CHAPTER 5 PROMOTING ACCOUNTABILITY THROUGH MEASUREMENTS Jamie Duffy

CHAPTER 5: PROMOTING ACCOUNTABILITY THROUGH MEASUREMENTS Jamie Duffy ETM 568/ Dr. Burtner

Presentation Summary 2 Acronyms Levels of Accountability Case Example: Self-Extubation Getting the Doctors on Board Analyzing Errors Overview Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

Acronyms 3 ACS- American College of Surgeons AHRQ- Agency for Healthcare Research and Quality APACHE-Acute Physiology, Age and Chronis Health Evaluation CEO- Chief Executive Officer CMS- Centers for Medicare and Medicaid Services ED- Emergency Department ICU- Intensive Care Unit JCAHO-Joint Commission on Accreditation of Healthcare Organizations LOS-Length of Stay NYS DOH- New York State Department of Health OR- Operating Room PDCA-Plan Do Check Act PIGG- Performance Improvement Coordination Group Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

Levels of Accountability 4 Figure 5. 1. Levels of Accountability Board of Trustees High level management Committee on Quality System Performance Improvement Coordinating Group (PIGG) Site-Specific PIGG Site Service Line Meeting System Medical Executive Committee System and Site Nurse Executive Middle level management Site-Specific Medical Boards Low level management System and Site Administration Unit-Specific Review of Data Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

5 Case Example: Self. Extubations Decrease patient self-extubation in ICUs PDCA methodology Specific goals for improvement: Standardize critical care quality indicators for monthly collection and analysis Develop admission and discharge criteria for the ICU Improve and monitor nursing competency Formalize protocols Leadership support was crucial Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

Getting the Doctors on Board 6 Mortality rating has an impact of doctor reputation. Financially punished for never events. Held to national standards of patient safety. Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

Analyzing Errors 7 Continuously measuring care allows for data to alerts leadership when a process is beginning to fail. A root cause analysis is used to identify the causes of the event and processes can be implemented in place to improve. Cause and effect (fishbone or Ishikawa) diagram illustrates how various factors impact a result. Must mandate that the hospital present a corrective action plan to alert the problem. Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

Overview 8 Accountability is promoted when leadership can evaluate the delivery of care. Physicians must be held to an objective standard. It is important that even nonclinical staff must understand their role in the process of care. The use of measurements must determine gaps in patient safety and then monitor improvements. Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

THANK YOU! 9 Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz