Skills Competency Education for New PI Directors & Coordinators

1. Skills Competency Education forNew PI Directors & Coordinators Session Four February 28, 2007 Performance Reporting Sponsored by: The MT Rural Healthcare PI Network Co-Sponsored by: Mountain Pacific Quality Health

2. Today’s Session • Recap Session 3: aggregation/assessment • Session 4 Performance Reporting • Value and potential pitfalls • 4 R’s of performance reporting • Audiences • Sample reports and tools • Questions

3. Value: Why Report Performance • Pay for Reporting, Pay for Performance • Basis for objective decision-making • Provides leverage for improvement • Increases team knowledge & understanding • Helps focus improvement efforts • Encourages proactive response

4. Value: Why Report Performance • Potential to improve organization culture • Shared knowledge = shared power • Unites individuals around common goals • Fosters learning • Encourages free exchange of ideas, creativity • Increases ownership of outcomes • All celebrate successes and ‘good tries’ • Can improve morale

5. Potential Pitfalls • Reporting only for “regulatory compliance” • Introduction of bias into data collection and/or analysis • Rushing to decision-making

6. Potential Pitfalls • Different people like to receive information in different ways • Potential for dysfunctional conflict • Blaming with data • Increasing resistance to change • Triangulation • Polarization of the organization

7. Our Reporting Commitment • Model the positive approach • Report performance objectively • Ensure the accuracy of the data • Validate assessments & recommendations • Encourage full discussion, persevere • Acknowledge, publicize and celebrate successes • Have some fun along the way

8. 4 R’s of Performance Reporting Right Information Right Time Right Way Right Audience

9. The Right Information • Is objective • Is relevant to the audience • To their role in the organization • To their span of control, scope • To the decisions they have to make • To the questions they have • To the questions they have to answer

10. The Right Time • When they can listen and receive it • In time to do something about the data • Length of report

11. The Right Way • Attitude • “process not people”; an opportunity • Style • Format: the way they prefer to receive info • Language they can understand while learning the vocabulary

12. Audiences Quality Management Team (QMT) Managers Medical Staff Governing Board Others: community

13. Role Development and/or implementation of strategic plan Deploy operational work plan facility-wide Monitor progress of PI teams The Right Info Strategic plan measures Operations measures, facility wide PI team performance Quality Management Team

14. Role Establish improvement priorities Allocate resources Field questions from all levels of the facility and community The Right Info Comparative info National, regional trends, requirements Costs, benefits Solid understanding of issues, in-depth information as needed Quality Management Team

15. Right Way Objective What’s going well What isn’t Why Interactive Recommendations Collaborative We’re all in this together Right Time Proactive Frequent reports Most comprehensive data set reported Long enough for full discussion of issues and questions; getting to consensus about actions Quality Management Team

16. QMT: Questions They Ask • What’s on the horizon? • What are we doing to meet future challenges? • What new resources do we need? • What opportunities we can take advantage of? • What pitfalls do we need to beware of? • What weaknesses do we need to mitigate?

17. QMT: Questions Asked of Them • Where are we now? • Where are we going? • Why are we going there? • What compelling reason can you give me for changing (ie, “What’s in it for me?”)

18. The QMT Report • High-level strategic and operational measures where no identified problems/ops for improvement exist • Low-level, in-depth performance data where problems are identified or active improvement is underway (“drill down”) • Follow-up reporting each month

19. Role Leaders Management functions Decisions are operational and strategic Oversee one or more departments/services Work with med staff Serve on PI teams Right Information Overall performance Management functions Strategic and operational data Department specific data Relevant clinical care data PI team data Managers

20. Right Way Format: help focus Style: not all are PI experts Drill down when warranted Collegial & supportive Questions answered or “I’ll find out” Right Time Frequency: in time to meet their performance requirements Length: subset of the QMT measure set Plenty of time for education Plenty of time for questions Managers

21. Managers: Questions They Ask • How is the organization doing? • How are the areas I’m responsible for doing? • Where are we going and why? • What’s coming down the road? • What’s in it for me and my staff to change?

22. Managers: Questions Asked of Them • How is the organization doing? • How is our department doing? • Where are we going? • Why are we going there? • What’s in it for me to change?

23. The Manager Report • Small set of high-level strategic measures • Small set of management function operational measures • Low-level, in-depth data directly related to their areas of responsibility • Low-level, in-depth data where problems are identified or active improvement is underway (“drill down”)

24. Role Responsible for quality of diagnosis, treatment Supervise allied health professionals Supervise care provided by nursing and ancillary clinical services The Right Info “Global” clinical data (mortality, returns, etc) Quality of med records Patient safety Peer review Medication use Nosocomial infections Relevant clinical data about ancillary services Medical Staff

25. Role Lead clinical PI MS appointments MS meetings & committees Strategic planning The Right Info Clinical PI team data Patient satisfaction Credentialing info Provider-specific performance data Data collected for committees (ER, OB, ICU, OR, LTC, Clinic) Strategic measures Medical Staff

26. Right Time Hot issues: before MS meetings General report: at MS meetings Brief: 5-10 min ; “cut to the chase” unless ask questions Right Way There to help them get their work done faster, easier Give them “heads up” Suggest They are used to asking the questions; watch defensiveness Plenty of supportive literature Medical Staff

27. Medical Staff Questions • How do our clinical outcomes compare with other, same-size, similar-practice facilities? • What are the diagnosis-specific performance measures for conditions we treat most often? How are we doing with them? • What can we reasonably do to adopt national diagnosis-specific practice guidelines to our unique rural/frontier healthcare delivery site?

28. Medical Staff Questions • How might my practice have to change to do that? • Do patients really care? • What’s in it for me to change? • How might pay for reporting or pay for performance impact my practice?

29. The Medical Staff Report • Targeted clinical measure set to help them move in the necessary direction • Including publicly reported clinical measures • Small set of high-level, global measures they can use to benchmark with other facilities • Additional data as requested • Encourage them to lead clinical PI

30. Role Full legal responsibility for the quality of care Fiduciary Risk management Accountable to community Implement the strategic plan The Right Info Highest level clinical measures Patient safety Financial information Risk management data Publicly-reported performance measures Patient satisfaction Strategic plan measures Governing Board

31. Role Position for the future Oversee CEO Oversee medical staff Bylaws, Rules, Regs Appoint medical staff The Right Info What’s coming He/she gives his/her own report Work with med staff to do this Credentialing, provider performance data Governing Board

32. Right Time At Board meetings Brief: often only 5-10 minutes unless linked to strategy discussions Right Way Give all they ask for Focus them on a few key areas Inform them: long time horizon Typically need lots of education Encourage questions, learning Governing Board

33. Board Questions • What is the standard of care? Are we meeting it? If not, what are we doing to change so that we consistently will? • Are we performing better today than we did last report period? • Are we making progress on our strategic plan? What new opportunities do we have?

34. Board Questions • Are our patients and community satisfied with our services, facility? • What risks do we need to be aware of and plan to manage (internal, external)? • What’s going on at the national level that we need to prepare for? • What are we getting out of our investment in PI?

35. The Board Report • High level strategic and operational performance measures: • Clinical care • Customer/patient/community satisfaction • Hospital operations, including risk management • CAH Annual Program Evaluation • Providing education, receiving direction

36. SampleReports “A Picture Speaks a Thousand Words” Focusing your audience

37. “The 2nd quarter mortality rate was 2.9. There were 9 ADEs, and 6 nosocomial infections. Overall, 80% of our patients were satisfied. 4 staff positions turned over.” Strengths Weaknesses Sample Report

38. Sample Report • Strengths • Weaknesses

39. Sample Report • Strengths • Weaknesses

40. Sample Report • Strengths • Weaknesses

41. Sample Report • Strengths • Weaknesses Adverse Drug Events Nosocomial Infections

42. Sample Report • Strengths • Weaknesses

43. Sample Report

44. Sample Report (Spidergram)

45. Sample Report

46. Sample Report

47. Sample Report

48. Electronic Support Tools • Spreadsheet software • EXCEL (www.mtpin.org) • Lotus 1-2-3 • Presentation software • Power Point (www.mtpin.org) • Publication software • Front Page • Page Maker

49. Questions? Next Time: Quality Management Team Meetings Wed, March 14, 1 pm