USING DATA TO ASSESS, PLAN, AND IMPROVE
Increasing Quality and Productivity Within an Organization
Leana Gadbois-Sills
OutcomesResource 2012
Organizational Systems
• Human Resources
• Leadership
• Health & Safety
• Accessibility
• Clinical / Treatment
• Information Management
• Quality Assurance
Organizational Systems
Leadership
Human Resource
Accessibility
Health & Safety
Clinical/Treatment
Information Management
Quality Assurance
Organizational Systems
• Leadership
• Financial
• Core Values
• Customer Service
• Performance
• Organizational Structure
• Risk Management
• Strategic Planning
• Grievance & Incident
Reporting Trends
Organizational Systems
• Human Resources
• Staff Recruitment
• Staff Hiring
• Staff Retention
• Cultural Competency &
Diversity
• Staff Training
• Staff Licensing &
Competency
• Incentive Package
• Performance Reviews
Organizational Systems
• Health & Safety
• Emergency Disaster Plan
• Security
• Fire Safety
• Infection Control
• Environment of Care
• Hazardous Materials /
Waste Management
• Utilities Management
Organizational Systems
• Accessibility
• Attitudinal
• Employment
• Environmental
• Financial
• Transportation
• Communication
Organizational Systems
• Clinical / Treatment
• Curriculum
• Program Structure
• Philosophy of Treatment
• Staff Competency
• Medication Management Plan
• Compliance with Policies,
Procedures, and Standards
• Rights of Clients
Organizational Systems
• Information Management
• Technology Plan
• Client and Personnel Records
• Communication Plan
• Performance Management
and Improvement (Outcomes
Data, Incident Report Trends,
Accessibility and Personnel
Data)
Organizational Systems
• Quality Assurance
• Quality Reviews on Systems
• Assessment and Monitoring
of Elements within Systems
• Corporate Compliance with
Legal and Regulatory Bodies
Elements within the Systems
• Leadership
• Budget: Assess for financial viability by reviewing profit/loss statements
• Billing: Review accuracy of billed amounts vs. client services, as well
as monitor client capacity levels and contracted insurance rates to
ensure desired level of revenue
• Customer Service: Assess the competency and knowledge of persons
answering the phones, greeting clients and community, and caring for
your clients
Elements within the Systems
• Leadership
• Performance: Monitor performance levels (financial, clinical,
administrative, operational) and develop goals and metrics for
assessments and improvements
• Structure: Assess and understand how the organization is structured
and how communication flows to create an effective and productive
workplace
• Strategic Plan: Develop a plan that outlines new goals and objectives
for specific systems to challenge, engage, and motivate the organization
to new levels of proficiency, quality, and care.
Elements within the Systems
• Human Resource
• Hiring Personnel: Assess methods of recruitment, hiring, orientation,
and retention efforts. Analyze rates of turn-over and replacement costs
for personnel
• Diversity: Assess the competency of staff in cultural issues and review
population served compared to the diversity of staff
• Training: Monitor and review personnel training at orientation and
annually. Assess competency of staff by tests, observations, or
performance reviews to determine skill level and performance
• Personnel Satisfaction: Inquire and analyze staff satisfaction with all
levels of the organization and systems to determine trends for potential
improvement initiatives
Elements within the Systems
• Health & Safety
• Emergency Evacuation Plan: Test and assess the effectiveness of
emergency drills and plans utilizing measurable goals
• Fire Safety: Monitor and document all fire equipment status and staff
knowledge on using equipment
• Infection Control: Record all reported illnesses and analyze for trends
and ways for decreasing reported trends or increasing prevention efforts
• Environment: Monitor the environment for safety and security,
analyzing the potential risks to the staff, clients and community
• Emergency Protocols: Review systems in place for medical and
psychiatric emergencies, including initial assessments, monitoring of
clients’ behaviors, and procedures that involve staff and emergency
teams
Elements within the Systems
• Accessibility
• Attitudinal: Review and assess the client feedback from surveys on
staff attitudes
• Employment: Monitor trends for hiring and/or staff turnover rates.
Assess the population served and diversity and cultural competency
among staff members
• Environmental: Assess safety, security and accessibility factors within
the buildings, grounds, and operations on consistent basis
Elements within the Systems
• Accessibility
• Financial: Monitor non-admits due to financial issues and trends for
non-payment of fees from clients and/or payer sources
• Transportation: Assess locations of program and types of
transportation available for population served
• Communication: Review types of communication available and styles
of staff communication to persons served – assess efficacy and
efficiency
Elements within the Systems
• Clinical / Treatment
• Curriculum: Measure efficacy by client competency tests and program
follow up outcome rates
• Program Structure: Assess the program content and schedule for
maximum quality and outcomes
• Philosophy of Treatment: Promote and monitor staff’s knowledge and
implementation of the organization’s philosophy on treatment and
services
Elements within the Systems
• Clinical / Treatment
• Staff Competency: Assess competency as it relates to the staff’s
specific job duties annually
• Medication Management Plan: Assess and monitor the quality of
medication management and adherence to medication standards
• Rights of Clients: Review procedures and practices for maintaining the
level of care and services that respects all clients’ rights
• Client Treatment Management: Assess individualization and
monitoring of client’s treatment protocol during treatment
Elements within the Systems
• Information Management
• Technology Plan: Assess and analysis functionality and efficiency of
the organization’s existing technology ,and develop strategies for future
technological needs
• Client and Personnel Records: Review existing protocols for storing,
safety, security, sharing, and destroying records to ensure all required
standards and laws are integrated and implemented within the
organization’s policies and procedures
• Communication Plan: Review and assess lines of communication to
the public, population served, and staff to ensure highest level of
effective marketing, communication, and outcomes.
• Performance Management and Improvement: Gather and analyze
outcomes data, incident reports, accessibility, health and safety, and
satisfaction ratings to determine level of performance, goals for desired
performance, and plans for improvements
Elements within the Systems
• Quality Assurance
• Quality Reviews: Assess all existing systems for compliance to
organization’s policies and procedures, best practices, and quality of
care
• Assessment and Monitoring of Elements within Systems: Review
and analyze level of functioning and desired levels of functioning in
order to establish realistic, achievable goals for systems
• Corporate Compliance: Assess and monitor compliance among all
levels of the organization from the board to direct care staff – establish
highest level of ethics and corporate compliance standards appropriate
for the organization based on governance, size, and structure
Tools for Assessment / Implementation
Assessing Tools
• Annual Analysis Review
• Risk Analysis and Performance Improvement Worksheet
• Quality Assurance Checklist or Review Form
• Checklists
• Client Questionnaires on Current Symptoms, Psychological Status, and
Level of Functioning
Tools for Assessment / Implementation
Measuring Tools
• Metrics (Capacity, Census, Length of Stay, Completion Rate,
Satisfaction)
• Data Sources (Discharge Summary, Surveys, Client Attendance, Call
logs, QA reports)
• Surveys / Questionnaires (Client, Personnel, and Referent)
Tools for Assessment / Implementation
Implementation Tools
• Strategic Plans
• Policies and Procedures
• Forms
• Performance Improvement Plans
• Clinical Treatment Plans
Tools for Assessment / Implementation
RISK ANALYSIS AND PERFORMANCE IMPROVEMENT WORKSHEET
Assess the level of risk and/or need for improvement in each area of your organization and
document the goal and objective(s), time frame, and outcome based on data analysis. In each
area, examples are given. The element or system listed may be used or replaced according to the
needs of your organization.
Tools for Assessment / Implementation
SYSTEM /
ELEMENT
RISK RATING
(High,
Moderate,
Low)
DESIRED
IMPROVEMENT
GOAL / BENEFIT
(Measurable)
WITH
OBJECTIVES OR
PROCESSES
THAT WILL BE
IMPLEMENTED
AND TESTED
ASSIGNED
STAFF
DATE
FIRST
ASSESSMENT
(Data Analyzed)
DATE
FINAL
ASSESSMENT
(Data Analyzed)
OUTCOME
(Achievement
of Goal or
Schedule for Re-
Assessment)
Staff Retention High
Moderate
Low
Goal:
Objective(s):
Date: Date: Achieved Goal
Analysis:
Goal not
Achieved -
Resubmit for re-
assessment
Human Resources
Tools for Assessment / Implementation
SYSTEM /
ELEMENT
RISK RATING
(High,
Moderate,
Low)
DESIRED
IMPROVEMENT
GOAL / BENEFIT
(Measurable)
WITH
OBJECTIVES OR
PROCESSES
THAT WILL BE
IMPLEMENTED
AND TESTED
ASSIGNED
STAFF
DATE
FIRST
ASSESSMENT
(Data Analyzed)
DATE
FINAL
ASSESSMENT
(Data Analyzed)
OUTCOME
(Achievement
of Goal or
Schedule for Re-
Assessment)
Staff
Training
(Competency
Based)
High
Moderate
Low
Goal:
Objective(s):
Date: Date: Achieved Goal
Analysis:
Goal not
Achieved -
Resubmit for re-
assessment
Human Resources
Tools for Assessment / Implementation
SYSTEM /
ELEMENT
RISK RATING
(High,
Moderate,
Low)
DESIRED
IMPROVEMENT
GOAL / BENEFIT
(Measurable)
WITH
OBJECTIVES OR
PROCESSES
THAT WILL BE
IMPLEMENTED
AND TESTED
ASSIGNED
STAFF
DATE
FIRST
ASSESSMENT
(Data Analyzed)
DATE
FINAL
ASSESSMENT
(Data Analyzed)
OUTCOME
(Achievement
of Goal or
Schedule for Re-
Assessment)
Financial High
Moderate
Low
Goal:
Objective(s):
Date: Date: Achieved Goal
Analysis:
Goal not
Achieved -
Resubmit for re-
assessment
Leadership
Tools for Assessment / Implementation
SYSTEM /
ELEMENT
RISK RATING
(High,
Moderate,
Low)
DESIRED
IMPROVEMENT
GOAL / BENEFIT
(Measurable)
WITH
OBJECTIVES OR
PROCESSES
THAT WILL BE
IMPLEMENTED
AND TESTED
ASSIGNED
STAFF
DATE
FIRST
ASSESSMENT
(Data Analyzed)
DATE
FINAL
ASSESSMENT
(Data Analyzed)
OUTCOME
(Achievement
of Goal or
Schedule for Re-
Assessment)
Customer
Service
High
Moderate
Low
Goal:
Objective(s):
Date: Date: Achieved Goal
Analysis:
Goal not
Achieved -
Resubmit for re-
assessment
Leadership
Tools for Assessment / Implementation
SYSTEM /
ELEMENT
RISK RATING
(High,
Moderate,
Low)
DESIRED
IMPROVEMENT
GOAL / BENEFIT
(Measurable)
WITH
OBJECTIVES OR
PROCESSES
THAT WILL BE
IMPLEMENTED
AND TESTED
ASSIGNED
STAFF
DATE
FIRST
ASSESSMENT
(Data Analyzed)
DATE
FINAL
ASSESSMENT
(Data Analyzed)
OUTCOME
(Achievement
of Goal or
Schedule for Re-
Assessment)
Curriculum High
Moderate
Low
Goal:
Objective(s):
Date: Date: Achieved Goal
Analysis:
Goal not
Achieved -
Resubmit for re-
assessment
Clinical / Treatment
Tools for Assessment / Implementation
SYSTEM /
ELEMENT
RISK RATING
(High,
Moderate,
Low)
DESIRED
IMPROVEMENT
GOAL / BENEFIT
(Measurable)
WITH
OBJECTIVES OR
PROCESSES
THAT WILL BE
IMPLEMENTED
AND TESTED
ASSIGNED
STAFF
DATE
FIRST
ASSESSMENT
(Data Analyzed)
DATE
FINAL
ASSESSMENT
(Data Analyzed)
OUTCOME
(Achievement
of Goal or
Schedule for Re-
Assessment)
Staff
Competency
High
Moderate
Low
Goal:
Objective(s):
Date: Date: Achieved Goal
Analysis:
Goal not
Achieved -
Resubmit for re-
assessment
Clinical / Treatment
Tools for Assessment / Implementation
Assessment Tool(s) Person Served Personnel Stakeholder
Questionnaire/Survey
Personal Interview
Incident/Office Report
Inspection
Evaluation
ACCESSIBILITY ASSESSMENT
ATTITUDINAL BARRIERS
ASSESSMENT:
ACTION PLAN TO REDUCE BARRIERS:
Tools for Assessment / Implementation
Assessment Tool(s) Person Served Personnel Stakeholder
Questionnaire/Survey
Personal Interview
Incident/Office Report
Inspection
Evaluation
ACCESSIBILITY ASSESSMENT
EMPLOYMENT BARRIERS
ASSESSMENT:
ACTION PLAN TO REDUCE BARRIERS:
Tools for Assessment / Implementation
ANNUAL ANALYSIS REVIEW
Documents No Change Revision Elimination Other Policies & Procedures
Forms
Outcomes System
Health, Security & Safety
Infection Control Plan - Analyze Trends in Risks in Population
- Analyze/re-assess TB trends in staff
Staff Development and Training
Insurance Policy Package
Risk Analysis
Technology & Systems
Human Resource Reports
Incident Reports Trends
Tools for Assessment / Implementation ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS
PART 1 - PROGRAM ANALYSIS
1. Capacity:
___Goals not met ___Goals met or exceeded
Action Plan:
Completion Date:
2. Quality (Treatment):
___Goals not met ___Goals met or exceeded
Action plan:
Completion Date:
Tools for Assessment / Implementation ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS
PART II – PERFORMANCE ANALYSIS
Phone System(s) ____ Adequate ____ Inadequate
Recommendations:
Computers ____ Adequate ____ Inadequate
Recommendations:
Fax / Copiers ____ Adequate ____ Inadequate
Recommendations:
Internet/DSL ____ Adequate ____ Inadequate
Recommendations:
Web Site ____ Adequate ____ Inadequate
Recommendations:
Tools for Assessment / Implementation
ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS
PART III - RISK ANALYSIS
INFECTION CONTROL
Identification of Risk Evaluation of Risk Inventory of operating
systems
Analysis of Current
Risk
Bloodborne Pathogens
Infectious Diseases
Common Viruses
Tools for Assessment / Implementation
ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS
PART III. ANNUAL RISK ANALYSIS
SUPPORT OF THE ENVIRONMENT
Identification of Risk Evaluation of Risk Inventory of operating
systems
Analysis of current risk
HVAC
Septic
Water Well
Electrical
Gas
Fire Alarm System
Analysis and Improvement
Planning for Improvement:
• Select two or three elements that are high risk or priority
• Engage diverse group of staff to plan for improvement
• Develop goals and objectives for each improvement
• Assign tasks to staff for implementing change
• Measure effects of change
• Monitor for trends and outcome results
• Document process and result of improvement
Analysis and Improvement
Analyze, Report, Follow-Up:
• Analyze data on an ongoing basis
• Establish goals with each metric
• Communicate reports to all levels of staff
• Set accountability for low performance levels
• Develop creative methods to motivate and engage staff
• Base action plans on performance levels and company goals
Analysis and Improvement
Performance Improvements:
• When efforts for improvement show increased outcomes
• When outcome metrics improve within time frame established
• When organizational goals are achieved
• When systems are consistent, effective and efficient
• When staff is engaged and motivated
• When clients are engaged and showing progress in treatment