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Jill A. Marsteller, PhD, MPPMay 24, 2011

Assessing Process and Audit Assessing Process and Audit MeasuresMeasures

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Learning ObjectivesLearning Objectives

• You will be able to:– Explain why measuring process is critical to success– Describe process measures planned for collection– Detail the planned collection process

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Donabedian ModelDonabedian Model

Structure Process Outcome

How we organize care

What we do during care delivery

The results we achieve

E.g., presence of policies or committees

E.g., how often are evidence-based interventions performed

E.g., how/ how many patients are harmed

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Approaches to measuring Approaches to measuring processprocess

• Measures of perception– Accessible– Subject to bias

• Regular process measures collection– More objective– Burdensome

• Less frequent auditing– Less burdensome– Less reliable

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Process measures you already Process measures you already collectcollect

• SCIP/STS– Abx selection– Abx timing– Abx stop w/in 48 hours– Glucose measure – Hair removal

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New Measures/ Audit TopicsNew Measures/ Audit Topics

• VAP process measures:– E.g., HOB elevation– E.g., sedation

vacation

• SSI: – Skin prep (type,

appropriateness)– Antibiotic redosing;

– Environment

• CLABSI: – Insertion (OR, ICU)– Maintenance (ICU,

Floor)

• CUSP:– Daily goals; Am

Briefing; LFD (ICU, Floor, universal)

– Briefing/debriefing ; Huddle; LFD (OR)

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Timeline-ORTimeline-OR

Baseline period

Jul2011

Aug Sep Oct Nov Dec Jan 2012

Feb Mar Apr May Jun Jul

CLABSI Process Wkly

Wkly

Wkly

X (90)

X (90) X (90)

SSI Audits Wkly Wkly Wkly X (90) X (90)

CUSP Audits brief huddle

Aug 2012

Sep Oct Nov Dec2012

Jan 2013

Feb Mar Apr May Jun Jul Aug Sep2013

CLABSI Process X

(90)

X (90)

X (90) X (90) X (90)

SSI Audits X (90)

X(90) X (90) X (90)

CUSP Audits LFD brief huddle LFD

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Timeline-ICUTimeline-ICUBaseline Jul

2011Aug Sep Oct Nov Dec Jan

2012Feb Mar Apr May Jun Jul

2012CLABSI Process Wkly Wkly Wkly X(90) X(90) X(90)

VAP Process Wkly Wkly Wkly X(90)

CUSP Audit DGs AMB

Aug 2012

Sep Oct Nov Dec2012

Jan 2013

Feb Mar Apr May Jun Jul Aug Sep2013

CLABSI Process X(90) X(90) X(90) X(90) X(90)

VAP Process X(90) X(90) X(90) X(90)

CUSP Audit LFD DGs AMB LFD

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Timeline-FloorTimeline-FloorBaseline period

Jul2011

Aug Sep Oct Nov Dec Jan 2012

Feb Mar Apr May Jun Jul 2012

CLABSI Process—Maint.

Wkly Wkly Wkly X(90) X(90) X(90)

CUSP Audits DGs AMB

Aug 2012

Sep Oct Nov Dec2012

Jan 2013

Feb Mar Apr May Jun Jul Aug Sep2013

CLABSI Process X(90) X(90) X(90) X(90) X(90)

CUSP Audits LFD DGs AMB LFD

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Timeline-Universal BedTimeline-Universal Bed

Baseline period

Jul2011

Aug Sep Oct Nov Dec Jan 2012

Feb Mar Apr May Jun Jul

CLABSI Process Wkly Wkly Wkly X(90) X(90) X(90)

VAP Process Wkly Wkly Wkly X(90)

CUSP Audits DGs AMB

Aug 2011

Sep Oct Nov Dec2012

Jan 2013

Feb Mar Apr May Jun Jul Aug Sep2013

CLABSI Process X(90) X(90) X(90) X(90) X(90)

VAP Process X(90) X(90) X(90) X(90) X(90)

CUSP Audits LFD DGs AMB LFD

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Audit data: “How To”Audit data: “How To”

• Reminder email will tell you what to audit for the coming month

• Collect data once a week and report at end of month

• Methods: Observations; counts with measure/ count total eligible; answer Qs

• When you enter web tool, it will tell you what audit data is due this month

• Web-based data entry forms

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ExamplesExamples

• Daily Goal Audit—Once weekly count the number of patients that had a Daily Goals sheet filled for them during interdisciplinary rounds; also count total number of patients. Report: DG patients and total

• LFD Audit—Count number of defects worked on in last quarter; number resolved; number posted; number evaluated for effects

• AM Briefing or Huddle/ OR Briefing Audit—observe XX opportunities for briefings; Report: number of briefings conducted and number of opportunities; (Or observe briefings for recommended elements; Report: successes/observations for each element)

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How process measurement How process measurement helps youhelps you

• Compliance is key to providing evidence-based practice

• EBP allows you to meet your outcomes goals• Process measures provide a “map” to what’s

working well and what’s not• Regular feedback on performance essential to

performance and buy-in (transparency)• Use your data to inform, motivate, communicate

laterally and upward