Chapter 10: Knowledge Management

What are some examples of internal data that feeds the data warehouse of an HCO?

- Electronic Health Record --- Patient counts --- Patient demographics --- Diagnoses --- Treatment outcomes and process quality - Clinical Support Services --- Demand --- Output --- Process Quality --- Scheduling --- Patient Satisfaction --- Physician Satisfaction - Environment of Care --- Supply Use --- Inventories --- Customer Satisfaction --- Disaster Preparation --- Hazardous Materials Management - Accounting and Payroll --- Hours Worked --- Indirect Costs --- Financial Accounting --- Budget Goals --- Long-Range Financial Plan - Human Resources --- Recruitment and Vacancy --- Retention and Turnover --- Absenteeism and Safety --- Associate Satisfaction - Planning and Marketing --- Epidemiologic Planning Data --- Patient Satisfaction --- Market Survey Data - Other Information Systems --- Medline Literature --- Management Literature --- Patient Guidelines --- Benchmarks (p.310)

What are three important questions that need to be answered when communicating about or transferring patient care?

- What is wrong with this patient? - What are we doing for this patient? What has been done in the past? - What must we NOT do for this patient (in terms of allergies, advance directives, other important contradictions)? (p.314) -- the EHR has dramatically improved communication in this area as we step further away from traditional paper files (p.314)

What does an effective use of knowledge management require?

- a strong user training - support program for stakeholders -- Training and support are generally provided in segments, beginning with the use of hardware and software, progressing through common applications, and continuing to analysis and interpretation -- A help desk, statistical consultants, and other experts are available for ongoing support. (p.312)

What is the content for the function: provide prompt and useful access to management information (the data warehouse)?

- captures, stores, and retrieves operational data to support management and clinical decisions - provides training in the use of electronic systems and consulting service in interpretation and information availability - provides protocols, processes, training videos, and other materials supporting training programs - conducts and interprets statistical analysis of performance and other data - maintains a historical record - supports ongoing audits to ensure data quality (p.309)

What are the characteristics of maintaining the reliability of information?

- define, standardize, and generate accurate performance measures - reduce causes of variation in performance (p.307)

What is the content for the function: ensure reliability and validity of data?

- defines measures and terminology - supports accurate, complete data input - applies appropriate specification and adjustment - estimates reliability of data (p.309)

What is the content for the function: improve continuously?

- establishes a prioritized agenda for progress - incorporates user view - commits a block of capital funds for several years - supports an annual review of specific projects (p.309)

What is the content for the function: ensure the appropriate use and security of data?

- guards against loss, theft, and inappropriate application (p.309)

What is the content for the function: maintain communications and software support?

- operates an around-the-clock electronic and voice communication utility with web access - supports software used in clinical and business functions - integrates information for multiple applications (p.309)

What are the normal protections against loss, destruction, or system failure?

- physical protection of sites - duplication of both data and hardware - separate geographic locations of originals and duplicates - selection of personnel - antivirus software (p.323)

What are the characteristics of protecting individual privacy, the archive, and the information systems?

- protect patient and associate privacy rights - guard against failure, misuse, theft, or destruction (p.307)

What is the content for the function: provide prompt and useful access to clinical information (the EHR)?

- records and communicates each patient's integrated care plan in the EHR - including medical condition, needs assessments, medical and nursing diagnoses, treatments, medication, and unexpected events (p.309)

What are the characteristics of translating knowledge to strategic performance improvement?

- support an evidence-based culture - relate knowledge improvement to clinical service improvement - use centralized and contract knowledge management services (p.307)

What are the characteristics of planning improvement and growth?

- systematically expand the use of knowledge to achieve the healthcare organization's mission - continuously improve knowledge management services (p.307)

What are the characteristics of promoting effective use of data?

- universalize the electronic health record - expand meaningful use - ensure prompt access to reports and records - provide statistical analysis and forecasting (p.307)

What important activities are made simpler with the utilization of the EHR?

- using patient management guidelines - automating order entry - accurately tracking medications - accurately tracking repeated treatments - summarizing patient progress - identifying unmet needs - reporting and analysis of outcomes - reporting and analysis of process quality measures (p.314)

What does the Sharp Healthcare* identify as criteria for accepting a measure when ensuring appropriate standardization?

-- reference in evidence-based literature -- use by regulatory and public reports -- availability of competitor data -- use by other Baldrige Award recipients -- availability of benchmarks in healthcare and beyond (p.317)

What are the two usual variability indicators?

-- standard deviation: used to compare two individual values -- standard error: used to compare two samples with several individual values in each (p.320)

Where is knowledge management involved in the training of new associates involved in patient registration?

1. A video describes the HCO's mission, vision, and values. Additional videos explain the HCO's policies regarding relations with patients and associates, dress, compensation, and benefits. Mastery of these policies can be tested. Learning can be repeated as necessary. 2. A training module teaches completion of electronic forms for data entry. The module can include multiple scenarios that test the associate's understanding. 3. Explanation and support materials for issues such as HIPAA (the Health Insurance Portability and Accountability Act), guardianship, and advance directives can be automated. Mastery of access and key content can be tested. 4. A set of appropriate answers to frequently asked questions can be provided for specific areas. Associates can supplement these with files of their own notes. (p.313)

What are the six properties of data, information, and knowledge when evaluating the data security processes of a given HCO?

1. Accuracy -- Quality Assurance Mechanisms: >> Integration between electronic systems >> Data capture, database design, entry and reporting >> Clinical documentation templates with edit capability, check boxes, and standardization -- Measurement >> Dashboard >> Scorecard 2. Integrity -- Quality Assurance Mechanisms: >> System integration >> Automation and Error Detection/Avoidance >> Discern Alerts-Drugs -- Measurement >> Advisor Reports 3. Reliability -- Quality Assurance Mechanisms: >> Mainframe database back-up systems at multiple sites >> Redundancies built into the system >> Downtime recovery plans & processes >> Workstation replacement 5 years -- Measurement >> Downtime Tracking >> Downtime Reports >> Unscheduled 4. Timeliness -- Quality Assurance Mechanisms: >> Real time data transfer >> Monthly Data Review & Reporting -- Measurement >> Unscheduled downtime and recovery 5. Security -- Quality Assurance Mechanisms: >> Log on by position with password >> Encryption of all electronic data >> Network fire walls >> Identity theft protection >> Auto-Sign Off >> Remote data removal on lost devices >> 8-digit password protection & mobile requirements -- Measurement >> Security Reports (AOS) 6. Confidentiality -- Quality Assurance Mechanisms: >> Patient and employee record access reports >> Access rights provided during NEO >> HIPAA privacy compliance >> Auto computer access & removal for non-compliance to mandatory annual computer privacy training -- Measurement >> Privacy Officer Reports (AOS) (p.322)

What steps ensure that information entered into a database is as accurate as possible?

1. All important information is electronically edited and audited at entry. 2. Automated entry is preferable to human entry. 3. Retrieval is preferable to reentry. 4. Training and consultation are used to improve accuracy. (p.318)

What are the two major sets of KM that are supported by the previously mentioned two parts?

1. Management Information 2. Clinical Information (p.309)

What are the six applications or common uses of information in high-performing HCOs?

1. Managing Individual Patients Data Warehouse Info: -- Patient Management Guidelines -- Functional Protocols (Standard Work) Internet Info: -- Journal Articles -- Guidelines -- Diagnostic Software 2. Reporting Performance Data Warehouse Info: -- Recent Data Relative to Goals -- Graphs and Statistical Process Control 3. Identifying OFIs Data Warehouse Info: -- Drill down to identify potential causes -- Local benchmarks and comparative performance Internet Info: -- External Benchmarks -- Best Practices -- Journal Articles -- Collaboratives -- Comparative Information 4. Setting Goals Data Warehouse Info: -- Local Trends -- Benchmarks -- Forecasts Internet Info: -- PITs -- Benchmarks -- Best Practices 5. Supporting PITs Data Warehouse Info: -- Analytic Models -- Simulations -- Forecasts Internet Info: -- Books -- Journal Articles -- Regulatory Standards -- Recommended Practices 6. Reviewing Protocols Data Warehouse Info: -- Reported Variances from Protocol -- Drill-Down of Outcomes to Show Patient-Specific Groups -- Analytic Models and Simulations Internet Info: -- National Clearinghouses -- Commission Reports -- Journal Articles -- Websites -- Books (p.311)

What are the six functions of the implementation of Knowledge Management?

1. Provide prompt and useful access to management information (the data warehouse) 2. Provide prompt and useful access to clinical information (the EHR) 3. Ensure reliability and validity of data. 4. Maintain communications and software support. 5. Ensure the appropriate use and security of data. 6. Improve continuously. (p.309)

What multi-step process does the KM ensure when evaluating that the apps, the training, and other work processes of an HCO are aligned?

1. Stakeholders identify needs via ongoing assessments. Hardware, software, and project requirements are specified. 2. Information technology (IT) develops solution alternatives in collaboration with stakeholders. Technology partners offer upgrades or innovative approaches. 3. IT steering committees and sub committees serve as investment review boards. Priorities are set and funding approved during annual budget planning. 4. IT updates three-year rolling strategic plans. Project plans include necessary resources. 5. Stakeholders evaluate project outcomes. IT steering committees assess effectiveness. (p.321)

What are the four necessary steps for minimizing error when working with data?

1. Standard definitions must be established 2. The definitions must be consistently applied as data are captured. 3. Statistical specification and adjustment must be included when necessary. 4. Random variation and confidence limits must be estimated. The debate should be about OFIs, not the data. (p.317)

What are the four essential parts of the complete knowledge resource?

1. The learning, from many sources, that each associate possesses. 2. The current communications that drive each associate's agenda of tasks and documentation of their completion. For clinical associates, this is principally the electronic health record (EHR). For all units, it includes team performance data supporting the unit scorecard and reports of relevant external events. 3. The data warehouse of guidelines, protocols, processes, performance information, proposals, and forecasts that guides the completion of tasks and the continuous improvement processes. 4. Assistance to all associates, helping them find, evaluate, and apply knowledge from the data warehouse, publications, and the internet. (p.308)

What are the two constraints that the supply of knowledge is subject too?

1. The privacy rights of individuals must be protected at all times. 2. The knowledge resource and the KM system must be protected against failure, loss, or misuse and the security of information ensured. (p.308)

What are the two parts of knowledge management?

1. The up-to-the-minute flow of specific data - such as orders, conditions, and performance - that guides the job to conclusion. 2. Refined and aggregated information that supports continuous improvement. (p.309)

What are the important characteristics of a KM planning process?

1. They are built around explicit collaboration with application units, because KM cannot itself control the results. >> Most planning proposals have four parts: >>> A KM change (new hardware, software, or information capability) will be installed inso HCO activity other than KM. >>> The installation will support improved work processes. >>> The improved work processes will improve operational measures. >>> Improved operations will create improvements in HCO strategic measures. 2. They establish project teams with detailed goals, analogous to facility construction projects. >> Any KM PIT must include all the care-providing, support and strategic units using or supplying the data, and any contractors supporting relevant software. 3. The project teams are monitored by the KMPC 4. Funding is established on a multi-year basis, usually by allocating a portion of the total funds available for new programs and capital to KM projects. 5. The governing board's review focuses on two questions: 'What are the strategic improvements that justify the investment?' and 'How closely do the documented successes from installed projects track the benefits expected?'

What are the five critical actions of knowledge management?

1. Translate knowledge to strategic performance improvement. 2. Maintain the reliability of information. 3. Promote effective use of data. 4. Protect individual privacy, the archive, and the information system. 5. Plan improvement and growth. (p.307)

What does the ONC do?

1. sets the standards and certification criteria that EHRs must meet to assure healthcare professionals and hospitals of what the systems they adopt are able to do 2. specifies minimum functions of EHRs 3. directs the State Health Information Exchange Cooperative Agreement Program, which funds states' efforts to rapidly build capacity for exchanging health information across systems within and across states 4. provides challenge grants to state to encourage innovations for health information exchange 5. guides Medicare and the EHR Incentive Program (p.315)

MACRA (Full Definition)

A CMS incentive program that rewards clinicians' use of certified health information technology. (p.315)

Specification

A statistical analysis that identifies values for a measure by defined subsets of a population, to allow accurate comparisons for each specified group. -- reduces error in data sets -- identifying subsets of the data that show less variation -- important for clinical measures (p.319)

Adjustment

A statistical technique to aggregate values from specified population subsets, allowing comparison of samples from populations with differences in the relative size of subset populations. -- using specification subsets to estimate comparable total populations -- important for clinical measures (p.319)

Data Management System

A system for aggregating and disaggregating electronic data designed to facilitate recovery and use. (p.311) - allows access to individual fields of data in a record so that different sets of records can be accessed, combined, and analyzed quickly - different variables are utilized to create specific outcomes statistics - patient management protocol is attached to each diagnosis, allowing counts of process statistics such as the number of patients receiving a recommended treatment - outcomes and process statistics can be aggregated into rigorously adjusted measures that permit comparison across varying patient populations - this comparison allows for quality reporting and the creation of benchmarks (p.311)

APCs

Ambulatory Patient Classifications (p.313)

What is the data warehouse of an HCO?

Data linked across multiple sources by patient, associate, accountability center, or other key stakeholders. (p.310)

DRGs

Diagnosis Related Groups (p.313)

What does the data warehouse provide?

Information for routine performance reports, budgeting, and special analysis used by accountability centers and performance improvement teams. (p.310)

ICD

International Classification of Diseases (p.313)

KMPC

Knowledge Management Planning Committee (p.324)

Meaningful Use

Measurement thresholds that range from recording patient information as structured data in the EHR to integrating the information across care providers and demonstrating value in exchange for incentive payments from the Centers for Medicare & Medicaid Services (CMS) (p.315) -- EHR Incentive Program -- Stage One: the ability to demonstrate implementation of the EHR -- Stage Two: integration of the record -- Stage Three: ability to derive value by improving the patient care experience (p.315)

MACRA

Medicare Access and CHIP Reauthorization Act of 2015 (p.315)

MHSL

Memorial Hermann Sugar Land (p.312)

MIPS

Merit-Based Incentive Payment System (p.315) -- a part of MACRA -- contains established measurement thresholds that range from recording patient information as structured data to exchanging summary care records -- Medicare EHR Incentive Program is one of it's four components (p.315)

ONC

Office of the National Coordinator for Health Information Technology (p.314)

Legacy System

Outdated computer software that lacks the features found in more current versions. -- not designed to integrate with other systems -- there is a core issue of meeting the needs of both the in-system user and the external user will remain (p.321)

QPP

Quality Payment Program (p.315) -- a part of MACRA -- multiple clinician payment tracks -- reward's clinicians' use of certified health IT (p.315)

Statistical Process Control

a method of identifying significant changes in measures subject to random variation -- SPC software calculates both measures, shows trends and significance graphically, and automatically flags significant differences -- Significant at 99 percent (3 standard deviations or 3 sigma) is a forecast that 99 times out of 100 a diligent team will find a potentially correctable cause -- All sigma 3 variations are OFIs -- Smaller variations can usually be ignored (p.320)

Big Data

large and complex data sets that may be analyzed for patterns (p.316)

What is the role of the ONC?

to support the adoption of health information technology and the promotion of nationwide health information exchange to improve health care and to support nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information (p.314)

What is the purpose of knowledge management (KM)?

to translate the healthcare organization's (HCO) complete knowledge resource into improvement of its strategic performance (p.308)