Robert Sutter Portfolio

Professional Portfolio

Harnessing Data For Performance Improvement

The following slides depict statistical analyses I conducted on patient level data and performance dashboards I developed that revealed performance improvement opportunities and catalyzed performance improvement projects.

Robert Sutter, RN MBA MHA

Quality Performance DashboardDeveloped this quality performance dashboard for a health system to assess and monitor the quality of care provided, as well as guide annual quality improvement planning.

The dashboard has several unique features:

Each category is comprised of sub-categories and associated metrics.

Category and sub-category performance is summarized by robust composite indicators.

Every metric is compared to an external benchmark.

The dashboard provides relevant information to all levels of the organization from the Board of Directors to middle managers and medical staff.

Dissemination of this information initiated the development of annual quality improvement planning and project reviews throughout the health system and stimulated the incorporation of quality improvement into the strategic planning process.

3 Robert Sutter, RN MBA MHA

Quality Performance DashboardThis figure depicts the additional information within each sub-category of the Quality Performance Dashboard.

On the prior slide, hospital H had a one star – less than the benchmark –performance in Core Measures.

Additional information available reveals that Pneumonia has a less than the benchmark performance and the following metrics are less than the benchmark:

Pneumococcal screening

Smoking cessation advice

Antibiotic selection

Antibiotic within 6 hours

Influenza vaccination

Subsequently hospital H launched performance improvement projects to close the performance gap.


Cardiothoracic Performance Dashboard

Harnessing the data collected for the Society of Thoracic Surgeons Adult Cardiac Database, this dashboard is updated monthly in order to provide feedback to the hospitals more frequently than the quarterly report from STS.

The comparative nature of the dashboard catalyzed benchmarking and initiated performance improvement projects throughout the health system. The data was also used in several data analysis projects to answer questions posed by the cardiothoracic surgeons (see slides 9-12).


Physician Performance MeasurementA physician performance measurement system was developed to answer three questions:

What proportion of variability is attributable to physicians?

Is there a statistically significant difference in physician performance?

Is there a distribution in outcome categories among physicians?

The answers to these questions provide the necessary information to develop an effective physician performance improvement strategy.

This analysis has notably enhanced physician engagement.


3.9

37.2

99.2

x

DIABETES

HERNIORRHAPHY

CHEST PAIN

Physician Variability Percent

2.09

1.26

-0.07

-0.13

-0.34

-0.38

-0.43

-0.53

-0.54

-0.58

Median

10

1

6

3

8

5

2

4

9

7

Risk-Adjusted LOS Excess

P<0.05

Attending Physician

Chest Pain

43

12

7

40

56

59

46

11

2

19

Att

end

ing

Phys

icia

n

-2 -1 0 1 2 3 4 5 6

Risk-Adjusted Median Excess LOS Confidence Interval

Better Than Expected

As Expected

Worse Than Expected

Length of Stay Outcome Categories

Confidence Level = 0.95

Attending Physician

Chest Pain

SCIP Core Measures Data Analysis & ImprovementA multilevel logistic regression analysis of the SCIP core measures patient level data, comprising all hospitals, revealed the following factors significantly associated with administering an antibiotic within one hour prior to incision:

Surgical Procedure

Surgical Day of Week

Shift

This analysis catalyzed a system-wide performance improvement project that resulted in significant improvement.

.94 .93 .9 .91 .86.95 .91

0.2

.4.6

.81

Porp

ort

ion

CABG

Oth

er C

ardiac H

ip

Kne

e

Colon

Hys

tere

ctom

y

Vas

cula

r

P=0.0445

Surgical Procedure

Antibiotic Within 1 Hr Prior to Incision

.83.93 .93 .94 .94 .92 .96

0.2

.4.6

.81

Porp

ort

ion

Sun Mon Tue Wed Thu Fri Sat

P=0.0222

Surgery Day of Week


.9 .94

0.2

.4.6

.81

Porp

ort

ion

Evening Day

P=0.0186

Shift


.93 .96

0.2

.4.6

.81

Pro

port

ion

Baseline Improvement

P<0.000

System Performance

Antibiotic Within 1 Hour Prior to Incision


SCIP Core Measures Data Analysis & ImprovementA multilevel logistic regression analysis of the SCIP core measures patient level data revealed that timely antibiotic discontinuation is significantly associated with patient’s acquiring an infection.

Further analysis revealed the following factors significantly associated with timely discontinuation of antibiotics post-operatively:

Hospitals

Surgical Procedure

These analyses catalyzed a system-wide performance improvement project that resulted in statistically significant improvement.

.013

.002

0

.005

.01

.015

Infe

ction R

ate

No Yes

P=0.037

Infection

Timely Antibiotic Discontinuation

.86 .85 .9.99

.911

.93

.79

1

0.2

.4.6

.81

Pro

port

ion

1 2 3 4 5 6 7 8 9P<0.000

Hospital Comparison


.95.88 .87 .91

.67

.96

.78

0.2

.4.6

.81

Pro

port

ion

CABG

Oth

er C

ardiac H

ip

Kne

e

Colon

Hys

tere

ctom

y

Vas

cula

r

P<0.0000

Surgical Procedure


.91 .93

0.2

.4.6

.81

Pro

port

ion

Baseline ImprovementP=0.003

System Performance



SCIP Core Measures Data Analysis & ImprovementUsing the SCIP Core Measures patient level data, statistically significant differences in the proportion of cardiac surgery patients with appropriate post-operative glucose control among hospitals was revealed.

This resulted in launching a system-wide performance improvement project that yielded a significant system-wide improvement.

9

.48

.87

.95

.8

.94 .94.91

.73

.81

0.2

.4.6

.81

Pro

port

ion

1 2 3 4 5 6 7 8 9P<0.000

Hospital Comparison

Cardiac Surgery Glucose Control

.82

.94

0.2

.4.6

.81

Pro

port

ion

Baseline ImprovementP<0.000

System Performance

Cardiac Surgery Glucose Control


Society of Thoracic Surgeons Data Analysis The following analyses of the STS patient level data catalyzed numerous performance improvement projects throughout the hospitals that are currently underway.

In addition, a monthly STS report was developed and disseminated via SharePoint to provide hospitals with more frequent and timely information to assist in their improvement projects.

A propensity score analysis revealed that pre-operative beta-blocker use in isolated CABG patients was significantly associated with a lower mortality rate.

Further analysis exposed significant differences among hospitals in pre-operative beta-blocker use as well as composite medication performance in isolated CABG patients.

10

.029

.013

0

.01

.02

.03

Mort

alit

y R

ate

No YesOdds Ratio 0.360: P<0.000

Pre-Operative Beta Blocker

Isolated CABG

.59.66

.78.7 .72

.57

0.2

.4.6

.8

Pro

port

ion

1 2 3 4 5 6P<0.000

Hospital Comparison

Isolated CABG Pre-OP Beta-Blocker

.39

.62.68

.55.49

.71

.45

0.2

.4.6

.8

Pro

port

ion

1 2 3 4 5 6 7P<0.000

Hospital Comparison

Isolated CABG Composite Medication


Society of Thoracic Surgeons Data Analysis A multilevel logistic regression analysis uncovered highly significant relationships between the occurrence of isolated CABG post-operative complications and mortality.

Numerous performance improvement projects were launched to reduce the incidence of post-operative complications.

11

.053

.18

0

.05

.1.1

5.2

Mort

alit

y R

ate

No YesOdds Ratio 3.0: P=0.010

Post-Operative Stroke

Isolated CABG

.029

.27

0.1

.2.3

Mort

alit

y R

ate


Renal Failure

Isolated CABG

.026

.23

0

.05

.1.1

5.2

.25

Mort

alit

y R

ate


Prolonged Ventilation

Isolated CABG

.043

.2

0

.05

.1.1

5.2

Mort

alit

y R

ate


Reoperation

Isolated CABG

.016

.17

0

.05

.1.1

5.2

Mort

alit

y R

ate


Prolonged Post-Operative LOS

Isolated CABG


Society of Thoracic Surgeons Data Analysis A multilevel logistic regression analysis uncovered highly significant relationships between the occurrence of isolated CABG post-operative complications and prolonged post-operative length of stay.

Numerous performance improvement projects were launched to reduce the incidence of post-operative complications.

12

.064

.25

0

.05

.1.1

5.2

.25

Pro

lon

ge

d P

ost-

OP

Lo

s R

ate

No YesOdds Ratio 4.9: P=0.001

Post-Operative Stroke

Isolated CABG

.05

.23

0

.05

.1.1

5.2

.25

Pro

lon

ge

d P

ost-

OP

Lo

s R

ate


Renal Failure

Isolated CABG

.032

.28

0.1

.2.3

Pro

lon

ge

d P

ost-

OP

Lo

s R

ate


Prolonged Ventilation

Isolated CABG

.062

.16

0

.05

.1.1

5.2

Pro

lon

ge

d P

ost-

OP

Lo

s R

ate


Reoperation

Isolated CABG


Society of Thoracic Surgeons Data Analysis Surgeon specific risk-adjusted mortality and reoperation performance was derived for hospitals to facilitate focusing improvement efforts.

13

3.5

2.8

0

5.5

1.7

9.8

0

02

46

810

Obse

rved

/Expe

cte

d M

ort

alil

ty R

atio

1 2 4 6 7 8 9

Surgeon

Isolated CABG Observed/Expected Mortality

.9

1.1

0

2.1

1

1.9

0

0.5

11.5

2

Obse

rved

/Expe

cte

d R

eo

pe

ration

Ratio

1 2 4 6 7 8 9

Surgeon

Isolated CABG Observed/Expected Reoperation


American College of Cardiology Data Analysis The American College of Cardiology patient level data was analyzed to determine if there were significant differences in hospital utilization of contraindicated antithrombotics in dialysis patients undergoing PCI.

The results revealed highly significant differences in hospital utilization of contraindicated antithrombotics.

This information was presented to the medical staff at each hospital and subsequent changes in practice patterns were initiated.

14

.25

.29

.06

.43

.29

.087

0.1

.2.3

.4

Pro

port

ion

1 2 3 4 5 6P<0.000

Hospital Comparison

PCI Dialysis Contraindicated Antithrombotics

.88

.38

.25

.85

1

.33

.67

.42

.57

.43

0

1

0.2

.4.6

.81

Pro

port

ion

1 2 3 4 5 6

Hospital Comparison

PCI Dialysis Contraindicated Antithrombotics

mean of enoxaparin

mean of eptifibatide


American College of Cardiology Data Analysis The American College of Cardiology patient level data was analyzed to determine if there were significant differences in the incidence of vascular complications among hospitals.

The results revealed highly significant differences.

This stimulated benchmarking and process improvement at various hospitals.

15

.0041

.012 .014

.041

.011

.02

0

.01

.02

.03

.04

Pro

port

ion

1 2 3 4 5 6P<0.000

Hospital Comparison

Cardiac Catheterization Vascular Complications

.0084

.037

.015

0

.022

.048

0

.01

.02

.03

.04

.05

Pro

port

ion

1 2 3 4 5 6P=0.014

Hospital Comparison

Percutaneous Coronary Intervention Vascular Complications

.0012 0

.012

.053

.0078.0039

0

.01

.02

.03

.04

.05

Pro

port

ion

1 2 3 4 5 6P<0.000

Hospital Comparison

Diagnostic Catheterization Vascular Complications


American College of Cardiology Data Analysis Based on the previous analysis one of the hospitals wanted to answer the following questions regarding diagnostic catheterization:

Is there a significant difference among physicians?

Are certain patient characteristics associated with vascular complications?

The results revealed highly significant differences among physicians.

Multilevel logistic regression analysis indicated that patient characteristics are not significantly associated with vascular complications.

This information stimulated evaluating physician practice patterns.

16

.8

0 0 0.034

.067

0

0.2

.4.6

.8

Pro

po

rtio

n

1 2 3 4 5 6 9P<0.000

Physician Comparison

Diagnostic Catheterization Vascular Complications

Variable P Value

Gender 0.265

Hypertension 0.508

Prior MI 0.273

Prior Heart Failure 0.494

Diabetes 0.867

Dyslipidemia 0.636

Peripheral Arterial Disease 0.337

Prior PCI 0.372

Age_spline1 0.444

Age_spline2 0.673


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