time

h) Revise the draft as needed

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i) Obtain additional approvals if necessary, publish and implement

4. Drafting Do’s and Don’ts

Use the words ‘may’ or ‘should’ (they allow deviation when necessary; this is especially important when clinical judgment is involved)

Write in the active voice (i.e., start the sentence with who is to do it)

Read the policy/procedure out loud

Test on users before final approval and/or adoption (this ensures new readers understand the intent without anyone having to explain it to them; the external reviewer on the CAH policy development team is great for this)

Write to the 8th Grade Reading Level for policies/procedures used internally

Write to the 4th Grade Reading Level for anything patients, families will read

Minimize multi-syllable words and abbreviations

use the words ‘must’ or ‘shall’ (they don’t allow deviation when it is necessary and set the organization up for failure in practice, in court and during surveys)

Don’t assume the subject of a sentence. For example:“Call the switchboard” assumes who will call; versus“The staff person finding a fire will call the switchboard” specifies who will call.

Don’t use an abbreviation or acronym without first defining it, and define it the first time it is used. Capitalize the abbreviation or acronym.

o Once defined, use the term as defined consistently throughout the rest of the policy/procedure

o When in doubt about defining a term, ask yourself if it makes the p/p easier to read, or clearer and easier to follow if you do define it (examples: defining what restrain or seclusion is; what your organization means by the term ADE)

Don’t use jargon (many readers, especially patients and families, will be unfamiliar with it and misinterpret it. Does ‘dc’ mean ‘discontinue’ or ‘discharge’?)

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When drafting policies and procedures, DO.....

When drafting policies and procedures, DON’T.....

Don’t use unreasonable time frames (they are frequently unmet and this sets the organization up for failure and liability

Don’t keep forms in manuals without telling people how to use them (if everyone knows how to use the form, remove it from the manual)

o Let surveyors ask for documentation tools that all staff are familiar with and are commonly found in the medical record

5. Drafting Pitfalls

Draft versions are not marked ‘draft’ and/or are not datedo Can accidentally be placed in manuals before ready, then used in survey or court

Use of the terms ‘standards’, ‘guidelines’, ‘protocol’, ‘policy’ without defining them first or using them interchangeably within one policy or among several policies

“Prescriptive” policies: policies that are so detailed there is no room for deviation based on professional and/or clinical judgment; liability is tremendous

o Add a statement to clinical care guidelines/protocols that says, “The clinician may deviate from this protocol when, based on his/her clinical judgment, it is in the patient’s best interest to do so.”

No regular review, revision conductedo C-0334 CAH requirement for annual review of all patient care

policies

Drafting a p/p and conducting the review aloneo C-0272 CAH policy development team

No tracking and/or retention of revisions; liability in courto A simple table works great for this

No monitoring to confirm implementationo C 0271 “evidence exists to show patients are receiving care according to

policies”o When p/p is not implemented at all, either correct the situation or remove it

6. Do You Need A “Policy & Procedures” Policy

a) Drafting a policy to clarify the process in your organization for reviewing, proposing, drafting, trialing and implementing a policy or procedure can:

Increase the consistency of the review, drafting, trialing and implementation processes

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Increase consistency among several versions of a similar policy/procedure in separate manuals

Increase defensibility and decreases liability in court Increase compliance with current law, including the CAH-CoPs

b) If you choose to develop this p/p, consider including in it:

How to draft a policy/procedure How to obtain approvals How to revise; when to review How long to retain old p/p How to conduct and document in-services

Working with departments and services, their leaders and their staff, involves two very different functions: a task function, or the actual work you need to accomplish, and an interpersonal function, that is, how you will relate to the individuals involved to get the work done. We will look at these two functions individually. The basic concepts presented here can be applied to any team or committee you work with.

I. The Task Function: establishing Measures, Benchmarks and/or Targets, and Reporting

A. The basic process we use to help departments monitor and report their performance includes:

Developing a list of potential measures, or focus areas for data collection and performance improvement

Using objective criteria to identify the “vital few” among the longer list Defining specific performance measures- numerator, denominator, and any calculations Clarifying data collection and reporting cycles Clarifying responsibilities, within the department and others’ roles

25

Working withDepartments and Services-

The Task Function

“What gets measured gets managed.But not everything that can be measured is worth managing...

And not everything that should be managed can be easily measured.”

1. Develop a List of Data to be collected: what we HAVE to collect, what we SHOULD collect, and what we WANT to collect

a) Data we HAVE to collect

SOM, Appendix W, for CAHs

o Compliance with federal, state and local laws (C-150); includes EMTALAo Staff licensing and certifications current (C-154)o Emergency Services provided (C-200)o Blood use and therapeutic gases (C-200)o Building and equipment maintenance (C-220)o Emergency Preparedness (C-227)o Life Safety (C-231)o Physicians (C-251) and mid-levels (C-263) meet their obligationso Medication Use (C-276)o Adverse drug events (C-277)o Nosocomial Infections (C-278)o Dietary department and nutrition (C-279)o Policies and Procedures review (C-280)o Ancillary clinical services and staff (C-281 through 284)o Contracted services quality (C-285)o Nursing services (C-294)o Medical records, several issues (C-300 through 310)o Surgery (C-320) and Anesthesia (C-322)o Annual CAH Program evaluation (C-330)o Effective QA Program (C-336)o CAH practice reflects policies, procedures, laws (C-335)o Quality of care improved (C-337)o Peer Review (C-339): quality and appropriateness of diagnosis and treatmento Survey deficiencies corrected (C-342)o Organ Donation (C-344)o Swing Bed Requirements met (C-350 and on)

OSHA: worker safety/incidents and workplace environment http://www.osha.gov/

Life Safety Codehttp://www.cms.hhs.gov/CertificationandComplianc/11_LSC.asp

Contracts: any area where clinical/patient care is contracted to a vendor

Liability carriers: risk management; adverse patient events

Voluntary accreditation organizations

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b) Data we SHOULD collect

CMS/QNet Exchange/CART/QIOo acute myocardial infarction (AMI)o heart failure (HF)o community-acquired pneumonia (CAP)o immunizations: pneumococcal and influenzae vaccinationso surgical care improvement project (SCIP)o Outpatient “Rural” Measure Set, potentially ready Nov 2008?

Strategic plan measures specific to your organizationo customer needs and expectationso patient careo hospital operations

National Patient Safety Agenda goals (IHI, others)

c) Data we WANT to collect

High risk processes and systems

o Emergency care, including transfer and EMTALA complianceo Obstetrics, especially C-sections and emergency deliverieso Surgery and anesthesia- operative procedureso Conscious sedation and the use of reversal agentso Non-operative but invasive procedures, therefore, nosocomial and other risks

- use of IV’s and catheters- cauterizations and incisions- invasive gynecological procedures

o Radiology procedures- echocardiograms- CT scans- MRI- thallium stress testing- other contrast media and/or invasive imaging techniques

o Medication use, all of it

High volume processes and systems

o Patient identificationo Medical Recordso Catheter useo Medication useo Special dietso Patient admission, discharge and transfer

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o Billing, coding and insurance processingo Orienting new staffo Payroll

Problem-prone processes and systems

o Complete, timely medical record documentationo Medication administration: right patient, right dose, right route, right timeo Right diet to right patient every timeo Preventing nosocomial infectionso Preventing patient fallso Preventing pressure soreso Admissions, transfers and dischargeso Accurate coding, billing and days in accounts receivable

Drill down data, areas where active improvement is underway in the facility

2. Use Objective Criteria, working as a team, to identify the “Vital Few”. Selected criteria need to work with the priorities in your organization, and might include:

It is specifically required by a regulator It is specifically required by a certifying agency It is an area specifically identified in the strategic plan or department’s goals It involves high risk patient care systems or processes It is a high volume system or process in this organization It is a problem-prone system or process in this organization It is a current focus for active improvement in this organization

PRACTICE identifying the “Vital Few” areas for data collection

CMS Strategic Plan

PIN High Risk

Problem Prone

Active Improvemt

Score

MR CompleteNosocomial infMed errorsC-section ratePatient SatisfactionFire drills doneWork orders timelyPatient Billing errorsPayroll errors

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The possibilities are almost endless...How do we choose what to measure?

3. After identifying the data collection priorities, pinpoint the exact process within the general category or system which you will monitor.

For example, if you are going to focus on medical records completion, will you monitor...

o the overall delinquency rate?o whether or not verbal orders are authenticated within 24 hrs?o if a supervising physician has signed off on the mid-level’s work?

Or, if you are going to focus on medication events, will you monitor...

o the total number of administration or dispensing errors?o the number of administration errors related to a specific drug?o the number of allergic reactions?

PRACTICE pinpointing one or two exact processes you will monitor using the table below:

Describe the Exact Process You Will Monitor

MR Completion

Med errors

Patient Satisfaction

Work orders timely

3a). Define specific performance measure for evaluating the process you are focusing on.

Performance measures generally fall into one of three types- prospective, concurrent and retrospective. This is because there is a point in time before the work process begins, the work process itself, and the outcome of that work process. Quality can be evaluated at any of point along this continuum.

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Make sure the data you want to collect for your measure is available. Beware of defining more measures than you really need to evaluate

the process or system!

Prospective Measures Concurrent Retrospectiveeducation competencies nosocomial infectionslicensure continuing ed med errors/eventsexperience daily performance patient/family satisfaction

Think carefully about the critical points in the process you want to evaluate, and use a balance of measures to help you get the ‘big picture’ in general, ensuring quality is going into and is coming out of your process and systems, and to appropriate ‘drill down’ or focus, on a specific step in the process which you want to examine closely.

Performance rates are frequently used for measuring and reporting performance because they allow us to compare our performance with others. This requires doing some kind of math calculation. However, when very small numbers are involved, it may be just as useful simply to collect and report the number of occurrences of an event.

PRACTICE defining performance measures using the table below:

Exact Process Numerator Denominator Any Calculations

MR Completion

Med errors

Patient Satisfaction

Work orders timely

3b) Define Benchmarks, Targets and/or Desired Performance Levels

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Nurse applies for a job

Patient experiences care and consequences

Nurse provides patient care

Once you have defined your performance measures, data collection can begin. But after all of the data ‘is in’, how can you tell whether your organization’s performance meets expectations or not? You need an objective way to evaluate your performance - you need a performance standard to assess your data.

A benchmark is a performance level we use when comparing ourselves with someone else. If it is an internal benchmark, we are comparing performance among units in the same organization. If it is an external benchmark, we are comparing performance with units or organizations outside of our facility. A target is simply the level of performance we want to achieve. It can be set independently of the performance of any other unit or organization. We often establish target performance levels when benchmarks are not readily available.

One notable exception to all of this is seen in quality control activities. When a licensing agency or the manufacturer of a product or piece of equipment states that, in order to ensure proper function, the product or instrument must operate within a specified range of values, you must use those values, called control values, for the performance standards in your organization.

Sample external benchmarks you might be familiar with include:

Medical Record delinquency rate: 0% (CMS) Fire Drill Completion as required: 100% (NFPA, Life Safety Code) Adverse drug events: less than 2% of all drugs administered (CMS, nursing homes) Nosocomial infection rate: less than 5% of nursing home admissions (CMS) Patient satisfaction survey: willingness to recommend your facility to others >/= 85% AMI: 100% of patients receive aspirin within 24 hrs of arrival (CMS) HF: 100% of discharged patients receive all of the required education

Sample targets you might set internally could include:

Maintenance work orders are completed within 3 days of receipt Employee performance evaluations completed within 14 days of due date 75% of more of the medical staff are Board-certified Reduce the amount of wasted food by 10% Proposal for a new service line to be developed completed within 30 days

Sources for benchmarks include:

CMS, especially the State Operation Manuals and their defined quality measures Mountain Pacific Quality Health, the MT QIO www.mpqhf.org Centers for Disease Control and Prevention (CDC) www.cdc.gov Institute of Healthcare Improvement (IHI) www.ihi.org Agency for Healthcare Research and Quality www.ahrq.gov Assoc of Peri-Operative Registered Nurses (AORN) www.aorn.org Assoc for Professionals in Infection Control... (APIC) www.apic.org Reference literature for the discipline/department/service under study PIN Benchmarking and Clinical Improvement Studies projects

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Other individual healthcare organizations that are similar to yours A larger group of healthcare organizations of which yours is one member

While benchmarks and targets can be established and/or adjusted after the data is collected, it tends to keep us more honest in our assessment of performance if those values are established before data collection begins.

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PRACTICE setting benchmarks or targets for the performance measures you identified above using the table below:

Exact Process Performance Measure Target/Benchmark

MR Completion

Med errors

Patient Satisfaction

Work orders timely

4. Clarify Data Collection and Reporting Cycles

a) Like performance measures, data collection can take place at any point along the continuum of the work process or system under study. Therefore, data collection can be prospective (before the work happens), concurrent (while the work is underway), or retrospective (examining what happened after the process is completed). For example:

Prospective Collection Concurrent Collection Retrospective Collectionwhat do we have what is happening review the MR after thein place to care while the patient patient is dischargedfor the patient is in the bed to see what happened

Think carefully again about the critical points in the process you want to evaluate, and at what point(s) in the process you might want to intervene to improve outcomes for the patient. If all of your data collection occurs retrospectively, even though you can make improvements to change the outcome for subsequent patients, you do not have the opportunity to change an outcome for any patient up to the point of data collection/review. If some of your data collection is concurrent, you do have the opportunity to change outcomes for individuals currently receiving care.

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Planning for the care of heart failure patients

Outcomes achieved for the heart failure patient

Heart failure patient admitted and receives care

b) Factors influencing both data collection and reporting cycles for a measure include:

How stable, or volatile, the process (the higher its volatility, the greater the risk) Whether the process simply being monitored or is under active improvement Who the end users of the data are (Board, Admin, med staff, managers, staff, public) How often the end users meet (daily, weekly, monthly, quarterly, annually) How accessible the data is Additional costs required to collect or report the data (like patient satisfaction data)

General guidelines to consider for data collection and reporting cycles are shown below:

Process under study is... Collection Cycle Report Cycle

Highly volatile, high risk weekly weeklyActive improvement, high volume weekly weeklyActive improvement, low volume monthly, quarterly monthly, quarterlyStrategic monthly, quarterly monthly, quarterlyModerate risk quarterly quarterlyLow risk, stable semi-annually, annually semi-annually, annually

You can use a simple table to help clarify data collection and reporting cycles:

ED & Medical RecordsPerformance Measures Risk Level End Users Collection

CycleReportCycle

Provider arrives within 30 minutes of notification active imp CEO daily weekly

Verbal orders authenticated survey defic, POC

admin, med staff monthly quarterly

MR Delinquency stable, mod risk

admin, med staff quarterly quarterly

conduct HIT assessment for eMR in 2010 strategic admin, board semi-ann semi-ann

PRACTICE clarifying the data collection and reporting cycles for the performance measures you identified above using the table below:

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The Process Risk Level End Users Collect Cycle Report Cycle

MR Completion

Med errors

Patient Satisfaction

Work orders timely

5. Clarify Data Collection and Reporting Responsibilities

It is important to clarify who will collect which kinds of data in order to:

Actively engage as much of the staff in performance improvement as possible Maximize coordination and efficiency throughout the organization Minimize duplication of effort Ensure timely and consistent performance reporting Enable individual or group

Factors to consider when assigning data collection and reporting responsibilities include:

Where is the data located Who has easy access to it Who attends the end users meeting where the data will be shared/reported Your role as spokesperson in the facility for the PI Program

You can use a simple table again to help clarify data collection and reporting responsibilities:

PerformanceMeasures

Data Source/Location

Access & WhoCollects End User Who Might

Report

Gross margin financials CFO Board, Admin, managers CFO

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Provider arrival within 30 min of notification ED record Nursing Nursing, MS,

Admin DON

MR delinquency rate medical records MR staff MS, Admin,Board

MR Dir, PI Coor

___________________________________

II. The interpersonal function of working with departments and services is all about how you will relate to the individuals involved to get the work done. It involves motivating and encouraging others as well as effectively managing the conflict that inevitably arises between individuals so that the output of the group or team is actually enhanced, rather than diminished. The basic concepts presented here can be applied to any team or committee you work with.

A. Motivating Departments and Managers: “What’s in it for me?”1

A dynamic speaker I once heard impressed upon his audience that in order to get others to do what you need or want them to do (whether spouses, children, volunteers, co-workers, administration or medical staff), you need to provide them with an answer to the question, “What’s in it for me?”

Furthermore, you need to provide the answer in a way that makes sense to the one asking it. Sounds easy enough, but it quickly becomes complex when we remember that human beings are individuals, and what makes sense to one person doesn’t make any sense at all to another. It follows that what motivates you and me may not be the same as that which motivates the folks we work with in our organizations. Study the people you are working with and try to identify what motivates them individually. Think creatively, ‘out of the box’, to engage them there if possible.

B. Managing Conflict

Wherever two or more are gathered together, there will be conflict. This is true simply because we are all individuals, with different personalities, life experiences, needs and core beliefs which mold the perspective we bring to the table when we meet with others to do work. No two of us

1 Dr. Joe Bujak, Champions for Quality Conference, 2006, Big Sky, MT.

36

Working withDepartments and Services-

The Interpersonal Function

believe, think, choose, speak or act on every issue exactly as any other human being. These differences generate conflict between us, the rubbing together of our different beliefs, thoughts, needs, ways of expressing ourselves and behaving.

Conflict can be constructive, or ‘functional’ as it is sometimes called. It can enlarge our understanding and appreciation for others and for complex situations. It can be an avenue for great creativity, and the synergy of several minds and personalities working in harmony to achieve together more than any one person can achieve alone. In performance improvement, we want to maximize functional conflict, developing an atmosphere of the respectful and creative interchange of ideas in an emotionally safe environment to achieve a common vision or goal. Clues that constructive conflict is present include:

All members share equally and respectfully different points of view and passionate beliefs

All members share equally the work of making the team successful Competing goals are clearly and plainly acknowledged without judging one another There are no ‘taboo’ work processes, departments or services Unique, creative solutions to problems are identified The group’s primary decision-making method is consensus, or a win-win-outcome, and

all members can honestly ‘live with that’ decision Mutual understanding, appreciation and respect are enhanced

Conflict can also be destructive, or ‘dysfunctional’. It can rip apart and destroy individuals, teams, families, organizations and nations. It undermines trust, honest communication, collaboration and therefore quality and genuine, long-lasting improvement. Dysfunctional conflict is present when the atmosphere is ‘not safe’ for the free, respectful and creative interchange of ideas. Clues that dysfunctional conflict is present include times when:

only one or two people are the primary contributors to the discussion members compete for control of the group, discussion and/or processes under study ideas or suggestions offered are not given thoughtful consideration but are immediately

rejected aggressive displays of authority, control and/or manipulation are accepted some members do not actively participate, failing to share the information they have no discussion is allowed about certain work processes, departments or services members routinely interrupt or cut each other off opinions that are offered or presented as facts are not respectfully questioned “win-lose” decisions are frequent and accepted; the prevailing attitude is, ‘live with it’ Most decisions are made by the individual present with the most organization authority

When your role in your organization requires that you work with others either one-on-one or in a group, you will be faced with managing conflict. This is a skill to be developed; it takes time and practice. The ultimate goal is to manage the conflict as well as possible so that all can achieve the best outcome from the work possible. In general, you will want to be aware of the

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Tips for Managing Conflict Constructively

atmosphere the work is taking place in. Watch for constructive, functional conflict and encouraging it while minimizing the dysfunctional, destructive forms of conflict. Here are some tips and tools for conflict management:

Clarify team roles and responsibilities (see previous section) Evaluate team and program effectiveness regularly Conduct one on one interventions with purposely disruptive members

Encourage the team to establish a set of ‘team rules’ that describe how the team will work together, such as:

o We will treat each other with mutual respect at all timeso All team members will contribute, all will listen respectfully to otherso Differences of opinion, perspective, and passion are desirable and can be

expressed freely hereo “What we say here stays here”o Titles are left at the door, all are equal hereo We will focus on process, not changing peopleo We will make data-based, objective decisionso Our primary decision-making method will be consensuso This meeting has value & is important; minimize outside interruptions using the

“100 mile Rule”o We will respect each other’s time by

- Complete between-meeting work assignments- Starting and ending each meeting on time- Reviewing minutes and reports prior to meeting

Use a team facilitator, because he/she...o Has a sole interest of getting to the best decisionso Focuses on how the team is working togethero Has no vested interest in any particular decisiono Can help keep discussion focused on the current topico Tactfully stops side conversationso Tactfully prevents domination of the discussion by one or a few memberso Stops the task work when dysfunction conflict is building and helps work out the

interpersonal side of the team’s worko Encourages members to deal honestly and respectfully with interpersonal conflict

I. Data Collection Tools There are many kinds of data collection tools, electronic and non-electronic. Some of the more common tools we use to collect data in our work include:

38

Data Collection, Aggregation and Assessment

A. Logs or check sheets are the simplest tool and the fastest to set up for data collection

B. Table (matrix) is a great tool for many QA activities, and is more efficient than several log sheets if you are collecting data on related measures from same source

Case # H & P Nursing Assessmt Care Plan DC Summary1 √ √ √ √2 √ √3 √ √ √4 √ √

C. Dot Plots are great for collecting the same data over a long period of time, good for QC

Medication Room Refrigerature Temperatures

34

34.5

35

35.5

36

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15Day

39

Case # H & P on MR in 24 hr1 √23 √4

D. Surveys standardized question and answer form to collection input about satisfaction, needs, experiences and/or opinions

Yes NoMy provider answered all of my questions. √My pain was well- managed. √My nurse was compassionate and caring. √

II. Data Aggregation and Assessment

Hospitals are great at collecting data as part of their quality/performance improvement activities. Unfortunately, all too often, the effort stops there, and the collected data is never turned into information the organization can use to improve . The primary reasons for taking the additional steps of data aggregation and assessment are:

To increase the usefulness of raw data by turning it into information To help make it ‘actionable’, i.e., to enable a decision based on the data To identify areas where other or more data needs to be collected To provide objective information as the foundation of objective decision-making

The data aggregation and assessment steps of quality/performance management should always end with a decision about how to go forward from where the data tells you that you are. Ultimately, this supports the organization in its efforts to achieve its mission and vision.

Data Aggregation

To aggregate simply means to gather or collect things together. When we aggregate data, we are grouping like-kinds of data together into what is called a data set. This process can begin at the same time data collection begins and, in fact, the same tools which are helpful for collecting data can be helpful for aggregating data- log sheets, tables and simple graphs.

For example, what is the primary difference between the two data sets showing wagon colors below?

Data Set A: yellow Data Set B: bluegreen blueblue bluered greengreen greenblue redblue yellow

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Can we determine if the color variation present is “significant”? Can we draw overall conclusions from Data Set B? Can we take constructive action based on it? If our data represents a sample, what can we say, or infer, about the rest of the

group (“population”) based on our aggregated data?

Data Assessment Techniques

Review the questions about our aggregated data above. The techniques developed for data assessment strive to answer one or more of those questions in a valid, objective way.

Two common approaches to data assessment in quality/performance improvement are:

Mathematical and/or statistical analysis of raw numberso Calculate rateso Calculate percentageso Calculate frequency or relative frequencyo Calculate the rangeo Calculate the average (mean) valueo Calculate the median, quartile and decile values

* see the appendix of sample tools for instructions for calculating these values.

Construct charts and graphso Apply limits for evaluation

- control limits, upper and lower- Threshold: a point at which we will intervene- Benchmark: a point we want to achieve

o Look for trends and relationships among data pointso Evaluate the variation between individual data points or points in a series

Is the variation normal? Record, but leave it alone.Example: normal body temperatures, pulse rates, blood pressures

Is the variation not normal? Take action to reduce or remove it.Example: treat elevated body temperature to reduce it.

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We have successfully aggregate the data in set B by grouping like colors together. But what do we know so far about the value or importance of the data we’ve collected?

Making valid statements of this kind is the work of data assessment.

Common cause and Special Cause Variation- The Standard Normal Curve

42

Glucose Control Values

86

88

90

92

94

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Day

mean

- 3 SD

+ 3 SD

If know what ‘normal’ looks like, you are able to....

Identify outliers: unusual, unexpected process/system events Evaluate the relative severity or importance of variation when multiple factors contribute Identify improvement when it happens, and work to maintain gains

Common Cause Variation: The expected variation inherent in any process due to the normal interaction of the process variables.

Special Cause Variation: The unexpected variation in the process due to a specific cause or causes. Sometimes called ‘significant’ variation.

Westgard Rules for Interpreting Control Charts www.westgard.com/mltirule.htm

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Normal Distribution

456789

10111213

1 2 3 4 5 6 7 8 9 10 11 12 13

Series1+3 SD- 3 SD

mean

1 Point Outside Control Limits

456789

1011121314

1 2 3 4 5 6 7 8 9 10

Series1

+3 SD

- 3 SD

mean

Even and varied distribution of points on both sides of the mean, all within control limits; common cause variation; the process is said to be ‘in control’ and/or ‘stable’.

1 point exceeding the upper or lower control limit is special cause variation

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2:2 SD Rule

456789

10111213

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Series1

UCL

LCL

mean

2 consecutive points greater than or less than 2 SD; special cause variation

1:4SD Rule

456789

10111213

1 2 3 4 5 6 7 8 9 10 11 12

Series1+3 SD- 3 SDmean

Change of 4SD up or down is special cause variation

1: 3SD Warning, Cross Center Line

456789

10111213

1 2 3 4 5 6 7 8 9 10 11

Series1

+3 SD

- 3 SD

mean

Change of 3SD crossing the center line; special cause variation may be present; investigate

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6 Points on One Side of Mean

456789

10111213

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Series1UCLLCLmean

6 consecutive points on one side of the mean is special cause variation

7 Point Trend, Ascending or Descending

456789

10111213

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Series1

UCL

LCL

mean

Sawtooth

456789

10111213

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Series1+3 SD- 3 SDmean

7 consecutive ascending or descending points is special cause variation

A sawtooth pattern is not normal, it is special cause variation

Resolving Data Quality Issues

Question about the validity of the data you have collected and are presenting, as well as the conclusions you draw from them, frequently come up in hospitals. You need to be able to answer the questions about whether or not the collected data is accurate and reliable.

Given the standard normal curve and our previous discussion about normal variation, it is safe to assume that no data are 100% accurate, nor 100% reliable. Some amount of variation will be present. How do we account for that expected variation but have a way of determining whether or not the data are accurate enough and reliable enough to act on?

Statisticians calculate confidence intervals (CI) , based on the standard normal curve, to mathematically express how confident you can be that the data values are the true values and that repeated measurement under the same conditions will produce the same results. They might include in their work a statement like, “We can be 95% confident that the results represented by these data demonstrate special cause variation (or ‘significant’ variation’) is present.”

Sample size can be a significant source of variation which we need to control in order to ensure our data is both accurate and reliable. Here are some sampling guidelines that will help you ensure your data is accurate and reliable, as well as the conclusions you draw from them:

30 data points approximates the standard normal curve, so try to have 30 data points For a population greater than 30, sample 30 randomly, or at least 10% of the population For a population less than 30, collect data from the entire population Never use less than 10 data points unless that is 100% of the population

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Accuracy is the term we use to express the precision of data; in other words, how close is the measured value to the true value?

Reliability is the term we use to describe whether or not repeated measurements under identical conditions produce the same results.

Remember: Data for QI/PI needs to be actionable, but not as rigorous as for a scientific study.

QI/PI Coordinators always seem to be looking for more effective ways to report organization performance. Effective in this situation seems to mean:

providing the right information... at the right time.... to the right people... in the right way, one that catches their attention, makes sense to them and motivates the

action needed or supports the decision that needs to be made

This appears to be true even in the arena of public reporting of performance, through CMS or another voluntary public reporting initiative. In those cases, we want our performance to convince CMS that our performance meets pre-established standards of care and is of high enough quality that they should pay us for providing it! In general, then, performance reporting:

Provides an objective basis for sound decision-making Leverages improvement by increasing team knowledge and understanding Helps focus the organization on improvement and helps maintain that focus Encourages a proactive response to opportunities for improvement Encourages a positive organization culture of shared knowledge, unity, continuous

learning, the free exchange of ideas, ownership of outcomes, the celebration of successes and improved morale

There are, however, some common pitfalls related to performance reporting, including:

Reporting only to meet regulatory standards The introduction of bias into the data and/or its analysis Rushing to make decisions before the data is adequately investigated, assessed and

understood Using the data to blame or shame others, to increase resistance to needed change, pitting

one group against another

Providing the right information: The right information:

Is objective, unbiased Contains the appropriate level of detail Is relevant to the audience (i.e., those who will receive it)

o relevant to their role in the organizationo relevant to their span of control, scope

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4 R’s for Performance Reporting

o relevant to the decisions they have to makeo relevant to the questions they haveo relevant to the questions from others they have to answer

Reporting at the Right Time

When they can listen uninterrupted, free from distractions In time to do something with the information Length of the report is proportional for the time available

Reporting to the Right Audience (those who can do something about the information presented)

Staff Managers Senior leaders The Quality Management Team Medical Staff Governing Board Others: community, regulators

Reporting the Right Way: attitude and style

Focus on process and system opportunities, not people as the problems Format considers the way they prefer to receive information Format focuses the audience to the points they need to notice Language they can understand while learning QI/PI vocabulary

Report Formats

“A Picture Speaks a Thousand Words”

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49

PRACTICE evaluating the strengths and weaknesses of the following common QI/PI reports:

1. Verbal or written: Strengths: Weaknesses:

“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.”

2. A table or matrix Strengths: Weaknesses:

J F M Q1 A M J Q2

Mortality Rate 2.0 2.5 2.2 2.2 3.5 2.7 2.5 2.9

ADE’s 1 1 2 2 3 2 4 3

NIR’s 0 1 0 0.3 1 3 2 2

Customer Satisf 85 86 85 85 82 79 80 80

Turn-over rate 0 1 0 0.3 3 2 0 1.3

3. Table or matrix with highlighting: Strengths: Weaknesses:

J F M Q1 A M J Q2

Mortality Rate 2.0 2.5 2.2 2.2 3.5 2.7 2.5 2.9

ADE’s 1 1 2 2 3 2 4 3

NIR’s 0 1 0 0.3 1 3 2 2

Customer Satisf 85 86 85 85 82 79 80 80

Turn-over rate 0 1 0 0.3 3 2 0 1.3

4. Table or matrix with color coding (dashboard): Strengths: Weaknesses:

J F M Q1 A M J Q2

Mortality Rate 2.0 2.5 2.2 2.2 3.5 2.7 2.5 2.9

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ADE’s 1 1 2 2 3 2 4 3

NIR’s 0 1 0 0.3 1 3 2 2

Customer Satisf 85 86 85 85 82 79 80 80

Turn-over rate 0 1 0 0.3 3 2 0 1.3

5. Graph with thresholds, benchmarks Strengths: Weaknesses:

6. Histogram, Bar Graph Strengths: Weaknesses:

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Adverse Drug Events

01234

J '06 F M A M J

Nosocomial Infections

7. Spidergram Strengths: Weaknesses:

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

Nothing helps ease the anxiety and tension often associated with regulatory surveys like being prepared for them. The more you know about how well your organization is prepared for a survey, the more relaxed you will be during the survey, and in general, the less surprised you will be with the findings.

You may need to prepare for several types of regulatory surveys:

State Licensure survey CAH Medicare Certification survey State Investigation of Complaint survey Life Safety Survey OSHA survey

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A Few Tips for Surviving Your Regulatory Survey

Voluntary certifications surveys, like Joint Commission or ISO 9000

Become very familiar with the surveys you should anticipate in your facility. If your organization provides long term care, home health, hospice, rural health clinic or other services, clarify your responsibilities for those surveys. Find the results of the last survey(s); note the date and findings of that survey.

Start a survey prep calendar. For State and Medicare certification surveys, there should be no more than 3 years in-between surveys. Estimate when you should expect to see these surveyors in the facility. A Life Safety survey will be conducted at or around that same time.

6-12 Months Prior to Estimated Survey: gather together the heads of the departments identified in the survey manual to serve as a survey prep team. As a group, read through each of the conditions of participation and survey tags in the manual (it also works to rotate department managers in and out of a team of senior leaders as you work your way through the standards). . Using a table, clearly identify how you are meeting each standard. If you don’t know how you are meeting it, find out and record it. If you aren’t meeting it, develop and implement a plan for doing so immediately, including who will be responsible for implementing the plan and the expected date of completion. Meet weekly until all survey standards have been reviewed.

Review the results of the last survey with your team. Verify that all deficiencies have been corrected and corrections are being maintained. Add any deficiencies to your table.

Work with members of maintenance and/or the Safety Committee to ensure all Life Safety and Emergency Preparedness requirements are being met. Verify all fire and emergency drills are being conducted, all fire wall penetrations have been fixed, all fire extinguishers are tested, all medical gas valves are tested, all ceiling tiles are in good condition, and all fire doors close properly. Develop plans for correcting any deficiencies noted.

3-6 Months Prior to Estimated Survey: meet again with your survey team. Revisit each of the standards and verify that all standards are now being met. If they are not, develop and implement a plan for meeting them immediately. Follow up on all Life Safety requirements for which you developed a plan of correction (above). Verify that all medical records are complete. If there are delinquencies, work with medical staff and the administrator to get delinquent medical records completed.

1-3 Months Prior to Estimated Survey: meet again with your survey team. Revisit each of the standards and verify that all standards are now being met. If they are not, develop and implement a plan for meeting them immediately as well as a plan for discussing the deficiency when your surveyors come onsite. Follow up on all Life Safety requirements for which you developed a plan of correction (above). Do a walk-through of the kitchen to verify cleanliness; ask managers to check all cupboards, under-sink storage areas, refrigerators and other storage areas for outdated supplies and ensure all are discarded. Ask managers to ensure all QC records are current and have been reviewed/signed off by them. Verify that all medical records are

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complete. If there are delinquencies, work with medical staff and the administrator to get delinquent medical records completed. Verify that all staff, including night staff, are prepared to answer surveyors’ questions. Provide scripting as needed.

Clarify prior to survey the process for how the organization will respond when the surveyors do present themselves. Include in the discussion:

Who will announce the surveyors’ arrival; helps to script what should be said (“--- welcomes....”

Who will attend the opening conference Who will attend daily briefings Who will substitute for the administrator should he/she be absent at time of survey Where you will locate the surveyors in the facility (near phone, copy machine, rest

rooms) Who will accompany surveyors when they visit patient care areas (never let them go

alone) Who will take notes about surveyors comments, questions as they visit patient care areas Who will respond to surveyors’ requests for additional information/documentation during

the survey A process for providing the surveyors fresh beverages throughout the day, including

water and coffee. Consider providing light morning and afternoon snacks as well. Whether or not you will provide surveyors’ meals while onsite. If you plan to do so,

clarify that process.

Survey Etiquette

Be polite, courteous and helpful at all times Never argue with the surveyors; if you think they are wrong, produce documentation that

demonstrates how you are meeting a standard in question Refrain from volunteering information unless it demonstrates how you have met a

standard well; attempt to answer questions truthfully without leading the surveyor to potential problem areas

If you don’t know the answer to a question, don’t fake it. Refer the surveyor to someone who can answer their question

Continuous Readiness is ultimately the best preparation for survey. Throughout the year, regularly review your facility’s performance in correcting past deficiencies and maintaining those corrections. Review with your team standards changes and proposed revisions, planning well in advance if possible how your organization will respond to those changes. Keep “survey preparation” on your quality management team’s agenda on at least a quarterly basis. Consider including problem areas in your CAH Annual Evaluation Work Plan for closer monitoring.

CAH Annual Program Evaluation Guidelines

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I. Requirement: CoP §485.641; Tag C-0330: Periodic evaluation and quality assurance review.

II. Purpose: to determine if the utilization of services was appropriate;to determine if patient care policies were implemented;to determine if any changes are needed.

III. Process:

1. “Periodic” means at least once a year. However, portions of the review can be conducted in an ongoing fashion throughout the year and the results presented at the annual evaluation meeting. Two good examples are using an ongoing approach to the review of active closed records, and for required policies review, revision and approval. You can shorten the time required to conduct the annual evaluation meeting when these two elements are conducted throughout the year and only the results are presented during the evaluation meeting.

2. “Total program” means all of the departments and services affecting patient care, health and safety (C-0337).

a. The review should not be limited to purely clinical departments and services. Services traditionally considered to be “non-clinical” that affect patient health and safety include human resources, the environment of care including laundry services, materials management or purchasing, information management, medical staff appointment and privileging, and others.

b. At a minimum, the evaluation must include:

The utilization of services: this includes the types of services provided, the volume of those services, and the number of patients served. Examples: # inpatients, swing bed patients, surgeries, deliveries, observation patients, ER visits, outpatient visits, etc.

A representative sample of both active and closed clinical records: surveyors will look to make sure a minimum of 10 % of active and closed records for each service provided are reviewed. If you provide emergency, inpatient and outpatient services, they will want to see you have reviewed 10 % of your emergency cases, 10 % of your inpatient services, and 10 % of your outpatient cases.

3 Notes about reviewing clinical records:

* the 10% review requirement is for your physician providers’ cases.

* A clarification issued by CMS in May 2005 states that 100% of the inpatient care provided by mid-levels must be reviewed (this includes physician assistants and advance practice nurses).* For Outpatient midlevel cases, if the provider is a mid-level licensed by the State to practice independently of physician oversight, 25% of their outpatient cases may be reviewed rather than 100%, In Montana, nurse practitioners and other advance practice

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nurses are allowed to perform their duties independently. Physician assistants are not licensed to practice independently, therefore 100% of their outpatient cases must be reviewed by the physician.

The review and revision as needed of patient care policies: these policies include all patient assessment, treatment and documentation policies or procedures, regardless of the provider of those services (medical staff, nursing, surgery, lab, radiology, dietary, therapies, medical records, etc.).

3. From the discussion that takes place during the evaluation, generate a work plan identifying needed changes and the mechanisms for making those changes, i.e., a plan for improving the CAH’s performance over the next 12 months. Present this work plan to the quality management team and Board of Directors for review, revision as needed, and approval. This is an important step in building consensus and cooperation, focusing and aligning the organization’s improvement efforts and obtaining needed resources for making improvement.

4. Implement the CAH Program improvement plan over the next 12 months. Monitor and report progress at least once a quarter throughout the year. At the end of the year, assess progress and the effectiveness of the organization in implementing its improvement plan as part of the CAH Annual Evaluation.

5. Participants:

a) The annual evaluation should be conducted by the organization’s senior leadership. At a minimum, include the chief executive officer/administrator, a physician, a mid-level provider, nursing leadership and the quality management director/coordinator. Other leaders and/or staff may be invited to participate as the organization desires, either ad hoc or as a member of the evaluation team.

b) If the organization’s patient care policy review is conducted as a single meeting and as part of the CAH Annual Evaluation meeting, a physician, a mid-level provider and an individual who is not a member of the CAH staff must all be in attendance (see tag C-0272).

c) When possible, invite a member of the Board to participate in the evaluation process and report to the Board the evaluation outcomes. This further aligns the mission, vision and goals of the organization and builds collaborative effort and cooperation.

d) Consider inviting a member of the community to participate in the evaluation if your organization is striving to improve patient/family/community satisfaction and/or developing and implementing patient-centered care models.

III. Maximize the effectiveness of your annual program evaluation:1. Conduct your annual CAH program evaluation as part of your larger annual performance

improvement program evaluation.

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2. If your organization provides long term care, home health care, hospice care, assisted living or any other non-hospital setting services, conduct all of your evaluations at the same time.

3. If possible, schedule your annual evaluation to be conducted two or three months before your organization’s budget cycle begins. Request resources identified as being needed in the annual evaluation process in the next operational and/or capital budgets.

4. Develop strategic vision. Incorporate objectives from the organization’s strategic plan into the annual CAH Program evaluation, CAH Program work plans for improvement and performance monitoring processes.

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