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Quality Reporting Challenges

Quality departments within healthcare have a tough challenge to meet the existing reporting needs of Quality Indicators throughout the organization. And that challenge is going to become ever more difficult as more and more processes are tracked and targeted for improvement.

Key issues include:

Many different Indicators / Metrics need to be tracked
While there are many indicators that your organization is currently tracking, that number is going to increase significantly in the near future. Many organizations are planning on the number of indicators tracked (many of them internal) to at least triple annually over the next couple of years. This is a natural and expected course of a Quality Improvement program.

Indicator Data is EVERYWHERE
Data for Quality / Performance Indicators is currently being maintained in multiple Excel files, paper records, internal data bases, ORYX providers, etc. While it is highly desirable to get all of the key indicator data into a centralized repository, that goal is a distant second to the immediate need to track and monitor the current processes.

Need both Operational and Executive reporting
It goes without saying that different people in the organization need access to different information and at different frequencies. Executives / Trustees are typically focused on quarterly time periods, whereas the Operational focus is often on more timely data (monthly, weekly) so that they can more closely monitor changes made to the process.

Automated Reporting
With multiple indicators being tracked now and more coming, it is critical that the process become as automated as possible to reduce / conserve resources. Emphasis within the Quality department should be on identifying / tracking more and more indicators rather than trying to keep the number of indicators to a minimum because manual report generation is so time-consuming. Automation is also critical to avoiding / reducing errors and inaccuracies that will inevitably occur when reports are generated manually. A typical example is the accurate reporting of data which has been changed / corrected during a reporting cycle.

Need effective / objective (SPC) analysis techniques
It is critical to distinguish abnormal variation in a process from the normal expected variation in a process. Without SPC techniques, much energy and resources are consumed on processes which are exhibiting normal variation. SPC allows teams to focus their efforts on the processes which show abnormal variation and statistically significant trends.

Different Indicators are available at different times during the Month / Quarter
Data for some indicators is going to be available on the last day of the month (e.g. Patients Admitted), whereas other indicators may not be available until the middle of the subsequent month (or even later). Different flow rates for different indicators are a reality and cannot be easily reduced. This is especially true when the underlying data for an indicator must be validated by an Expert for that indicator to review possible coding errors, data entry errors, etc. The typical solution to this scenario is to generate the report on all of the indicators after the data for the last indicator is completed. For Operational indicators, this means that valuable time is lost improving on critical indicators. Indicators should be made available to the teams at their natural “flow rate”. When new data for an indicator is available, anyone interested should be able to review the performance of that indicator (and ideally be automatically notified that new data is available).

Need to easily visualize performance of many indicators
As more and more indicators are tracked, it becomes increasingly important to visualize and focus on the indicators which are not performing, otherwise poor performing indicators will be lost in the clutter of those performing well.

Report Distribution
Making indicator performance available to others in the organization is critical to the success of any improvement program. With lots of indicators being tracked, it is imperative that different users get different reports. The other challenge is in making updated information available as mistakes or inaccuracies are detected after the report has been distributed. When there are 100’s of indicators being tracked within an organization, it becomes essential to allow users to “subscribe” to the indicators that they are interested in and to automatically be notified about the performance of critical indicators when data is available for a new period.

Closing the Process Improvement Loop
To truly improve the performance on critical indicators, it is critical that an “Expert / Owner” for the process be assigned the responsibility for the indicator’s performance. The Experts need to be held accountable for improving the process and need to perform the following tasks:

  • Ensurevalidity of the underlying data
  • Assess the process
  • Create action plans for improvement
  • Keep everyone informed on the process

Excel- and Word-Based Solutions are NOT THE SOLUTION
The first reporting solution deployed by most organizations is to use the solutions that they already have in place. Initially when there are few indicators to report on, this approach seems completely natural. However, Quality departments quickly find themselves completely consumed by the reporting process as the number of indicators grows and the focus becomes truly improving the performance of these indicators rather than just reporting on their status.

Many organizations have deployed Microsoft Office solutions for reporting on indicator performance. The main reasons for this are these tools are deployed in-house and there is not a single reporting system that can generate a comprehensive report for all of the various indicators (Patient, Clinical, Quality, Financial, Efficiency, etc). While this is typically the first approach deployed, it has some significant shortcomings that should be understood:

Multiple copies of the data are typically made
Different teams / individuals are responsible for different sets of indicators. These teams typically summarize the data for a period from the source data (by running specific reports, data entry, etc) and maintain this data in a summarized form by period (e.g. an Excel file). This data file is then passed onto the Quality group responsible for generating the overall report. The first thing typically done is to make a copy of this data (e.g. add it to a worksheet in the specific report for a period). The act of making a copy of the data creates a severe weakness in the whole reporting structure. Anytime multiple copies of the same data set are made, errors and inaccuracies will occur. These errors are introduced through copy / paste mistakes, data entry or failure to propagate any changes made to the source data (e.g. correcting an inaccurate patient record).

Excel-based reports make copies of the Data
Indicators can get out of sync and report is available when ALL are available

Report is distributed when all indicators are complete
Reports typically contain all of the indicators and are not released until the data / summary for the last indicator has been completed. This results in lost time / opportunity to take action on indicators which are underperforming and whose information is available but has not yet been distributed.

No Automation is deployed
The preparation of the report is typically done manually by copying / pasting sections from various sources and previous reports to the final document (Excel spreadsheet, Word or PowerPoint document). This is very time consuming and can lead to inaccurate or omitted information in the final report.

SPC Analysis not included
Typically the indicator trends and performance are presented as bar and trend charts. These are not suitable techniques for identifying abnormal process variation or significant trends.

Integration of Process Assessment / Action Plans not included or generated by lots of copy / paste
Key to true Process Improvement is to identify Owners/Experts and hold them accountable for leading efforts to make improvements. This information is often maintained separately from the report and may or may not be included in some reports. If it is included in the report, it is likely to be copied / pasted from some other source so inaccuracies often occur. Additionally, it is critical that the history of Assessments / Action plans are an integral part of the reporting process.

Because of resources required not as many indicators are tracked
Focus of Quality Departments has become to get out the existing reports when their focus should be on improving processes and identifying others for improvement. To truly improve the multitudes of processes in healthcare, more and more indicators need to be tracked in the future. If tracking / reporting of existing indicators is difficult and time consuming, overall improvement is going to suffer accordingly.

Report Distribution is one big batch and can lead to multiple copies
MS Office documents are typically mailed out to individuals and then archived by them on their local desktops. Multiple copies of these reports are a source for inaccuracies due to source data changes.

Statit piMD provides the Quality Reporting Solution Now and for the Future
To solve the Quality Reporting challenges in healthcare organizations and to help them focus their efforts on true Process Improvement, Statit developed Statit piMD. Statit piMD was developed with the help of a focus group of healthcare professionals who understand the benefits of utilizing SPC techniques for Process Improvement.

Advantages of Statit piMD:

Reads directly from the source data – no copies made
Statit piMD reads data directly from multiple data sources and does not make copies of the data for reporting. Data for CHF indicators might be in an Excel file and data on Patient falls might be stored in an Access data base or some other source.

Statit piMD does not make copies of the data
All indicators are always current

All Indicators always current
Every time a user views information about a specific indicator, the data is directly read in from the associated data source. As soon as data for a new period is available, the user will see that data. An Expert can be associated with each indicator and will receive an automatic e-mail whenever new data is detected. If required for a specific indicator, the Expert can “validate” the new data and the end-user will know when they look at new data whether or not the Expert has performed the validation.

SPC is the foundation
Statit piMD includes SPC (Statistical Process Control) techniques as an integral part of the system. Indicators will be flagged if they violate any SPC condition (e.g. Out of Control, Upward Trend, Downward Trend, etc.)

Dashboards / Scorecards
Statit piMD incorporates informative Dashboards and Scorecards to allow users to assess the performance of many indicators and to drill down on those not performing as expected.

Integrates other information – Office Docs, links, etc.
A key feature identified by our focus group was the ability to centralize all information about an indicator into a single location. To facilitate this, Statit piMD allows any document on your network or on the Internet (e.g. JCAHO site) to be accessed for a specific indicator.

Integrated Comparisons / Drill Down
A key feature identified by our focus group was the ability to compare the indicator performance across sites, departments, providers, etc. Statit piMD allows end-users to see the overall performance and then to compare performance between different entities.

Integrated Assessment / Action Plans
To truly make process improvements, Statit piMD allows Experts to be identified for each indicator. The Expert's Assessment and Action Plans become an integral part of information available for an indicator.

Easy to add new Indicators
Key to managing more indicators is making it simple to add new indicators to the system. This is extremely easy to do within Statit piMD and performed routinely at our customer sites by nurses and others who are in the Quality team within the organization. No IT resources are required!

For More info on Statit piMD, please click here.

You may review Statit piMD on your own by going to Some functionality of Statit piMD (expert action plans, creating indicators, accessing data) cannot be shown in an “unhosted review.” Statit welcomes the opportunity to provide a 30-minute, no-obligation remote demonstration and potentially, to include your data in the demonstration. To request a demonstration of Statit piMD, please click here and complete the information as requested