Data Collection with Benchmarking Provides Great Quality Improvement Opportunity
Technology makes it easier, affordable
July 1, 2017 5 minutes read
EXECUTIVE SUMMARY
Quality improvement projects can benefit from data collection and benchmarking. Small surgery centers now can afford the resources necessary to make these happen.
- Internal benchmarking lets an organization see how it’s performing year to year.
- External benchmarking lets an organization compare itself to peers.
- Benchmarking services also can include opportunities to network with peers and learn from their processes and experiences.
Quality improvement projects in ASCs have not always benefited from data collection and benchmarking. Not so many years ago, small healthcare organizations could not afford the manpower and platform resources necessary for data collection and comparison.
Fortunately, technology has made it possible for ASCs to extract and analyze data efficiently and quickly.
“By extracting data, we were able to see how we were performing,” says Michelle George, RN, MSN, CASC, group director of clinical services for Surgical Care Affiliates of Deerfield, IL.
“Initially, we were doing internal benchmarking, looking at our own performance from year to year,” she says. “External benchmarking is the next level of saying, ‘I’m doing pretty good. How do I look in comparison to the ASC down the road?’”
Data collection and benchmarking are the first steps of a strategy that helps organizations either maintain their current performance or drive it to the next level, George says.
The Ambulatory Surgery Care Association (ASCA), state associations, and ASC Quality Collaboration efforts have helped ASCs compare their own performance to their peers.
“They’ve helped put together data warehouses where 1,500-plus facilities participate, and you get a broad picture of how you are doing,” George says.
It also makes networking possible.
“Once you know how you’re doing compared to the rest of the world, then that allows you to say, ‘How are they doing? What are they doing? And who can I call?’” she says. “Once you can do networking with the organization, it gives your data pool credibility; the larger the number, the more confidence you have, and you can network with peers and facilities like yours.”
George suggests ASCs take the following steps:
1. Find your key performance indicators.
These are metrics that are most important to a facility’s patients, physicians, and owners. They might include:
- What are the turnaround times?
- Do your first cases of the day start on time?
- What do patient outcomes look like?
- Are there medication errors?
- Are there surgical site infections?
- Are patients falling?
“Once you establish a baseline of what your performance metrics would be, then you have a sense of how you are doing with them,” George says.
2. Identify a benchmarking organization and networking options.
“Identify the organization that can provide the external comparisons for you,” George says. “If you want to look at on-time starts and turnaround times, those are efficiency metrics. So you find an organization that has those benchmarking metrics.”
For instance, ASCA’s benchmarking program is very comprehensive and includes operational efficiencies, as well as financial metrics and patient outcomes, she says.
“There are two good ways to determine if there are networking opportunities,” George explains.
“First, talk to the benchmarking organization and ask them whether they provide training and assistance for participants so they can reach out to other folks,” she adds. “Also, ask whether they host opportunities to meet and talk to other people, and ask them about their program and services.”
3. Determine how to collect data.
“You may not be Excel-savvy, so do you need someone on your team to help you with that?” George asks.
Other questions to ask include:
- How do you submit data?
- How do you get data back?
- How do you present data to your audiences, such as the governing body, medical executive committee, and others?
- What do those reports look like?
“Some reports are data-rich,” she says.
An organization’s governing body and others will look at data and provide feedback on where the surgery center’s priorities should be.
Another decision involves how to disclose data results. Besides sharing the information internally, there is some information that a facility might want to share with their customers. Some information must be reported through Medicare’s Quality Reporting Program, George notes, while there might be some data that the organization will want to share. For example, if the surgery center has a 95% patient satisfaction rate, then the ASC might want to put that number on its website.
“Presenting performance results with a pictogram, graphic, or visual representative tells the story better than something narrative,” George suggests. “Graphic reports provide the ability to do a side-by-side comparison, if you want to do that.”
4. Use data to drive the performance improvement program.
“Hopefully, no one stops before this juncture,” George says.
Ask the following quality improvement questions:
- What are we doing?
- How did we do it?
- What kind of results did we get from it?
“Quality committees are a great way to look at this data. They look at it and ask, ‘How are we doing compared with the rest of the folks?’” she explains. “Also, ‘If we’re not doing as well and we want to be better than anyone else, how do we get there?’”
This is the start of a performance improvement or quality improvement project. An ASC performance improvement team decides to hardwire a process that is working or try a new strategy and roll it out to staff.
“Or maybe they work on something for a while and can’t budget the numbers,” George says. “So they try a number of things, and if they haven’t gotten the desired results, they might seek additional clinical best practices from their external networks.”
George offers this example of patient falls to show how the data-driven performance improvement process might work: “It’s a patient harm event that no ASC wants to see, and many facilities can go years and years without one patient fall,” she says. “Other facilities may have as many as four to six falls in a year. Your goal should be zero falls.”
Let’s say some patients have fallen at an ASC. The organization tried several changes that did not work. The ASC decides to identify the root cause of the falls to see why they’re continuing to happen.
The quality committee reviews data and discovers that most of the falls occurred in the patient recovery room when patients awoke from the anesthesia and tried to dress or use the restroom.
“So, you have isolated the problem to your recovery area,” George says. “Now that you have that level of insight into the problem, you know patients should not be getting dressed alone.”
One solution would be to require a member of the staff to be available to assist the patient as needed.
“That’s how you drive performance,” George says. “Write a policy and educate the entire team that patients cannot get dressed or go to the restroom without an attendee or escort.”
Once an organization executes these changes, the falls stop and the problem is solved, she adds.
“Then you continue to monitor falls within the recovery area, and you should see your baseline return to zero,” she says.
The take-home message is for ASCs to determine what they want to measure, identify a benchmark source, determine how they’ll communicate their results, and make sure they’re sharing information broadly with leaders in the facility, George says.
“The more people know about it, the more engaged they are in helping you achieve your results,” George says.
Quality improvement projects can benefit from data collection and benchmarking. Small surgery centers now can afford the resources necessary to make these happen.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content