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Quality Reporting Challenges
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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 100s 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 indicators
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
Software 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 http://pimd.statit.com.
Some functionality of Statit piMD (expert action
plans, creating indicators, accessing data)
cannot be shown in an unhosted review.
Statit Software 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
If you would like additional information, please
call our Support staff at (541) 752-4100 or
send email to
.
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