UC Benchmarking Presentation.pptx [Read-Only]...Title Microsoft PowerPoint - UC Benchmarking Presentation.pptx [Read-Only] Author dyoungberg Created Date 9/24/2013 4:48:58 PM

Copyright 2013 Digital Innovation, Inc. All Rights Reserved. 1

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Benchmarking Using the Trauma Registry

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Objectives

Review use of registry as a benchmarking tool

Review importance of “Data Quality Management” in benchmarking process

Review trauma registry Best Practices

Review report writing & analysis basics

Review how benchmarking is used to support a PI process

Provide benchmarking examples


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Trauma RegistryCornerstone of the Benchmarking Process

Evaluate quality of patient care

Data repository for the evaluation of injury care & preparedness

Aids in developing better injury scoring & outcome measures

Supports injury & prevention education

Supports local, regional, & national research/outreach initiatives

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Data Quality Management

Benchmarking is only as good as the data used to support it

Garbage in = Garbage Out

Program data should be reviewed regularly by all trauma team members

Nothing should be a surprise when data is returned in aggregate form


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Best Practices for Trauma Data Management

Data must be abstracted in accordance with a standard data set

Registry staff must possess a certain skill set

A team approach to data collection should be utilized

Data validation techniques must be applied

A concurrent method of data collection is preferred

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Best Practices for Trauma Data Management

Implement a process to review all aspects of data management Staffing Work Processes Technology

This process should include trauma registrars, trauma program directors/managers and performance improvement staff


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Staffing

Define Staffing Plans

Recruitment/Retention

Job Descriptions

Compensation

Orientation/Training

Continuing Education / Professional Growth

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Work Processes Data Abstraction/ Entry Model Role in Performance Improvement Policies & Procedures Data Validation Techniques Data Submission Guidelines Standard & Ad‐Hoc Reporting Quality Audits/Inter‐rater Reliability Clinical Documentation Requirements Standard /Custom Data Definitions Accreditation/Verification Support


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Technology Hardware/Software Requirements Network Configurations Use of Electronic Medical Records Implementing/Supporting Electronic Interfaces Portability Issues Software Upgrades User Defined Customization Routine Maintenance/Back‐Up Procedures

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Report Writing & Analysis Process

Define Reporting Needs Who

Who is requesting the report and who will be reviewing the information

What What type of information is being requested and is it

available to report on

When What specific time frame is being requested


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Report Writing & Analysis Process

Standard/Routine Monthly Statistics

Registrar Productivity

PI Reports

Audit Filter Compliance

ED LOS Tracking

Occurrence Reporting

Timeliness of Submission

Ad Hoc Research Requests

Injury Prevention/Outreach

Strategic / Business Planning

Benchmark Reports Self (Trending)

Regional System

State

National

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Registry Use as a Benchmarking Tool

Performance Improvement Process

Issue Identification

Analysis of the Issue

Action Plan Development & Implementation

Re‐Evaluation

Data Benchmarking Process

Report Identification

Identify Comparison Group

Define Time Intervals

Generate Pre‐Intervention Data

Generate Post‐Intervention Data


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Example #1 Emergency Department Length of Stay


During the last verification visit, prolonged ED LOS was identified as an opportunity for improvement 0

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Avg ED LOS(hrs)

ED LOS TrendingData Source – Trauma Registry

CY 2012

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

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Analysis of Issue

• Data reveals a steady incline in overall ED LOS

• Additional data trending will be needed • Average ED LOS by Activation Level

• Average ED LOS by Day of Week & Time of Day

• Average ED LOS by Injury Type

• Average ED LOS by Hemodynamic Instability (SBP <90)


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Don’t jump to conclusions simply looking at data, other factors must also be considered

when studying an issue!

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Analysis of Issue

• A long ED LOS does not necessarily correlate to delays in care or poor care

• Hospital bed capacity is at 95% majority of the time

• Some ED’s can provide surgical intervention and provide critical care for extended periods of time


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• Identify working group responsible for this issue

• Discuss reporting needs

• Generate baseline data “Pre‐Intervention”

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• Statistical Report

• Gather by “Activation Level”

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Trauma Activations Non‐Trauma Activations

Average ED LOS by Activation LevelData Source – Trauma Registry

CY 2012



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• Gather by “Day of Week”

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Average ED LOS by Day of WeekData Source – Trauma Registry

CY 2012


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• Gather by “Shift of Day”

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1st Shift 2nd Shift 3rd Shift

Average ED LOS by Shift of DayData Source – Trauma Registry

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• Gather by “Injury Type”

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Blunt Penetrating

Average ED LOS by Injury TypeData Source – Trauma Registry

CY 2012


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• Query – “SBP<90”

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SBP<90

Average ED LOS Hemodynamically Unstable Patients (SBP<90)

Data Source – Trauma RegistryCY 2012



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So what have we learned by looking at this data?

ED LOS is longer in the non‐trauma activation population Triage seems to be an issue in some cases

ED LOS is longer on Fridays & Saturdays

ED LOS is longer on the 3rd shift

High risk populations appear to get through the system appropriately

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• Present data to stakeholders• Action – share data results and identify areas of concern

• Talk to hospital administrator about bed capacity issues• Action – hospital is planning to expand ICU capacity by 20 beds

• Talk with ED leadership about potential staffing issues• Action – additional staff will be added to 3rd shift and weekends

• Re‐educate ED staff on proper triage criteria• Action – TPM re‐educates ED staff on triage guidelines


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Re‐evaluation

• Generate data “Post‐Intervention”

• Run identical reports as used in the Pre‐Intervention

• Demonstrate improvement in ED LOS

• Continue to demonstrate that patients with prolonged ED LOS are cared for timely & appropriately

• Continue to trend to assure sustained improvement

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Example #2 Incidence of Pneumonia


Review of complications reveals a steady incline of Pneumonia Rate over the last calendar year.

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Pneumonia Rate

Incidence of PneumoniaData Source – Trauma Registry

CY 2012



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Example #2Incidence of Pneumonia

Analysis of Issue

• In analyzing Facility A quarterly data, an increasing trend in Pneumonia rate is reflected

• Identify need to compare to benchmark data (state, regional, national)

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Don’t jump to conclusions simply looking at data, other factors must also be considered

when studying an issue!


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Analysis of Issue – (other things to consider)

• Has there been any change in clinical practice relating to management of pneumonia

• Has there been any change in the patient characteristics within this patient population

• Data will be needed in the following areas:• Avg. Age of Patients, # of patients w/ Pulmonary PEC, # of patients

with chest injuries (AIS>3)

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Example #1 Incidence of Pneumonia


• Identify working group responsible for this issue

• Discuss reporting needs

• Generate baseline data “Pre‐Intervention”


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NTDB Benchmark Comparison

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Pneumonia Rate IncidenceHospital vs. NTDB

CY 2012

Facility A NTDB

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16.00%

Age BreakdownHospital vs. NTDB

CY 2012

55‐64 65‐74 75‐84 > 84


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0.00%

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AIS > 3: Thorax/Chest InjuryHospital vs. NTDB

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Facility A NTDB

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State Benchmark Comparison

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# of Patients w/ Respiratory ComorbidityHospital vs. State

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Facility A State


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• Present data to stakeholders• Action – share data results; it appears Facility A is caring for older,

sicker patients who sustain more chest injuries and therefore are at higher risk for developing pneumonia

• Talk to clinicians about any change in clinical protocols • Action – no change in clinical management. Aggressive pulmonary

protocols in place.

• Educate clinical staff about increase in pneumonia rate and need to continue aggressive pulmonary toilet

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Re‐evaluation

• Generate data “Post‐Intervention”

• Run identical reports as used in the Pre‐Intervention

• Continue to compare to state & national benchmarks

• Continue to provide aggressive pulmonary care in this patient population

• Continue to monitor characteristics of this patient population


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Summary

Benchmarking only as good as the data supporting it

Team approach to data collection & analysis is pivotal

Consider all/other factors when studying an issue

In lieu of issues, use data to show care is timely & appropriate

Documents

UC Benchmarking Presentation.pptx [Read-Only]...Title Microsoft PowerPoint - UC Benchmarking Presentation.pptx [Read-Only] Author dyoungberg Created Date 9/24/2013 4:48:58 PM