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USING DATA TO ASSESS, PLAN, AND IMPROVE

Increasing Quality and Productivity Within an Organization

Leana Gadbois-Sills

OutcomesResource 2012

Organizational Systems

• Human Resources

• Leadership

• Health & Safety

• Accessibility

• Clinical / Treatment

• Information Management

• Quality Assurance


Leadership

Human Resource

Accessibility

Health & Safety

Clinical/Treatment

Information Management

Quality Assurance


• Leadership

• Financial

• Core Values

• Customer Service

• Performance

• Organizational Structure

• Risk Management

• Strategic Planning

• Grievance & Incident

Reporting Trends


• Human Resources

• Staff Recruitment

• Staff Hiring

• Staff Retention

• Cultural Competency &

Diversity

• Staff Training

• Staff Licensing &

Competency

• Incentive Package

• Performance Reviews


• Health & Safety

• Emergency Disaster Plan

• Security

• Fire Safety

• Infection Control

• Environment of Care

• Hazardous Materials /

Waste Management

• Utilities Management


• Accessibility

• Attitudinal

• Employment

• Environmental

• Financial

• Transportation

• Communication



• Curriculum

• Program Structure

• Philosophy of Treatment

• Staff Competency

• Medication Management Plan

• Compliance with Policies,

Procedures, and Standards

• Rights of Clients



• Technology Plan

• Client and Personnel Records

• Communication Plan

• Performance Management

and Improvement (Outcomes

Data, Incident Report Trends,

Accessibility and Personnel

Data)



• Quality Reviews on Systems

• Assessment and Monitoring

of Elements within Systems

• Corporate Compliance with

Legal and Regulatory Bodies

Elements within the Systems

• Leadership

• Budget: Assess for financial viability by reviewing profit/loss statements

• Billing: Review accuracy of billed amounts vs. client services, as well

as monitor client capacity levels and contracted insurance rates to

ensure desired level of revenue

• Customer Service: Assess the competency and knowledge of persons

answering the phones, greeting clients and community, and caring for

your clients


• Leadership

• Performance: Monitor performance levels (financial, clinical,

administrative, operational) and develop goals and metrics for

assessments and improvements

• Structure: Assess and understand how the organization is structured

and how communication flows to create an effective and productive

workplace

• Strategic Plan: Develop a plan that outlines new goals and objectives

for specific systems to challenge, engage, and motivate the organization

to new levels of proficiency, quality, and care.


• Human Resource

• Hiring Personnel: Assess methods of recruitment, hiring, orientation,

and retention efforts. Analyze rates of turn-over and replacement costs

for personnel

• Diversity: Assess the competency of staff in cultural issues and review

population served compared to the diversity of staff

• Training: Monitor and review personnel training at orientation and

annually. Assess competency of staff by tests, observations, or

performance reviews to determine skill level and performance

• Personnel Satisfaction: Inquire and analyze staff satisfaction with all

levels of the organization and systems to determine trends for potential

improvement initiatives


• Health & Safety

• Emergency Evacuation Plan: Test and assess the effectiveness of

emergency drills and plans utilizing measurable goals

• Fire Safety: Monitor and document all fire equipment status and staff

knowledge on using equipment

• Infection Control: Record all reported illnesses and analyze for trends

and ways for decreasing reported trends or increasing prevention efforts

• Environment: Monitor the environment for safety and security,

analyzing the potential risks to the staff, clients and community

• Emergency Protocols: Review systems in place for medical and

psychiatric emergencies, including initial assessments, monitoring of

clients’ behaviors, and procedures that involve staff and emergency

teams


• Accessibility

• Attitudinal: Review and assess the client feedback from surveys on

staff attitudes

• Employment: Monitor trends for hiring and/or staff turnover rates.

Assess the population served and diversity and cultural competency

among staff members

• Environmental: Assess safety, security and accessibility factors within

the buildings, grounds, and operations on consistent basis


• Accessibility

• Financial: Monitor non-admits due to financial issues and trends for

non-payment of fees from clients and/or payer sources

• Transportation: Assess locations of program and types of

transportation available for population served

• Communication: Review types of communication available and styles

of staff communication to persons served – assess efficacy and

efficiency



• Curriculum: Measure efficacy by client competency tests and program

follow up outcome rates

• Program Structure: Assess the program content and schedule for

maximum quality and outcomes

• Philosophy of Treatment: Promote and monitor staff’s knowledge and

implementation of the organization’s philosophy on treatment and

services



• Staff Competency: Assess competency as it relates to the staff’s

specific job duties annually

• Medication Management Plan: Assess and monitor the quality of

medication management and adherence to medication standards

• Rights of Clients: Review procedures and practices for maintaining the

level of care and services that respects all clients’ rights

• Client Treatment Management: Assess individualization and

monitoring of client’s treatment protocol during treatment



• Technology Plan: Assess and analysis functionality and efficiency of

the organization’s existing technology ,and develop strategies for future

technological needs

• Client and Personnel Records: Review existing protocols for storing,

safety, security, sharing, and destroying records to ensure all required

standards and laws are integrated and implemented within the

organization’s policies and procedures

• Communication Plan: Review and assess lines of communication to

the public, population served, and staff to ensure highest level of

effective marketing, communication, and outcomes.

• Performance Management and Improvement: Gather and analyze

outcomes data, incident reports, accessibility, health and safety, and

satisfaction ratings to determine level of performance, goals for desired

performance, and plans for improvements



• Quality Reviews: Assess all existing systems for compliance to

organization’s policies and procedures, best practices, and quality of

care

• Assessment and Monitoring of Elements within Systems: Review

and analyze level of functioning and desired levels of functioning in

order to establish realistic, achievable goals for systems

• Corporate Compliance: Assess and monitor compliance among all

levels of the organization from the board to direct care staff – establish

highest level of ethics and corporate compliance standards appropriate

for the organization based on governance, size, and structure

Tools for Assessment / Implementation

Assessing Tools

• Annual Analysis Review

• Risk Analysis and Performance Improvement Worksheet

• Quality Assurance Checklist or Review Form

• Checklists

• Client Questionnaires on Current Symptoms, Psychological Status, and

Level of Functioning


Measuring Tools

• Metrics (Capacity, Census, Length of Stay, Completion Rate,

Satisfaction)

• Data Sources (Discharge Summary, Surveys, Client Attendance, Call

logs, QA reports)

• Surveys / Questionnaires (Client, Personnel, and Referent)


Implementation Tools

• Strategic Plans

• Policies and Procedures

• Forms

• Performance Improvement Plans

• Clinical Treatment Plans


RISK ANALYSIS AND PERFORMANCE IMPROVEMENT WORKSHEET

Assess the level of risk and/or need for improvement in each area of your organization and

document the goal and objective(s), time frame, and outcome based on data analysis. In each

area, examples are given. The element or system listed may be used or replaced according to the

needs of your organization.


SYSTEM /

ELEMENT

RISK RATING

(High,

Moderate,

Low)

DESIRED

IMPROVEMENT

GOAL / BENEFIT

(Measurable)

WITH

OBJECTIVES OR

PROCESSES

THAT WILL BE

IMPLEMENTED

AND TESTED

ASSIGNED

STAFF

DATE

FIRST

ASSESSMENT

(Data Analyzed)

DATE

FINAL

ASSESSMENT

(Data Analyzed)

OUTCOME

(Achievement

of Goal or

Schedule for Re-

Assessment)

Staff Retention High

Moderate

Low

Goal:

Objective(s):

Date: Date: Achieved Goal

Analysis:

Goal not

Achieved -

Resubmit for re-

assessment

Human Resources


SYSTEM /

ELEMENT

RISK RATING

(High,

Moderate,

Low)

DESIRED

IMPROVEMENT

GOAL / BENEFIT

(Measurable)

WITH

OBJECTIVES OR

PROCESSES

THAT WILL BE

IMPLEMENTED

AND TESTED

ASSIGNED

STAFF

DATE

FIRST

ASSESSMENT

(Data Analyzed)

DATE

FINAL

ASSESSMENT

(Data Analyzed)

OUTCOME

(Achievement

of Goal or

Schedule for Re-

Assessment)

Staff

Training

(Competency

Based)

High

Moderate

Low

Goal:

Objective(s):


Analysis:

Goal not

Achieved -

Resubmit for re-

assessment

Human Resources


SYSTEM /

ELEMENT

RISK RATING

(High,

Moderate,

Low)

DESIRED

IMPROVEMENT

GOAL / BENEFIT

(Measurable)

WITH

OBJECTIVES OR

PROCESSES

THAT WILL BE

IMPLEMENTED

AND TESTED

ASSIGNED

STAFF

DATE

FIRST

ASSESSMENT

(Data Analyzed)

DATE

FINAL

ASSESSMENT

(Data Analyzed)

OUTCOME

(Achievement

of Goal or

Schedule for Re-

Assessment)

Financial High

Moderate

Low

Goal:

Objective(s):


Analysis:

Goal not

Achieved -

Resubmit for re-

assessment

Leadership


SYSTEM /

ELEMENT

RISK RATING

(High,

Moderate,

Low)

DESIRED

IMPROVEMENT

GOAL / BENEFIT

(Measurable)

WITH

OBJECTIVES OR

PROCESSES

THAT WILL BE

IMPLEMENTED

AND TESTED

ASSIGNED

STAFF

DATE

FIRST

ASSESSMENT

(Data Analyzed)

DATE

FINAL

ASSESSMENT

(Data Analyzed)

OUTCOME

(Achievement

of Goal or

Schedule for Re-

Assessment)

Customer

Service

High

Moderate

Low

Goal:

Objective(s):


Analysis:

Goal not

Achieved -

Resubmit for re-

assessment

Leadership


SYSTEM /

ELEMENT

RISK RATING

(High,

Moderate,

Low)

DESIRED

IMPROVEMENT

GOAL / BENEFIT

(Measurable)

WITH

OBJECTIVES OR

PROCESSES

THAT WILL BE

IMPLEMENTED

AND TESTED

ASSIGNED

STAFF

DATE

FIRST

ASSESSMENT

(Data Analyzed)

DATE

FINAL

ASSESSMENT

(Data Analyzed)

OUTCOME

(Achievement

of Goal or

Schedule for Re-

Assessment)

Curriculum High

Moderate

Low

Goal:

Objective(s):


Analysis:

Goal not

Achieved -

Resubmit for re-

assessment

Clinical / Treatment


SYSTEM /

ELEMENT

RISK RATING

(High,

Moderate,

Low)

DESIRED

IMPROVEMENT

GOAL / BENEFIT

(Measurable)

WITH

OBJECTIVES OR

PROCESSES

THAT WILL BE

IMPLEMENTED

AND TESTED

ASSIGNED

STAFF

DATE

FIRST

ASSESSMENT

(Data Analyzed)

DATE

FINAL

ASSESSMENT

(Data Analyzed)

OUTCOME

(Achievement

of Goal or

Schedule for Re-

Assessment)

Staff

Competency

High

Moderate

Low

Goal:

Objective(s):


Analysis:

Goal not

Achieved -

Resubmit for re-

assessment

Clinical / Treatment


Assessment Tool(s) Person Served Personnel Stakeholder

Questionnaire/Survey

Personal Interview

Incident/Office Report

Inspection

Evaluation

ACCESSIBILITY ASSESSMENT

ATTITUDINAL BARRIERS

ASSESSMENT:

ACTION PLAN TO REDUCE BARRIERS:


Assessment Tool(s) Person Served Personnel Stakeholder

Questionnaire/Survey

Personal Interview

Incident/Office Report

Inspection

Evaluation

ACCESSIBILITY ASSESSMENT

EMPLOYMENT BARRIERS

ASSESSMENT:

ACTION PLAN TO REDUCE BARRIERS:


ANNUAL ANALYSIS REVIEW

Documents No Change Revision Elimination Other Policies & Procedures

Forms

Outcomes System

Health, Security & Safety

Infection Control Plan - Analyze Trends in Risks in Population

- Analyze/re-assess TB trends in staff

Staff Development and Training

Insurance Policy Package

Risk Analysis

Technology & Systems

Human Resource Reports

Incident Reports Trends

Tools for Assessment / Implementation ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS

PART 1 - PROGRAM ANALYSIS

1. Capacity:

___Goals not met ___Goals met or exceeded

Action Plan:

Completion Date:

2. Quality (Treatment):

___Goals not met ___Goals met or exceeded

Action plan:

Completion Date:

Tools for Assessment / Implementation ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS

PART II – PERFORMANCE ANALYSIS

Phone System(s) ____ Adequate ____ Inadequate

Recommendations:

Computers ____ Adequate ____ Inadequate

Recommendations:

Fax / Copiers ____ Adequate ____ Inadequate

Recommendations:

Internet/DSL ____ Adequate ____ Inadequate

Recommendations:

Web Site ____ Adequate ____ Inadequate

Recommendations:


ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS

PART III - RISK ANALYSIS

INFECTION CONTROL

Identification of Risk Evaluation of Risk Inventory of operating

systems

Analysis of Current

Risk

Bloodborne Pathogens

Infectious Diseases

Common Viruses


ANNUAL OUTCOMES PERFORMANCE AND RISK ANALYSIS

PART III. ANNUAL RISK ANALYSIS

SUPPORT OF THE ENVIRONMENT

Identification of Risk Evaluation of Risk Inventory of operating

systems

Analysis of current risk

HVAC

Septic

Water Well

Electrical

Gas

Fire Alarm System

Analysis and Improvement

Planning for Improvement:

• Select two or three elements that are high risk or priority

• Engage diverse group of staff to plan for improvement

• Develop goals and objectives for each improvement

• Assign tasks to staff for implementing change

• Measure effects of change

• Monitor for trends and outcome results

• Document process and result of improvement


Analyze, Report, Follow-Up:

• Analyze data on an ongoing basis

• Establish goals with each metric

• Communicate reports to all levels of staff

• Set accountability for low performance levels

• Develop creative methods to motivate and engage staff

• Base action plans on performance levels and company goals


Performance Improvements:

• When efforts for improvement show increased outcomes

• When outcome metrics improve within time frame established

• When organizational goals are achieved

• When systems are consistent, effective and efficient

• When staff is engaged and motivated

• When clients are engaged and showing progress in treatment

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