measurement systems to support quality and safety · world ‐ class criteria 4.1 how do you...

Measurement Systems to Support Quality and Safety

Chuck Derus, MDVice President - Medical Management

Why? Mrs. Stevens

Bill Saunders

Mr. Jones

World‐class Criteria

4.1

How do you select, collect, align, and integrate data and information for tracking daily operations and overall organizational performance including progress relative to strategic objectives?

How do you use data and information to improve performance at all levels of the organization?

Leadership System

UnderstandStakeholder Requirements

1

Role Model &

Build CommitmentInspire

&

“Raise th

e Bar”

Comm

unica

te,

Enga

ge &

Em

power

Accountabilityfor Results

PatientCommunity

SuppliersPartners

PhysiciansVolunteersAssociatesFamilies

MissionValues

Philosophy

IntegrityPassionCaring

Motivate &

Acknowledge

Organize, Plan & Align

Perform toPlan

Develop, Reward

& Recognize

Learn, Improve& Innovate

Set DirectionEstablish Goals

Performance Measurement System

Managers Tracked Many Goals and Measures

.

Associate Engagement

Patient Satisfaction

Physician Engagement Growth

Funding Our

Future

Health Outcomes

Key Strategic Objectives

• Sustain Excellence of Health Outcomes

• Reduce Preventable Harm to Patients

• Sustain Loyal Associate Relationships

• Sustain Loyal Patient Relationships

• Sustain Loyal Physician Relationships

• Grow Service Area Overall Net Revenue

• Generate Financial Resources to Fund Our Future

7.5 Core Measures4.5 Falls with Injury4.5 CPOE4.5 Post OP DVT/PE3.0 ICU Central Line

Infection3.0 ICU Mortality1.5 Acute Care Readmits1.5 ED Sepsis Mortality0.0 LOS

30% 5% 20% 10% 5% 30%

35%

Building Loyal Relationships

Organizational Alignment

5.0 Assoc Sat 5.0 Inpatient5.0 Outpatient5.0 ED5.0 HCAHPS

10.0 Physician Sat 5.0 Net Revenue 15.0 Oper Margin12.0 Expenses3.0 Philanthropy



Physician Engagement

GrowthFunding

Our Future

Health Outcomes

7.5% Core Measures4.5% Falls with Injury5.0% Inpatient5.0% Outpatient5.0% ED

15.0% Oper Margin

Mission Critical: Goal AlignmentAdvocate Goals /

Strategy GSAM ET Determines Preliminary Goals & Targets

Goal Deployment Worksheet Completed

Directors Provide Input into Goals/Targets

Goals/Targets Finalized

Individual Goals Populated

Organizational and Department Action Plans Created

Goals, Targets, Action Plans Shared with Teams

GSam Strategy

Regulatory

Sample Deployment with Weights

Core Measure Bundles

Executive Team

Weight7.5%

(AMI/PN/CHF/SCIP)

PNBundle

Med/Surg Nursing Director

Weight10.0%

(8 CMS Measures)

Pneumoccocal Vaccination

Nurse Manager

Weight15.0%

(1 Measure)

Integration Using Automation

Advocate Management System (AMS)

• Profiles• Annual Goals, Weights & Results• Quarterly Action Plans• Annual performance evaluation

– Transparency– Goals are Objective

& Measureable– Intranet based for all

85 Leaders– Evaluation and

Management System

Deployment Organization‐wide

Hospital Goals & Results

Dept Goals & Results

Information Sharing

Department Pillar Boards

KRA Baseline Goal/Stretch Jan-11 Feb-11 Mar-11 1st Qtr Apr-11 May-11 Jun-11 2nd Qtr 2011 TargetHealth OutcomesAcute Care Readmission within 30 Days % 11.8% (10.9 / 10.0) 10.8% 10.9% 11.2% 11.2% 11.4% 11.4% 11.4% 11.4% 10.9%CHF Readmissions within 30 Days Percent 14.6% (16/13) 14.0% 11.4% 20.0% 15.0% 20.0% 16.0%Overall LOS Index 0.90 (0.91 / 0.87) 0.89 0.85 0.84 0.84 0.85 0.84 0.84 0.84 0.91STS Composite ** (**/***) ** ** ** *** *** **ACC Outcome Measures

Risk adjusted mortality index 90th (75th/90th) 90th 0.85 1.07% 75thEmergency CABG 25th (75th/90th) 25th 0.5% 0.5% 75thPost Procedure Stroke 99th (75th/90th) 99th 0.0% 0.0% 75th

AHRQ Post-operative PE/DVT* Worse* As expected/ Better Worse Worse Worse Worse Worse Worse Worse Worse As ExpectedICU Mortality* As expected As expected/ Better As Expected As Expected As Expected As ExpectedSepsis Mortality* As expected As expected/ Better As Expected As Expected As Expected As ExpectedNICU Mortality* As expected As expected/ Better As Expected As ExpectedMeaningful Use** Not Compliant Compliant NC NC NC NC NC NC NC NC CompliantCore Measure Bundles HQA All or None Overall Bundle 94% (94 / 97) 96% 97% 95% 96% 95% 98% 94%

AMI Core Measure Bundle 99% (100/100) 100% 100% 100% 100% 100% 100% 100%CHF Core Measure Bundle 99% (100/100) 100% 100% 100% 100% 100% 100% 100%Pneumonia Core Measure Bundle 94% (95/97) 97% 95% 91% 94% 88% 100% 95%

Pneumococcal Vaccine U51/52 97% (98/100) 100% 100% 100% 100% 100% 100% 98%Influenza Vaccine U51/52 97% (98/100) 100% 100% 100% 100% N/A N/A 98%

SCIP Core Measure Bundle 93% (95/97) 90% 96% 93% 92% 96% 95% 95%Antibx DC within 24 hours 97% (97/100) 100% 100% 97% 99% 100% 98% 97%Beta Blocker 96% (98/100) 95% 100% 100% 98% 100% 100% 98%VTE Prophylaxis Ordered 99% (96/100) 100% 100% 100% 100% 100% 100% 96%Post op Urinary Cath Removed POD 91% (91/95) 86% 89% 86% 87% 88% 95% 91%

Patient Safety /Infection PreventionAHRQ Bundle Index Better As expected/ Better Better Better Better Better Better Better Better Better Same AsNDNQI Falls with Injury Rate/1000 Pt Days 0.37 (0.25/0.00) 0.39 0.00 0.19 0.19 0.00 0.18 0.38 0.19 0.25

Unit 41 (0.25/0.00) 1.28 0.00 1.31 0.90 0.00 1.28 1.35 0.88 0.25Unit 42 (0.25/0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.25Unit 43 (0.25/0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.25Unit 51/52 (0.25/0.00) 0.88 0.00 0.00 0.31 0.00 0.00 0.90 0.29 0.25Unit 53 (0.25/0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.25CCU (0.25/0.00) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.25

Infection Prevention SSI Knee/Hip/Spines/CABG (1.0/0.70) 1.42 1.06 0.97 0.97 0.99 0.87 1Influenza Vaccine Associate Compliance % 59% (65%/75%) 62% 66% 68% 68% 68% 65%Hand Hygiene Compliance 85% (85%/95%) 98% 99% 100% 99% 99% 98% 99% 99% 85%

Emergency Department (85%/95%) 93% 100% 100% 96% 100% 100% 96% 99% 85%CCU (85%/95%) 100% 100% 100% 100% 100% 100% 100% 100% 85%U41 (85%/95%) 100% 100% 100% 100% 96% 100% 100% 98% 85%U42 (85%/95%) 98% 100% 100% 98% 100% 100% 100% 100% 85%U43 (85%/95%) 97% 100% 100% 99% 100% 100% 100% 100% 85%

All Pillars / Key Result AreasElectronic

Used by Leaders to Populate AMS

Tracking by Month/QuarterCompared to Baseline, Goals, Targets

By Individual Unit/Area

Stoplight Allows for Visual Management

How do we track organizational performance aligned with strategic objectives

Key Data Review ScheduleData By Pillar Daily Weekly Monthly Quarterly

Health Outcomes




Growth

Funding our Future

Other

Data By Pillar Daily Weekly Monthly Quarterly

Health Outcomes

Safety events - PRN Safety events Hand hygiene metricsPatient Safety Dashboard

Apache dataSTS data


Complaints Patient satisfaction scores Discharge call results


Open position report Turnover


CPOE volumes

GrowthVolumes Volumes Growth report

Funding our Future

RevenuesCash collections


Productivity reportRevenue cycle dashboard

Solucient reports

OtherPM/Night shift

administrative report

Data Savvy Assessment1. We don’t know what data to look at or how to use

them.

2. We have lots of data; we look at them, but we are not sure how to use them.

3. We translate data into information and use them to make improvements and drive decisions.

4. As an organization, we analyze data rigorously to drive breakthrough change.

Data Rigor Scale

Decisions based on ‘gut,’

mood, orintuition

Rigorous data analysis leads

to breakthroughimprovement

Key decisions and improvements are

driven by data

VariabilitySteady

Improvement World Class Performance

Rigorous Use of Data

• Select and collect relevant data• Participate in national databases to provide

risk-adjusted comparisons • Analyze and translate data into information

for action and improvement• Allow data to drive decisions• Track your performance against goals• Share results with your one-up and staff

Competent

Key Data Review ScheduleData By Pillar Daily Weekly Monthly Quarterly

Health Outcomes




Growth

Funding our Future

Other

Analysis

Decisions Made from Data

How I Make Results Visible

Data By Pillar Daily Weekly Monthly Quarterly

Health Outcomes

Safety events - PRN Safety events Hand hygiene metricsPatient Safety Dashboard

Apache dataSTS data


Complaints Patient satisfaction scores Discharge call results


Open position report Turnover


CPOE volumes

GrowthVolumes Volumes Growth report

Funding our Future



Productivity reportRevenue cycle dashboard

Solucient reports

OtherPM/Night shift

administrative report

Analysis

Variances to goalTrending

Gap analysisTrendingVariances to goal

Budget to actualStatistical

Quarterly variances

Decisions Made from Data

Service recoverySafetyRegulatory complianceStaffing

Reinforce action plansStaffingRecognition

Modify action plansCharter new teams

How I Make Results Visible

Daily Huddle Pillar board fillerManager email

Pillar boardsAdministrative Council meeting

World‐class Criteria

4.1

How do you select, collect, align, and integrate data and information for tracking daily operations and overall organizational performance including progress relative to strategic objectives?

How do you use data and information to improve performance at all levels of the organization?

Rigorous Use of Data: Senior Leaders

Data • Healthcare reform• Action OI data• Cost per adjusted discharge• 100 Top Hospital metrics

Analysis • Variance analysis• Does performance support our vision?• Are we positioned for healthcare reform?• Will current performance sustain us?

Decision • Add ‘value’ to GSAM vision• Implement LEAN Enterprise strategy to reduce

waste and increase value

100 Top Hospital Metrics

Top Decile

Rigorous Use of Data: Senior Leaders

Data • Healthcare reform• Action OI data• Cost per adjusted discharge• 100 Top Hospital metrics

Analysis • Variance analysis• Does performance support our vision?• Are we positioned for healthcare reform?• Will current performance sustain us?

Decision • Add ‘value’ to GSAM vision• Implement LEAN Enterprise strategy to reduce

waste and increase value

Rigorous Use of Data: Departments & Frontline Associates

Training Workshops

Department Indicators Selected

Senior Leaders Review / Selection

Department: Collect, Review, Analyze Process

Data

PI Action Plans

Developed

Presentation of Results /

Plans

Senior Leader Debrief

Feedback to Presenters

AnnualPI Superbowl

Annual Review and Evaluation of Process

PI Showcase Process

Executive Team Selection Criteria

Alignment with Health Outcome key result areaAlignment with pillar(s)Meets customer requirementsBenchmark available

Scores added up – top 36 departments/units selected for presentation

2010 PI Showcase

Environmental Services and

Infection Control

Improving High-Touch Surface Cleaning

Marking a Telephone

Improve Cleaning Via Fluorescent Tagging

Indicator: Percentage of tagged high-touch surfaces that are cleaned

Goal: 100% of high-touch surfaces will be cleaned completely

2010 PI Showcase

Unit 43 Oncology

Improve Documentation of Chemotherapy Medication

PDSA ‐

Study

Indicator– Percentage of documentation of verifications of

correct chemotherapy drug, dose, patient, and rate by 2 RN’s.

Goal– 100% of all chemotherapy drugs administered will

have documentation of specific verifications by 2 RN’s.

Rigorous Use of Data: In the OR

ANTICIPATION…2007 First NSQIP Semi‐Annual Results

30-Day Mortality

* Includes General and Vascular Surgery Cases

Observed rate: 1.23% Expected Rate: 1.70% O/E Ratio: 0.72 Status: As Expected

GSA

M

Participating Hospitals: Baylor, Stanford, Mayo Clinic, Duke,Cleveland Clinic

Cardiac Complications

* Includes General and Vascular Surgery Cases

Observed rate: 0.00% Expected Rate: 0.64% O/E Ratio: 0.0 Status: Exemplary

GSA

M

High Outlier “Higher than expected” number of

postoperative occurrences of renal failureImprovement Needed!

A PROBLEM WAS IDENTIFIED!

Overall Renal Failure GSA

MObserved rate: 2.16 % Expected Rate: 0.75 % O/E Ratio: 2.89 Status: Needs Improvement

Rigorous Use of Data: In the OR

Data • NSQIP results• Chart reviews• Interviews with MDs/OR staff• Benchmarking w/other

organizationsAnalysis • Failure Mode And Effect Analysis

[FMEA]Decisions • Process changes

• Patient education – prep for surgery• Hydration protocols

Overall Renal Failure

GSA

M

The rigorous use of data has been used to improve performance at all levels of our organization:– Executives– Housekeepers– Nurses– Surgeons and Anesthesiologists

So that…

In Conclusion

Mrs. Stevens

Bill Saunders

Mr. Jones

Questions

measurement systems to support quality and safety · world ‐ class criteria 4.1 how do you...

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