Set collection priorities, manage data requests
As demands rise, don't get caught short-handed
By Patrice Spath, ART
Consultant in Health Care Quality and
Resource Management
Forest Grove, OR
The demands for performance measurement data are increasing, and quality management departments are being challenged to do more with less. No one wants to refuse a request for quality-related data, yet priorities must be established to prevent the quality management staff from becoming overburdened. Actively coordinating the information that flows throughout the organization is more important than ever.
Effective information management will reduce redundant data collection and ensure that only data important to quality improvement efforts are being collected and reported. In addition, many hospital departments use personal computer systems to collect patient care data that would be useful to the quality management department. If quality professionals can tap into the data stockpiles scattered throughout the institution, production of performance measurement reports can be simplified.
Development of an information management plan for the quality department:
* enables the combination of data/information;
* makes information from one database available to another;
* ensures a consistent flow of information;
* minimizes duplication.
Once the plan is on paper, administrative and medical staff leadership can determine whether the data being captured are necessary for ongoing performance measurement purposes. Hospitals are likely to find they are collecting more information than is necessary to support their quality improvement initiatives.
The first step in developing an information management plan for the quality department is to identify who in the organization is gathering, analyzing, and using performance data. Efficiencies in data collection activities and opportunities to share information will go unnoticed if quality management staff are unaware of their colleagues' activities.
Distribute a database inventory questionnaire to all department managers. Ask them to list all logs, records, files, and information systems that are maintained in their department. For each database they have, ask them three questions:
* Is the information kept in a manual or an automated (computerized) system?
* If applicable, what software system is used to gather automated data?
* What is the period of time for which all databases are maintained?
Those departments with automated data systems should be able to provide a computer dump, which allows for a complete downloading of information, or a list of all data elements in their system. Once all surveys are returned, tally them. (A sample of a quality management database inventory is illustrated in Figure 1, p. 61.)
Once all the sources of performance measurement data are identified, the quality management department can begin to design electronic linkages with computerized databases that contain information necessary to support improvement efforts. Access to hard-copy databases will be more challenging; usually quality management staff must personally gather the data found in logs, registers, and other paper-based information sources. Even manual data collection from an already-established patient log, however, is usually less time-consuming than retrospective patient chart reviews.
Before you make data available
An element of the quality management department's information management plan should be a policy or procedure covering the release of performance measurement data. The purpose of this statement is to ensure a consistent process for accessing quality measurement information, to set forth confidentiality standards that shall be maintained for all information sharing, and to regulate the distribution of data for internal and external functions.
In planning the release of information policies and procedures, several issues should be considered:
* the patients' right to confidentiality;
* the standards of the Joint Commission on Accreditation of Healthcare Organizations and state statutes pertaining to hospital information systems;
* hospital policies and procedures pertaining to individual information systems within departments or divisions;
* physicians' and employees' right to confidentiality.
Underlying the policy or procedure should be the need to treat performance measurement data in a confidential manner while still allowing sufficient access to those who need to know for purposes of planning, marketing, and financial and clinical analysis. Individuals who receive data should be asked to agree to respect the confidentiality and propriety concerns. Any person who breaches confidentiality should be subject to appropriate disciplinary action.
Where performance measurement data are divulged to external groups, adequate steps should be taken to ensure that such information is treated as confidential and proprietary, including the requirement that a written agreement be executed stating that such information will not be re-disclosed without authorization from the initial authorized signer.
Document special requests
The quality management department frequently releases data for routine performance measurement purposes, for example, committee activities, board reports, and medical staff credentialing. Procedures for dealing with special requests for performance measurement data, however, should be clearly defined to be certain all reasonable steps are taken to ensure the confidentiality of sensitive information and to protect unauthorized disclosure or use. (A form used by a quality management department to document special requests for performance measurement data is shown in Figure 2, p. 62.)
New performance data requests must be submitted for each report, except in the case of standard reports for periodic generation for which only one initial request form is needed. If the information in standard reports is changed, a new request form and authorizing signature must be submitted. Requiring division managers or medical staff department chiefs to approve the preparation of special performance measurement reports can help to minimize frivolous requests.
The organization's need for performance measurement data is steadily increasing. A comprehensive assessment of data sources, linkages with those data sources, and management of special requests for data can greatly improve the efficiency of the hospital quality management department. *
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