Post on 19-Jun-2015
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BUILDING AND MONITORING INDICATORS
DR MOHAMED ELFAIOMY
You can’t manage or
improve
what you can’t measure
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“a variable, which purpose it is to measure
change in a phenomenon or process”
Indicator
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FOUR SYSTEMATIC STEPS
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STEP 1: IDENTIFY
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IDENTIFY
WE have to choose the most relevant indicators
according to our :
Scope of service
Complaint
Problem prone
Budget
High risk areas
KPIs
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Structure indicators:
•Supplies
•Man power
•Medications
•………
Process indicators:
•Medical record completion
•Site marking policy compliance
•Hand hygiene compliance
Outcome indicators
•Mortality rate •Patients
satisfaction rate
•……
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STEP 2: DESCRIBE
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STEP 2: DESCRIBTION
We use what we call: Indicator Information Set
It describes what data will be collected:
Name of indicator
Indicator definition
Data elements
Who will collect the data
When?
To whom data will be reported
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INDICATOR
INFORMATION
SET
No.
1 Title :
2 Domain:
3 Definition of the Indicator:
4 Rationale:
5 Type of measure: □ Structure □ Process □ Outcome □ Process & Outcome
6 Numerator Definition:
7 Denominator Definition:
8 Include Population:
9 Excluded Population:
10 Data Source (s)
11 Sampling method and size:
12 Reporting frequency:
13 Performance target and Benchmark value ( if available) and source (local or international:
14 Department or committee responsible:
15 Person/s Responsible for collecting data:
16 Dimension of Quality:
17 List of departments, services, committees, or individuals who should receive reports:
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KINGDOM OF SAUDI ARABIA General Administration for Primary Healthcare Centers
Quality indicator
/ 3
Percentage of the availability of essential supplies and equipment in the dental room / 3 months
Indicator's definition
, ( 3 )
The indicator determines Percentage of availability of the essential supplies and
equipment in the dental room in the health center, as there will be periodic checking (every 3 months) on the availability of the essential supplies and
equipment.
Indicator's type
Structure indicator
How to measure the indicator
Responsible person for measuring
Dental assistant
Frequency
3
Every 3 Months
Source of data collection
Essential supplies and equipment list registry in the dental room
How to collect data
. At the end of every 3 Hijri months, The dental assistant will calculate the
number of the available essential supplies and equipment in the dental room in
the center to the number of them in the dental supplies and equipment list.
Formula
No. of the available essential supplies& equipment in the dental room
No. of the essential supplies & equipment in the dental manual
The Target 100 %
Responsible Committee or person
-
Utility utilization committee - Quality Coordinator
To whom reporting
-
Utility utilization committee chairman - Quality Coordinator
References
1424
Approved essential supplies and equipment list in emergency services manual.
Primary Health Care manual 1424 H.
Standards of the central board of accreditation for health institutions.
×100
100×
STEP 3: COLLECT
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variable operational
defenition
data
source
data collection
method
who will
collect
data
when data
will be
collected
waiting time
in file room
it starts since the parent
ask for his child's medical
record till the file reaches
the well baby room
waiting time
data
collection
sheet
the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he takes
the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
waiting time in
well baby room
it starts since the file reach
the room till the child name is
called in well baby room
waiting time
data collection
sheet
the medical record clerck register
the time when the parent ask for
the file and record it in the
collection sheet the
vaccination nurse record the time
when the child enters the room
and before he takes the
vaccination the
nurse supervisor collect the data
from data collection sheet
nurse
supervisor
between 21
march and 28
march
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No. Chart No. Time of Request Time of vaccination D, E, B
Title: Waiting time for vaccination room
indicator definition: Waiting time for vaccination from ordering the file till entering vaccination room
sample size: sample methodology: Target: Month: Responsible person: nurse supervisor Data Source: E: Nominator, D: Dominator, B: Exclusion
Data collection sheet
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STEP 4: ANALYSIS
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AVERAGING:
MEASURING CENTRAL TENDENCY
Arithmetic mean ( M ) The "average" or "mean".
Mode (Mo.)
Median (Mdn.)
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GROUP ACTIVITY
Find mean , mode and median : 2, 3, 3, 5, 7, and 10
Mean: sum them then divided by their NO.
30/ 6= 5
Median which is the middle number of a group of numbers
(3+5) / 2= 4
Mode which is the most frequently occurring number in a group
=3
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GRAPHS
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.بسيطاً و واضحاً الرسم البياني المؤثر يجب أن يكون • . ح ً ب •
.للرسم البياني رقم مسلسليجب أن يعطى • .عنوان وصفي مكتمليجب أن يكون له •
.الوحدات المستخدمةمع توضيح عنونة محاورهيجب •لنوع المناسبيجب أن يتم اختيار الرسم البياني •
.البيانات المعروضة
الرسوم البيانية
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بعض أنواع الرسوم البيانية الشائعة
• Bar Chart الرسم البياني باألعمدة Histogramالرسم البياني التصويري • Line Graphالرسم البياني الخطي • Pie Chartالرسم البياني الدائري •
Scatter Diagramالرسم البياني للتشتت • pictogramالرسم البياني بالصور •
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الرسم البياني باألعمدة
0
10
20
30
40
50
60
70
80
90
1422 1423 1424 1425
مالريا
ليشمانيا
بلهارسيا
أل ض ط ط ( 2) ط ط
(1425 – 1422)خ م ( )
ض ح
ص
م ض
ظ ه ز
م
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Pareto Chart
33.94
50.68
66.52
79.19 84.62
89.59 94.57 96.38 98.19 99.10 100.00
0.00
20.00
40.00
60.00
80.00
100.00
120.00
0
10
20
30
40
50
60
70
80
conc dose dur h wr diagn form sign code g name freq stamp
يوضح أنواع األخطاء في ( 1)مخطط رقم وصفات أطباء مركز صحي أم سرار خالل
1431شهر جماد ثاني عام
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الرسم البياني بالدوائر المجزأة
تخط ط قم )6( ضح نس ض عف ت
س ي ل ضى سجل خالل 1427
55%
19%
15%
6%
3%
2%
العيون
الكلوية
األقدام
القلب
غيبوبة
أخرى
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الرسم البياني الخطي
تخط ط قم )5( ق الت ج ي ي
خ خالل ع ي 1426 1427
0
5
10
15
20
123456789101112
ه ال
تال ع
1426
1427
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Run Chart
يستخدم لتوضيح األداء على مدى زمني
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“You can’t improve what you can’t measure.”
F IND AN OPPORTUNITY
O RGANIZE A TEAM
C LARIFY THE PROCESS
U NDERSTAND THE
PROBLEM
S ELECT A DESIRED
OUTCOME
The FOCUS PDCA Methodology
1. Plan Identify
problem and
develop plan
for
improvement.
2. Do Implement
plan on a test
basis.
3. Study/Check Assess plan; is it
working?
4. Act Institutionalize
improvement;
continue cycle.
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