SSM Health Care Category 4: Information and Analysis Information and Analysis The MBNQA Information & Analysis criteria SSM’s approach to information management and measurement – Information systems infrastructure –
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SSM Health Care Category 4: Information and Analysis Information and Analysis The MBNQA Information & Analysis criteria SSM’s approach to information management and measurement – Information systems infrastructure – Performance Management Process – Use of comparative data MBNQA Categories 1. Leadership 2. Strategic Planning 3. Focus on Patients, Other Customers, and Markets 4. Information and Analysis 5. Staff Focus 6. Process Management 7. Results Malcolm says….. Baldrige National Quality Program 1995 Average Category Scores Percent Score 70 60 50 40 30 20 n t s nt e sis ing tio en ult y n c l m s m n a a e e Re tisf An ag ad Pla ag e a n e n c & c i a S L n M an Ma 1 teg tio s& & m s a r r a s u t t o c e n f S er orm Fo roc me 3 P r p P Inf e lo 6 m 5 2 ve e sto u D C HR 7 4 hip s r e Categories Service Health Care Education Categories an ss lts en t es u R m ag e an M cu s Fo ly si s An a s tF oc u ce ou r in e Bu s ss R es d hi p ni ng Pl an ke ar an M gi c te io n at an d Pr oc e H um fo rm In m er C us to St ra rs ad e Le Percent Score Malcolm says….. Baldrige National Quality Program 1999 Average Category Scores 70 60 50 40 30 20 Service Health Care Education Framework Organizational Purpose: Environment, Relationships and Challenges 2: Strategic Planning 5: Staff Focus 7: Organizational Performance Results 1: Leadership 3: Focus on Patients, Other Customers and Markets 6: Process Management 4: Measurement, Analysis and Knowledge Management MBNQA Category 4 INFORMATION AND ANALYSIS Performance Measurement/Analysis Select and align measures Gather/integrate data to support daily operations/decision making Ensure effective use of comparative data Analyses to support leaders’ review and strategic planning Communicate results to enable effective decision-making Align results of analysis MBNQA Category 4 INFORMATION AND ANALYSIS Information Management Make needed information available to all stakeholders Ensure data integrity, reliability, accuracy, timeliness, security, confidentiality Ensure hardware/software reliability and user-friendliness Keep system current with health care needs SSM Information Center (SSMIC) 2002 recipient of the Missouri Quality Award Client Response Center Information technology Applications development Decision support Compliance Administration Group IS Planning and Management L I S T E N I N G P O S T N E E D S A S S E S S M E N T S Vendors / Consultants SSMHC System Strategy Network / Entity IMC Nursing Informatics I N P U T S Capital Allocation Committee System IMC Medical Informatics Entity Service Level Agreements SSM Information Center e-Health / Web IMC HIPAA Revenue Cycle Tactical Teams Operational Teams Project Office Plan / Check ePMI Entity Membership Do / Act Network/User Group Teams Physician Connectivity Access Anytime, Anywhere… Hospital 1 E-mail access Hospital 2 SSM Physician Portal SSM Connect Lotus Notes access Hospital 3, etc Fax machine * Pager Hand-held PDA Our Mission Exceptional patient, employee, and physician satisfaction Exceptional clinical outcomes Exceptional financial performance Performance Management Process Alignment of Indicators Through our exceptional health care services, we reveal the healing presence of God. Exceptional clinical outcomes Exceptional patient, employee & physician satisfaction Exceptional financial performance Unplanned readmission rate within 31 days of discharge Inpatient loyalty Overall employee satisfaction Overall physician satisfaction Service & quality indicators Inpatient loyalty indicators Employee satisfaction indicators Physician satisfaction indicators Operating margin % Growth indicators Reimburse -ment indicators Productivity/ expense indicators Liquidity indicators Profitability indicators Gathering, Integrating and Presenting Data Performance Indicator Reports (PIR) Data Warehouse Different Source Systems - General Financial (ERP) - Materials Management (ERP) - Human Resources - Clinical Systems - Satisfaction Systems Performance Indicator Report (PIR) Rollup SystemLevel Indicators (SSMHC PIR) Operations PIR Hospital Operations PIR Hospital Operations Performance Indicator Report Operations Performance Indicator Report – System Performance Analysis – System-Level Indicators Year YeartotoDate Date Initiative Initiative Indicators Indicators Actual Actual Performance Performance To To Plan Plan Plan Plan Consolidated Operations Profitability Liquidity Operating Margin % Unrestricted Days Cash on Hand 1.5% 182 2.4% 209 Hospital Operations Growth Reimbursement Producitvity/Cost Profitability Clinical Service & Quality Satisfaction Satisfaction Acute Admissions Patient Revenue Per APD Operating Expense Per APD Operating Margin % 31 Day Acute Readmission Rate Inpatient Loyalty Index Employee Satisfaction Indicator Physician Satisfaction Indicator 137,656 $1,410 $1,402 3.7% 4.5% 49.5% 74.1% 77.6% 136,884 $1,336 $1,321 4.4% 4.2% 52.9% 71.8% 73.6% 1.4% 3.9% -1.9% 5.1% . . 12.0% 56.9% 8.4% 64.0% .. $33,739 68.4% Skilled Nursing Home Profitability Service & Quality Operating Margin % Daily Physical Restraints Prevalence Home Health Profitability Service & Quality Operating Margin % Homecare Patient Loyalty Index . Physician Profitability Productivity Net Revenue Per Physician Practice Direct Operating Cost % > 5% favorable Within 5% of plan $35,074 66.6% > 5% unfavorable Corrective Action Plans Hospitals and networks use them frequently … for virtually every red light that exists on the PIR. Required by policy for certain indicators: Indicator Variance Inpatient loyalty index < 70% of entity goal Operating margin % > 5% unfavorable to YTD Plan 31-day acute readmission rate 160% of entity goal Acute admissions > 5% unfavorable to YTD Plan Employee satisfaction < 60% of entity goal Physician satisfaction < 60% of entity goal Inprocess Measures Category 4: Gather/integrate data to support daily operations/ decision-making Category 6: Inprocess measures used to manage day to day processes? In-process indicators: Measurements that indicate how a process is working. Also called leading indicators. Provide early warning signals to tell us if we are moving towards/away from our goals. Functional Groups’ Inprocess Measures ER – Time from door to treatment or physician time (whichever is earlier) Surgery - % limbs marked: – Correctly – Incorrectly – Not marked Radiology turnaround time Pharmacy- Drug cost/patient day (measured daily) Deploying the Plan Departmental Posters Passport Program Comparative Data Patient-level information Improved clinical outcomes Opportunities National health care database Cost reduction Departmental-level information Clinical Indicators with Statistically Significant Variation Indicator Total Total Denominator Numerator HCO Rate Cases Cases CI Perf Stat Compare Compare Group 1 Group 1 % Significance Compare Variance Comp Grp 1 Group 1 Rate Sign. In 2002 3 quarters HBS900 Overall Mortality Rate 18266 372 2.04% 2.28% (10.63%) S + 0 HBS1512 Live born infants with a birth weight of less than 2500 grams 1340 50 3.73% 5.95% (37.27%) S + 1 HBS1620 MDC 04: Respiratory system medical readmissions within 31 days 999 47 4.70% 7.01% (32.86%) S + 0 HBS504 Patients with indwelling lines or central lines or arterial line with sepsis 414 20 4.83% 1.99% 142.35% S - 2 HBS814 Home Health Referrals For CHF Patients 346 12 3.47% 13.25% (73.83%) S - 2 HBS815 Home Health Referrals For Pneumonia Patients 354 14 3.95% 9.55% (58.58%) S - 1 HBS916 Intrahospital mortality of patients following isolated CABG 356 14 3.93% 2.30% 71.00% S - 0 HBS1400 Post-op CNS complication for all Operating Room cases 4705 27 0.57% 0.28% 101.99% S - 0 HBS1403 Carotid endarterectomy developing post OP CNS complications 137 6 4.38% 1.43% 206.33% S - 0 HBS1619 MDC 01: Nervous system surgical readmissions within 31 days 209 15 7.18% 2.56% 180.13% S - 1 HBS1623 MDC 05: Circulatory System Surgical Readmissions within 31 days 1978 91 4.60% 2.77% 65.90% S - 3 HBS1628 Readmits within 31 days of discharge 18266 2637 14.44% 10.49% 37.66% S - 3 HBS1629 Readmits within 15 days of discharge 18266 1946 10.65% 7.21% 47.78% S - 3 HBS1630 Readmits within 7 days of discharge 18266 1462 8.00% 4.75% 68.34% S - 3 Direct Cost Opportunities by Service Line Lessons Learned Measurement is essential to improvement Don’t compare yourself to just averages - unless you want to be average Attention to inprocess (leading) indicators as well as to outcome (lagging) indicators Alignment of measures and strategic goals is essential Measure what is important