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Putting the Tools to Use: One Hospital’s Experiences
Donna Farley, PhD – RANDEllen Robinson, PT ATC – Harborview Medical Center
Format for This Discussion
Goals of the discussion– Highlight how groups of tools apply at
different steps of an improvement process– Offer opportunity for audience questions
as each group of tools is discussed
Three groups of tools to be addressed– Work with data for the PSIs and IQIs– Diagnose issues and develop strategies– Implement improvement plans
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Structure of the Toolkit
Introduction and RoadmapA. Readiness to ChangeB. Applying QIs to the Hospital DataC. Identifying Priorities for Quality ImprovementD. Implementation MethodsE. Monitoring Progress and Sustainability
of ImprovementsF. Return-on-Investment AnalysisG. Existing Quality Improvement Resources
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Working with PSIs and IQIs
Introduction and RoadmapA. Readiness to ChangeB. Applying QIs to the Hospital DataC. Identifying Priorities for Quality ImprovementD. Implementation MethodsE. Monitoring Progress and Sustainability
of ImprovementsF. Return-on-Investment AnalysisG. Existing Quality Improvement Resources
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Tools for Working With the PSIs and IQIs
A.1 Fact sheets on the PSIs and IQIsA.2 Template Powerpoint presentations on
the Quality Indicators for Board or staff
B.1 Applying PSIs and IQIs to hospital dataB.2 Examples of AHRQ software outputsB.3 Spreadsheets and presentations of hospital
rates for PSIs and IQIs
B.4 Documentation and coding guidanceB.5 Assessing hospital rates using trends and
benchmarks
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Harborview’s Project Goals
Internal Reporting: – Utilize the AHRQ software to identify cases
of possible preventable harm– Standardize case referral across all teams
in the hospital External Reporting:
– Understand and validate publicly reported rates of hospital performance
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Readiness for Change
– Medical Director - previous director of QI Dept– Leadership support and directive for project– The Board was “on board”
– Challenges identified: information dissemination about quality and patient safety to staff at all levels of the organization
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Applying your Data
Input data challenges– Format billing system export into a file format
that can run through the AHRQ software Output data challenges
– Validate rates against external source to ensure capture of all cases
– Software versions (currently 4.3) and format (SAS vs. Windows)
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Sharing your Data
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Surgical Council, Medical Executive Board, Critical Care Council, Hospital Board, Clinical Documentation Specialists, Health Information Management– What are the PSIs? Why do we care?– Current performance/UHC ranking– How are we going to review cases and
expectations from the medical teams– Possible opportunities for improvement
Documentation and Coding
Specifications for each PSI and common challenges for “false positives”
Recognize limitations of administrative data, but also recognize the potential
Partnerships with clinical documentation programs and coding department are critical to success of the project
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QUESTIONS?
Diagnose Issues and Develop Strategies
Introduction and RoadmapA. Readiness to ChangeB. Applying QIs to the Hospital DataC. Identifying Priorities for Quality
ImprovementD. Implementation MethodsE. Monitoring Progress and Sustainability
of ImprovementsF. Return-on-Investment AnalysisG. Existing Quality Improvement Resources
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Tools to Assess Readiness, Priorities, Strategies
A.3 Getting ready for change self-assessment– Readiness for quality improvement– Readiness to work with the QIs
C.1 Prioritization matrixC.2 Example of completed matrix
D.1 Improvement methods overviewD.2 Project charterD.3 Examples of effective PSI improvementsD.4 Best practices for PSI improvementsD.5 Gap Analysis
F.1 Return-on-investment analysis
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Tools to Assess Readiness, Priorities, Strategies
A.3 Getting ready for change self-assessment– Readiness for quality improvement– Readiness to work with the QIs
C.1 Prioritization matrixC.2 Example of completed matrix
D.1 Improvement methods overviewD.2 Project charterD.3 Examples of effective PSI improvementsD.4 Best practices for PSI improvementsD.5 Gap Analysis
F.1 Return-on-investment analysis
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An important decision-support tool
Considers factors that influence choice of improvement priorities– Benchmarks– Costs– Strategic alignment– Regulation– Barriers to implementation
Factors Addressed in the Prioritization Matrix
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A useful tool for assessments– Planning phase – estimate potential
effects on hospital finances– Post-implementation – estimate actual
effects on hospital finances
The tool provides instructions for performing an ROI and an example
Role of a Return-on-Investment Analysis (ROI)
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Prioritization Matrix
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Tool allows you to compare to a like group for benchmarking, identify areas that are highest impact, assess barriers.
Return on Investment
Currently partnering with our Decision Support/Finance teams to identify a meaningful reporting metric
“Costs” of PSI events vary in the literature so makes it difficult to have a “target”
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QUESTIONS?
Implement Improvement Plans
Introduction and RoadmapA. Readiness to ChangeB. Applying QIs to the Hospital DataC. Identifying Priorities for Quality ImprovementD. Implementation MethodsE. Monitoring Progress and Sustainability
of ImprovementsF. Return-on-Investment AnalysisG. Existing Quality Improvement Resources
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D.6 Implementation planningD.7 Implementation measurementD.8 Project evaluation and debriefing
E.1 Monitoring progress for sustainable improvement
F.1 Return-on-investment analysis
Tools to Help Make Improvements Happen
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D.6 Implementation planningD.7 Implementation measurementD.8 Project evaluation and debriefing
E.1 Monitoring progress for sustainable improvement
F.1 Return-on-investment analysis
Tools to Help Make Improvements Happen
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For use after completion of an improvement initiative
Focus on sustainability Guidance for monitoring system
– A limited set of effective measures– Schedule for regular reporting– Report formats to communicate clearly– Procedures to act on problems found– Periodic assessment of sustainability
Monitoring for Sustainable Improvement
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A Project Management “Toolkit”
Useful tools for clinicians who may not have as much experience with project management
Selected Best Practices Assisted with development of “task
forces” in our selected PSI areas Kept teams focused and on track during
early stages of the implementation
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Monthly PSI Case Review
Monthly Data Feed AHRQ
QI Analysis
Coding or Documentation issue?
Documentation Coding Review
Update coding
Agree?(Wrong code or exclusion
criteria code missing)
Real Event?
Service Review
No EventNo Coding Issue
No QI Concerns
QI Concerns
Monitoring and Sustainability
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Case analysis and Tracking of outcomes
Ongoing Reporting
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Web-based reporting on Harborview Intranet
Lessons Learned
Validate, Validate, Validate Understand details of the specifications
and be able to apply to your population Leadership backing for project importance Presentations to clinical staff should begin
with real case examples Coding lead liaison is critical
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Harborview MC Outcomes
Standardized Case Review - 2011 PSI 3,6,7,9,11,12,15
– 45% no quality concerns– 18% teams identified possible QI system
opportunities– 25% related to documentation/coding – 12% “flawed metric”
PSI 11 flagged in a planned two stage surgery PSI 9 flag related to intra-operative bleeding
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Hospital Challenges
AHRQ Software is one tool to assist with identification of improvement opportunities
As Health Care IT becomes more sophisticated, hospitals have more data
Challenge ourselves to be creative and identify clinical systems to provide additional sources for events
How do we find the “false negatives?”
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VTE Events from Exams vs. PSI 12
Jan to Dec 2011: HAC - VTE Events
70% also identified by AHRQ PSI 12
30% flagged by diagnostic systems– Not identified in administrative data (not coded, not in top 24
diagnosis, or “POA” = Y)– Did not have an operative procedure, so not included in the
denominator for PSI 12
Without our internal clinical event search tool, these cases would be missed QI opportunities.
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Allowed our hospital to translate from rate- based tracking to one that provides an opportunity for real changes for patients
Hospitals can use the QIs to analyze “gaps” in current clinical care
Toolkit can assist with “what to do” about areas of opportunity you identify
Download the toolkit at: http://www.ahrq.gov/qual/qitoolkit.
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AHRQ QI Toolkit
QUESTIONS?
Getting More Information
Where can I find the Toolkit? http://www.ahrq.gov/qual/qitoolkit
Can other people hear this presentation later? Yes, a video of this Webinar will be available on the Toolkit page.
Will I be able to learn more about the Toolkit? Yes, audio interviews about specific tools will be added to the Toolkit page.
