More core measure data for 2008: Don't neglect your internally defined priorities
Resources are 'increasingly limited'
With data collection requirements continuing to increase, you'll need to be sure that internally identified priorities aren't falling by the wayside.
As of Jan. 1, 2008, hospitals accredited by The Joint Commission will be required to collect and submit data for an additional core measure set. The current requirement is for the collection and submission of three core measure sets, or a combination of core and noncore measures.
Several quality professionals interviewed by Hospital Peer Review reported having to reduce measurement of internally identified areas in order to comply with public reporting requirements.
At Mission Hospitals in Asheville, NC, independent service line analysis has been limited at times in favor of national quality targets, says Tom Knoebber, director of quality and performance improvement. "We continue to operate under a service line model with a centralized PI [performance improvement] department," says Knoebber. "Agendas tend to be set by areas targeted by national goals, so prioritization has been done for us."
The Joint Commission's requirements, as well as many others, definitely do tax data collection resources at York, PA-based Wellspan Health's two hospitals, says Sandra Abnett, director of quality.
"We are currently involved in other nationally known collaboratives, which also expect data collection on clinical measures," says Abnett. "We want to participate in the mandatory and non-mandatory requirements, but it does put a strain on the workforce in our hospitals."
Both required and internally defined improvement initiatives are considered and prioritized by the organization's management team, says Abnett. "We have about 300 clinical indicators that our departments collect information on, and a few dozen internally defined, which don't relate to a reporting requirement," she says. These include dialysis anemia management, whether patient contact is initiated within 10 minutes of arrival in the emergency department, lost laboratory specimens, and safety training for pediatric trauma patients and families.
At Sisters of Mercy Health System in St. Louis, more than 200 measures are being reported to various entities, with different scorecards used for The Joint Commission, the Hospital Quality Alliance, and the health system's own initiatives.
"We understand and support the need to measure what's important — and that includes national measures such as the Joint Commission's," says Sue Sinclair, director of quality management. "But the focus on national reporting hasn't stopped us from identifying and measuring our own Mercy-specific activities."
Having the local resources and technology available to support data collection — for both required and system-specific measures — is an ongoing challenge for all health care providers, Sinclair acknowledges. "That doesn't mean it's not important and we shouldn't be doing it. In fact, it's only going to continue to expand because our consumers are now demanding these measures," she says. "So whether it's part of an accreditation requirement or in response to the expectations of our patients, we are going to have to figure it out, because it's not going away."
Measurement is an important component of quality and performance improvement, Sinclair adds. "We know we can't improve if we don't measure. We have no doubt that measurement supports quality and safety," she says. "That's why we are committed to doing it." The organization recently implemented changes to medication administration processes as a result of internal measures that were not required as part of a public reporting effort.
Because The Joint Commission's measures are now aligned with those required by the Centers for Medicare & Medicaid Services (CMS), some organizations are able to comply with the new requirements by drawing from data already being collected.
"We are looking at the fourth set to come from something we are already doing for CMS, so it won't be as burdensome," says Jan Brewer, PhD, RN, director of quality improvement at Mission Hospital in Mission Viejo, CA. "We are happy that CMS has joined forces with The Joint Commission to make it easier for us to comply."
Quality and clinical managers at Mission are currently determining which set of data is the "best match" for the indicators the hospital is reporting.
"In this way, the impact to the workload and use of the data should be lessened," says Brewer. "Still, this is another data mouth to feed. As always, the match will not be quite perfect and the data load may take a bit more effort. But we are hopeful that the additional workload will be minimized, and will be in concert with quality activities we are already doing."
That some measures are aligned is certainly good news, but it's equally true that data collection requirements are making it challenging to find resources for internally identified areas. "It is very difficult keeping up with the many priorities, and not just The Joint Commission's. There are any number of benchmarking projects that are competing for our time," says Pat Wardell, vice president of quality management and patient safety officer at St. Jude Medical Center in Fullerton, CA. "It keeps us all very busy, and in some respects does make it difficult for us to get things accomplished."
Quality managers at St. Jude are doing their best to balance internal priorities with external regulatory and voluntary indicators and projects, says Wardell. "We review these to see if the internal and external indictors align. If they do, and if the definitions are the same, we are in luck," she says. "If not, we have to continue to assess who we have collecting and analyzing the data."
Based on the assessment, focus might be shifted for an individual to be able to accommodate the need, whether short or long term. "It is not realistic to believe we can just add staff for every project, so we continue to assess work loads and adjust accordingly," says Wardell.
Strategies to identify improvement areas
When addressing internally identified areas in need of improvement, consider the following strategies:
• Provide broader oversight of opportunities.
Mission Hospitals recently expanded the responsibilities of its centralized PI department, to provide a broader oversight of system quality assurance (QA) and PI opportunities. "The global 'QA' identification still resides within the PI department, but the role of investigation and verification is sent to the service line for them to respond to," says Knoebber. "Within PI, we have developed a macro calendar to review throughout the year." Specific data sources include HealthGrades, patient safety indicators, the Hospital Quality Alliance and CMS reports, and internal "Top 10" reports based on APR-DRG data on length of stay, mortality rates, and readmissions. "This was traditionally a QA activity that we have assigned to the service lines," says Knoebber.
These are then reported through a newly developed centralized physician leadership team, to prioritize and balance all the issues within the service area. In some cases, the team "re-prioritizes" opportunities within the service line, or special teams may be created.
Recently, the new HealthGrades reports were reviewed by one team, showing that the organization had one-star performance in three areas. "We have found flaws with HealthGrades in the past, and since this is public data we are obligated to at least validate and develop a response," says Knoebber. "The various vendors manipulating public data are more of a problem than CMS or The Joint Commission. Their motives are to sell reports."
In this case, the three areas were assigned to the various service lines and after replicating the methodology internally, the organization is working on case review. "In many cases we find the issue is in exclusion criteria according to their definition," says Knoebber.
For example, for abdominal aortic aneurysm bypass surgery, the vendor might exclude all patients with a length of stay less than one day, but at Mission Hospitals many patients are treated and released within 24 hours. "Only the very critical patients stay past 24 hours, thereby leaving us with a smaller denominator to divide our deaths into, showing us to have a high mortality rate when, in fact, we send the healthy ones home," says Knoebber. The organization worked with HealthGrades to modify the definition so the hospital's score was not misleading.
In other cases, there is mainly a need for education and bringing a fresh objectivity to the problem. "The concept of harmonization has been positive in most areas, since these are based on high-risk and high-volume procedures," says Knoebber. "But this only adds to the pressure to investigate and respond to all areas, whether they are opportunities or not. Resources are an increasing problem."
• Integrate staff requests with existing requirements.
Physicians may come forward with "pet projects" that don't fit into your organization's priorities. "They may want me to review 100 charts for them and we will take it to the quality leadership committee. If they say it has importance, we find the resources somehow," says Brewer. "But if they say it doesn't fit with our strategic needs, either internally or externally, then we have to put it on the back burner."
However, sometimes staff requests can fit in with other requirements. When an emergency physician came forward with a request to look at sepsis, Brewer found a way to integrate it with Joint Commission requirements and also, the hospital's participation in an Institute for Healthcare Improvement (IHI) project.
"I took his need, and our need to comply with The Joint Commission, and the work of our IHI impact team, and wrapped it up in one nice package so we could move forward on this," says Brewer. "Sometimes I feel like a traffic cop, trying to get all the traffic that is similar moving in the same direction."
Quality professionals will need to do more of this kind of strategic thinking to ensure that internal priorities are met, such as aligning Joint Commission requirements for an annual failure mode and effects analysis with IHI requirements, says Brewer. The goal is to "work smarter, not harder" by aligning various data collection needs, both internal and external, she says. "We are looking at things we are concerned about, that are not to the point where it would be a reaction to something that is wrong, but a preventive type of project, so we can use it to serve both The Joint Commission's requirements as well as our own internal requirements," says Brewer.
• Have units do their own data collection and analysis.
A quality manager at Mission Hospital set up a computerized system to allow unit staff to do their own independent PI projects. Staff run their own data to determine whether an issue is significant, and may then present their findings to the quality leadership committee.
"We've got all kinds of independent PI projects going on all over the hospital because we have this computer capability," says Brewer. "They can gather, analyze, and report their own data and that has helped a lot. When staff come to us, we tell them, 'We can't do this for you, but we will set it up so you can.'"
For example, a nursing unit started out with a pilot project to improve communication during handoffs, and the SBAR (situation, background, assessment, recommendations) process was implemented hospitalwide as a result. The unit's project also helped the hospital to comply with The Joint Commission's National Patient Safety Goal on improving handoff communication.
Data collection burdens are forcing quality to move out of a "silo" approach to a "network" approach, says Brewer, adding that your PI or quality department can act as a central hub. "If we know what is going on, we can connect people and integrate all the different projects," she says. "There are just not enough people and not enough hours in the day. But if something is really important, we'll find a way."
[For more information, contact:
Sandra Abnett, Director of Quality, Wellspan Health, 1001 South George Street, York, PA 17405-7198. Phone: (717) 851-5869. E-mail: [email protected].
Jan Brewer, PhD, RN, Director of Quality Improvement, Mission Hospital, 27700 Medical Center Road, Mission Viejo, CA 92691-6426. Phone: (949) 364-1400 ext. 5642. E-mail: [email protected]
Tom Knoebber, Director of Quality and Performance Improvement, Mission Hospitals, 509 Biltmore Avenue, Asheville, NC 28801. Phone: (828) 213-9194. E-mail: [email protected].
Sue Sinclair, Director of Quality Management, Sisters of Mercy Health System, 14528 S. Outer Forty Drive, Suite 100, Chesterfield, MO 63017. Phone: (314) 628-3630. E-mail: [email protected].
Pat Wardell, Vice President, Quality Management and Patient Safety Officer St. Jude Medical Center, 101 E. Valencia Mesa Drive, Fullerton, CA 92835. Phone: (714) 992-3000, ext. 3763. E-mail: [email protected].]
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