SKMC experience in Selecting Clinical Indicators

8/12/2019 SKMC experience in Selecting Clinical Indicators

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SKMC Experience In Selecting TheClinical Indicators

.

Samer Ellahham,MD,EFQM,FACP,FACC,FCCP

Chief Quality Officer

Senior consultant

February 19, 2013


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Purpose

Quality Improvement and Patient

Safety

Determine how well SKMC

Designs processes

Measures performance

Analysisperformance

Improves on performance

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SKMC Experience In Selecting The Clinical IndicatorsFebruary 19, 2013


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JCIA Requirements

Quality mprovement and Patient Safety

Organization leaders must make the final selection for the clinical and

managerial processes and outcomes based on its mission, patient needs,

and services.

The process, procedure, or outcome to be measured.

how measurement will be accomplished.

how the measures fit into the organizations overall plan for quality

measurement and patient safety.

the frequency of measurement.Required monitor review.

the availability of science or evidence supporting the measure.Pathway/guideline discussion

International library of measures

Data validation

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Quality Improvement and Patient Safety Plan

Framework for planning/designing, measuring,

assessing, and improvement of all care and

services provided.



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2013 Quality Strategic Initiatives (needs to be updated)

SKMC has identified strategies that focus the efforts and energy of the organization on:

Clinical Areas

Managerial/Operational Areas

Governing Body Identified Areas

Clinical Guidelines, Pathways, Protocols

Failure Mode Effects Analysis (FMEA)

Quality Training Curriculum



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Monitoring Process Prioritization

Data are collected that address required measures in support of the hospital mission, vision, values,

clinical priorities, patient safety priorities, managerial priorities and priorities identified by the governing

body.

Monitoring

Process

Prioritization

Patient

Safety

Clinical

Measures

Managerial

Measures

Governing

Measures

MissionVision

Values

1

Red - Green JCIA Dashboard

**

**

**SKMC Experience In Selecting The Clinical Indicators

February 19, 2013


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C. Governing Measure

Patient safety goals

Implementing surgical check

list

Hospital acquired infection

prevention

Hospital acquired pressureulcer prevention

Falls prevention

Sentinel events & adverse

events

Adverse drug events &

medication error

Patient Satisfaction

Admitted Patients That

Would Recommend SKMC

ER Patients That Would

Recommend SKMC

Outpatient Patients That

Would Recommend SKMC

UCC Patients That Would

Recommend SKMC

Clinical starter sets

Heart Attack (AMI)

SCIP Measure: Colon Surgery

SCIP Measure: Vascular

SCIP Measure: Hip and Knee

SCIP Measure: CABG

SCIP Measure: Other cardiac

SCIP Overall (surgeries,

antibiotics, VTE)

SCIP Measure: Cardiac control

glucose

VTE: ICU VTE Prophylaxis

Children's Asthma Care (CAC)

Stroke



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INDICATOR:

Heart Attack (AMI)

* AMI -1: Aspirin at arrival

* AMI-2: Aspirin at discharge

* AMI-3: ACEI or ARB for LVSD

* AMI-4: Smoking cessation counseling

* AMI-5: Beta blocker at discharge

AMI-8a: Primary PCI within 90 min of arrival

AMI-9: Mortality

Governing Clinical Measures (Clinical starter sets)

* JCIA Library of Measures



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INDICATOR:

Heart Failure (HF)

HF-1: Discharge instructions

* HF-2: Evaluation of LVS Function

* HF-3: ACEI or ARB for LVSD

* HF-4: Smoking cessation counseling

Governing Body Approved Clinical Core

Measures

* JCIA Library of Measures



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INDICATORs:

Patient Safety Measures

Hospital Acquired Infection Prevention

Compliance with Hand Hygiene

Central Line-Associated Primary Bloodstream Infection (BSI) Rate

Central Line Bundle Compliance

Surgical Site Infections rate (per 100 surgeries) Class 1

Surgical Site Infections rate (per 100 surgeries) Class 2

CA-UTI per 1000 device days

VAP Rate per 1000 Ventilator Days

VAP Ventilator Bundle Compliance

MRSA Bloodstream Infections per 1000 Patient Days

Governing Body Approved Patient Safety

Measures



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INDICATOR:

Hospital Acquired Pressure Ulcer Prevention

Hospital acquired Pressure Ulcers incidence

Percentage of Patients Receiving Pressure Ulcer preventative care

INDICATOR:

Falls Prevention

Patient falls rate per 1000 pt days

Patient falls with harm rate (per 1000 pt days)

Patients with risk of falls receiving preventative care

INDICATOR:

Implementing Surgical Checklist (WHO)

Comprehensive Surgical Checklist Completed (based on WHO)

Governing Body Approved Patient Safety

Measures



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Monitoring Validation Process

SKMC Quality and The Use of DataFebruary 19, 2013

Quality Measures Review and Validation Process- Quality Management Department

Lead

perform

Approval

Data Quality Team Clinical AuditorsQuality StatisticiansSource

Receive ICD9 Code

Extract the data for the

required KPIs

Data verified by

extracting the same

data using same

methodology

Clinical Auditors

(Physicians, Nurses,

Pharmacists,...)

Quality Clinical Auditor

verifying results

Quality statisticians calculate

the data

Quality Clinical

Auditors checks thecalculated data

Data Published

on iShare

Data re-checked by data

quality team

Confirmed

Not Confirmed

10% for validation from

Quality Monitors

Confirmed

1stQuality

Statistician

2ndQuality

Statistician

Approved

Not Confirmed

Approved

ICD9

coding

completed

by HIMS

Data

Reconciliation

Discussion /

Reconciliation


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Key Measures of Quality

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OutcomeMeasure

Indicates theresult of

performance/non

performance

ProcessMeasure

Focuses onprocess that is

designed to

achieve a certainoutcome

StructureMeasure

Assesses whetherorganizationalresources and

arrangements arein place to deliver

healthcare


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Measure Selection and Data Collection

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QPS.3

QPS.3The organizations leaders identify key measures

in the organizations structures, processes, and

outcomes to be used in the organization-wide quality

improvement and patient safety plan

Cont15


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Note:

oThe clinical areas identified in 1) through 11) of the intent statement

for standards QPS.3 through QPS.3 are included in the organizations

quality measurement plan

oAt least five (5) of the eleven (11) measures required in QPS.3.1 must

be selected from the JCI International Library of Measures. Data

collection, analysis, and use by all organizations will begin in 2011.

Submission of data to JCI for the five (5) measures is voluntary in 2011.

Mandatory submission will begin in 2012 or later.

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QPS.3


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QPS.3.1 The organizations leaders identify key measures for

each of the organizationsclinical structures, processes, and

outcomes

Note: The managerial areas identified in a) through i) of the intent

statement for standards QPS.3. through QPS.3.3 are included in the

organizations quality monitoring. Managerial measures will be added to

the International Library of Measures at a future date.

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QPS.3.1


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QPS.3.2 , QPS.3.3

QPS.3.2 The organizations leaders identify key

measures for each of the organizations managerial

structures, processes and outcomes.

QPS.3.3The organizations leaders identify key

measures for each of the International Patient Safety

Goals.

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Intent of QPS.3- QPS.3.3

Intent of QPS.3 through QPS.3.3

Effective use of data is best accomplished in the

broader context of evidence-based clinical practices and

evidence-based management practices.

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Because most organizations have limited resources,

they cannot collect data to measureeverything they

want. Thus, each organization must choose which

clinical and managerial processes and outcomes are

most important to measurebased on its mission, patient

needs, and services.

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Measurementoften focuses on those processes that

are high risk to patients, provided in high volume, or

are problem prone.

An organizations leaders are responsible for making

the final selection of areas to target measurement

activities and the relatedkey measures to be included in

the organizations qualityactivities

Cont..21




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The measures selected relatedto the important

clinical areas and include

1. patient assessments;

2. laboratory services;

3. radiology and diagnostic imaging services

4. surgical procedures

5. antibiotic and other medication use;

Conti22



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6. medication errors and near misses;

7. anesthesia and sedation use;

8. use of blood and blood products;

9. availability, content, and use of patient records;

10. infection prevention and control, surveillance, and

reporting; and

11. clinical research

Conti23



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The measures selected related to the important

managerial areas include:

a. the procurement of routinely required supplies and

medication essential to meet patient needs

b. reporting of activities as required by law and

regulation

c. risk management

d. utilization management

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e. patient and family expectations and satisfaction

f. staff expectations and satisfaction;

g. patient demographics and clinical diagnoses

h. financial management; and

i. prevention and control of events that jeopardize the

safety of patients, families, and staff

Conti25



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For each of these areas, leaders decide:

the process, procedure, or outcome to be measured;

the availability of science or evidence supporting

the measure;

how measurement will be accomplished;

how the measures fit into the organizations overall

plan for quality measurementand patient safety; and

the frequency of measurement

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Measurable Elements of QPS.3

1.The organizationsleaders identify targeted areas for

measurementand improvement.

2. The measurementis part of the quality improvement

and patient safety program.

3. The results of measurementare communicated to the

oversight mechanism and periodically to the

organizationalleaders and thegovernance structure of

the organization27

QPS.3


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Measurable Elements of QPS.3.1

1.The clinical leaders identify key measures for each clinical

area identified in 1) through 11) in the intent statement.

2. At least five of the eleven required clinical measures are

selected from the JCI InternationalLibrary of Measures.

Conti..

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QPS.3.1


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3. The leaders look at the science or evidence supporting

each of the selected measures.

4. Measurement includes structure, processes, and

outcomes.

5. The scope, method, and frequency are identified for each

measure.

6. Clinical measurementdata are used to and evaluate

the effectiveness of improvements.

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QPS.3.1


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QPS.3.2

Measurable Elements of QPS.3.2

1.The managerial leaders identify key measures for

each managerial area identified in a) through i) in the

intent statement

2. The leaders look at the science or evidence

supporting each of the selected measures.

Conti..30


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QPS.3.2

3. Measurement includes structure, processes, and

outcomes.

4. The scope, method, and frequency are identified for

each measure.

5. Managerial measurementdata are used to and

evaluate the effectiveness of improvements.

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Quality is a Journey,

not a Destination


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Thank you!

Samer Ellahham, MD

971508113142

[email protected]

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SKMC experience in Selecting Clinical Indicators

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