Using Quality Tools To Enhance Performance

1. Using Quality Tools To Enhance Performance The Access Database for (ACM) and (SCIP) Data Collection

2. AHQA Technical Conference Nancy West, RN, MPH, CPHQ Using Quality Tools to Improve Performance Session F-3 Hospital

3. Best Practice Methods Project Findings Multidisciplinary teams Concurrent Review of Data Engaging senior leadership Competition Frequent interactions We wanted to leverage some of the attributes that we found from the BPM project. This was a new project for the 8th SOW- with 5 other QIOs and 50 hospitals- we looked at a subset of the ACM- we looked back to find some answers to guide us in decision making about the ACM. We wanted a mechanism to share the data. One hospital concurrentkly reviewed data and was far ahead of the others-when thye tried this method their performance improved. We wanted to leverage some of the attributes that we found from the BPM project. This was a new project for the 8th SOW- with 5 other QIOs and 50 hospitals- we looked at a subset of the ACM- we looked back to find some answers to guide us in decision making about the ACM. We wanted a mechanism to share the data. One hospital concurrentkly reviewed data and was far ahead of the others-when thye tried this method their performance improved.

4. Goals of the Access Data Base Focus on the ACM Begin to concurrently review data Use the tool for performance improvement Discuss QI performance on teleconferences Improve! But we really wanted them to improve performance through data collection But we really wanted them to improve performance through data collection

5. About measurement W e wanted this to be more than data audit and feedback. We wanted process improvement. W e wanted this to be more than data audit and feedback. We wanted process improvement.

6. We didn’t want to repeat some of the mistakes in the 7thSOW, where there was not a cohesive focus on the work. We were skeptical about whether hospitals would collect the dataWe didn’t want to repeat some of the mistakes in the 7thSOW, where there was not a cohesive focus on the work. We were skeptical about whether hospitals would collect the data

7. Qualis Health and (Hospital Name) Appropriate Care Measure TeamMemorandum of Understanding     Establish a multidisciplinary team Complete a provided self-assessment tool Complete an action plan Collect and submit timely data and activity reports according to schedule Plan, implement, and support the project Support participants by providing teleconferences, educational forums, consultative services, and on-site visits Participate in on-site clinical team meetings as needed and appropriate From the best practice methods project we learned that when expectations were clarified –there was better compliance. We had each CEO sign an memorandum of understanding MOU; This was written to clarify expectations about the project. What we will do and what the hospital is expected to do. And they started collecting dataFrom the best practice methods project we learned that when expectations were clarified –there was better compliance. We had each CEO sign an memorandum of understanding MOU; This was written to clarify expectations about the project. What we will do and what the hospital is expected to do. And they started collecting data

8. On the 15th of every month teams would send in the ACM data We asked them to start out collecting 10 charts per month-first on PNE to look at processes around the indicators of PNE immunization and timing of antibiotics. We collected this data for three months and provided them monthly reports about their progress compared to others in the group. On the 15th of every month teams would send in the ACM data We asked them to start out collecting 10 charts per month-first on PNE to look at processes around the indicators of PNE immunization and timing of antibiotics. We collected this data for three months and provided them monthly reports about their progress compared to others in the group.

9. Heart Failure We created a very simplistic tool that anyone could use. The data definitions were very BRIEF. The tool that showed a summary, when they put the chart data in the tool. They also wanted to concurrently review the discharge instructions See the case number and the chart review date-I will get back to thatWe created a very simplistic tool that anyone could use. The data definitions were very BRIEF. The tool that showed a summary, when they put the chart data in the tool. They also wanted to concurrently review the discharge instructions See the case number and the chart review date-I will get back to that

10. Pneumonia Initially there were problems-they cherry picked the charts-we had data from Oct in Jan’s report We found that people used it for all the chartsInitially there were problems-they cherry picked the charts-we had data from Oct in Jan’s report We found that people used it for all the charts

11. AMI Under the push pins were very basic questions from CART, which would guide the user in the yes, no exclude answer.Under the push pins were very basic questions from CART, which would guide the user in the yes, no exclude answer.

12. TransparencyShared DataAttend Monthly Teleconferences Quarterly Progress Reports Transparency -All the monthly data was open to all the participating hospitals on each report. They could compare their data and discuss it openly on a monthly teleconference-Transparency -All the monthly data was open to all the participating hospitals on each report. They could compare their data and discuss it openly on a monthly teleconference-

13. On the 15th of each month, each hospital would send back the data base to us and we would compile these charts together and send out a performance report to all the teams. This black line is the 50% RFR HQA target and this reports shows how they are progressing or exceeding the goal. The lines below and above it the percentages needed to achieve the goals or above the goal.On the 15th of each month, each hospital would send back the data base to us and we would compile these charts together and send out a performance report to all the teams. This black line is the 50% RFR HQA target and this reports shows how they are progressing or exceeding the goal. The lines below and above it the percentages needed to achieve the goals or above the goal.

14. ACM Data This report shows quarterly data collection –we began collecting monthly but it didn’t show a lot of change-So we collected their self reported data for three months and those that were concurrently collecting data showed higher rates of performance –so other hospitals began to concurrently reviewThis report shows quarterly data collection –we began collecting monthly but it didn’t show a lot of change-So we collected their self reported data for three months and those that were concurrently collecting data showed higher rates of performance –so other hospitals began to concurrently review

15. SCIP DATA For SCIP, there was not a data collection tool and we initially sent out the excel tool created by IPRO , then we changed over to the Access.For SCIP, there was not a data collection tool and we initially sent out the excel tool created by IPRO , then we changed over to the Access.

16. What Happened?Questions!Difficult MailingWanted Enhancements (DC Instructions)Modified the Tool With MD Information Initially there was high variation -There was difficulty at first with emailing the database back and forth. A firewall would block the tool We had to change the name to an mdb to an xyz file sometimes we had to send it in a zip file- sometimes their software blocked it Initially there was high variation -There was difficulty at first with emailing the database back and forth. A firewall would block the tool We had to change the name to an mdb to an xyz file sometimes we had to send it in a zip file- sometimes their software blocked it

17. Who Collected Data?Case ManagersQI Data Abstractors Basically these were the people that used the tool- and so this wasn’t really what we hoped for-we wanted them to use either the paper tool or the database on the unitsBasically these were the people that used the tool- and so this wasn’t really what we hoped for-we wanted them to use either the paper tool or the database on the units

18. How Does It Work?

19. Did It Work? The question-is the access data base a catalyst for change? Through the monthly teleconferences and transparent sharing of data-QI directors and teams began to compete-they saw that those that concurrently reviewed data had higher performance; and they discussed process improvement ideas on the teleconferencesThe question-is the access data base a catalyst for change? Through the monthly teleconferences and transparent sharing of data-QI directors and teams began to compete-they saw that those that concurrently reviewed data had higher performance; and they discussed process improvement ideas on the teleconferences

20. This hospital began concurrently reviewing the data in the third Q This hospital began concurrently reviewing the data in the third Q

21. See for yourself; this shows a correlation between those hospitals that collected concurrently data with the tool The purple line is the self collected data and the blue is the HQA dataSee for yourself; this shows a correlation between those hospitals that collected concurrently data with the tool The purple line is the self collected data and the blue is the HQA data

22. Take a look at hospital 12-they began concurrently reviewing chart around May Take a look at hospital 12-they began concurrently reviewing chart around May

23. Hospital 12 began concurrently reviewing data in MayHospital 12 began concurrently reviewing data in May

24.  Survey Results? We thought they were using it as a process improvement tool-the only thing they really thought were helpful were the reports-they liked knowing where they were compared to othersWe thought they were using it as a process improvement tool-the only thing they really thought were helpful were the reports-they liked knowing where they were compared to others

25. Do You Use the Data Base for Process Improvement?Yes=71.4% SCIPYes=41.7% ACM

26. Our Team Would Like to Discontinue Sending Data to Qualis Health ACM 81.8%=no! SCIP 72%=no

27. Barriers They cherry picked the charts, put old data in, put small amounts of data- Tool needed revisions in the data definitions And the chart review date instead of the discharge date made it impossible to locate the patient once again.They cherry picked the charts, put old data in, put small amounts of data- Tool needed revisions in the data definitions And the chart review date instead of the discharge date made it impossible to locate the patient once again.

28. What They Said …great way to aggregate data from many sources …has helped us to make some positive changes …allows clarification and feedback accountability … helped us to stay focused on our ongoing work Some found it helpful in the following ways the teleconferences helped them discuss best practicesSome found it helpful in the following ways the teleconferences helped them discuss best practices

29. What They Also Said

30. What Did You Do With the Data? Took It to the PI Team for Benchmarking Gave It to the Managers to Review With Staff Served as a double check for HQA data Gave it to the MD Champion Some found it helpful in the following ways: They had very high variation initially Helped them see where they need improvement Provided a sort of benchmark to look at their performance against the other hospitals Some found it helpful in the following ways: They had very high variation initially Helped them see where they need improvement Provided a sort of benchmark to look at their performance against the other hospitals

31. Met Primary GoalExpand to 24 measures?Seamless process for HQA data collection Make them get the reports through QNET-put MR# in so they can track patients in light of the 9th SOW coming we are not necessarily jumping toward the 24 measures. What they really liked were the reports-that showed where they were compared to everyone else.Make them get the reports through QNET-put MR# in so they can track patients in light of the 9th SOW coming we are not necessarily jumping toward the 24 measures. What they really liked were the reports-that showed where they were compared to everyone else.

32. Lessons Learned The Access Data base is easy use and provides current reports Did not assist in concurrent data collection It is not a data abstraction tool-it is a data collection tool Reports helped teams to see performance Competition sometimes expedites improvement

34. Nancy West, RN, MPH, CPHQClinical ConsultantQualis Health206 364-9700 Ext 2007