dashboards for quality management

8/9/2019 Dashboards for Quality Management

1/22


2/22

Discuss Quality dashboards as auditing andReporting Methods for Quality Management

Provide examples of Administrative/

Operational and Clinical Dashboards indifferent size transplant organizations

Discuss Auditing and Reporting Methods for

Quality Management though use ofDashboards.


3/22

What is a Dashboard? What should itdisplay? How do I use it? Why Now?

What are common Issues Survey results

How do other centers use Dashboards?

What are Core measures for transplantprograms?-Whats going on?


4/22

Government and other regulatory reportingrequirements- Show me the Data

Payer and Accreditation organization requestsfor information and Standards compliance

Show me the data

Report to High level Administrative boardsShow me the data

Monitoring patient safety and quality of thecare we provide our patients. WOW


5/22

Driving for Quality in Acute Care: A Board of

irectors ashboard GovernmentIndustry

Roundtable

On November 10, 2008, the Office of InspectorGeneral (OIG) of the U.S. Department of Health andHuman Services and the Health Care ComplianceAssociation (HCCA) cosponsoredgovernmentindustry roundtable called Driving forQuality in Acute Care

Dashboards were recommended as means to assessand oversee an organizations performance basedon quality of care metrics.


6/22


7/22

A Dashboard is designed to display data, be

intuitive and simple expanding data accessfrom highly trained data analysts to thecasual user.

Insight from the dashboard is used todetermine program viability, identify areas forimprovement, make changes, and reallocateresources if necessary.

Goals are to track data, improve operationaland clinical performance and promoteaccountability and transparency


8/22

Data

Display


9/22

Determine Key objectives or areas for display

Develop Key performance indicators/measures for areasrelated to structure, process and outcomes.

Select best practice benchmarks externally and orinternally.

Develop scorecard, monitor/audit overtime.

Use Quality management principles to Identify areas whichrequire Closer look exceed or below benchmark. Focus

on High risk High volume indicators.

Use Quality Management principles of process mappingand step analysis to develop an improvement plan ordocument acceptable outcome


10/22

1. Do you utilize a

dashboard for

monitoring

key performance

indicators

2. Are you:

an administrator/

quality specialist/

department manager/

Other

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

an administrator

a quality specialist

a department manager

other

32.4

59.5

10.8

8.1

Are you....

82.1

5.1

12.8

Do you utilize a dashboard for monitoring key performance indicators

Yes

No

In development


11/22

3. What is the volume

of transplants performed

annually at your center?

4. Do you use a quality

dashboard for reporting

during quality meetings

28.9

23.7

26.3

5.3

15.8

What is the volume of transplants performed annually at your

center?

0-100

100-200

200-300

300-400

greaterthan400

22.2

66.7

13.9

5.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

monthly quarterly annually other

Do you use a quality dashboard for reporting during quality

meetings


12/22

5. Describe your

dashboard focus

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Clinical Administrative/operational Combined

40.5

8.1

67.6

Describe your dashboard focus

6. What is the biggest

challenge you feel in

using the dashboard

effectively

17.9

46.2

28.2

7.7

What is the biggest challenge you feel in using the dashboard effectively

Getting internal data

getting external

benchmarks

selecting meaningful

indicators

other


13/22

7. Do you feel the use of a dashboard has led to identifying a

need for improvement or has led to improvements in your

transplant program

55.3

0.0

44.7

Do you feel the use of a dashboard has led to identifying a need for improvement or has

led to improvements in your transplant program

yes

no

unsure


14/22

Getting external benchmarks 46.2

Selecting meaningful indicators 28.2

Getting internal data 17.9

Our Challenges continue to be:

Developing Quality Management Programs which

includes the selection of Key performance

indicators based on regulatory and accreditation

requirements and program needs

Working to develop internal quality reporting data

systems

Collaborating to identify core measures for

transplant programs for external benchmarking


15/22

NMDP - National Marrow Donor Program

http://www.bethematch.org

CIBMTR Center for International Blood & Marrow TransplantResearch-Stem Cell Therapeutic Outcomes Database(SCTOD)

http://www.cibmtr.org/

ASBMT-American Society for Blood and Marrow

Transplantationhttp://www.asbmt.org/

C4QI Comprehensive Cancer Center Consortium

http://www.c4qi.net/

UHC University Healthcare Consortiumhttps://www.uhc.edu/

BMT Quality Roundtable Googlegrouphttp://groups.google.com/group/bmt-quality-roundtable
http://www.bethematch.org/http://www.cibmtr.org/http://www.asbmt.org/http://www.c4qi.net/https://www.uhc.edu/https://urldefense.proofpoint.com/v1/url?u=http://groups.google.com/group/bmt-quality-roundtable&k=I3sHQbq58hEL6CE99FxIjw==&r=Xs8eI3uO5S8/Px+vmo+6Xr0TnRTWA0fT53ptllI9F3k=&m=dV6nAObFJpUe/R1a7MDCz74xcqq+lZp2op4jEMJZQg0=&s=017e6a39fb4c23405ef80ea95a989ddee3e710f95ee025b45b2f957fb835fe22https://urldefense.proofpoint.com/v1/url?u=http://groups.google.com/group/bmt-quality-roundtable&k=I3sHQbq58hEL6CE99FxIjw==&r=Xs8eI3uO5S8/Px+vmo+6Xr0TnRTWA0fT53ptllI9F3k=&m=dV6nAObFJpUe/R1a7MDCz74xcqq+lZp2op4jEMJZQg0=&s=017e6a39fb4c23405ef80ea95a989ddee3e710f95ee025b45b2f957fb835fe22https://urldefense.proofpoint.com/v1/url?u=http://groups.google.com/group/bmt-quality-roundtable&k=I3sHQbq58hEL6CE99FxIjw==&r=Xs8eI3uO5S8/Px+vmo+6Xr0TnRTWA0fT53ptllI9F3k=&m=dV6nAObFJpUe/R1a7MDCz74xcqq+lZp2op4jEMJZQg0=&s=017e6a39fb4c23405ef80ea95a989ddee3e710f95ee025b45b2f957fb835fe22https://urldefense.proofpoint.com/v1/url?u=http://groups.google.com/group/bmt-quality-roundtable&k=I3sHQbq58hEL6CE99FxIjw==&r=Xs8eI3uO5S8/Px+vmo+6Xr0TnRTWA0fT53ptllI9F3k=&m=dV6nAObFJpUe/R1a7MDCz74xcqq+lZp2op4jEMJZQg0=&s=017e6a39fb4c23405ef80ea95a989ddee3e710f95ee025b45b2f957fb835fe22https://urldefense.proofpoint.com/v1/url?u=http://groups.google.com/group/bmt-quality-roundtable&k=I3sHQbq58hEL6CE99FxIjw==&r=Xs8eI3uO5S8/Px+vmo+6Xr0TnRTWA0fT53ptllI9F3k=&m=dV6nAObFJpUe/R1a7MDCz74xcqq+lZp2op4jEMJZQg0=&s=017e6a39fb4c23405ef80ea95a989ddee3e710f95ee025b45b2f957fb835fe22https://urldefense.proofpoint.com/v1/url?u=http://groups.google.com/group/bmt-quality-roundtable&k=I3sHQbq58hEL6CE99FxIjw==&r=Xs8eI3uO5S8/Px+vmo+6Xr0TnRTWA0fT53ptllI9F3k=&m=dV6nAObFJpUe/R1a7MDCz74xcqq+lZp2op4jEMJZQg0=&s=017e6a39fb4c23405ef80ea95a989ddee3e710f95ee025b45b2f957fb835fe22https://www.uhc.edu/http://www.c4qi.net/http://www.asbmt.org/http://www.cibmtr.org/http://www.bethematch.org/


16/22

Kathie Viers RN,BSN,MS CPHQ

HCT Regulatory/Quality Compliance Specialist

Department of Quality, Risk, and Regulatory


17/22

City of Hope is a National Cancer Institute designated

Comprehensive Cancer Center.

Recognized for translating basic laboratory research intoinnovative patient care.

The Hematopoietic Cell program is the largest provider of Blood

and Marrow Transplantation (BMT) in California

Over 11750 transplants completed, More than 600 BMTprocedures performed annually.

Adult and Pediatric transplant programs

AUTO, ALLO, URD, CORD, Haplo

Only center for 9th year in a row, to perform aboveexpectations according to the Stem Cell TherapeuticsOutcomes Database.(CIBMTR) transplant outcomes data.


18/22

Volume Length of stay

Readmissions

Cost/Payer contracts and reimbursement Staffing and staff competency

Coding and documentation compliance

Electronic Medical Record Development and

use Utilization


19/22

Some Key Clinical Performance Indicators

Total transplant volumes by type and cell type

Other cellular therapy-DLI, HPC., volume and outcomes

Length of stay by transplant type

Readmissions within 30 days of discharge

Marrow collections volume, AE, product cell counts, recipient outcomes

Mortality -30, 100, and 1year, Treatment related(non-relapse).

Engraftment, by transplant and cell type, ANC and Platelet, median time toengraftment

Patient satisfaction Press-Ganey-Transplant survey, case management

discharge survey, donor followup reports.

Critical event/quality reviews- Adverse events, ICU admits, data audits

Trans Med Service indicators: collection, processing and administrationand infusion, mobilization, positive microbial reports.

Known Complications GVHD,ECP for GVHD, Infectious disease monitors.

Chemo-verification procedure audits, ADRs.

Donor and recipient screening and consent

Support Service reports and focus compliance audits


20/22

Indicator Benchmark

Engraftment ANC >95% of HCT by Day +28

Time to engraftment Autologous 100% 10-11days

Time to ANC engraftment ALLO

Sib/MRD

100% 14-16 days

Time to ANC engraftment MUD 100% 14-28 days


21/22

Scorecards Indicators benchmarks

Dashboard

Graphs

Treatment Related Mortality Benchmark

Treatment Related Mortality-Autologous


22/22

Do we need Core measures (Indicators)forBlood an Marrow Transplant Program Qualityreporting and standardize for ExternalBenchmarks?

Does it matter how you display and or reportyour data internally?

Do we need to collaborate and support eachother?

dashboards for quality management

Documents