Performance Indicators In Hospitals - Ayman Salah

IT Solutions from Doctors to Doctors

Performance Indicators in Hospitals

Dr. Ayman SalahManaging Director - Meditech IT Solutions

Medical Informatics Consultant / Instructor AUC

M.B.B.Ch – MCSE - PMP


Index

• What is an indicator?

• Why measure?

• Why measure?

• Selection of indicators

• Categorizing indicators

• Process and outcome measures

• Joint commission requirements


Development of Indicators

• What is an indicator?An indicator or measure refers to numerical information that

quantifies input, output, dimensions of processes and outcomes. An indicator or measure can be simple and measure a single aspect of a process or a composite. The term indicator is sometimes preferred if:• The measurement relates to performance but is not an exclusive

measure of such performance (e.g., the number of complaints is an indicator of dissatisfaction, but not an exclusive indicator of it)

• The measurement is a predictor or “leading indicator” of more significant performance (e.g., a gain in patient satisfaction might be a leading indicator in HMO retention


Why measure?

• To provide facts by which to manage

• To take advantage of the reality that people pay more attention to facts

• To help make decisions based on fact

• To help prioritize opportunities for improvement

• To recognize successes

• To evaluate performance


What should be measured?For customer satisfaction:

What are the customers’ expectations? What aspects of customer satisfaction should be measured? How can these aspects be measured?

For outcomes related to key quality attributes:What evidence is available to demonstrate whether the care or service provided have met the customers’ expectations and/or current professional standards? Which outcomes are most important to our customers? Can they be measured? Which professional standards can be measured? How?

For performance of key processes: What are the key steps in the processes that contribute to the outcome? Which critical control points should be monitored to ensure the process is functioning to produce the desired outcome? How can these be measured .


Selection of indicators• “Experts” most familiar with the relevant aspects of care or service

are best able to develop indicators. • Ideally, it should be a group effort with decisions reached by

consensus. • This method has the advantage of gaining acceptance or “buy-in”

for the indicators. • Members of the group should have a basic understanding of the

organization and the relevant day-to-day processes. • In addition, the group must be knowledgeable about customer

needs and expectations.• It is the group’s task to select the indicators that will provide the

most information and identify opportunities for improving organizational performance.

• Focusing on activities that are high-volume, high-risk, high-cost, or problem- prone is best.


Sentinel event indicators

• Sentinel event indicators

• An adverse sentinel event is defined as “an unexpected occurrence-involving death or serious physical or psychological injury, or the risk thereof”


Rate-based indicators

• Unlike sentinel event indicators that identify single occurrences, rate-based indicators are used to monitor many events or a process over a specified period of time (e.g., Caesarean sections [C—sections], vaginal births after C-section [VBACsJ, unexpected deaths, clean wound infections).

• Rate-based indicators measure the proportion of occurrences or events in relation to the population at risk. To determine the rate, divide the number of occurrences (numerator) by the number of individuals at risk (denominator)


Indicator definitions

• Indicator definitions must be clear and precise. • An indicator statement should include a

description of the intended focus, the rationale for use, supporting evidence, and the population expected to be affected.

• Terms should be clearly defined so that all involved understand them in the same way.

• Each indicator should be identified as a process, outcomes, rate-based, or sentinel event type.

• Data sources and a description of how the data will be collected should also be included


Process and outcome measures

Measures of healthcare performance can be process or outcomes measures. – Process measures answer the question, “Are

we doing the right things?” – Outcomes measures answer the question,

“Are we doing the right things well?”

(Example next slide)


Process and Outcomes Measures for Outpatients with Diabetes MelIittis

• Process measures– Rate of glycosylated hemoglobin testing– Percent of patients self-monitoring of blood glucose– Rates of dilated ophthalmoscopic examination– Rates of foot examination

• Outcome measures– Average value of glycosylated hemoglobin testing– Hospitalization rates– Percentage of patients developing foot ulcers


Required performance measures

• Joint commission-accredited hospitals must collect performance measurement data dealing with the following topics or issues:

1. All adverse events or patterns of adverse events occurring during anesthesia use, including sedation of patients while the patients are conscious

2. Processes and outcomes related to behavior management, including (when possible) the perceptions of the patients or individuals served, their families, and the hospital’s clinical staff

3. Processes and outcomes related to the use of restraint and seclusion4. Appropriateness of admission and continued stays (i.e., utilization management

activities)5. Significant adverse drug reactions6. Processes and outcomes related to medication usage7. Processes and outcomes related to surgery and invasive or noninvasive

procedures8. Processes and outcomes related to blood usage9. Appropriateness, completeness, and timeliness of health record documentation10.Deficiencies, problems, failures, and user errors in safety management, life

safety management, equipment management, and utilities management


11. Information solicited from patients and mdividuals served, their families, hospital staff members, and others about how well the organization is meeting needs and expectations, the level of satisfaction with the organization, and areas where the organization could improve

12. Competence of all staff, including licensed independent practitioners13. Risk-management activities14. Quality control activities covering the following services: clinical laboratory.

nutrition, equipment used in administering medication, and pharmaceutical equipment used to prepare medication (only those services provided in the organization)


PATIENT CENTERED STANDARDS

• Access to Care & Continuity of Care (ACC)

• Patient & Family Rights (PFR).

• Assessment of Patient (AOP)

• Care of Patient (COP).

• Patient & Family Education (PFE).


Healthcare Organization Management Standards

• Quality Improvement and Patient Safety (QPS)

• Prevention and Control of Infection (PCI)

• Governance, Leadership and Direction (GLD)

• Facility Management and Safety (FMS)

• Staff Qualification and Management (SQE)

• Management of Information (MOI)


The Relationship Between Quality Goals and Performance Measures

PERFORMANCE IMPROVEMENT GOALS PERFORMANCE MEASURES

1. Improve patient-reported satisfaction with

carng aspects of our services by 20%

2. All non-English speaking patients are provided

a means of communicating with caregivers.

Percent Increase in patient satisfaction scores related to caring and respect.

Percent of non-english speaking patients who are provided a translator within one hour of admission.

1 Reduce inpatient admissions through the development of an outpatient case management process,

2. All transfers from a behavioral health unit to a medical unit shall be completed according to relevant protocols and appropriateness criteria,

Percent reduction in inpatient admissions following implementation of outpatient case management (subcategorized by reason for admission)

Percent of transfers from behavioral health to medical unit that meet appropriateness criteria.

Percent of transfers from behavioral health to medical unit with all paperworti completed as required.

1. Reduce over-utilization of at least one high cost diagnostic test.

2 Identity the scope of patient assessment required in each discipline and ensure consistency regardless of where the patient receives services.

Percent of geropsychiatric patients who receive a CT scan for appropriate indications.

Percent of patient assessments completed as defined by hospital protocol.

I. Develop and implement clinical practice guidelines for managing dual diagnosis patients.

Percent of cases in which practitioners followed guideline or documented their rationale for deviating from the guideline.


Problems identified through program evaluation

• lack of commitment by the board and top management• lack of involvement by all departments• lack of practitioner involvement• committee structure and meeting frequency not adequate to accomplish the scope of activities• activities not tied to patient or member demographics• insufficient resources (i.e., staff, computer hardware, databases/management information system

support, analytical support)• oversight of delegation not sufficiently documented in program description and work plan

(managed care)• limited evaluation and monitoring across multiple settings over time• focus on utilization management, not performance improvement• Lack of balance of clinical staff to service staff • Lack of tracking, trending, and aggregate reporting• Lack of data analysis• Scope that is too broad or too narrow• “Silo” culture in organization that precludes integration• limited practitioner input • monitoring someone else’s performance• Confusion about who owns a process


Problems identified through program evaluation (cont.)

• Choosing irrelevant or meaningless indicators (eg., low volume indicators, outdated measures that are easy to measure but strategically unimportant)

• lack of education on prioritizing and selecting a process• inadequate samples• Too frequent a change in measurement techniques or indicators• ineffective actions (quick fixes every quarter, weak actions)• lecturing the guilty (make fewer errors, work faster, or be nicer)• Memo wars (reinforcing the obvious)• continuing to monitor • jumping to solutions• Basing decisions on opinions• Arguing• forgetting root causes• committee meeting frequency that is not adequate for the task• Providers who refuse access to records• limited evidence that the program made a difference• Inadequate time to effect improvements • small numbers or random positive change • Occurrence-based individual change• Improvement that affects a small percentage of members or patients• inappropriateness for membership or patients at risk• evaluation that is merely a list of activities


Examplesfor Indicators


INDICATOR MEASUREMENT SYSTEM

• Perioperative Indicators:Denominator: All patients undergoing inpatient procedures involving anesthesia (defined as administration of general, spinal, or regional anesthesia or sedation) for which there is a reasonable expectation that the sedation anesthesia will result in the loss of protective reflexes for a significant percentage of patients (all settings, purposes, routes)

1. “Focus: Preoperative patient evaluation, intraoperative and postoperative monitoring, and timely clinical intervention Numerator: Patients developing a CNS complication occurring within two postprocedure days of procedures involving anesthesia administration (subcategorized by ASA-PS class, patient age, and CNS- versus non-CNS-related procedures”

2. Focus: Same, plus appropriate surgical preparation “Numerator: Patients developing a peripheral neurological deficit within two postprocedure days of procedures involving anesthesia administration”

3. “Focus: Preoperative patient evaluation, intraoperative and postoperative monitoring, and timely clinical intervention Numerator: Patients developing an acute myocardial infarction within two post procedure days of procedures involving anesthesia administration [subcategorized by ASA-PS class, patient age, and cardiac- versus noncardiac-related procedures]”

4. Focus: Same “Numerator. Patients with a cardiac arrest within two postprocedure days of procedures involving

anesthesia administration [subcategorized by ASA-PS class, patient age, and cardiac-versus noncardiac-related procedures]”

5. Focus Same “Numerator: Intrahospital mortality of patients within two postprocedure days of procedures involving anesthesia administration [subcategorized by ASA-PS class and patient age]”


Obstetrical Care Indicators:6. Focus: Prenatal patient evaluation, education, and treatment selection Numerator: Patients delivered by cesarean section

Denominator: All deliveries7. Focus: Same

Numerator: Patients with vaginal birth after cesarean section (VBAC)Denominator: Patients delivered with a history of previous cesarean section”

8. Focus: Prenatal patient evaluation, intrapartum monitoring, and clinical interventionNumerator. Live-born infants with a birthweight less than 2500 gramsDenominator: All live births

9. Focus: Prenatal patient evaluation, intrapartum monitoring, neonatal patient eva1uatIc and clinical interventionNumerator. Live-born infants with a birthweight greater than or equal to 2500 grams, who have at least one of the following: anApgar score of less than 4 at five minutes, a requirement for admission to the neonatal intensive care unit within one day of delivery for greater than 24 hours, a dinically apparent seizure, or significant birth traumaDenominator: All five-born infants with a birthweight greater than 2500 grams*

10. Focus: Same“Numerator. Live-born infants with a birthweight greater than 1000 grams and less than 2500 grams who have an Apgar score of less than 4 at five minutesDenominator: All live-born infants with a birthweight greater than 1000 grams and less than 2500 grams”


Cardiovascular Indicators:Focus: Extended postoperative stay as a means of assessing multiple aspects of coronary artery bypass graft (CABG)

careIndicator Statement: Patients undergoing isolated CABG procedures: number of days from- surgery to discharge

Focus: Timing of thrombolytic therapy administration Indicator Statement: Patients admitted through the emergency department who have a principal discharge diagnosis of acute myocardial infarction (AM I) and ST segment evaluation on their initial electrocardiogram: time from emergency department arrival to administration of thrombotytic therapy

“Focus: Diagnostic accuracyNumerator Patients with principal discharge diagnosis of congestive heart failure (CHF) with documented etiologyDenomator Patients with principal discharge diagnosis of CHF

“Focus: Extended postprocedure Stay as a means of assessing multiple aspects of percutaneous-transluminal coronary angioplasty (PTCA) careIndicator Statement: Patients undergoing PTCA: number of days from procedure to discharge

“Focus: Intrahospital mortality as a means of assessing multiple aspects of coronary artery bypass graft (CABG) patient careNumeratoar Intrahospital mortality of patients undergoing an isolated CABG Denominator Patients undergoing an iso!ated CABGW

“Focus: Intrahospital mortality as a means of assessing multiple aspects of percutaneous transluminal coronary angioplasty (PTCA) patient careNumerator: lntrahospital mortality of patients undergoing a PTCADenominator: Patients undergoing PTCA

“Focus: Intrahospital mortality as a means of assessing multiple aspects of acute myocardial infarction (AMI) patient careNumerator: Intrahospital mortality of patients with a principal discharge diagnosis of AMIDenominator: Patients with a principal discharge diagnosis of AMI”


Oncology Indicators:16. “Focus: Availability of data for diagnosis and staging

Numerator. Patients undergoing resection for primary cancer of the lung, colon/rectum or female breast for whom a surgical pathology consultation report is present in the medical recordDenominator: Patients undergoing resection for primary cancer of the female breast, lung, or colon/ rectum.

17. “Focus: Use of staging by managing physiciansNumerator: Patients undergoing resection for primary cancer of the female breast, or colon/ rectum with stage of tumor designated by a managing physicianDenominator: Patients undergoing resection for primary cancer of the female breast, lung, of colon/rectums

18. “Focus: Use of tests critical for prognosis and clinical management of female breast cancerNumerator. Female patients with American Joint Committee on Cancer (AJCC) Stage I or greater primary breast cancer who, after initial biopsy or resection, have estrogen receptor analysis results in the medical recordDenominator Female patients with Stage I or greater primary breast cancer undergoing initial biopsy or resection’

19. “Focus: Effectiveness of preoperative diagnosis and staging Numerator. Patients with nonsmall cell primary lung cancer undergoing thoracotomy with complete surgical resection of tumorDenominator Patients with nonsmall cell primary lung cancer undergoing thoracotomy

20. “Focus: Comprehensiveness of diagnostic workup Numerator: Patients undergoing resection of primary cancer of the colon or rectum whose preoperative evaluation by a managing physician included examination of the entire colonDenominator: Patients undergoing resection for primary cancer of the colon or rectum.


Trauma Indicators:21 “Focus: Ongoing monitoring of trauma patients.

Numerator: Trauma patients with systolic blood pressure, pulse rate, and respiratory rate documented on arrival to the emergency department (ED) and at least hourly for three hours or until ED disposition, whichever is earlierDenominator: All trauma patientsNumerator Trauma patients with selected intracranial injuries with Glasgow Coma Scale (GCS) score documented on arrival to emergency department (ED) and at least hourly for three hours or until ED disposition, whichever is earlierDenominator Trauma patients with selected intracranial injuries

22. Focus: Airway management of comatose trauma patients Numerator Comatose trauma patients with selected intracranial injuries discharged from the emergency department (ED) prior to eridotracheal intubation or cricothyrotornyDenominator: ED comatose trauma patients with selected intracranial injuries

23. Focus: Timeliness of diagnostic testingIndicator Statement: Trauma patients with head computerized tomography (CT) scan performed: Time from emergency department arrival to initial CT scans

24a. “Focus: Timeliness of surgical intervention for selected head injuriesIndicator Statement: Trauma patients undergoing selected neurological procedures:Time from emergency department (ED) arrival to procedure -

24b Focus: Timeliness of intervention for selected orthopedic injuriesIndicator Statement: Trauma patients undergoing selected orthopedic procedures:Time from emergency department (ED) arrival to procedure”

24c “Focus: Timeliness of surgical intervention for selected abdominal injuriesIndicator Statement: Trauma patients undergoing selected abdominal surgical procedures: Time from emergency department (ED) arrival to procedures

25a “Focus: Clinical decision-making for potentially preventable deathsNumerator lntrahospital mortality of trauma patients with a diagnosis of pneumothorax or hemothorax who did not undergo a thoracostomy or thoracotomyDenominator lntrahospital mortality of trauma patients with a diagnosis of pneumothorax or hemothorax”

25b “Focus: Clinical decision making for potentially preventable deathsNumerator Intrahospital mortality of trauma patients with a systolic blood pressure of less than 70 mm Hg within two hours of emergency department (ED) arrival, who did not undergo a laparatomy or thorocotomy.Denominator: Intrahospital mortality of trauma patients with a systolic blood pressure of less than 70 mmHg within two hours of ED arrivaL


Medication Use indicators26. “Focus: Individualizing dosage

Numerator lnpatients 65 years of age or older in whom creatinine clearance has been estimated or measuredDenominator Inpatients 65 years of age or older

27 “Focus liming of medication administration - -Indicator Statement Patients with selected surgical procedures receiving intravenous prophylactic antibiotics Timing of prophylactic antibiotic administration

28 “Focus Informing the patient about the medication -Numerator lnpatients with a discharge diagnosis of insulin-dependent diabetes mellitus who demonstrate self-blood-glucose monitoring and self-administration of insulin before discharge or are referred for postdischarge follow-up for diabetes managementDenominator: Inpatients with a discharge diagnosis of insuIin-dependent diabetes

29 a “Focus Monitoring patient responseNumerator. Inpatients receiving digoxin who have no corresponding measure drug level or whose highest measured level exceeds a specific limitDenominator Inpatients receiving digoxin’

29b “Focus Monitoring patient responseNumerator lnpatients receiving theophylline who have no corresponding measured drug level or whose highest measured level exceeds a specific limitDenominator Inpatients receiving theophyllin

29 c “Focus Monitoring patient responseNumerator: Inpatients receiving phenytoin who have no corresponding measured drug level or whose highest measured level exceeds a specific limit

Denominator lnpatient receiving phenytoin ”29 d “Focus: Monitoring patient response

Numerator: Inpatients receiving lithium who have no corresponding measured drug level or whose highest measured level exceeds a specific limitDenominator inpatient receiving lithium”

30 “Focus Reviewing complete drug regimenIndicator Statement: Inpatients Number of prescribed medications at discharge”


Infection Control Indicators:1. Focus: Surgical site infection

Numerator: Selected inpatient and outpatient surgical procedures complicated by a surgical site infectionDenominator: l’1umber of selected inpatient and outpatient surgical procedures”

2. Focus: Ventilator pneumoniaNumerator: Ventilated inpatients who develop pneumoniaDenominator: Inpatient ventilator days

3. Focus: Concurrent surveillance of primary bloodstream infectionNumerator: Inpatients with a central or umbilical line who develop primary bloodstream infectionDenominator. Inpatient central or umbilical line days


2- PERFORMANCE MEASUREMENT SYSTEM

ACUTE CARE INDICATORSDevice-associated infections in the surgical intensive care unit• Device use in the surgical intensive care unit (central lines, ventilators, indwelling urinary catheters)• Surgical site infections• Prophylaxis [antibiotic] usage for surgical procedures • Total inpatient mortality (10 DRGs and all other DRGs)• Neonatal mortality (direct admissions and transfers)• Total perioperative mortality (Within 48 hours of anesthesia, by ASA class) • Management of pregnancy (cesarean sections and VBACs)• Unscheduled readmissions (within 15 and 31 days for 6 DRGs)• Unscheduled admissions following ambulatory procedure (inpatient and observation admissions)• Unscheduled returns to an intensive care unit Unscheduled returns to the operating room• Isolated CABG perioperative mortality (by ASA class, observed and expected)• Physical restraint use (total events, patients with multiple events, duration, reasons)• Documented falls (10 measures)• Complications following sedation and analgesia (4 areas)

ACUTE CARE AMBULATORY INDICATORS• Unscheduled returns to the emergency department for same or related conçiition within the specified time frame

(within 24 48 and/or 72 hours)• Registered patients’ time in the ED• ED x-ray discrepancies requiring a change in patient management• Registered patients leaving the ED before completing treatment • Cancellation of ambulatory procedures on the day of the procedure


PSYCHIATRIC CARE INDICATORS• Adult—Injurious behaviors (physical assault and self-injury eventsj• Adult—Unplanned departures resulting in discharge• Adult—Transfers to inpatient care unit Adult—Readmissions after discharge• Adult—Use of involuntary restraint• Adult—Use of seclusion• Adolescent and Adult—Partial hospitalization (21 mea• Adolescent—Injurious behaviors (physical assault and self-injury evenls)• Adolescent—Unplanned departures/discharge• Adolescent—Readmissions (within 15,31, 60 days)• Adolescent—Use of involuntary restraint• Adolescent-Use of seclusionLONG TERM CARE INDICATORS• Uplanned weight change (5% loss or gain)• Pressure ulcer prevalence (stages I — IV and muitip• Documented falls (falls, falls resulting in injury, ratio)• Unscheduled transfers to inpatient acute care (7 measures)a Nosocomial infection incidence (6 measures)• Use of physical restraint (15 measures)HOME CARE INDICATORS• Unscheduled transfers to inpatient acute care (12 mea,a Use of emergent care services (5 measures)• Home care discharge to nursing home care (5 rni.• Acquired infections (6 measures)

Performance Indicators In Hospitals - Ayman Salah

Documents

Transcript of Performance Indicators In Hospitals - Ayman Salah