Using Data

for
Improvement
Nazzar Butt
CQI&PS Director
 Quality and
Patient Safety
Program
 PURPOSE
The purpose of Armed Forces Hospital, Southern
Region Quality Improvement and Patient Safety
Program is to identify the hospital systematic
approach to improving and sustaining its
performance through the prioritization, design,
implementation, monitoring, and analysis of quality
improvement and patient safety improvement
initiatives.
 SCOPE
The AFHSR CQI & PS program includes all
departments and services in the organization and
all related quality activities such as clinical,
laboratory, quality improvement, patient safety and
risk management activities.
How quality and safety information flows through the
hospital/committee structure.

Director of Armed Forces

Hospitals Administration
Southern Region
Leader

Hospital Director

Hospital Steering Team

(HST)
Senior Medical
Management Team
Senior Nursing
Management Team
Executive CQI&PS
Senior Administrative
Team
Team

Tracer Quality Hospital Audit Forms Committee

Methodology Team Improvement Team
Teams (CAC, MAC)
Quality Method
 How quality and safety information flows through the
hospital/committee structure.

Department Management Teams

Heads of Departments
Quality Facilitators
Staff level
 How quality and safety
measures were chosen
Hospital Steering Team
High risk, high cost, high volume or problem
prone, processes that most directly relate to
the quality and safety of care.
Review of previous data
How the measures were
prioritized for data
collection
 Potential Financial Benefit

Variation demonstrated
Ease of Data Availability
Impact on Customer
Linkage to Startegic

with Avaialble Data

Impact on Working

Time to Complete
Regulatory Need
Environment
Satisfaction
Priorities
Project Selection Criteria

3 4 4 2 3 2 5 5 Priority Score
Domain Project Name
Hospital Wide Patient identification compliance 7 5 2 6 9 8 9 9 194
Hospital Wide Telephonic/verbal order compliance 7 4 2 8 7 8 9 7 178
Hospital Wide Implementation of ISBAR Handover 7 4 2 8 9 8 9 9 194
Hospital Wide High Alert Medication Inspection Compliance 7 4 5 8 7 8 9 9 200
Hospital Wide Safe Surgery Marking Compliance 7 3 2 6 9 8 9 9 186
Hospital Wide 5 Moments Hand Hygiene Compliance 7 5 2 8 8 8 9 9 195
Hospital Wide Reduce number of Falls 7 7 3 8 9 8 9 9 210
Hospital Wide Implement patient safety culture 8 3 6 9 8 8 8 7 193
Hospital Wide Implement electronic incident reporting system 8 4 7 8 9 8 7 9 207
Hospital Wide Implement JCI International Library of Measures 8 5 5 6 8 8 9 8 201
Hospital Wide Selection for 5 Clinical Practice Guidelines/pathways/protocols 8 6 4 6 7 8 9 6 188
Hospital Wide Reduce Discharge Against Medical Advice 5 8 8 2 7 8 3 5 160
Hospital Wide Incomplete Discharge Summaries 4 5 3 3 5 7 3 6 124
Hospital Wide Impact Analysis on Clinical Waste Disposal 5 5 9 4 8 8 9 7 199
Hospital Wide Reduce readmission rates 4 7 8 4 6 7 5 7 172
Hospital Wide Improve quality of medical record documentation 5 6 5 5 4 6 6 6 153
Hospital Wide Improve compliance to pain assessment and management 5 6 4 4 5 6 5 7 150
Hospital Wide Reduce the number of prescribing errors 4 6 5 4 3 6 5 6 140
Hospital Wide Ensure avaialability of essential medications 6 7 5 6 5 5 5 8 168
Hospital Wide FMEA Infant Abduction 5 7 6 9 9 6 9 8 209
Hospital Wide FMEA Concentrated Electrolytes 5 7 6 9 9 6 9 8 209
Hospital Wide Improve Patient Satisfaction 8 9 6 7 8 6 8 9 219
Hospital Wide Improve Staff Satisfaction 8 9 6 7 8 6 8 9 219
Hospital Wide Improve Patient Flow in ER 7 9 4 8 3 6 8 4 170
456 564 460 306 510 342 895 905 4438
Generic Hospital Wide Indicators
Hospital Wide Indicators

IPSG 1 Identification of Patients

IPSG 2 Effective Communication

IPSG 3 High Alert Medications

IPSG 4 Safe Surgery

IPSG 5 Hand Hygiene
IPSG 6 Patient Falls
Impact Analysis QI Project

Patient Satisfaction
Staff Satisfaction
Culture of Safety
Nursing Department Core Measures

Nursing Core Measures

I-NSC-2 Pressure Ulcer Prevalence (hospital

acquired)

I-NSC-4 Patient falls

I-NSC 5 Patient Falls with Injury

I-PC-05 Exclusive Breast Feeding

Outpatient Nursing Rate of No Shows in Clinic Visits

Utilization Management Turnover Time Between Operations

Monitoring of High Risk Services

Dialysis Patients
High Risk Service Quality Indicator % of dialysis patients with hemoglobin of 11
Hemoglobin achievement 12

High Risk Service Quality Indicator - Dialysis % of patients with URR between 65% to 80%
adequacy

Renal Dialysis Infection Control Dialysis Event Care Bundle Compliance

 Five Priority Areas for Clinical Practice

Guidelines/pathways/protocols
Diagnosis Process Owner Process/Outcome Measure

C/S Director of Oby/Gyne ILM PC

STEMI Director of Cardiac Services To be selected

NST-ACS Director of Cardiac Services To be selected

Community Acquired Director of Medicine To be selected

Pneumonia

Kidney Transplant Director of Nephrology Compliance to Guideline

 Medical Departments Core Measures
Department Measures

Emergency Room ER Documentation Compliance

Radiodiagnostics and Medical Imaging 85% of CT reported within 24 hours
85% of U/S reported within 24 hours
85% of Fluoroscopy reported within 24 hours

85% of MRI reported within 7 days

85% of general radiography in 7 days
Quality Control Reports
Cardiac Services International Library of Measures AMI
Surgical site care bundle compliance (Cardiac Surgery
Only)
Medicine International Library of Measures Stroke

Obs/Gyne International Library of Measures Perinatal Care

Laboratory External Proficiency Testing Compliance

TAT for Critical Results Reporting

Surgical Specialities Surgical Site Infection Bundle Compliance

Paediatrics International Library of Measure Children Asthma Care

Anesthesia and ICU International Library of Measure VTE

Rate of completed Pre-anesthesia assessments

Pharmacy Rate of Dispensing Errors

Prescription errors
Compliance to antibiotic protocol
Physiotherapy LBP Assessment Compliance
LBP Assessment for reduction of 2 point from pain scale

Nutrition and Dietetics Percentage Diet Orders By Physicians

Percentage Nutritional Screening
Diabetic Clinic Average HBA1C Level

CCL Number of complications with sedation

Dental Patient satisfaction survey

 Administrative Department Core Measures

Departments Measures

Finance Monthly Expenditure on Clinical waste

Supplies and Warehouse % availability of Infection Control Supplies

% availability of Life Saving Medications

IS/T % of Staff trained in new HIS System

% availability of computer terminals
% staff use of internal email

Patient Services % of receptionist who have trained in communication

skills
% of resolved patient complaints

Medical Records % of complete discharge summaries within one week

of patient discharge
Purchasing % compliance of contractors to quality monitoring

Housekeeping Scheduled toilet cleaning compliance

Scheduled ward room cleaning compliance

Housing Housing staff satisfaction survey

Transport Transport staff satisfaction survey

Recreation Recreation staff satisfaction survey

Human Resources JCI staff file review compliance

Staff turnover rate

Academic Affairs and Training Education needs analysis

JCI International Library
of Measures
Acute Myocardial Infarction Indicators
I-AMI 1 Aspirin at Arrival
I-AMI 2 Aspirin Prescribed at Discharge
I-AMI 3 ACEI or ARB for LVSD
I-AMI 4 Adult Smoking Cessation
Advice/Counselling
I-AMI 5 Beta Blocker Prescribed at Discharge
I-AMI 9 Inpatient Mortality

Childrens Asthma Care Indicators

I-CAC 1 Relievers for Inpatient Asthma
I-CAC 2 Systemic Corticosteroids for Inpatient
Asthma

Venous Thromboembolism Indicators

I-VTE 2 Intensive Care Unit Venous
Thromboembolism Prophylaxis
 Continued
Nursing Sensitive Care Indicators
I-NSC 2 Pressure Ulcer Prevalence (Hospital
-Acquired)
I-NSC 4 Patient Falls
I-NSC 5 Falls with Injury

Perinatal Care Indicators

I-PC 5 Exclusive Breastfeeding
I-PC 1 Patients with elective vaginal deliveries or
elective cesarean sections at >= 37 and <
39 weeks of gestation completed
I-PC 2 Nulliparous women with a term, singleton
baby in a vertex position delivered by
cesarean section
Using Data for
Improvement
Importance of measurement
for improvement
The aim of improvement
endeavours in healthcare is to
make services better
o Be safer (less errors, infections, falls)
o More effective (delivering care that is based on
science - neither over or under treating)
o More efficient (less waste)
o More person-centred (caring, compassionate,
fitting with patient/family requests)
o Timely
Measurement for improvement
asks questions like:
What does "better" look like?
How will we recognise better when we
see it?
How do we know if a change is an
improvement?
 Data and measurement is
required:
To plan for improvement
For testing changes
For tracking compliance
For determining outcomes
For monitoring long term progress
To make improvement visible and tell
an improvement story
Measurement Journey

Source: Lloyd, R. Quality Health Care: a

guide to developing and using indicators.
Jones & Bartlett Publishers 2004
Managing data for
improvement
 Planning for data
collection
There are several factors to
consider when planning for data
collection:
o What information needs to be collected in order
to address each quality measure?
The data that you need to collect will be
influenced by the areas where you are seeking
improvement and the measures you intend to
use. As the types of questions differ, so will the
kinds of data best suited for use in the evaluation
of your program
 Continued
o What are the information sources?
You must determine where to find the best
source of data to answer each of your
evaluation questions. Possible sources of data
include people (e.g. program staff, clinicians, or
patients), records, or clinical observations.
 Continued
How should information be collected
(methodology)?
Surveys, interviews, focus groups, literature reviews,
and record analysis (e.g. chart audits) are just a few
examples of data collection methods.
There is often more than one way to collect data to
answer a given question. Some questions are best
answered by using more than one data collection
method. For example, you may want to do a chart
review to understand practice patterns and then
conduct interviews with a smaller number of
providers to understand more detailed information
about the observed practice patterns.
 Continued
How much data should be collected?
It is not always necessary to collect all of the data
available to you. If the data on the full population
you are looking at is very large, evaluating a subset,
or sample, may be sufficient. On the other hand, if
you are interested in using QI reports to create
profiles, or snapshots of provider performance
measures, and manage the performance of
providers, then you may want comprehensive data.
 How do you use these data
to construct measures?
Quality measures are constructed using a
variety of methods, including proportions,
ratios, means, medians, and counts
Proportions or percentages with a
numerator and a denominator are the most
common way to construct quality
measures.
 When and why do you
sample?
There are times when you will want to look at quality
measures that represent all eligible patients within
an organization.
Sampling allows you to make inferences about a
large group (e.g., all diabetic patients in the
hospitals) based on observations of a smaller subset
of that group (a smaller subset of those patients)
Sampling your data saves time and resources while
still accurately evaluating performance.
 Continued
Random sampling is a technique used to reduce
the likelihood of bias when collecting samples
The main benefit of random sampling is that it
ensures that the sample you choose will be
representative of the larger population that it was
drawn from
In random sampling, each subject is selected
entirely by chance. There are several different
methods for selecting random samples. For quality
improvement, a simple sample is often sufficient.
 What is the best way to
standardize data processes?
A standardized data collection procedure is
essential for successful quality improvement.
When collecting data from medical charts,
standardized chart audit forms are a simple way to
ensure that data collection is consistent and
thorough
How Can You Present Data in a
Meaningful Way? (Charts)
Data analysis and interpretation is the process of
assigning meaning to the information you have
collected and determining the significance and
implications of the findings
Charts are a useful way to provide a visual display
of your data and to help convey ideas about the
data that might not be readily apparent if they
were displayed in a table or as text.
Run Charts
Run charts are linear
graphs that allow you
to track improvements
by displaying data in a
time sequence.
Allow you to see if
improvement is really
taking place by
displaying a pattern of
data that you can
observe as you make
changes to your
process.
Control Charts
Includes three reference
lines which are
determined by historical
data: a central line which
represents the average,
an upper line which
represents the upper
control limit, and a lower
line which represents the
lower control limit
you can assess whether
the process variation is in
control (consistent) or out
of control
(unpredictable.)
Dashboard Reports
Allows you to
present at-a-
glance
information on
your measures
It provides a
quick overview of
the current state
of your data,
without detailed
information on
causes or
solutions
 How do we assess and
measure our progress?
Now that you have collected and analyzed your
data, you can compare your measures to your
quality improvement goals
If the measures show room for improvement, you
may find it necessary to launch a quality
improvement project.
To implement quality improvement projects, it is
necessary to examine the underlying causes behind
the data you have collected. What possible factors
may be contributing to the results that your data
collection produced?
 FOCUS-PDCA for
Continuous Improvement
Thank You