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Skills Competency Education for New 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. Today’s Session. Recap Session 3: aggregation/assessment

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Skills competency education for new pi directors coordinators

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

Today s session
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

Value why report performance
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

Value why report performance1
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

Potential pitfalls
Potential Pitfalls

  • Reporting only for “regulatory compliance”

  • Introduction of bias into data collection and/or analysis

  • Rushing to decision-making

Potential pitfalls1
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

Our reporting commitment
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

4 r s of performance reporting

4 R’s of Performance Reporting

Right Information

Right Time

Right Way

Right Audience

The right information
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

The right time
The Right Time

  • When they can listen and receive it

  • In time to do something about the data

  • Length of report

The right way
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



Quality Management Team (QMT)


Medical Staff

Governing Board

Others: community

Quality management team


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

Quality management team1


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

Quality management team2

Right Way


What’s going well

What isn’t





We’re all in this together

Right Time


Frequent reports

Most comprehensive data set reported

Long enough for full discussion of issues and questions; getting to consensus about actions

Quality Management Team

Qmt questions they ask
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?

Qmt questions asked of them
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?”)

The qmt report
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




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



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 questions they ask
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?

Managers questions asked of them
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?

The manager report
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”)

Medical staff


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

Medical staff1


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

Medical staff2

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”


They are used to asking the questions; watch defensiveness

Plenty of supportive literature

Medical Staff

Medical staff questions
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?

Medical staff questions1
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?

The medical staff report
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

Governing board


Full legal responsibility for the quality of care


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

Governing board1


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

Governing board2

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

Board questions
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?

Board questions1
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?

The board report
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

Sample reports


“A Picture Speaks a Thousand Words”

Focusing your audience

Sample report

“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.”



Sample Report

Sample report1
Sample Report

  • Strengths

  • Weaknesses

Sample report2
Sample Report

  • Strengths

  • Weaknesses

Sample report3
Sample Report

  • Strengths

  • Weaknesses

Sample report4
Sample Report

  • Strengths

  • Weaknesses

Adverse Drug Events

Nosocomial Infections

Sample report5
Sample Report

  • Strengths

  • Weaknesses

Electronic support tools
Electronic Support Tools

  • Spreadsheet software

    • EXCEL (

    • Lotus 1-2-3

  • Presentation software

    • Power Point (

  • Publication software

    • Front Page

    • Page Maker



Next Time:

Quality Management Team Meetings

Wed, March 14, 1 pm