cphq review course nov 28-29 2012

8/10/2019 CPHQ Review Course Nov 28-29 2012

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CPHQ Review Course

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This course is designed to help focus the study efforts of candidates planning to take the Certified Professional in Healthcare Quality (CPHQ)

examination.Completion of a NAHQ CPHQ Review Course product does not guarantee a passing grade on the CPHQ examination.

Copyright 2012 by the National Association for Healthcare Quality. All rights reserved. No part of the product, nor any part of electronic files, in part

or in whole, may be reproduced or transmitted in any form to anyone other than authorized users, including transmittal by e-mail, file transfer protocol

(FTP), or by being made part of a network-accessible system, without the prior written permission of NAHQ. Users shall not merge, adapt, translate,

modify, rent, lease, sell, sublicense, assign, or other transfer any of the product, or remove any proprietary notice or label appearing on any of the product.

Any violation of this Agreement is cause for revocation of this license.

Agenda Introduction Review of handouts

-

Foundations, techniques, and tools

Information management

Using Data For Improvement: The Toolkit

Strategy and leadership

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Continuous readiness

Change management and innovation

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Crosswalk (Exam Content and Q Solutions, 2nd ed.) Content outline included in Candidate

Examination Handbook

Healthcare Quality Certification Commission(HQCC)

Percentage of questions included from eachsection

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Page numbers where information is found

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and Test-Taking Tips

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About the CPHQ Exam

Computerized comprehensive, job-related,objective test

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Distribution of questions

- Recall 32%

- Application 50%

-

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About the CPHQ Exam Application questions test ability to interpret orapply information to a situation.

,

problems, or integrate a variety of information or

judgments into a meaningful whole.

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About the CPHQ Exam

Questions are written by practitioners in healthcarequality management and case, care, disease,

, .

Test content covers important aspects of the

healthcare quality professionals job.

Content is based on an international practice

anal sis.

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About the CPHQ Exam Each question on the test relates to one of the taskson the CPHQ Exam Content Outline.

quality management professionals.

The tasks are significant to practice in the major

types and sizes of healthcare facilities and

organizations, including managed care.

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About the CPHQ Exam

Management and leadership- 28 questions (22%)

n orma on managemen

- 30 questions (24%)

Performance measurement and improvement

- 47 questions ( 38%)

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- 20 questions (16%)

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About the CPHQ Exam Deleted through 2012 and reinserted beginningJanuary 1, 2013-

- National Committee for Quality Assurance (NCQA)

- Regulatory information

- Health Insurance Portability and Accountability Act

(HIPAA)

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- Patient Safety

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Test-Taking Tips

Calculators are allowed. (Candidate Examination Handbook, p. 8) Answer questions you are comfortable answering.

Pass over t ose or w c you raw a an .

On the actual test, a check box allows you to

return to skipped questions.

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Test-Taking Tips Read carefully for words such as except, not, andleast.

.

Anticipate the answer, and then look for it.

Consider all alternatives.

Exclude obviously wrong answers.

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Test-Taking Tips

Relate each option to the question. Balance options against each other.

Use og ca reason ng.

Choose answers that contain words you know.

Watch your time, and pace yourself.

Dont be distracted by others taking the test.

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Remember that there is no penalty for guessing.

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Scheduling the Test You can apply online at www.goamp.com. If eligibility is confirmed, you can proceed to

.

Eligibility to take the test is valid for 90 days.

Appointments can be scheduled online 24/7.

You can take the test within a week.

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est ng t mes are am an : pm.

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Day of the Exam

Relax the night before. If you dont know thematerial by then, you dont know it.

H&R Block offices.

Allow plenty of time to travel to the testing center;

plan to arrive 30 minutes early. (Candidates arrivingmore than 15 minutes after the scheduled testing time wont be

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a m tte an w nee to pay t e ee aga n to ta e t e test.)

Allow yourself 3 hours to take the exam.

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Day of the Exam Bring two forms of ID (one a legal government-issued photoID and one verifying name and signature).

,

photograph using the computer terminal (the photo

will also print on your score report).

You can take a break, but you will not be allowed

to make up the time.

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Day of the Exam

Upon arrival at the testing center, you will have your identification checked

og n

have your photo taken

take a 15-minute pretest to familiarize yourself

with the keyboard and questions

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e g ven ours to comp ete quest ons.

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Day of the Exam Use ! to write a note to yourself or to the examcommittee (Candidate Examination Handbook, p. 8).

. ou canno reen er eexam after clicking on Cover.)

After completing the exam, answer the evaluation

questions concerning the test-taking process.(Time taken to answer these questions does not count toward the 3-

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.

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Day of the Exam

Exit the system. Receive the score report from the proctor.

Tota t me: 3.5 to 4 ours

Log on to www.goamp.com for a preview of

software navigation.

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Self-Assessment Exam Diagnostic tool at www.cphq.org andwww.nahq.org

content and difficulty

Presented in same computer format as the exam

NAHQ members: $65 nonmembers: $95

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order is placed

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After the Exam

Testing agency forwards list of passing candidatesto HQCC monthly (first week of month for

HQCC sends a congratulatory letter, CPHQ pin,

and informational items approx. 2 weeks after the

close of the month.

- Exam passed on first of month, expect to receive packet

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in about 6 weeks

- Exam passed at end of month, expect to receive packetin about 2 weeks

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After the Exam The official certificate for framing will arriveseparately about 4 weeks after you receive the

.

GOOD LUCK!

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Objectives

To identify key concepts in- quality management approaches

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- patient safety

- confidentiality

- peer review

- evidence-based ualit mana ement.

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DefinitionsQuality Management Philosophy Healthcare quality is the extent to which health

populations improve desired health outcomes

(Institute of Medicine).

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Definitions

Total quality is an attitude, an orientation, thatpermeates an entire organization and the way the

business.

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Quality Pioneers Statistical process control (SPC)- Walter Shewhart

- - - -

- Shewhart Cycle

World War II

War Production Board

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Quality Pioneers

W. Edwards Deming- Plan-Do-Study-Act (PDSA)

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Joseph Juran

Phil Crosby

Dr. Ernest Codman

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r. ve s ona e an

Dr. Donald Berwick

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Performance Assessment Quality improvement (QI)- Early 1990s: Total quality management

- Collaborative culture Focus on processes

Quality defined by customer

Reduction in variation

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Current and Evolving Approaches

Six sigma: Uses statistical analysis to measure andimprove performance

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- Normal distribution (bell-shaped curve) of errors

- Six standard deviations from the mean (only 3.4

defects per million opportunities)

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Current and Evolving Approaches Lean enterprise: Emphasizes reducing waste andfocusing on activities that add value for the

- Applies value stream analysis

- Eliminates waste

- Makes changes in a short period of time

- Uses cross-functional teams

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Current and Evolving Approaches

Rapid cycle improvement- Identifies and prioritizes aims for improvement

- , ,

evidence-based QI


Focus on Patient Safety Elimination of medical errors- Creating a safe environment

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- Analyzing where and how patients are at risk

- Integrating risk management

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IOM Priorit ies for Patient Safety

Patient safety and harm- To Err Is Human: Building a Safer Health

- Direct relationship between quality of care and

patient outcomes

3 types of quality issues

- Underuse of care

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- Overuse of care

- Misuse of care (errors)

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Establish Safety Goals Establish patient safety as a visible commitment tothe philosophy of putting patients first.

processes.

Improve use of technology to prevent and detect

error.

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Fair and Just Culture

Everyone makes mistakes and implements work-arounds. Emphasize the importance of learning

.

The individual is accountable to the system. The

greatest error is to not report a mistake, preventing

the system and others from learning.

A new culture of atient safet is successfull

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created when everyone advocates for safety

Performance Problems as Safety Issues1. Focus on the issue or error, not the outcome.

2. Interpret the error (intentional or unintentional?).

3. I ent y contr ut ng actors.

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Approaches to Improving Safety

Improve medication practices. Improve emergency services.

Improve wor p ace sa ety.

Prevent nosocomial infections.

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Focus on Patient Safety1. Structure- Facility design

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- Policies and procedures

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Focus on Patient Safety

2. Environment assessment- Lighting

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- Temperature

- Noise levels

- Storage

- Er onomics

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Focus on Patient Safety3. Equipment and technologies- Examination of labels, instructions, and safety

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Focus on Patient Safety

6. Leadership and culture: willingness to- allocate resources

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- implement changes

- support nonpunitive error reporting

- promote evidence-based practice.

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Steps to Creating a Safety Culture Recognize that leadership owns the culture,whether the leaders want to or not.

.

Compare where the organization is to its stated

values and goals.

Create tools to reinforce the behavior and culture

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.

Link culture and performance review every year.

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Patient Safety Program

Patient safety officer Program development and coordination

L n w t strateg c p ann ng

Link with quality management, risk management,

information management, and infection control

Structure

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ec an sms or program coor nat on

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Patient Safety Program Communicating with patients about safety Safety education

Program goa s cons stent w t organ zat ons

mission)

Scope of the program

Safety improvement activities

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e n t on o terms Prioritization of improvement activities

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Routine safety data collection and analysis- Incident reporting

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- Infection surveillance

- Facility safety surveillance

- Staff perceptions of patient safety and suggestions

for improvement

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- ta w ngness to report errors

- Patient and family perceptions of patient safety andsuggestions for improvement

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Patient Safety Program Identification, reporting, and management ofsentinel events

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- Identification of high-risk processes

- Failure mode, effects, and criticality analysis

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Reporting of results- to the safety program

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- to executive leadership and the governing body

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Sample Events to Report Suicide Infant abduction or

Falls

Medication errors

family

Rape

Hemolytic transfusion

A verse rug events

Missing patients

Major loss of function

Death

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Wrong-site surgery

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Role of External Reporting

Allows lessons to be shared so others can avoidthe same mishaps

Sends alerts about new hazards generated

Allows sharing of information about experience of

individual institutions in using new methods to

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Reveals trends and hazards that require attention

and leads to recommended best practices

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Principles for Safer Healthcare:

Human FactorsProcess

Simplify work processes and standardize procedures.

e uce re ance on memory an v g ance.

Use checklists and trigger tools.

Use constraints and forcing functions.

Eliminate look-alike/sound-alike names.

Provide education and trainin .

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Eliminate design failures.

Use technology appropriately.

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Principles for Safer Healthcare:Human Factors

Organization Increase feedback and direct communication.

a e roun s.

Emphasize teamwork and crew resource management.

Drive out fear of reporting.

Solidify leadership commitment and safety culture.

Provide trainin ro rams for staff.

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Make environmental adjustments.

Adjust work schedules.

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Confidentiality PrinciplesConfidentiality Organizations are required by state and federal

, ,

confidentiality of patients personal data and other

information.

Organizations must protect records against loss,

defacement, tampering, and unauthorized use.



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Effective Confidentiality Policies Identify individuals with access.

Delineate accessible information.

.

Specify conditions for release of information.

Specify conditions for removal of medical records.

Protect personal health information.

Establish a policy for handling root cause analysis (RCA).

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Establish mechanisms for securing information.

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HIPAA (2013) Requirements for release of health information, HIPAA1996

Policies for rotection of ersonal health information

HIPAA 2002- Names; all geographic subdivisions smaller than a state

- Dates: Birth, admission, discharge, death, all ages over 89 unless

aggregated

- Telephone/fax numbers

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- -ma a resses; s, a resses- Medical record, health plan, beneficiary numbers

- Certificate/license; vehicle ID; biometric identifiers

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Medical Records Confidentiality

Healthcare facilities must maintain adequate medical records as the basis for

have clear policies regarding access to records

preserve confidentiality (in accordance with

physician-patient privilege and the Patients Bill of

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Information Security Methods Separate storage of some portions of medicalrecords

Adequate backup plan and firewalls for computer

applications

Requirement of signed forms for release of

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Release of Information

Release withoutwritten authorization (as regulatedby national and state statute) may include

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- the organization director

- healthcare personnel

- quality improvement staff

- health information management staff.


Credentialing Process Process used for- appointments and reappointments

- rantin renewin and revisin clinical rivile es

Organization credentials applicants using clearly defined

process

Credentialing process based on recommendations by

organized medical staff

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Credentialing process outlined in medical staff bylaws

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Credentialing Process

Clearly defined procedure for processingapplications for the granting, renewal, or revision

Procedure for processing applications for the

granting, renewal, or revision of clinical privileges

approved by organized medical staff

A licant submits statement that no health

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problems exist that could affect ability to perform

the privileges requested

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Credentialing Process Criteria Current licensure or certification

S ecific relevant trainin

Evidence of physical ability to perform the requested privilege

Data from professional practice review by an organization(s)

that currently privileges the applicant (if available)

Peer or faculty recommendation

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,performance within organization

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Credentialing Process Peer recommendations

- Medical/clinical knowledge

- Technical and clinical skills

- Clinical judgment

- Interpersonal skills

- Communication skills

- Professionalism

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Temporary privileges

- Need, new applicant waiting

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FPPE Period of focused professional practice evaluation(FPPE) implemented for all initially requested

Organized medical staff develops criteria for

evaluating performance of practitioners when

issues affecting provision of safe, high-quality

patient care identified

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FPPE

Performance monitoring process clearly definedand includes

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- method for establishing monitoring plan specific

to requested privilege

- method for determining duration of performance

monitoring

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- circumstances under which monitoring by

external source required

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Clinical Privi legesMay be defined several ways and categorized by- practitioner specialty

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- patient risk categories

- lists of procedures or treatments

- any combination of the above.

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Credentials Files

Departmental or major clinical servicerecommendations may be made by a department,

, .

Clinical privileges may change over time.

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OPPEOngoing professional practice evaluation (OPPE)includes

practitioners professional practice

data collected determined by individual

departments and approved medical staff

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to continue, limit, or revoke any existing

privilege(s)

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Medical Peer Review

Medical staff must be involved. Outcomes and processes should be measured.

Per ormance n re at on to es gn o processes an

expected or intended outcomes should be assessed.

Individuals with clinical privileges whose

performance is questioned as result of QI activities

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Consistency: Peer review is conducted according

to defined procedures.

Effective Peer Review Process

process are supported by a rationale.

Balance: Minority opinions and views of the

person being reviewed are considered and

recorded.

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Documenting Peer Review

Medical records are highly confidential. Policies and procedures define access and

.

Legal representative is consulted.

State laws govern peer review.

Peer review files are marked confidential.

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nutes are usua y protecte .

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Practitioner Profiles Profiles are based on performance. Profiles are provided to each physician or provider

.

Organizations may use risk-adjusted software.

Evidence-based medicine determines metrics used.

Data are timely and accurate.



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Physician Profi les

Profiles are process focused. Physician data are grouped by specialty type or

.

Data are reported regularly.

Physician champions talk directly with medical

staff about numbers.

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Physician Data Data are meaningful to physicians. Data represent major service lines and patient

.

National targets and benchmarks are used.

Data are easily accessed and used.

Profiles vary according to physicians specialty or

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Physician Profiles: Examples Patient volume

Length of stay

Average length of stay

Use of unapproved

abbreviations

Severity-adjusted mortality rate

Diagnosis-related groups

Average cost per case

Conformity with system-wide

initiatives (e.g., use of deep vein

thrombosis/pulmonary

Severity-adjusted morbidity

rate

Death or loss of function

related to nosocomial infection

Unexpected transfers to

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em o sm prop y ax s

Legibility of records

Unexpected death actions

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Physician Profiles: Examples Unplanned return to surgery Procedure complications

Charges for the patients treated

Medication errors

Aspirin given within 24 hours

of arrival

by the physician compared with

those for physicians in the same

specialty

Discharges

Full-time equivalent (actual vs.

Aspirin given at discharge

Angiotensin-converting enzyme

inhibitors prescribed at

discharge

Beta blockers given within 24

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Patient falls Smoking cessation counseling

Patient satisfaction

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Sample Physician Profile (Primary Care Clinic)

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Profile Confidentiality Develop a mechanism to track activity. Use a log or sign-out sheet (date of request, reason

, ,

notes).

Establish circumstances for copies in policies and

procedures.

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Utilization Review

Internal review- Policies and procedures to ensure confidentiality

- Patients to be informed of policies and

procedures related to utilization management

External review

- Tele hone review

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- Onsite review by external agencies

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Research vs. Quality ImprovementScientific Process Identify information needs,

Quality Improvement

Identify process

investigated.

Define variable(s) or

elements for which data are

required.

,

literature, and construct

flowchart of process.

Define customers and

problem.

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or hypothesis. .

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Research vs. Quality Improvement

Scientific Process Choose the research design

Quality Improvement Choose one or a

instruments.

Collect the data.

Analyze the data.

Display the data.

quality management

planning tools.

Collect the data.

Analyze the data; look for

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Report data and findings. .

Display the data.

Report data and findings.

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Research vs. Quality ImprovementScientific Process Draw conclusions.

Quality Improvement

Draw conclusions.

c upon recommen a ons

deduced from conclusions.

Continue to monitor the

process.

Evaluate and communicate

c upon

recommendations deduced

from conclusions.

Continue to monitor the

process.

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conc us ons. va uate an commun cateconclusions.

Hold the improvement.

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Objectives

To identify key concepts in- management of quality information

-

- risk adjustment

- comparisons and benchmarking

- evidenced-based information and practice

- statistical techni ues and tools

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- balanced scorecard

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Systematic Healthcare Quality Development of quality information system- Data: abstract representations of facts, concepts,

- Information: data translated into results and

statements useful for decision making



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Quality Information System

Identify who needs to know. Determine what information they need.

Deve op a system w ere y r g t peop e rece ve

right information at right time in right way.


QM Information1. Healthcare data must be carefully defined andsystematically collected and analyzed.

.

information are available.

3. Mature QI information revolves around clearly

established patterns of care.

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QM Information

4. Most quality indicators are useful only asindicators of potential problems, not as definitive

.

5. Multiple measures of quality need to be

integrated.

6. Using outcomes information without monitoring

the rocess of care is inefficient.

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7. Cost and quality are inseparable.

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Decision Support Helps in making comparison with competitors Identifies practitioners and providers who meet

Allows providers to respond rapidly to marketchanges

Justifies pay for exceptional performance

Used to develop outcomes information

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managemen p an

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Decision Support

Analyzes and interprets outcomes data- Chart-based system

Severity and risk-adjusted information identified

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Decision Support Analyzes and interprets outcomes data- Code-based system

Uses clinical information spanning entire stay

Has lower cost and larger sample size

Submission of payer data deemed public information

required by states

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Decision Support

Identifies positive and negative outcomes Includes risk/severity adjustment data

Fac tates cross- unct ona ana yses

Integrates clinical and financial data

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Risk Adjustment Takes into account the fact that different patientswith the same diagnosis might have additional

outcomes

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Risk Adjustment

Some systems define differences between riskadjustment and severity.

-

(yes/no) data.

- Severity adjustment methodologies are applied to

cost or length-of-stay data.

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Risk Adjustment Both raw and risk-adjusted data can be availablefor outcomes.

approach.

The best system includes every patient,

practitioner, and payer.

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Benchmarking vs. Comparison

Benchmarking identifies processes and results thatrepresent best practices for similar activities inside or

outside the healthcare industr and uses an ideal

reference point.

Comparison measures processes and results against a

reference point either internally or externally with

competitors and other organizations providing similar

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.

Both comparison and benchmarking results should be

interpreted.

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Benchmarking Involves asking the right questions- What is the best practice?

-

- How well are we doing it? What are the

measurement results?

- Why are we looking for improvement?

Is an essential art of clinical athwa

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development

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Interpret and Util ize Information

Step 1. Planning and organizing- Anticipate barriers, identify responsibilities, lay

.

- Develop data dictionary.

Step 2. Verifying and correcting

- Identify data limitations.

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Interpret and Util ize Information Step 3. Identifying and presenting findings- How do data compare with data from other

- What is the trend over time?

- How are data likely to be interpreted?

- Is there an opportunity for improvement?

- Who should receive the data?

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- For what purpose?

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Step 4. Studying and developing recommendations- Perform variation analysis.

- .

- Conduct retrospective medical reviews.

- Perform process analysis.

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Interpret and Util ize Information Step 5. Taking action- Empower teams to make decisions and

discovered by data analysis

- Educate and train staff.

- Report findings.

- Make necessary changes in policies and

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processes.- Implement changes in practice patterns.

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Step 6. Monitoring performance- Have proposed changes actually been

- How could compliance with changes be

enhanced?

- What effect are changes having on patient

outcomes?

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- Should changes be modified and then tested

further, tested longer, or ended?

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Interpret and Util ize Information Step 7. Communicating results- Barriers to interpretation and utilization of

Human

Statistical

Organizational

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Data Help Leaders

Assess progress toward mission and values Understand changes

Deve op a v s on an eva uate program

achievements

Prioritize strategic goals

Judge progress toward strategic goals


Data Help Leaders Weigh long-term and short-term financial viability Assess the impact of budgetary decisions

Mon tor aspects o organ zat ona per ormance an

take corrective action

Understand mechanism for physician appointment

and credentialing



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Data Help Leaders

Make individual credentialing recommendations Determine goals regarding community

Eva uate e ect veness o programs

Defend organizations resources, efficiency, and

effectiveness

Help governing body evaluate and improve its


Information Systems Clinical information systems support direct careprocesses.

- -

operations in healthcare organizations

Decision support systems deal with strategic

planning functions.

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Implementation

Evaluating systems- allow capture, storage, and retrieval of clinical

- interface with existing systems

- allow triggers or thresholds

- send critical alerts (e.g., for abnormal values)

- allow rules-based processing

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- are flexible.

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Implementation Evaluating systems- support accreditation requirements

- ,

- allow multiple users access

- have an open operating system

- have networking capabilities

- dis la data ra hicall

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- provide for drill-down analysis

- allow accessing of reports via website.

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Buy or Build?

Factors to evaluate- In-house expertise

-

- Staff provision of documentation, training,

support, and ongoing maintenance

- Plan to be implemented if staff member leaves


Buy or Build? Factors to evaluate- Expertise to build with broad picture in mind

-

- Dedicated time of programmer or coordinator

- Benefits to joining vendor network

- Cost-benefit analysis

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Data and Data Management

Two types of data- Measurement or continuous

-

Different sampling method, data collection, and

analysis for each type


Data and Data Management Count or categorical data- Nominal: count, discrete, qualitative, attributes

- . .,

- Ordinal: categories rank-ordered



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Nominal Data

Nominal Variables Surgical Patients

Values Preoperative

Patient Education

Postoperat ve

Attended video

Didnt attend video

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Ordinal DataOrdinal Variables Nursing staff rank

Values

Nurse Level 1

Education

Nurse Leve II

Nurse Level III

Associate Degree

BS

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MS

PhD

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Continuous Data

Measured on scales that theoretically have nogaps, variables data

-

equal

- Ratio data: distance between each point is equal,

but there is a true zero


Continuous Data Measurement or continuous data could beconverted to count or categorical data.

counted.

Most QI data readily available are analyzed

because they are easy to retrieve.



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Statist ical Power

Categorical data have the least statistical power. Continuous data have the most power and need

.


Data Collection Constructing a data collection plan- Determine who, what, when, where, how, why.

- .

- Choose and develop sampling method.

- Determine and conduct training.

- Delegate responsibilities.

- Facilitate coordination.

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- Forecast budget.

- Conduct pilots.

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Basic Sampling Designs

Population (N): total aggregate or group Sample (n): a portion of the population

Samp ng

- Provides a logical way of making statements

about a larger group

- Allows quality professionals to make statements

or eneralize from the sam le to the o ulation

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Basic Sampling Designs Probability sampling: Every element in thepopulation has an equal or random chance of being

.

Nonprobability sampling: It is not possible to

estimate the probability that every element has

been included.



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Probability sampling- Simple random sampling: Each individual in the

of being chosen.

- Systematic sampling: After random selection of

first case, every nth element from a population is

drawn.


Basic Sampling Designs Probability sampling- Stratified random sampling: Population is

equal probability of being selected.

- Cluster sampling: Population is divided into

groups or clusters to derive random sample.



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Nonprobability sampling- Convenience sampling: Any available group of

. Snowball sampling: Subjects suggest other subjects

(subtype of convenience sampling).


Basic Sampling Designs Purposive or judgment sampling: Particular groupis subjectively selected based on criteria.

-

selected because of their access to relevant

information.

- Quota sampling: A judgment is made about the

most representative sample.



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Sample Size

A larger sample yields a more valid and accuratestudy.

the mean.

Copyright 2012 14141-42

Sample Size Regardless of shape of original populationdistribution, as sample size increases, shape of

.

With a sample size of at least 30, sampling

distribution appears almost normal; no perfect

minimum sample size exists; power analysis

determines appropriate sample size.

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Sample Size

Calculating sample size depends on four variables:population size, estimate of population standard

, ,

bounds of error estimate

www.macorr.com/ss_calculator.htm

- calculates appropriate sample size from a

population

Copyright 2012 14341-42

Data Analysis Reporting- Report and analyze data regularly.

- .

- Display data in easily understood format.

- Provide a brief summary of data.

- Analyze variances and identify unexpected

patterns.



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Data Analysis

Context- Provide background.

- .

- Report summarizing values.

- Identify removed outliers.

- Include time order.


Data Analysis Variation in process performance- Use SPC chart.

- - .

- Look for special-cause variation.

Trend identification

- Initiate investigation to determine cause of trend.



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Statist ical Analysis and Interpretation

Measurement tools Reliability: extent to which an instrument yields

- Reliability coefficient: stability of an instrument

(>70) Test/retest

Split-half

Copyright 2012

e a y y equ va ence

- Interrater reliability: the likelihood that tworaters will assign same rating

14742-43

Statist ical Analysis and Interpretation Validity

- Content (face) validity: the degree to which the

content

- Construct validity: the degree to which the

instrument measures the theoretical construct or

trait it is designed to measure



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Statist ical Analysis and Interpretation

Validity- Criterion-related validity: the degree to which

Concurrent validity: assessed when the criterion

variable is obtained at the same time as the

measurement

Predictive validity: assessed when the criterion

measure is obtained at some future time


Statistical Techniques Measures of central tendency: describe theclustering of a set of scores or values of a

,

refers to trend

- Mean: average Most commonly used measurement

Most sensitive to extreme scores

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, ,distribution

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Mean Calculation

Example 1 Apgar scores: 7, 8, 8, 9, 8

um o va ues = ; v e y =

Mean = 8

Example 2

Apgar scores: 7, 8, 8, 1, 8

= =

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.

Mean = 6.4

15144

Mean CalculationExample 3 Infection rates: 0, 0, 0, 0,1.5, 3.2, 4.3, 5.6

um o va ues = . ; . v e y = .

Mean = 1.44

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Statistical Techniques

Measures of central tendency- Median: measure that corresponds to the middle

value of individual scores

- To determine the median, arrange values in rank

order; if number of values is odd, count up or

down to middle value; if number of values is

Copyright 2012

even, compute mean of two middle values.

15345

Median CalculationExample 1 Values: 2, 2, 3, 4, 5, 6, 6, 8, 9

s e m e num er

Median = 5

Example 2

Values: 2, 2, 2, 3, 4, 5, 6, 6, 8, 9

=

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.

Median = 4.5

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Median Calculation

Example 3 Values: 2, 2, 2, 3, 4, 5, 6, 6, 8, 84

e an = .

Median doesnt take into account quantitative values of

individual scores.

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Statistical Techniques Measures of central tendency- Mode: score or value that occurs most frequently

Can be calculated quickly and easily, tends to be

unstable

Describes typical values in nominal data



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Mode Calculation

Example Values: 30, 31, 31, 32, 33, 33, 33, 33, 33, 34, 35, 36

o e =

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Statistical TechniquesMeasures of Variability Range: difference between highest and lowest

- Reported as values, not distance

- Provides quick estimate of variability; is unstable

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Range Calculation

Example Test scores range from 60 to 98.

ange s - , or .

Copyright 2012 159

Statistical TechniquesMeasures of variability Standard deviation (SD)

- os requen y use s a s c or measur ng

degree of variability

- Standard: average spread of scores around the

mean

- Deviation: how much each score is scattered

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from the mean

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Measures of variability Standard deviation (SD)

- e grea er e sprea o s r u on, e grea er e

dispersion or variability from the mean.

- The more values cluster around the mean, the smaller

the variability or deviation.

- All scores are taken into consideration.

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-

data.

- A normal distribution is a standard bell curve.

16146

Bell Curve

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Measures of variability Interpercentile measures

- n erquar e range: ex reme scores exc u e ,

only middle cases used, measures lined up in

order of size and divided into quarters (growth

charts are a common example)

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Copyright 2012 164Q Solutions, 2nd edition, Table1-4


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Parametric Tests

ttest: used to analyze difference between twomeans (scores)

-

two group means is significant, a distinction

must be made between the two groups.

Copyright 2012 16547-48

t TestExample: Test effects of an educational program Two-sample independent ttest

-

group and receive education on quality tools.

- Remaining 10 = control group.

- Attitudes toward using tool are evaluated.

Paired sample ttest

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- ra n a .- Give pre- and posttest

- Compare results.

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Parametric Tests

Regression analysis: based on statisticalcorrelations, associations among variables

- ,

predict second variable (y) (e.g., weight used to

predict height)

Multiple regression analysis estimates effects of 2

or more independent variables (x) on dependent

Copyright 2012

measure (y)

16747-48

Nonparametric Tests Chi square: measures statistical significance of adifference in proportions

- ,

calculate averages (e.g., of gender); can describe

ratio of counts (e.g., 2 times as many men as

women in clinic) or proportions (e.g., 50% male,

75% female)

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- Easiest statistical test to calculate manually

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Example of Chi-Square 15 of 30 men (50%) and 10 of 40 women (25%) missed

appointments.

Referent rate (RR) 0.5 divided by 0.25 = 2. Men are twice as likely

to m ss appo ntments; cou t s ave appene y c ance?

Null hypothesis is that men and women fail to show up for

appointments at the same rate (RR = 1).

Chi square indicates likelihood of noting a twofold difference in

missed appointments.

- =

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. ,


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Level of Significance

Level of significance (p) gives the probability ofobserving a difference as large as the one found in

the null hypothesis is true).

Historically, whenp values


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PI Tools Decision-making tools (covered in Using Data for Improvement:The Toolkit DVD )

- Histogram or bar chart

- Pareto diagram

- Scatter diagram or scatter plot

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Histogram

Frequency distribution tool for one value; plottingpoints shows center and spread of data;

- 25 data points; rank smallest to largest; subtract

smallest from largest

- Estimate number of bars (square root of data

points)

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- Divide range by number of bars for width

175



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Pareto Diagram

Displays series of bars with tallest bar representingthe most frequently occurring issue

-

compare them.

- Rank the order in descending categories.

- Calculate percentage of total each category

depicts.

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Scatter Diagram or Scatter Plot

Used to determine extent to which two variablesrelate to one another (correlation)

- .

- Plot paired sets of data.

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PI Tools

Analysis- Root cause analysis (RCA): a systematic process

and taking action to correct the problem

- Failure mode and effects analysis (FMEA): a

systematic method for reducing risk before an

event happens

Copyright 2012 181

PI Tools Decision-making tools- Cause-and-effect, Ishikawa, or fishbone diagram

problem (after the fact)

Used to identify potential causes to make something

occur (before the fact)

Uses common categories

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Cause-and-Effect Diagram

Cause-and-effect, Ishikawa, or fishbone diagram- Determine effect or label and place on far right.

- .

- Determine categories.

- Draw diagonal line for half of categories above

and half below line.

- Organize each of causes on each bone.

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- Draw branch lines for relationships.

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Root Cause Analysis

Root cause must be identified when variation isinherent in process.

- .

- Verify potential causes by collecting data.

- Analyze data utilizing tools to determine actual

causes or most probable causes.

- Develop and implement action plan.


Root Cause AnalysisFactors to address in analysis Human factors: communication and information

Human factors: training

Human factors: fatigue, scheduling

Environment factors

Equipment factors

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Rules, policies, procedures

Leadership systems and culture

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Data Analysis and PI

Prioritization matrix- Select appropriate format.

- .

- Create matrix and indicate relationships.




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Data Analysis and PI

Flowchart or process flowchart- Select process.

- .

- Place first step in an oval.

- Place each of next steps in a rectangle.

- If decision is made, describe it in a diamond.

- Decision loo reenters rocess.

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- Place last step in an oval.

18964

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Statistical Process Control

Control chart- Types of control charts

- Common-cause variation: points between control

limits in no particular pattern- Special-cause variation: points outside limits that

exhibit special patterns

Copyright 2012191

66-69

Run or Trend Chart Line graph displays data points plotted over time. Use run chart with measurement/continuous data

over time.

Data are kept in time order.

Chart makes it possible to see flow of data from

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.

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Run Chart Help show flow of data Help answer such questions as

- ow muc var a on o we ave

- Is the process changing significantly over time?

- Has our change resulted in improvement?

- Was the improvement held?

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Run Chart

Analyze run charts using rules for determiningstatistically important events.

-

above or all below the median

- Rule 2: Five points all going up or all going

down

- Rule 3: Number of runs above and below the

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median

- Rule 4: Data that are obviously different values

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UCL 37.1

31.2

36.2

41.2

Facility Falls

CL 21.7

LCL 6.3

1.2

6.2

11.2

16.2

21.2

26.2

Number

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Months

Balanced Scorecard Views organization from multiple perspectives Four perspectives of measurement

- nanc a

- Customer

- Internal business processes

- Learning and growth



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Balanced Scorecard Example

Strategic Goals Be recognized as one of the

Strategic Objectives Hire skilled staff and set

- -

the community.

Establish outreach program

for management of chronic

illness.

ratios.

Obtain communication

technology.

Copyright 2012 199

Balanced Scorecard ExampleStrategic Goals Develop state-of-the-art

Strategic Objectives

Provide incentives forh sicians to train.

detection and treatment.

Reduce patient costs by

15%.

Control costs withcomputerized planningtools.

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Question 1

Which part of a job description should be used

-

Copyright 2012 201

Question 1A. Salary gradeB. Duties and responsibilities*

C. Wor ng con t ons

D. Qualifications

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Question 2

Which of the following monitors

-

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Question 2A.Nosocomial infection rate*B. Degree of compliance with nursing care

C. Degree of compliance with renewal of antibiotics

therapy

D. Equipment malfunction rate

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Question 3The following represents two samples of five hospitals hysterectomy

rates per 1,000 women 4060 years of age.

Rates Mean Standard

Deviation

Sample A 3,5,7,8,5 5.6 1.8

Sample B 4,5,6,7,5 5.4 1.1

Copyright 2012

,

it can be concluded that

205

Question 3A. Sample A has more variability than Sample B.*B. Sample As performance is superior to Sample

.

C. There are more cases in Sample B.

D. There is a data collection error in Sample B.

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Question 5

A surgeons wound infection rate is 32%.

will provide the most useful information

in determining the cause of this surgeons

infection rate?

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Question 5A. Mortality rateB. Facility infection rate

C. Use o prop y act c ant ot cs

D. Type of anesthesia used

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The Toolkit

2-disc DVD set by Sandra Murray

available through NAHQ

211

Section 3Strategy and Leadership

212


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Objectives

To identify key concepts in- strategic planning

-

- alignment of culture to support quality

- PI teams

- risk management, utilization management, and

case management

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- education and training

213

Frameworks Avedis Donabedian: founder of quality assurance,a theoretical framework for evaluation of patient

- Structures

- Processes

- Outcomes

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Excellence and Quality Models

Evaluate quality models. Provide education to staff regarding quality model

.

Assess applicability of model.

Determine whether to change quality model based

on assessment.


Frameworks Baldrige National Healthcare Criteria Department of Commerce initiative to improve

and organizations.

Baldrige Award honors organizations

demonstrating a commitment to quality excellence



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Baldrige Criteria for Performance Excellence

Organizational Profile: Environment,Relationships, and Challenges

Leadership

Strategic

Planning

Workforce

Focus

ResultsFocus on

Patients, Other Process


us omers,

and Marketsanagemen

Measurement, Analysis, and Knowledge Management

External Quality Awards Evaluate applicability of external quality award. Review quality award components and criteria.

Ass gn teams to con uct assessments.

Assess organizations processes according to

quality award criteria.

Determine whether to apply for quality award

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.

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Strategic Planning

Strategy- The plans and activities developed by an

objectives

Without a strategy the organization is like a ship

without a rudder, going around in circles.

Copyright 2012 21983-84

J. Ross and M. Kami

Strategic Planning Goals of strategic management- Create a framework for operations.

- .

- Establish process for coping with change and

renewal.

- Foster anticipation, innovation, and excellence.

- Facilitate consistent decision making.

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- Create organizational focus.

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Strategic Management Process

Vision: future of organization- Department of Veterans Affairs

and contribute to the nations well-being through

education, research and service in National

emergencies.

Organizations direction: built on mission and

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gu e y v s on

22384

Strategic Management Process Guiding principles: help direct vision Core value: customer focus

- ey s now ng an un ers an ng cus omer

needs and expectations.

VA Core Values

- I CARE: Integrity, Commitment, Advocacy,

Res ect Excellence

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Baldrige Core Values

Visionary leadership Customer-driven

Management forinnovation

Organizational and

personal learning

Valuing of employees

Public responsibility

and citizenship

Focus on results and

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Agility

Focus on future

Systems perspective

225

Strategic Management Process Assessment of what the organization wants to do Goals and objectives guide actions, serve as

.

Goals must be

- observable

- measurable

- challenging but attainable

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- controllable- visible

- time-limited.

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VA Goals Become the national benchmark for quality, safety, and

transparency of healthcare, particularly in those health

issues associated with military service.

Provide timely and appropriate access to health care and

eliminate service disparities.

Transform VHAs culture through patient-centered care to

continuously improve veteran and family satisfaction.

-

Copyright 2012

,

workforce to meet the needs of veterans and their families.

22785-86

Strategic Management Process Objectives should- be action-oriented statements, written precisely

-

- state specific activities and results or outcome

- specify actions to be taken, conditions and

criteria for completion

- be prioritized.

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Assessment of the external environment (what theorganization should do)

Immediate environment

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Strategic Management Process Assessment of the internal environment (what theorganization can do)

, ,

Intangible: reputation



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Strategy formulation: gap analysis Strategy implementation

- n egra on o w s ra eg c p ann ng Hoshin planning: one approach


Strategic Management ProcessHoshin planning Component of TQM system used to ensure that

long-term strategic goals

Three levels

- General (senior management)

- Intermediate middle mana ement

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- Detailed (implementation teams)

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Measure and control- Management evaluates accomplishment of goals.

-

to performance goals and objectives.

- Gaps require action.


Leadership:Translating Strategic Goals into Quality Outcomes The board bears ultimate responsibility for

TQM/QI.

-

- Public policy and external relationships

- Strategic planning

- Resource management

- Human resource development

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- Education and research

- Quality

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Leadership:Translating Strategic Goals into Quality Outcomes

Distinction between leadership and management- Leaders develop vision and align subsystems.

-

on path.

Both strong leadership and strong management

necessary

Sellin the vision to the or anization

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23590-91

Leadership:Translating Strategic Goals into Quality Outcomes Leadership framework

Principles of excellent leaders

- nsp re s are v s on.

- Challenge the system.

- Enable others to act.

- Model the way.

- Encoura e the heart.

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Culture Supports Quality

Culture: shared values and behavioral norms Strong culture

Enhances cooperation

Creates system of informal rules

Creates distinctions between organizations, allowing

competitive edge


Culture Supports Quality Elements of culture- Values and norms

-

- Language

- Rituals and ceremonies

- Stories, legends, and myths

- Heroes

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Assessing culture related to quality- Involvement of leader

-

- Reward of QI behaviors

- Active involvement in QI activities

- Time spent on QI activities and discussion

- Prevailin I attitude


Culture Supports Quality Strengthening culture for QI- Leaders

have annual budget for QI

make QI part of strategic planning

reward QI behaviors.



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Attention to visible culture elements- Old negative stories replaced

-

- QI successes celebrated

- Persistent leadership shown

Copyright 2012 241

Structure Supports Quality Organizational structure: identifies parts and linkstogether

- Focus on processes

- Recognition of internal customers

- Reduction of hierarchy

- Creation of a team-based or anization

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- Use of steering committees

- Development of agile organization

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Process: Risk Management

Risk management (RM): an organized effort toidentify, assess, and reduce risks to patients,

, , .

- Initially was organizational reaction to increasing

litigation

- Now has more proactive role


Process: Risk Management Clinical risk management- Regulatory compliance, safety management,

, - ,

and media coverage, patient care

- RM and QM/QI closely related



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Process: Risk Management

Risk management plan Education and skills for risk managers: clinical,

,


Utilization Management Utilization management (UM): organized,comprehensive approach to analyzing, directing,

Response to changing needs of consumers

UM goal: to facilitate delivery of high-quality,

low-cost, efficient, and effective care to all patients

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Legislation (2013) Title XVIII Social Security Act 1965

- Established Medicare Program

- Medicaid Program

Amendment to Social Security Act 1972

- Established professional standards review organizations

Federal HMO Act 1973

Copyright 2012

Omnibus Budget Reconciliation Act 1981 Diagnostic

Related Groups (DRGs)

24995-97

Legislation (2013) Tax Equity & Fiscal Responsibility Act 1982- Prospective payment based on DRGs

- Incentives to increase dischar es decrease len th of

stay and ancillary services; shift care; HMOs

Peer Review Improvement Act 1982

- Peer Review Organizations

Social Security Amendment 1983

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-

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Legislation (2013) Patient Safety & Quality Improvement Act 2005

Safety of Seniors Act 2007 (reduce falls)

Public demand for more efficient use of resources while

providing access created healthcare reform movement

Copyright 2012 25395-97

Utilization Management Medical necessity appropriateness review Using targets (Interquals Severity of

Approved by medical staff and governing body

Review each patient encounter against criteria

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Utilization Management

Discharge planning and monitoring Move patient through healthcare system

Provide patient with appropriate level of service

delivery each point in continuum of care timely

Monitor and facilitate process

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Utilization Management Overutilization and underutilization surveillance Fundamental to every utilization management

Review cases for appropriate use of resources and

evaluate impact on quality outcomes

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Utilization Management

Quality of care and liability problems During review, quality of care and risk/liability

- be identified

- be reported

- have timely follow-up.

Copyright 2012 25795-97

Utilization Management Financial issues Obtain concurrent as well as clinical data on all

Data educates provides regarding cost of treating

patients

Provides governing body with

-

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- length of stay

- complications

- mortality.

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Process: Case Management

Case management models- Reimbursement-based model- -

- Social services

- Private management-based model

- Insurer-based model

- Life-care planners

Copyright 2012

mpor ance o case managemen : cr ca o e

continuum of care, patient satisfaction, andefficient use of resources

26197-98

Process: Case Management Case management process- Intake and assessment

-

- Discharge planning

- Monitoring of outcomes for effectiveness of care



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Process: Case Management

Discharge planning- Care coordination among various case managers

-

- Expected discharge date

- Goals to be met before discharge

- Specific instructions

- S ecifics re ardin follow-u lans


TQM/QI Structural Elements Recognition of internal customers- Every process has internal and external

.

- Employee is customer when he or she receives

material, information, or services from others in

organization.

- Internal customers may also be suppliers of

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goods to external customers.

99 264


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Internal customer approach- Remind departments without direct external

TQM/QI Structural Elements

satisfaction.

- Improve relationships.

- Make work process flow smoothly.

- Avert potential bottlenecks.


TQM/QI Structural Elements Reduction in hierarchy (flattening oforganizations)

- ,

governance

- is affected by leadership style Autocratic

Participative

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Teams

Types of QI teams- Steering committee or council

-


Teams QI council responsibilities- Set priorities.

- .

- Maintain focus on identified goals.

- Foster teamwork.

- Provide resources.

- Formulate I olicies.

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Teams

PI teams- Natural work teams

- -

- Temporary or permanent

Use of teams dependent on

- Task complexity

-

Copyright 2012

- Task objectives

271101-102

Teams Team charter- Description of process: why and who

-

- Timeline for meetings

- Resources available

- Structure of leadership

- Ex ected communication of ro ress and results



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Teams

How do teams develop?- Stage 1: Forming

-

- Stage 3: Norming

- Stage 4: Performing

Copyright 2012 273102-103

Teams Characteristics of effective teams- Competent members with skills

-

- Standards of excellence

- Contributions from all

- Collaborative environment

- Leadershi su ort



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Teams

How should teams be evaluated?- Productivity: progress or success in meeting

- Satisfaction of team members

- Individual growth

Copyright 2012 275103-104

Team Roles Team leader- guides team to achieve successful outcomes and reach

established oals

- specific responsibility for guiding team through meeting

process to achieve objective

- involved in meeting content and process

- provides direction and support for the team

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Team Roles

Team facilitator- promotes effective group dynamics within the team-

- is not a member of the team

- serves as a coach or consultant for team

- has specific responsibility for focusing on meeting and

improvement process

-

Copyright 2012

- expertise regarding use of tools

277103-104

Team Roles Team member- shares knowledge and expertise of process or issue

addressed b team

- responsible for both content and process of team

meetings

- shares responsibility for focusing on objective,

contributing information, analyzing data, staying on

track, making decisions, managing time, continually

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improving team

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Education and Training Issues

Top management sequence- Quality as strategic advantage

-

- Integration of quality values

- Indicators for measuring and evaluating

- Components of QM implementation process

- Basic I tools

Copyright 2012

- Role as team leaders

- Awareness of accreditation standards

281105

Education and Training Issues Middle management sequence- Quality management

-

- Management of process performance

- Measurement of quality outcomes

- Management practices



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Consultants

Advantages of using consultants Disadvantages of using consultants

Mon tor ng o consu tants act v t es

Consultant contracts

Consultant evaluation

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Contracts Quality management elements of contracts- Identify all contracted services.

- accreditation requirements

data submission

evaluation.

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PI in Performance Appraisal

Work motivation: psychological forces thatdetermine direction of a persons behavior, level of

,

Skills to perform well

Coach employees

Outcomes

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PI in Performance Appraisal Setting up a reward system- Determine priorities, values, and behaviors.

- .

- Establish a budget.

- Determine accountability for recognition.

- Develop procedures.

- Obtain feedback.

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- Modify program based on feedback.

- Give rewards based on the program.

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Financial Systems Support Quality

Capital budgeting- Large initial cash outflows

-

- Trigger: capital request presented to senior

management and expenditures committee and

prioritized


Financial Systems Support Quality Cost-benefit analysis: performed for capitalexpenditures requests to determine viability and

resources

QI projects should

- be carried out only if benefits exceed costs over

life of project

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- include time frame demonstrating costs andbenefits over time.

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Financial Systems Support Quality

Establishing a business case for quality-relatedexpenditures

-

- Reduced expenditures or cost avoidance

- Costs

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Organizational Renewal Learning organizations are adept at experimenting with new approaches

learnin from own ex erience

learning from past experiences and best practices of

others

transferring knowledge quickly

solving problems systematically.



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Question 2

A social service department regularly monitors thenumber of inappropriate referrals, the timeliness of

,

discharge delays.

What additional monitor should be added

to evaluate the a ro riateness

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of social service interventions?

295

Question 2A. Inadequacy of documentation in progress notesB. Attainment of social service goals*

C. T me ness o re erra s to soc a serv ces

D.Number of social service referrals from nursing

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Question 3

A patient was in the operating room when a piece ofa surgical instrument broke off and was left in the

.

removal of the foreign object.

Which of the following would

most likel a l in this situation?

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Question 3A. Res ipsa loquitur*B. Contributory negligence

C. Contractua a ty

D. Tort liability

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Question 4

Which of the following is most likely

of ambulatory surgical cases?

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Question 4A. Decreased medical record review at discharge*B. An increase in the number of cases failing

C. An increase in reviewer competence

D. Decreased employee turnover

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Section 4:Continuous Readiness

301

Objectives To identify key concepts in- accreditation processes

-

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Continuous Readiness

Context of continuous readiness- Past survey experiences -

Meetings, new work, copy and production costs

Relief after survey

Difficulty getting leadership attention

Unplanned surveys

Crisis-management mode


Continuous Readiness Context of continuous readiness- Now: culture of continuous readiness (company

throughout the organization) Unknown survey dates

Immediate readiness to demonstrate compliance

required

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Surveys requiring continuous readiness- Corporate surveys

-

- Surveys by regulatory agencies

- Accreditation surveys


2013 Centers for Medicare & Medicaid Services (CMS;www.cms.gov)

-

- Administers Medicare

- Works with states to administer Medicaid and

State Childrens Health Insurance Program

- Social insurance program financed by payroll

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taxes, premium payments, general revenues- Works to improve outcomes of care

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2013

Individual State Departments of Health Services- Licensing and certification programs

-

Federal Certification Requirements

- Clinical Laboratory Improvement Amendments

(CLIA)

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2013 National Committee for Quality Assurance(www.ncqa.org)

-

by healthcare organizations

Healthcare Effectiveness and Data Information Set

(HEDIS)

- Accredits managed care organizations, managed

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behavioral healthcare organizations, preferredprovider organizations, disease management,

new health plans

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2013

The Joint Commission(www.jointcommission.org)

-

certification as risk reduction activities

- Accredits hospitals, healthcare networks, home

healthcare, nursing homes, long-term care

facilities, behavioral health, assisted living,

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ambulatory care, clinical laboratories, disease-

specific care

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2013 Utilization Review Accreditation Commission(www.urac.org)

URAC American Accreditation Healthcare Commission

Accreditation programs: case management, claims

processing, consumer-directed health, core accreditation,

credentials verification organization, disease management,

health call center, health network, health plan, health

provider credentialing, health utilization management,

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HIPAA privacy, HIPAA security, workers compensationutilization management

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2013 DNV (Det Norske Veritas) independent foundation

(www.dnv.com and www.dnvusa.com)

- Purpose to safeguard life, property, and the environment

- Established in Norway in 1864 to inspect and evaluate

the technical condition of Norwegian merchant vessels

- Hospital accreditation program approved by CMS

- Annual deemed status surveys and quality improvement


Continuous Readiness Accreditation cycle- Application submitted

-

- Inspection team assigned

- Date determined

- Documents possibly requested in advance

- On-site review conducted

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- Length of site visit determined by organizations

size and complexity

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Accreditation cycle following visit- Summation conference and report of findings

-

- Action plan submitte