Driving Practice Improvement Using Dashboards

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Driving Practice Improvement Using Dashboards

• Nancy Donaldson RN, DNSc., FAAN
• UCSF Stanford Center for Research Innovation in
  Pt. Care

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The Context Nursing Practice The Strategic
Goal
To reduce the cost of healthcare delivery while
improving the quality, effectiveness and safety
of patient care
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Era of Performance Accountability

• Administrators
• Stockholders
• Payers
• Purchasers
• Consumers
• Legislators
• Regulators
• Policy Makers

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Components of Care Delivery
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Quality

• the degree to which health services for
  individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge
• IOM (1994)

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Quality of Care Re-Defined

• By Structure--Continuous shifting of skill mix
  and hours of care based on acuity AND pressure to
  reduce costs in new market place
• By Processes--Safety comfort disaster
  avoidance risk vs. complication prevention
• By Outcomes--Cost per case patient satisfaction
  functional status adherence clinical status and
  quality of life.

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Examples of Popular Press Headlines
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Quality of Care Concerns

• Use of unnecessary or inappropriate care
• Underuse of needed, effective and appropriate
  care
• Shortcomings in technical and interpersonal
  aspects of care
• Patient safetyerrors omissions
• IOM (1994 1999)

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November 1999--IOM Panel Reports--Medical
mistakes cost 29 Billion (NY Times CNN)
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Medical Error Defined

• ...an unintended act (by omission or commission)
  or one that does not achieve its intended
  outcome.
• Lucien Leape, MD, Agency for Health Care Policy
  and Research
• from Reducing Errors in Health Care Research in
  Action Fact Sheet. Agency for Health Care Policy
  and Research Pub. No. 98-P018, Sept. 1998
  http//www.ahrq.gov/research/errors.htm.

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Types of Healthcare Errors

• Diagnostic (delay/ failure to use or act on test)
• Invasive diagnostic procedure
• Surgical procedure
• Anesthesia
• Prevention

• Drug (dose, interaction, allergy, wrong drug)
• Equipment failure
• Diet (eg, salt-free)
• Nosocomial infection
• Nursing procedures
• Blood transfusion safety

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How Errors Occur

• Medication errors
• Diagnostic inaccuracies
• Inaccurate information recall
• System failures
• from Reducing Errors in Health Care Research in
  Action Fact Sheet. Agency for Health Care Policy
  and Research Pub. No. 98-P018, Sept. 1998
  http//www.ahrq.gov/research/errors.htm.

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Institute of Medicine Report

• Four-tiered approach to reducing
• medical errors
• Establish national focus on patient safety
• Identify and learn from medical errors through
  mandatory and voluntary reporting systems
• Raise standards and expectations for improvement
  through oversight, group purchasers, professional
  groups
• Implement safe practices at the delivery level
• PUBLIC - PRIVATE PARTNERSHIP!

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Improving Patient Safety

• Computerized ADE monitoring
• Computerized MD order entry (CPOE)
• Computer-generated reminders for follow-up
  testing
• Standardized protocols
• Computer-assisted decision-making
• Understanding relationships between factors,
  i.e., nursing staffing and adverse events.
• from Reducing Errors in Health Care Research in
  Action Fact Sheet. Agency for Health Care Policy
  and Research Pub. No. 98-P018, Sept. 1998
  http//www.ahrq.gov/research/errors.htm.

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Types of Healthcare Errors

• Diagnostic error
• Equipment failure
• Infections
• Blood transfusions
• Misinterpretation of other medical orders
• from Medical Errors The Scope of the Problem.
  Fact sheet, Pub. No. AHRQ 00-P037. Agency for
  Healthcare Research and Quality, Rockville MD.
  http//www.ahrq.gov/clinic/errback.htm

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Errors are Preventable !Studies of Medical
Records Show Promise

• A landmark study indicated
• --70 of adverse events were preventable
• --6 were potentially preventable
• --only 24 were not preventable
• A 1999 study showed 54 of surgical errors were
  preventable
• from Reducing Errors in Health Care Research in
  Action Fact Sheet. Agency for Health Care Policy
  and Research Pub. No. 98-P018, Sept. 1998
  http//www.ahrq.gov/research/errors.htm.

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The Best Offense Is a Good Defense Against
Medical Errors

• John M. Eisenberg, MD, Director
• Agency for Healthcare Research and Quality
• The Best Offense Is a Good Defense Against
  Medical Errors Putting the Full-Court Press on
  Medical Errors. John M. Eisenberg, MD, Director,
  Agency for Healthcare Research and Quality, at
  the Duke University Clinical Research Institute,
  Jan. 20, 2000. Agency for Healthcare Research
  and Quality, Rockville, MD. http//www.ahrq.gov/ne
  ws/spch012000.htm

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The role of measurement in perpetual practice
improvement
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Managing a company by means of the monthly
report is like trying to drive a car by watching
the yellow line in the rear-view mirror. Myron
Tribus (Wheeler, 1996)
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Diverse Sources of Quality Data

• Centralized Public/Private/Professional databases
• Unusual occurrence database
• Adverse event database
• Payer claims data
• Clinical information systems
• Financial/billing systems
• Surveys
• Drill down charts/logs/records review
• (c) Nancy E. Donaldson DNSc., RN (1997)

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JCAHO Screening Indicators www.jcaho.org (Whats
new!)
1. Overtime 11. Staff injuries on the job
2. Family complaints 12. Injuries to
patients 3. Patient complaints 13. Skin
breakdown 4. Staff vacancy rate 14.
On-call per diem use 5. Staff satisfaction
15. Sick time 6. Patient falls
16. Pneumonia 7. Adverse drug event 17.
Postoperative infection Staff turnover rate
18. Urinary tract infection 9. Understaffing
as compared 19. Upper GI Bleed to
organizations staffing plan 20. Shock/cardiac
arrest 10. Nursing care hours per 21. Length
of stay patient day
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Limitations for Current Reporting Strategies

• Monthly Quarterly Reports
• difficult to interpret
• retrospective delayed data
• impossible to explore relationships between
  data elements
• difficult to understand variation
• poor integration and standardization

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Impact on Performance

• Decisions lack 3-dimensional perspective
• Decisions now based on data then
• Data is not integral to strategic business
• Data is not source of information

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Current Tools

• Common process improvement analytic strategies
• Root Cause Analysis
• Focused Data Queries
• Benchmarking
• Quality Studies
• Process Control Charts

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The Ultimate Challenge--Converting Data into
Information and Information into KNOWLEDGE
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Data DashboardHealthcare Instrument Panel
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Imagine the Dashboard

• One page summary of all critical measures needed
  to guide business practice
• Actionable information
• Early warning of emerging issues/problems
• Current data
• Integrated data systems/sources

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Variation In Health Care

• Significant treatment variation is associated
  with suboptimal costs, quality outcomes
• Wide clinical diversity associated with
  suboptimal outcomes
• Common Cause vs. Special Cause
• Reducing variation generally increases quality

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Statistical Process Control Chart

• Documents performance or outcomes over time
• Upper and lower control limits allow special
  cause variation and common cause variation to be
  discriminated
• Aim is to eliminate special cause variation
  (stabilize process) and then focus efforts on
  reducing common cause variation

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Evidence-based Outcomes Improvement
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Innovation
A change in nursing practice that is perceived as
new by those adopting it, and that represents a
significant alteration in the status quo.
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Catalysts to Innovation Action

• Suboptimal performance (processes or outcomes)
• Strategic imperative (grow market/margins)
• Customer feedback
• Important new knowledge/technology
• Grass roots identification of recurring problem
• Retrofitting solution to a lesser problem

c. Nancy Donaldson RN, DNSc.
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Sources of Innovation

• Invention
• Borrowing - - Benchmarking
• Enhancing Processes
• Transfer of new knowledge
• Adoption of new technology
• Vision

c. Nancy Donaldson RN, DNSc.
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Using Evidence-based Clinical Innovations

• The Research Utilization Process
• The CQI Process
• Organizational Adoption Process

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Role Activities of the Nursing Research Consumer

• Evaluation
• Translation
• Interpretation
• Dissemination
• Application and/or utilization

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CalNOC Partners for Quality TRIP to Reduce
Hospital FallsYEAR 1Nancy E. Donaldson RN,
DNSc., FAANPIPat McFarland RN, MSProject
DirectorCo-Investigators Drs. Brown, Burnes
Bolton, Aydin, Dunton, Rutledge,
PravikoffSupported By Grant 1U18HS1370401
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The CalNOC Partners to Reduce Patient Falls
Project builds on the infrastructure of the
California Nursing Outcomes Coalition Database
Project, a joint venture of ANA\California the
Association of California Nurse Leaders (ACNL)

• California Nursing Outcomes Coalition Database
  Project

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CalNOC Database ProjectOverview

• The California Nursing Outcomes Coalition
  (CalNOC) Database Project is a collaborative
  initiative engaging a diverse team of staff
  nurses, advanced practice clinicians, educators,
  researchers, administrators and leaders in
  nursing in attaining a shared vision of
  designing, systematically implementing, and
  evaluating a statewide nursing outcomes database.

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CalNOC Mission

• CalNOC advances improvements in patient care
  quality, safety, and effectiveness by...
• Building and sustaining a valid and reliable
  statewide outcomes database
• Conducting research to advance evidence-based
  interventions to achieve quality
• Synthesizing and disseminating data to shape
  public policy, practice, and education

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CalNOC Indicators

• Structural Indicators
• Hours per Patient Day
• Skill Mix
• Ratios
• Use of Contract Staff
• Nurse Education--highest degree

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CalNOC Indicators

• Process Indicators
• Falls--Risk and Consequential
• Pressure Ulcers (prevalence)
• Restraint Use (prevalence)

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CalNOC Falls Indicator

• The rate per 1000 patient days at which patients
  experience an unplanned descent to the floor.
• Database only contains information on patients
  who fell.
• Reported by unit per calendar month
• Falls with injury excludes falls with injury
  level reported as none and mild.

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Falls Indicator Information

• Age Gender
• Observed or assisted by ANY member of the staff
• Injury level
• Risk identified for falling and risk assessment
  tool information
• Type of fall Accidental, Unanticipated
  Physiological, Anticipated Physiological Fall
  prevention protocol in place
• Restraints at time of fall

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CalNOC Partners TRIP to Reduce Patient
Falls ProjectThe primary aim of this 4 year
quality improvement demonstration project is to
reduce the incidence of patient falls and
severity of fall related injury in 100 medical
surgical patient care units in CalNOC hospitals
through evidence-based coaching, education and
consultation through improving falls risk
assessment and prevention intervention clinical
effectiveness.
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CalNOC Hospitals
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Trip to Reduce Falls Intervention

• Institutional baseline self-assessment
• Individualized falls related drill down data
  analysis report and facilitated presentation
• Coaching for performance improvement
• Linker role development
• CE for key staff related to falls reduction
• Strategic resources
• Networking, benchmarking synergy

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Important Web Sites

• CHIPP.CAHWNET.gov
• ahcpr.gov
• hcqualitycommission.gov
• nih.gov or ninr.gov
• amhpi.com/eyeonpatients (Picker Institute)
• ncqa.org. (HEDIS)
• jcaho.org
• nursingworld.org (ANA)