How to use standardized measure data to improve performance: An HCSS Example. Copyright, The Joint Commission
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1 How to use standardized measure data to improve performance: An HCSS Example
2 Transmitted Data Report (CMIP) HCO MIF Short Name reporting numerator denominator result date xxxxxx 3 Completeness of Personnel File 0/0/ % xxxxxx 3 Completeness of Personnel File 02/0/ % xxxxxx 3 Completeness of Personnel File 03/0/ % xxxxxx 3 Completeness of Personnel File 04/0/ % xxxxxx 3 Completeness of Personnel File 05/0/ % xxxxxx 3 Completeness of Personnel File 06/0/ % xxxxxx 3 Completeness of Personnel File 07/0/ % xxxxxx 3 Completeness of Personnel File 08/0/ % xxxxxx 3 Completeness of Personnel File 09/0/ % xxxxxx 3 Completeness of Personnel File 0/0/ % xxxxxx 3 Completeness of Personnel File /0/ % xxxxxx 3 Completeness of Personnel File 2/0/ % 2
3 Plotted Monthly Data Points 00.00% Completeness of Personnel Files Data 90.00% Files Complete 80.00% 70.00% 60.00% X = % 40.00% Month graphical data displays completed by firm and shared with reviewer at time of recertification
4 Use Data to Evaluate Processes and Outcomes Completeness of personnel files inconsistent over past 2 months Overall upward trend with improvement noted in Q Most frequently missing requirements: Documentation of annual competency assessment Expired CPR certification 4
5 Identify Potential Opportunities for Improvement Completeness of personnel file averages 78% over 2 month period Timely completion of competency assessments would significantly improve performance 5
6 Describe Interventions or Process Modifications Modified HR software to flag files 3 months before renewal / expiration dates Allow employee time to complete testing Allow time to update documentation in file Computer generated notices attached to employee pay statements as reminder 6
7 Explain Variances May files with expired CPR certifications. BLS class scheduled for April 25 th cancelled. July 2008 New HR software installed. Steep learning curve. Staff had difficulty keeping up with electronic documentation for a few months. July, Aug, Sep many files incomplete. 7
8 Do Not Return Data Display and Analysis Clinical vs. Professional Reasons 00% 5% 6% 6% 6% Percentage of Reasons By Category 80% 60% 40% 20% 0% 73% 74% 46% 76% 48% 22% 20% 8% Qtr- Qtr-2 Qtr-3 Qtr-4 Other Professional Clinical 2008 Quarter 8
9 Professional Data Display and Analysis Professional Reasons for Do Not Return Percentage of Reasons By Category 00% 80% 60% 40% 20% 0% Qtr- Qtr-2 Qtr-3 Qtr-4 Unlawful Activity Insubordination Tardiness Attendance 2008 Quarter 9
10 Clinical Data Display and Analysis Clinical Reasons for Do Not Return Percentage of Reasons By Category 00% 80% 60% 40% 20% 0% Qtr- Qtr-2 Qtr-3 Qtr Quarter Pt Abuse Credentialing Documentation Med Errors 0
11 Use Data to Evaluate Processes and Outcomes Professional reasons for Do Not Return significantly greater than clinical reasons 3: ratio Over 90% of professional reasons due to attendance and tardiness issues Medication errors # clinical reason followed by documentation issues 5% to 6% of all Do Not Return Occurrences consistently due to reasons unrelated to clinical or professional events
12 Identify Potential Opportunities for Improvement Attendance / Tardiness issues damage firm s reputation to consistently provide reliable staff Improve customer service Enhance customer perceptions Attract new business and retain previous customers Medication errors can be prevented Reduce adverse patient events Improve patient outcomes Increase clinical staff competency 2
13 Describe Interventions or Process Modifications Implemented new HR policy addressing unexcused absences Interviewed staff following med error occurrences Tracking types of med errors and possible reasons to help identify patterns, causes, and future interventions Purchased medication safety tools and educational resources from the Institute For Safe Medication Practices (ISMP) 3
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