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Armstrong Institute for Patient Safety and QualityJill A. Marsteller, PhD, MPPSept. 27, 2012Assessing Process and Audit Measures The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011Learning ObjectivesYou will be able to:Explain why measuring process is critical to successDescribe process measures planned for collectionDetail the planned collection process2Donabedian ModelStructureProcessOutcomeHow we organize careWhat we do during care deliveryThe results we achieveE.g., presence of policies or committeesE.g., how often are evidence-based interventions performedE.g., how/ how many patients are harmed3Approaches to measuring processMeasures of perceptionAccessibleSubject to biasRegular process measures collection (audits)More objectiveBurdensomeLess frequent auditingLess burdensomeLess reliable4Process measures you already collectSCIP/STSAbx selectionAbx timingAbx stop w/in 48 hoursGlucose measure Hair removal 5New Measures/ Audit TopicsVAP process measures:E.g., HOB elevationE.g., sedation vacationSSI: Skin prep (type, appropriateness)Antibiotic redosingCLABSI: Insertion (OR, ICU)Maintenance (ICU, Floor)CUSP:Daily goals; AM Briefing; LFD (ICU, Floor, universal)Briefing/debriefing ; Huddle; LFD (OR)

6Timeline-ORAug 2012SepOctNovDec2012Jan 2013FebMarAprMayJunJul2013CLABSI Audit InsertionXXXSSI Audits Skin Prep, Abx RedosingXXXCUSP AuditsDebriefLFDBriefHuddleDebrief

LFD7Timeline-ICU & UniversalAug 2012SepOctNovDec2012Jan 2013FebMarAprMayJunJul2013CLABSI Audit - InsertionXCLABSI Audit MaintenanceXXVAP ProcessXXXXXXXXXXXX CUSP AuditLFDDGsAMBLFD8Timeline-FloorAug 2012SepOctNovDec2012Jan 2013FebMarAprMayJunJul2013CLABSI Process MaintenanceXXXXCUSP AuditsLFDDGsAMBLFD9Audit data: How ToThe timeline will tell you what to audit for the coming monthCollect data once a week and report at end of monthMethods: Observations; counts with measure/ count total eligible; answer QsWhen you enter web tool, it will tell you what audit data is due this month Web-based data entry forms 10ExamplesDaily Goal AuditOnce weekly count the number of patients that had a Daily Goals sheet filled for them during interdisciplinary rounds; also count total number of patients. Report: DG patients and totalLFD AuditCount number of defects worked on in last quarter; number resolved; number posted; number evaluated for effectsAM Briefing /Huddle/ OR Briefing/ Debriefing Auditobserve XX opportunities for briefings; Report: number of briefings conducted and number of opportunities11How process measurement helps youCompliance is key to providing evidence-based practiceEBP allows you to meet your outcomes goalsProcess measures provide a map to whats working well and whats notRegular feedback on performance essential to performance and buy-in (transparency)Use your data to inform, motivate, communicate laterally and upward 12Example: Central Line Maintenance Audit Tool

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14Portal home page.14Armstrong Institute for Patient Safety and Quality15

15You will need to log in to use the next few links. My projects takes you to your projects.15

16Your project will be bright and other Armstrong Institute projects will be greyed out.16Armstrong Institute for Patient Safety and Quality17

17My Tools takes you to your data entry tools.17

Armstrong Institute for Patient Safety and Quality18A list of data collection tools applicable to your facility/unit will be shown.18Armstrong Institute for Patient Safety and Quality19

19Click the tool you would like to enter data for.

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20Begin data entry.

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21You will have the option to Save and Finish Later or submit your data by clicking Continue.

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22Processing may take several moments.

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23A snap shot of data entry will be provided.

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24Click on Continue to proceed to the next data entry period.24Action ItemsTry out our new site!Set up new membersBegin data entry for:RatesTCTAudits

Contact us at csts@jhmi.edu for support.

Training for Surveys, VAP Daily Process Forms, Reports, and additional features are upcoming.2525