HIM 229: CH 18 Performance Improvement

* Effective communication is important.

Communicate, listen, and understand everyone's point of view. Communication must exist at all levels of the organization and in all directions.

* Setting goals is crucial.

Specific measurable objectives can be completed in a reasonable time.

T or F: Performance monitoring is data-driven

True

3 Quality improvement tools used for Risk Management purposes: / Investigational technique:

1. Cause and Effect Diagram (Fishbone Diagram) (Ishikawa) 2. Root-cause analysis 3. Force field analysis

TEAM-BASED PERFORMANCE IMPROVEMENT 9 Elements of Team Success:

1. Establishing ground rules for the team 2. Stating the team's purpose and mission 3. Identifying customers and their requirements - identify internal or external customers and their needs and modified processes to meet customer requirements. 4. Documenting current processes and identifying barriers 5. Benchmarking - being able to compare an organization's performance against that of external standards 6. Collecting current process data (flow chart, brainstorming problem areas, cause-and-effect diagram, force-field analysis) 7. Analyzing process data 8. Process redesign 9. Recommendations for process change

3 Basic Responsibilities of the PI dept

1. Helping departments/group of depts with similar issues to identify potential quality problems. 2. Assisting determination of the best methods for studying potential problems (for ex: survey, chart review, or interview with staff) 3. Participating in regular meetings across the organization as appropriate, and training organization members on quality and PI methodology, tools, and techniques

Continuous Cycle of Performance Improvement:/ Steps of Performance Improvement:

1. IDENTIFY PERFORMANCE MEASURES = identify areas that need performance monitoring such as important organization functions, those that are high risk, high volume, or problem-prone such as discharge not final build or DNFB, coding compliance or patient safety issues. Outcomes of care, customer feedback, and the requirements of regulatory agencies are additional areas that organizations consider when prioritizing performance measures. 2. PERFORMANCE MEASURE = is a quantitative tool for example a rate, ratio, index, or percentage that provides an indication of an organization's performance in relation to a specified process or outcome. 3. ANALYZE AND COMPARE INTERNAL/EXTERNAL DATA = if the health record delinquency rate exceeds the hospitals established performance standards (an internal comparison), an opportunity for improvement has been identified. 4. IDENTIFY OPPORTUNITIES FOR IMPROVEMENT = changes in policy and procedures, workflow process change. 5. ONGOING MONITORING = monitoring performance based on internal and external data is the foundation of all Performance Improvement or PI activities. = culmination of all steps

4. RISK MANAGEMENT

1. RISK MANAGEMENT = any risk occurrence or circumstances that might result in a loss. Loss includes any damage to an entity's person, property, or rights, including physical injury, cognitive injury, emotional injury, wrongful death, and financial loss. = the purpose of the risk management program is to link risk management functions to the related processes of quality assessment and PI. The Risk Management Program aims to: a. Help provide high-quality patient care while also enhancing a safe environment for patients, employees, and visitors. b. Minimize financial loss by reducing risk through prevention and evaluation. 3 Basic Functions of Healthcare Risk Management Programs are: 1. Risk identification and analysis = collect and analyze information on the actual losses and potential risks. Incident or Occurrence Report = a structured tool used to collect data and information about any event not consistent with a routine operational procedure, such as wrong side surgery or foreign body left in following surgery. Incident reports are prepared to help healthcare facilities identify and prepare for legal defense. An incident report documents the event for operational purposes and is not used for patient care, so it is considered an extremely confidential document that is never filed in the health record and should not be photocopied or prepared in duplicate. The healthcare provider should never document that an incident report was completed. Incident reports are not part of the legal health record and are not discoverable in event of legal action. += not written in medical record? = it is very important because it is used for legal defense Potentially Compensable Event = a potentially compensable event is an occurrence such as an incident or medical error that may result in personal injury or loss of property to patients, staff, visitors, or the healthcare organization. 2. Loss Prevention and Reduction = design systems that lessen potential losses in the future. = Risk manager is responsible for developing systems to prevent injuries and other losses within the organization. 3. Claims management = is the process of managing the legal and administrative aspects of the healthcare organization's response to injury claims such as injuries occurring on the facility's property. Organizations manage claims and risks by incorporating patient advocacy, incorporating regulatory accreditation requirements, and having an organizational incidence response mechanism in place.

Performance Improvement Tools and Techniques: 4. Statistic-based modeling techniques

1. Statistic-based modeling techniques = they assist in the display of data. It's for data points for a specific time frame. Data points are planted on a graph. It is the use of analytical and graphical techniques to assist in the display and interpretation of raw data. a. Run chart = time (months, years) = displays data points for a specific time frame to provide information about performance. In a run chart, the measured points of a process are plotted on a graph at regular time intervals to help team members identify whether there are substantial changes in the numbers over time. For example, suppose a HIM professional wished to reduce the number of incomplete health records in the HIM department. He or she might first plot the number of incomplete health records each month for the past six months. Based on an analysis of the health records process, he or she then might enact a change designed to improve the process. = A run chart is an excellent tool for providing visual verification of how a process is performing and whether an improvement effort has worked. b. Statistical Process Control chart = upper control limit and lower control limit = uses standard deviation = looks like a run chart except that it has a reference lines indicating the upper control limit (UCL) and lower control limit (LCL) drawn horizontally at the top and the bottom of the chart. The statistical process control chart makes it possible to see whether the variation within a process is the result of a common cause or a special cause. It lets the PI team know whether the team needs to try to reduce the ordinary variation occurring through common cause or to seek out a special cause of the variation and try to eliminate it.

Three types of Quality Dimensions or quality indicators of performance improvement:

1. Structure indicators = measure the attributes of the healthcare setting such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures. Example: HIM staff with nationally recognized credentials. 2. Process indicators = measure steps in a process and tasks people or devices do, from conducting appropriate tests, to making a diagnosis, to carrying out a treatment. 3. Outcome indicators = measure the actual results of care for patients and populations, including patient and family satisfaction.

Accreditation organizations such as

1. The Joint Commission (TJC) 2. Healthcare Facilities Accreditation Program 3. DNV GL Healthcare

5 Brainstorming Approaches:

1. Unstructured brainstorming method - results in the free flow of ideas. Allows everyone to throw in ideas. 2. Structured brainstorming - the team leader or facilitator asks team members to create their own list of ideas. 3. Affinity grouping - allows the team to organize similar ideas into logical groupings. Write ideas generated in sticky notes. Without talking to each other, each team member reviews the ideas on the notes and places each in natural groupings that seem related or connected to each other. Each member is empowered to move the ideas in a way that makes the most sense. 4. Nominal group technique - ranking ideas according to importance. 5. Multivoting technique - a variation of the nominal group technique and serves the same purpose. Instead of ranking, team members rate issues by marking them with a distribution of points.

Quality improvement tools used for Risk Management purposes: / Investigational technique: 1. Cause and Effect Diagram (Fishbone Diagram) (Ishikawa)

= An investigational technique that facilitates the identification of the various factors that contribute to a problem. It facilitates root cause analysis.

Sentinel events

= a TJC term = occurrences that resulted or could have resulted in life-threatening injuries to patients, medical staff, visitors, or employees. = an occurrence with an undesirable outcome usually happening only once. = examples include medical errors, explosions, fires, and acts of violence

Performance Improvement Tools and Techniques: 1. Check sheets

= a data collection tool that records and compiles observations or occurrences. = records every time something happens. = a simple tool that records how many times things happen to identify where the problem is = tallying = a simple way to obtain a clear picture of the basic facts

Performance indicators

= a measure used by healthcare facilities to assess the quality, effectiveness, and efficiency of their services = Ex: Financial indicator - ave cost per lab test Productivity indicator - # pt's seen per Dr.

Interpersonal dimension quality

= recognizes that caregivers must have the communication skills and social attributes necessary to serve patients appropriately. The interpersonal aspect of quality recognizes the importance of empathy, honesty, respectfulness, tactfulness, and sensitivity to others.

Technical dimension of quality

= recognizes that caregivers must have the knowledge and judgment to arrive at an appropriate strategy for providing service and the technical skills to execute it. * technical dimension is easier to measure than interpersonal dimension

a. Accreditation Standards

= all the programs base accreditation on data collection and submission process followed by a comprehensive survey process. > The Joint Commission = is the oldest and most established healthcare accreditation agency. = largest healthcare standards accrediting body in the world = emphasis is on performance improvement = looks at what's going on in the facility by checking outcomes NPSG (National Patient Safety Goals) = outlines the areas of organizational practice that most commonly lead to patient injury or other negative outcomes that can be prevented if standardized procedures are used. = list of most prevalent problem areas (Ex: wrong site, wrong pt, wrong procedure) Tracer methodology = this is how TJC collect data when they do on-site evaluation. = consists of following or tracing a few patients through their entire stay at the hospital to identify quality and patient safety issues that might indicate quality problems or patterns of less than optimum care. > DNV = cheaper than TJC = is a voluntary accreditation organization that has operated in the United States since the late 1800s but is relatively new to healthcare. = the organization is recognized by CMS to have deemed status, which means Healthcare organizations accredited by DNV are recognized as meeting the Medicare Conditions of Participation.

· Patient Advocacy Program

= also known as patient representative or ombudsperson or ombudsman. = they handle minor complaints, seek remedies on behalf of patients, recognized serious problems to be routed to PI or Risk Management. = Patient Advocate responds to complaints from patients and their families.

Quality improvement tools used for Risk Management purposes: / Investigational technique: 2. Root-cause analysis

= analysis of an event from all aspects such as (human, procedural, machinery, material) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence. = the purpose of this tool is to permit the team to explore, identify, and graphically display all the root causes of a problem.

Scorecards (outcome measures)

= another means by which customers can see how healthcare organization performs. = scorecards are tools that present metrics from a variety of quality aspects in one concise report. They may present measures of clinical quality such as infection rates, financial quality, volume, and patient satisfaction. = rate services make reviews.

Performance Improvement Tools and Techniques: 2. Data Abstracts

= are defined and standardized set of data points or elements common to a patient population that can be regularly identified in the health records of the population and coded for use in analysis in a database management system. Example is diabetic patients who have some usual items that need to be looked at.

External Customers

= are those people outside the organization for whom it provides services. For example, the external customers of a hospital would include patients, third-party payers, and the Department of Health.

Quality improvement tools used for Risk Management purposes: / Investigational technique: 3. Force field analysis

= identifies specific drivers of barriers and to an organizational change, so that positive factors can be reinforced, and negative factors reduced. = force field analysis enables team members to identify factors that support or work against a proposed solution. = a t-shaped graph or diagram or visual representation that illustrates pros and cons.

Collecting Current Process Data: 1. Flowchart

= is a graphic tool that uses standard symbols to visually display detailed information, including time and distance of the sequential flow of work on an individual or a product as it progresses through a process. = is created to illustrate the current process used because the team must first examine and understand the current process before making improvements. = Flowcharts help all the team members understand the process in the same way.

Process Improvement

= is a mindset that, when adopted into organizational culture, can produce significant and continuous improvement. = is a proactive cycle that ensures key processes, products, and services are performed efficiently and within set quality standards. = one key to successful process improvement is proactively measuring, monitoring, and improving indicators before the process or indicator is considered broken or unacceptable. = an example would be putting an effective coding compliance plan in place that includes measuring, monitoring, and improving the coding in the facility before a negative outside audit or non-compliance fine is assessed and the in-house auditing process or coding product is determined to be unacceptable. = process improvement assumes that organizations should continuously and systematically identify and test small, planned changes and processes and systems.

Benchmark

= is a systematic comparison of one healthcare organization's measured characteristics with those of another similar organization or with internal, regional, or national standards. = this is the "monitoring and improving customer satisfaction" process; also a PI activity

Collecting Current Process Data: 2. Brainstorming

= is a technique used to generate many creative ideas from a group. = it encourages PI members to think outside of the box and offer original ideas to address the problems in the process. = brainstorming is highly effective for identifying several potential process steps that may benefit from improvement efforts and for generating solution to specific problems. = it helps people to begin thinking in new ways and involves them in the process. = it is an excellent method for facilitating open communication.

Performance

= is the execution of an activity or pattern of behavior = the application of inherent or learned capabilities to complete a process according to prescribed specifications or standards.

The key to successful monitoring is the appropriate analysis, display, and application of...

= measurement data

Quality

= meeting or exceeding customer expectations.

Delinquent Health Record Rate

= one of the main areas accreditation agencies look for = Number of incomplete health records that exceed the established standard divided by Average monthly discharges

a. Government Regulations Quality Improvement Organization (QIO)

= quality improvement organizations or QIOs are responsible for monitoring the quality of care provided to Medicare patients.

Quality indicators

= standards against which patient care is measured to identify a level of performance for that standard

Internal Customers

= such as employees. The employees receive services from other areas in the organization that make it possible for them to do their jobs. For example, a nurse in ICU would be an internal customer of the hospital pharmacy; the nurse depends on the pharmacy to provide the medications needed to fill the physician's orders for his or her patient.

Performance Improvement Tools and Techniques: 3. Time ladders

= support the collection of data that must be oriented by time. This is necessary when we want to know something oriented by time. For example, how many staffing needed at a specific time or how many receptionists needed at the time. Collecting time ladder data over an appropriate period develops a detailed clear picture of the workflow or process.

Team-based PI begins with

= the assembly of the team.

Dashboard

= the display of the most important information needed to achieve one or more objectives that has been consolidated so it can be monitored at a glance. = a dashboard can be disseminated in either electronic or paper format. The organization's leadership uses the information displayed on the dashboard to guide operations and determine improvement projects. = a dashboard allows leaders to keep track of high impact, high risk, or high value processes and make adjustments on a daily basis if needed.

b. State and Local licensure requirements

= to maintain its licensed status, each facility must adhere to the state regulations that govern such as quality of care.

a. Government Regulations Medicare Conditions of Participation (COP)

= to participate in the Medicare program, healthcare providers must comply with Federal Regulations known as The Conditions of Participation. The CMS develops the Conditions of Participation.

In HIM systems, for example, common-cause variation can be observed in the number of health records that can be coded each day. On a day when one of the regular coders is out sick, the number of records coded might drop significantly because the coder will have no productive work time while home sick leaving the team short-staffed. This would be an example of special-cause variation.

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* Success should be celebrated.

Celebrate success and recognize staff involved in success

* Staff and management must be involved in the process.

Leaders should invest in their employees and they must realize that these PI activities takes time and training.

* Data must support PI activities and decisions..

PI activities should be guided and driven by data. Data, transformed into information is the key to the success of PI activities.

* Support must come from the top down.

PI must become part of the healthcare organization's culture. Model and do it yourself if you want your employees to do something or the same thing. Culture of the organization must include everyone.

What is a standard and what are the 4 types of standards within the context of Clinical Quality Assessment?

Standards - a written description of the expected features, characteristics, or outcomes of a healthcare-related service. 4 types of standards (within the context of clinical quality assessment): 1. Clinical practice guidelines/protocols 2. Accreditation standards 3. Government regulations 4. Licensure requirements

CMS + AHRQ = HCAHPS

The Centers of Medicare and Medicaid Services or CMS and the Agency for Healthcare Research and Quality or AHRQ, collaborated to develop the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS survey. This was the first standardized survey used to compare Hospital performance and quality at the national level. Hospitals are required to administer and participate in this survey if they provide services to Medicare patients.

Performance Improvement (PI)

The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes.

Performance Measurement

The process of comparing the outcomes of an organization, work unit, or employee against pre-established performance plans and standards.

3. UTILIZATION MANAGEMENT and what are it's 3 important functions?

UTILIZATION MANAGEMENT = conducts reviews to see if the medical procedure is warranted or medically necessary = utilization management or UM is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care. = utilization management is an important part of quality patient care as it helps to ensure necessary and appropriate care, effectiveness of the services provided to the patient, and timely and safe discharge of patients. Three important functions of Utilization Management: 1. Utilization Review 2. Case Management 3. Discharge Planning

* The organization must have a shared vision.

Vision, mission, and value statements guide employees as they make their contributions to the organization in fulfilling their professional responsibilities.

4 types of standards (within the context of clinical quality assessment): 1. Clinical practice guidelines/protocols

a. Clinical Practice Guidelines and Clinical Protocols = Clinical Practice Guidelines are flexible and do not apply to all cases. = Clinical Protocols are step by step instructions used by healthcare practitioners to make knowledge-based clinical decisions directly related to Patient Care. Example, there are specific protocols for pregnant women. Clinical Protocols standardize clinical decision-making. IV solution prep.

* Variation is constant:

· Common-cause variation - variation that is inherent within the system. For example, when a nurse takes a patient's blood pressure, she may believe she is performing the procedure in the same way every time, but in practice she will get slightly different readings each time. For example, the cuff may be applied to a different place on the patient's arm. The patient may have a slightly different emotional or physiological status at the time of the measurement. The nurse may have a different level of focus or concentration. · Special-cause variation - caused by factors outside the system, produces a negative effect.. An example of this type of variation occurs when a patient is diagnosed with hypertension and the physician prescribes a blood pressure medication for the patient. After taking blood pressure medication and there is a substantial drop in the blood pressure measurement. All the factors like diet, exercise, stress, family history, have remained unchanged demonstrating that the medication caused the decrease in blood pressure values, which is considered a special cause. In this situation, the variation is intentional and desired. In other situations, the variation may produce an undesirable and unintentional effect. For example, if a patient is upset about a phone call he received just before the nurse came in to take his vitals, his blood pressure may register exceptionally high. The change in values occurred due to a special cause which is the phone call and resulted in a blood pressure reading much higher than expected.

Fundamental Principles of Continuous Performance Improvement: (know at least 3)

· The problem is usually the system · Variation is constant · Data must support PI activities and decisions · Support must come from the top down · The organization must have a shared vision · Staff and management must be involved in the process · Setting goals is critical · Effective communication is important · Success should be celebrated

* The problem is usually the system: Define: System - Inputs - Outputs - System Thinking -

· a System is a set of related and highly interdependent components that are operating for a purpose. · Inputs - or data entered into hospital system; for example, in the hospital admitting system, the patient's knowledge of his or her condition, the admitting clerk's knowledge or the admission process, and the computer with its admitting template are all inputs. · Outputs - or the outcomes of inputs into a system; for example, the output of the admitting process is a patient's admission to the hospital. · Systems thinking - is a vital part of PI and is an objective way of assessing work-related ideas and processes with the goal of allowing people to uncover ineffective patterns of behavior and thinking and then finding ways to make a lasting improvement.