Information Management

Chapter 5

INFORMATION MANAGEMENT PROCESS

• Identify Current Available Data Sources

• Identify Critical Information Needs

• Define Data Elements

• Determine Data Collection Plan

• Acquire/Collect Data

• Aggregate & Display Data

2

INFORMATION MANAGEMENT PROCESS

• Analyze Data

• Interpret Data / Information

• Act on Information

• Report Data/Information/Knowledge/ Decision

• Collect More Data to Monitor/Analyze the Decision.

3

INFORMATION

RESOURCES• Access

o Authority, security, etc.

• Availability

o In the form/format needed

• Timeliness o How close to real time is data collected

and/downloaded

• Internal/External

4

DATA INVENTORY

PROCESS• Where data is collected in organization

• Collection Stepso What being collected, from where

• Analysis Steps

• Reason for Collecting this Datao Being used?o Duplicate Information?

5

Electronic Medical Record /

Information Technology• Institute of Medicine (IOM) started the

movement in Aug 2003

• Four Goalso Inform clinical practiceo Interconnect cliniciansoPersonalize careo Improve population health

6

Other IT Topics

• Impact of Health Information Management on Quality

o ICD-10oCodingoMeaningful use

7

CONFIDENTIALITY IN HEALTHCARE

• Confidential information – information that one keeps or entrusts to another with the understanding it will be kept private and not shared

• Protected/Privileged Information – information that can not be obtained by others or used in a court of law

8

CONFIDENTIALITY IN HEALTHCARE

• HIPAA• Access

o Without Written Authorization of Patiento With Written Authorization of Patient

• Security

o Sequestered records

• Consent - Release of Medical Information

9

Committee Meeting Organization• Meeting

• Minutes

• Reminders

• Meeting Date• Agenda• Packet

10

Epidemiological Contributions to

QM

• Definition – The study of populations

• Specifying good practice• Specifying good system design• Developing measurement tools• Developing and conducting measurement

and assessment ( monitoring)

11

Epidemiological Concepts & Methods

• Concepts and Methods

- Causality- Cause & Effect

- Frequency- Rate- Proportion- Ratio

12

Epidemiological Concepts and Methods

• Morbidity – rate of disease or proportion of diseased persons in a given location

I Incidence – rate during specific time period

I Prevalence – proportion in a defined population at one point in time

• Mortality – proportion of deaths in a population within a time range

13

Data Definition And Collection

• Sensitivity – inclusion of all appropriate items or descriptors

• Specificity – differentiate between included & excluded items• How specific/exclusive do you want the

measure to be?

• Usability – ease of use of tool or indicator

understood• Recordability – ability to identify, capture &

measure needed information

• Stratification – breaking data down into groups

14

Data Definition And Collection

• Reliability o Ability to reproduce the same resultso Test / Retest o Inter-rater Reliability

• Validityo Measure what you are supposed to

measureo Face Validityo Criterion Validityo Construct Validity

15

Defining a Population

• Entire population – 100%

• Sampling o Nonprobabilityo Probability

16

Nonprobability Sampling

• ConvenienceoUsing data readily available

• Quotao Set number of data sets

• PurposiveoDemonstrate a desired characteristico Expert samplingoMen vs Women

17

Probability Sampling

• Simple Randomo All items have an equal chance of being

chosen

• Stratified Randomo Creating 2 or more homogeneous groups

and then randomly selecting itemso Men vs Women

• Systemic Randomo Every n’th case

18

Types of Data

• Categorical (Attribute, Qualitative) (Descriptions of qualities or kind)oNominaloOrdinal

• Continuous (Variable, Quantitative)(Specific measurement units)o Interval

19

20Type Categorical / Count Continuous / Measured

AKA AttributeDiscreteNominalOrdinalQualitative

VariableQuantitativeIntervalRatio

Examples # Members, Patients, Births, Procedures, Occurrences, Gender

Age, Height, Weight, Temperature, Time, Charges (money), LOS

Usually Reported as % in each category(whole numbers)

MeanMedianMinimum MaximumPercentiles(whole and fractional units)

Usual statistical test of difference between 2 groups

Chi Square T test

Usual display tools TableScorecardHistogramPareto

Run chartControl chartScorecard (not the best to use)(data display over time = use one of these tools – but only 1 item per line on graph)

See Section V page 51 for a similar comparison table

Tools & Statistics

• What it is• When to use it• What does it say?

21

Simple Statistics

(Central Tendency)• Mean – average

• Median – middle

• Mode – most frequently occurring

• Range (Dispersion)– lowest to highest

22

• 2 4 6 8 10 Mean: Median:

• 2 4 6 8 100 Mean: Median:

• 2 4 6 7 8 10 Mean: Median:

• 2 4 6 6 8 10 Mode:

• 2 4 4 6 6 8 10 Mode:

• 2 4 4 6 6 6 8 8 10 Mode:

• 2 4 6 8 10 Range:

• 102 104 106 108 110 Range:

• 0, 0, 0, 0, 0, 0, 2, 8, 12• Mean = Median =• Mode = Range =

• 392, 625, 17, 495, 89, 234, 106, 322, 982

Weighted Means

• A mean where some values contribute more than others.

• Weighted means can help with decisions where some things are more important than others

• Use a table to make sure you have all the numbers correct

25

Weighted Means26

Score Weight Multiply

65 1 65

60 1 60

80 2 160

95 3 285

Total 7 570

Final Total 81.43 (570 divided by 7)

Other Math You May Need

• Percentage of the whole:oWhat percent of the patients have

complications?o Total patients = 100oNumber of patients with comp. = 45

X% of 100 = 45

X% = 45 / 100 X = .45 or 45%

27

Other Math You May Need

• Percentage of the whole:o If 55% of the patients have

complications, how many patients would that be?

o Total patients = 100

55% of 100 = X

0.55 x 100 = X55 = X

28

Standard Deviation29

STANDARD DEVIATION30

C BD AF

**

**

• Data must be displayed in the proper manneroMust be concise and easily understood

by the reader

• Analysis could include use of statistics, simple or complex

Data Analysis Tools31

Data Comparison Between 2

Groups• Chi Square (X2)

o Use with Count data

• T-Test (t)o Use with Continuous data

• Both give you a “p score”

• 0.05 or less indicates statistically significantly different – NOT BY CHANCE

32

10 0.500.250.05

Scatter Diagrams Looking for the relationship of two variables

Positive Relationship Negative Relationship No Relationship

33

See V 64 for more information on Scatter Diagrams

Positive Correlation

0

20

40

60

80

100

120

0 1 2 3 4 5

34

Negative Correlation

0

20

40

60

80

100

120

0 1 2 3 4 5

35

No Relationship or Correlation

01020304050

60708090

100

0 1 2 3 4 5

36

37

Calories vs Weight Gain

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

0 500 1000 1500 2000 2500 3000 3500 4000 4500

Calories Consumed

Weight gained

y=mx+b

n=13

Regression Analysis• Mathematical version of a Scatter Diagram• Compare the distribution of two dispersions• Correlation Coefficient (r)

Strong No StrongNegative Relationship PositiveRelationship Relationship

38

0- 1 + 1

(One up & One down)

(Both up or both down)

• Most common tool but not always the best one

• Highlight the important information

• Clearly label the different parts/columns

• Stop Light approach

Nov Dec

General Consent 0 0

Entries Dated 100 90

Entries Signed 100 90

Entries Timed 0 55

Author Identified 100 95Abbrev. Used Correctly 60 70

Legible writing 40 59

2 Patient Identifiers 100 90

Data Analysis Tools - Tables

39

Measure Description Nov Dec Year End

General 0.0% 0.80% 0.40%

Consent Informed NA NAResearch NA NA

Threshold 100%

Risk, Benefits, Anesthesia NA NA

Alternative Surgery NA NAThreshold 100%

Health History Significant 0.0% 13.3%Summary Diagnoses

Health history 0.0% 37.5%

Drug Allergies 0.0% 3.3%

Current 0.0%

Medication 10.8%

Past Surgical 0.0% 3.3%

Procedures

Past 0.0% 3.3%

Hospitilazation

Threshold 85%

Screening 40.0% 87.50%

Reason for visit 20.0% 85.0%

Nursing Pain 40.0% 49.1%

Assessment Nutritional 20.0% 76.6%

Social/Econ 20.0% 79.1%

Falls Risk 0.0% 61.6%

Allergies 20.0% 65.8%

Abuse 0.0% 54.1%

Reassessment 0.0% 53.3%Threshold 85%

Med. Assess. 100.0% 86.6%

Physical 80.0% 72.5%

Medical System review 0.0% 15.0%

Assessment Findings 80.0% 75.8%

Diagnostics 100.0% 45.0%

Plan 0.0% 75.8%

Reassessment 20.0% 40.8%Threshold 85%

Open Record OPD MONTHLY RATE-BASED INDICATOR AGGREGATE DATA 2012

Red < 70

Yellow>70 but

< 85

Green >85

SCORECARD

EXAMPLE

Medical Record Review

40

Histogram / Bar Chart

• Often confused with each other• Histogram = one stratified variable• Bar Chart = Discrete categories

41

HISTOGRAM

100

80

60

40

20

0-16 17-30 31-50 51-65 >65

BAR CHART

100

80

60

40

20

CHF COPD MI Pneum

• Illustrates the variability or distribution of the data

• Use with Count data unless over time

• Then move to Run Chart

Data Analysis Tools – Histogram/Bar Charts

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

EastWestNorth

42

Gener

al C

onse

nt

Entrie

s Dat

ed

Entrie

s Sig

ned

Entrie

s Tim

ed

Autho

r Ide

ntifi

ed

Abbre

v. U

sed Cor

rectly

Legib

le w

ritin

g

2 Pat

ient

Iden

tifer

s0

20

40

60

80

100

120

OPD Open Record Audit Nov - Dec 2012

NovDec

43

• Prioritizes a series of data sets or possible causes of problems

• Best if you use more than one

Data Analysis Tools – Pareto Diagram

0

2

4

6

8

10

12

14

16

Brown Yellow Green Red Blue Orange

44

45

Pareto Diagram

0

5

1015

20

25

3035

40

45

50

Brown Yellow Green Red Blue Orange

100%

50%

25%

75%

Total Number

Available

Percent of the Whole

46

Pareto Diagram

1512 10

73 3

0

5

1015

20

25

3035

40

45

50

Brown Yellow Green Red Blue Orange

100%

50%

25%

75%

x

xx

x x

47

Pareto Diagram

1512 10

73 3

0

5

1015

20

25

3035

40

45

50

Brown Yellow Green Red Blue Orange

100%

50%

25%

75%

x

xx

x x

80%

Pareto ChartPatient Transfer – In To XXX Hospital

23.8

47.6

71.485.7

100.0

0

20

40

60

80

100

0

2

4

6

8

10

No communicationwith referring

Hospital

No eforcement of"contac t

precaution"to allstaff

New machine forMRSA screeningresult within 2hr

(current result 48hrs)

All transfer-inpatients are not

treated as"sc reened and

c leared"

MRSA screeningshould be initiated

in Acc ident &Emergency.

Perc

enta

ge

Num

ber of V

ote

Main Concerns

48

• Can use pareto charts to drill down to find a specific area to make improvements

• For example: Patients requiring greater then 1 hour in Recovery Room

Drill Down with Paretos49

Aug Sept Oct Nov0

5

10

15

20

25

Percent of Patients requir-ing > 1 hour in Recovery

Room

Clinical Non-clinical0

50

100

150

200

250

Reason for Prolong Re-covery Time

50

Pain

Hypot

herm

ia

Cardi

o

Resp

Rate

LOC

Mot

or

Bleed

ing

0

10

20

30

40

50

60

70

80

Pareto - Clinical Delay in Recovery Time

Unit RN MD Assess Porter File Bed CCU/ICU

05

1015202530354045

Pareto - Non-Clinical Delay in Recovery Time

51

Not reassessed Pt not medicated Med did not work Pt not assessed Pt not complain0

5

10

15

20

25

30

Pain Delay in Recovery52

• Monitors variation in data/

• processes over time

• Use with continuous /measured data

Data Analysis Tools – Run Chart

0

10

20

30

40

50

60

70

80

ADC

53

• Breaks down single variables into its meaningful parts

• Helps to focus on where the problem really lies

Data Analysis Tools - Stratification

0

10

20

30

40

50

60

Jan Feb Mar Apr May Jun

Total FallsMed UnitSurg Unit

54

Average Daily Census

If one wanted to see the Average Daily Census Over the Year, a Run chart will show this better than a Histogram

55

What type of data is this?

Average Daily Census

0

10

20

30

40

50

60

70

80

Jan

FebM

ar AprM

ay Jun

July

AugSep O

ctNov Dec

ADC

56

Number of CHF Patients vs AMI

Patients for 1st Half of Year

Have Categories of patients:

1. CHF

2. AMI

This is Nominal Data since there is no real order here

Could use a Histogram to show this

57

Number of CHF Patients vs AMI Patients for 1st Half of

Year

0

10

20

30

40

50

60

Jan Feb Mar Apr May Jun

CHFAMI

58

Number of CHF Patients vs AMI Patients for 1st Half of

Year

0

10

20

30

40

50

60

Jan Feb Mar Apr May Jun

CHFAMI

59

Events Reported (Patients with unknown status – considered negative who had positive screening at XXX)

0

1

2

Jan Feb Mar Apr May Jun Jul Aug Sept Oct

Repo

rted

Eve

nt

2012

Total Number of Reported Events per Month

# of Events Target

60

Prevention & Control of Infection Program61

• Statistically illustrates the upper & lower control limits of a process & the variation of the process within those limits

Data Analysis Tools – Control Chart

R Chart Title

RUCL=0.395

CL=0.187

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

6/88am

10am 12pm 2pm 6/98am

10am 12pm 2pm 6/108am

10am 12pm 2pm 6/118am

10am 12pm 2pm 6/128am

10am 12pm

Date/Time/Period/Number

RangeUCL+2 sigma+1 sigmaAverage-1 sigma-2 sigmaLCL

n=19

62

Control Charts

63

As easy as: Run charts with the Bell Curve

turned on its side

Control Charts64

0102030405060708090

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

PROCESS VARIATION

• Variation – change or deviation in form, condition, appearance, extent, etc. from former or usual state, or from an assumed standard

• Clinical Variation – can be

positive or negative

65

PROCESS VARIATION

• Random/Common Cause - Intrinsic to the Process Itself

Common Cause Variation What you would expect to happen with

random variation Do not try to improve the process unless the

mean is not where it needs to be

66

Special Cause - Extrinsic to the Usual Process; Related to Identifiable Characteristics. Example - Sentinel Events

Special Cause Variation What you would not expect to happen If a pattern or trend exists Need to investigate and make changes

Good = try to get it to repeat Bad = try to eliminate it from happening again

67

Based on Variation

And Spread of Data

Special Cause / Trend Rules

• Run charts & Control charts both use Trend/Special Cause rules

• Basically theses show trends, shifts, & other changes in the data

• Run & Control chart rules are basically the same but with difference in the number of data points

• Control Charts are more precise in identifying special cause variation

68

Outside the Upper and Lower Control limits on a Control chart or an outrageous value compared to the other

ones on a Run chart (Astronomical Value)

Six or Seven consecutive points going up or going down (Trend)

Seven or Eight consecutive points above or below the mean (Shift)

69

Special Cause Rules -Use with both run chart & control

chart

• Any dot that is outside of the upper or lower control limit (or in a run chart an astronomical value)

• Control limits are mathematically calculated based on the mean of the data

Special Cause Rules - Outside

limit (Astronomical Value)

70

• Seven or Eight dots in a row either above or below the mean

• If a dot in the run lands on the mean, it is skipped & not counted

Special Cause Rule – 7 or 8 in a

row (Shift)

71

Shift – Dot on Mean72

• Six or Seven dots in a row going up or gong down

• If two dots are side by side in a run of data, one of those is not counted

Special Cause Rule – 6 or 7 in a

row

73

Trend – Dot Next To Each Other74

75

R Chart Title

RUCL=0.395

CL=0.187

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

6/88am

10am 12pm 2pm 6/98am

10am 12pm 2pm 6/108am

10am 12pm 2pm 6/118am

10am 12pm 2pm 6/128am

10am 12pm

Date/Time/Period/Number

RangeUCL+2 sigma+1 sigmaAverage-1 sigma-2 sigmaLCL

n=19

76

Catheter-Related BLOOD-STREAM INFECTION(CRBSI) NICU

1 case CRBSI identified

77

HEALTHCARE-ASSOCIATED INFECTION RATE

ADULT ICU

11.02

14.23

3.73

33.22

24.65

21.98

13.96

7.87

22.06

13.98

18.94

22.39

17.9

11.49.7

7.7 7.7

10.9

19.9

17.7

11.7 9.55 9.71

0

5

10

15

20

25

30

35

Ra

te /

10

00

ICU

P

AT

IEN

T D

AY

S

KFMMC-AICU- 2011 KFMMC -AICU-2012 CDC median Rate 23.9 kfmmc 2011 median rate (18.8)

1 case developed CRUTI ,AND 2 RTA cases developed VAP, with the same organism isolated from the tracheal aspirate(A.baumanii MDR) IC Practitioner focused on Environmental screening & audit on hand hygiene practices.

79

HEALTHCARE-ASSOCIATED INFECTION

HOSPITAL WIDE RATE

5.11

2.25

3.4

2.18

4.2

2.14

3.55

2.85

3.063.012.983.14

2.1

3

2.472.05

2.462.9

3.22.7

2.7 2.5 2.2

6.7

0

1

2

3

4

5

6

7

8

JANFEB

MARAPR

MAYJUN

JULAUG

SEPOCT

NOVDEC

Ra

te /

10

00

HO

SP

ITA

L D

AY

S

2011 KFMMC 2012 KFMMC CDC ( up to 6.7 )

19 infections with 30 organisms

79

• A method of analyzing the data utilizing diagrams of a healthcare process

• Measure process variations & look for ways to improve the process & the administrative or clinical outcome

• Tools include a cause & effect diagram, flowchart, process mapping, tree diagram, interrelationship diagrams, affinity diagram, and many other such tools

• Frequently used in RCA and FMEAs

Process Analysis Tools80

• Purpose

• Steps

81

CAUSE AND EFFECT DIAGRAM

(Ishikawa)

82

Cause & Effect Diagram

Effect

Cause

Cause & Effect Diagram

5 P’so Peopleo Provisions

(supplies)o Policieso Procedureso Place

(environment)

83

4 or 5 M’soManpoweroMaterialsoMachinesoMethodsoManagement

84

Why Bed Assignment Cannot be Made in <

30 minutes

Physical Environment

People

Process Patients

Transportation

Transportation

Waiting for education

Waiting to talk to MD

Not wanting discharge

Bed not clean

Technical difficulties with text pager

Tubing system

Patient education

Too many discharges

Current patient waiting for tests

Waiting for test results

Discharge order

Discharge Summary

Transcriptions

Waiting for oxygen, visiting nurse

Not enough to do the work

Other department delays

Not adhering to process

MD communication

Access nurse

Reluctance to discharge

Gantt Chart85

• Project Planning Tool

• Includes list of tasks and estimates of time, people & resources to complete task

• Actions down left side

• Horizontal bars to indicate time frames

  Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6

Data collection            

Data Analysis            

Prepare Reports            

Present Reports            

             

Survey Process

Chapter 7

New Objectives

• Facilitate evaluation & selection of appropriate accreditation or recognition programs

o The Joint Commission (TJC)o Det Norske Vertis (DNV)o Healthcare Facility Accreditation Program (HFAP)

• American Osteopathic Association (AOA)o National Committee for Quality Assurance (NCQA)o Magneto Baldrige

• http://www.jointcommission.org/assets/1/6/Comparison_Document2013.pdf

• Facilitate communication with accreditation and accrediting and regulatory bodies

88

New Objectives• Develop / Provide survey preparation

training (accreditation, licensure, equivalent)

• Aid in evaluating survey readiness for accrediting and regulatory bodies

• Aid in evaluating the readiness to apply for external quality awards

• Coordinate survey process (accreditation, licensure, equivalent)

88

Determine Survey Readiness

• Assess compliance with standardso Review of documentation

o Onsite mock surveys

o Verbal interaction with staff

o Review of medical records

o Assessment of service/support systems

89

Accreditation Survey Readiness

• Leadership

• Readiness/ Regulatory Teamo Mock Surveyso Implementation of new standardso Knowledge readiness

• Communication !!!!!!!!!

90

Coordination of Survey• Have a process in place and tested for when ANY

surveyors come through the front door

• Have a headquarters (war room) for all information to flow through

• Have scribes (with a phone) to write down all that the surveyor asks or looks at

• If documentation is needed, call war room to get the information – NOT the scribe

• Have a separate person to accompany the surveyor.

91

Coordination of Survey• NEVER leave the surveyor alone, even in the

restroom or outside for a smoke

• When surveyors leave in the evening, key personnel stay and meet to discuss the day and determine if work needs to occur before the next day to “make things better” or find things the surveyor wants that were not found that day.

• Notify all managers/other appropriate staff what the surveyors looked at that day and what the next day will be like

92

End of Survey

• Typically, the CEO determines who hears the exit interview

• After the exit interview, staff should be informed of the results

• Regardless of what the results are, celebrate !

• Then buckle down the next day or so and start an action plan for what has to been done to clear any citations

93

Licensure

• Mandatory act of granting and receiving a license to provide healthcare services in a state in the U.S.

• Usually the state Department of health Services grants the license and monitors the license

• Onsite survey to determine compliance with all applicable state and federal laws and regulations

• License specifies the number of beds permittedo Acute, skilled, subacute, long term, etc.

94

The Joint Commission• Organizations

o Hospitalso Critical Access hospitalso Home Careo Ambulatory Surgeryo Primary Care medical Homeo Behavioral healtho Long Term careo Laboratoryo Disease Specific Care certification

• Core Measures for hospital programs • Other quality measurement systems for

other types of organizations

http://www.jointcommission.org/

95

Det Norske Vertis (DNV)

• National Integrated Accreditation for Healthcare Organizations (NIAHO) – standards

• CMS Conditions of Participations plus ISO 9001 standards

• Hospitals & Critical Access Hospitals

• Primary Stroke Center certification

http://www.dnvusa.com/industry/healthcare/index.asp

96

Healthcare Facility Accreditation

Program (HFAP)• American Osteopathic Association (AOA) sponsors

this accreditation• All Acute Care facilities (general, specialty, LTAC)• Behavioral/mental health• Ambulatory care/office-based surgery• Ambulatory Surgery Centers• Clinical laboratories• Primary Stroke Centers• Critical Access Hospitals

• Focus: CMS plus patient safety & quality of care standards

http://www.hfap.org/

97

National Committee for Quality

Assurance (NCQA)• Health Plans, including:

o Health Maintenance Organizations (HMO), o Managed Care Organizations (MCO), o Preferred Provider Organizations (PPO) and o Point of Service (POS) plans

• Managed Behavioral Health Organizations (MBHO)• Disease Management accreditation or certification• Wellness & Health Promotion• Health Effectiveness Data and Information Set

(HEDIS)o Evaluate the structure and functions of medical and

quality management systems in managed care organizations

http://www.ncqa.org/

98

Commission for Accreditation of

Rehabilitation Facilities (CARF)• Promotes quality, value, & optimal

outcomes of services to the following types of facilitieso Aging Serviceso Behavioral Healtho Business & Service Mgmt Networkso Child & Youth Serviceso Employment & Community Serviceso Medical Rehabilitationo DMEPOS (medical equipment, etc)

99

www.carf.org

Baldrige Performance Excellence Award

• Managed by the National institute of Standards & Testing (NIST) – o an agency of the U.S. Department of Commerce

• Seven Categories of Criteriao Leadershipo Strategic planningo Customer Focuso Measurement, Analysis and Knowledge Managemento Workforce Focus (environment & engagement)o Operations Focuso Results (outcomes)

http://www.nist.gov/baldrige/

100

Magnet Recognition Program

• Developed by American Nurses Credentialing Program to recognize healthcare organizations for nursing excellence

• Five Model Components (14 Forces of Magnetism)o Transformational Leadershipo Structural Empowermento Exemplary Professional Practiceo New Knowledge, Innovation & Improvementso Empirical Quality Results

http://www.nursecredentialing.org/Magnet.aspx

101

Susan MellottPhD, RN, CPHQ, FNAHQmellottandassoc@att.netmellottandassociates.com

102