From Chaos to Clarity: Summarizing Hospital Quality Data

1
From Chaos to ClaritySummarizing Hospital
Quality Data
David Zaun, MS Nancy Wolf, RN, CIC, CPHQ

• AHQA Technical Conference
• February 2005

2
Building the Bridge

• In the beginning . . . (Fall 2003)
• How can Stratis Health add value?
• How can Stratis Health help hospitals interpret
  their data?

• How can Stratis Health transform hospital-
  generated data (HGD) into a meaningful and
  useful format?

3
Bridge Building Team

• 2b Team Members
• Hospital Project Managers
• Assistant Project Manager
• Analysts
• IS
• Communications
• Abstraction Coordinator
• Ad hoc
• Hospital QI contacts

4
Got Data! Got Chaos!

• Plan
• Inventory what type(s) of reports hospitals have
  access to
• CART data reports
• Vendor data reports
• QNet data reports
• JCAHO data reports
• HQA preview data reports

Report chaos!
5
Got Data! Need Clarity!

• Plan
• Assess what type of report is lacking
• The ideal report would

• Synthesize topic data in a concise format
• Verify data submitted to the QIO Clinical
  Warehouse
• Facilitate hospital sharing of data with medical
  staff, QI committee, etc.
• Demonstrate hospital improvement over time
• Identify areas for concentrated organizational
  improvement

6
Got Data! Create Report!

• Do
• Create the perfect report
• The ideal report would
• Fit on one page
• Verify QNet Administrators, vendor, CART use, HQA
  sign-on, APU participation
• Contain data for all four CMS topics
• Include four quarters of data
• Include a summary of data

Report Clarity!
7
Got Data! Got Report!

• Do
• Create Excel template
• Get and manipulate HGD in SAS
• Get other hospital information
• Export data from SAS to an Exceltemplate
• Example of Excel template

8
SAS Code

• Do
• Get the data
• Manipulate the data
• Add in other hospital information
• Open Excel workbook and export data to Excel
• Call Excel macros (e.g., save as, print, and
  close)

9
Got Data! Use Report!

• Do
• Shared with hospitals on a quarterly basis
• Initially mailed in Spring 2004 as mechanism to
  verify accuracy of HQA preview data reports
• Mailed in mid-July 2004 to verify APU sign-on and
  progress with data submission prior to the APU
  data submission deadline
• Distributed and discussed during Fall hospital
  visits

10
Got Data! Refine Report!

• Study
• What we heard from hospitals
• Hospitals appreciate the report
• Hospitals request the report on an ongoing basis
• Hospitals share the report with their committees
• Special request combine data for system
• Ongoing changes needed to keep the report current
  and user friendly
• Consider this a dynamic document

11
Bridging the Gaps

• Act
• SAS
• State comparisons
• JCAHO/CMS alignment
• 8SOW maintenance

12
A Bridge to . . .

• Strengthening hospital relationships
• Building trust
• Developing the groundwork for quality
  improvement work
• 8SOW and beyond!

13
Summary

• Working in teams often creates the best product
• Envisioning the product from a provider
  perspective allows creation of a user-friendly
  product
• SAS/Excel can save time when creating mass
  reports or when repeatedly creating the same
  report over time (or both!).

14
Summary (cont.)

• Added bonus
• Identifies hospital leaders by topic/measure,allo
  ws organization of QIO work, etc.
• Always think of what the future may bring

15
Contact Information

• David Zaun, MS
• Senior Research Analyst, Stratis Health
• 952-853-8588
• dzaun_at_mnqio.sdps.org
• Nancy Wolf, RN, CIC, CPHQProject Manager,
  Stratis Health
• 952-853-8582
• nwolf_at_mnqio.sdps.org

16
Stratis Health is a non-profit independent quality
improvement organization that collaborates with
providers and consumers to improve health care.

• This material was prepared under a
  contract with the Centers for Medicare Medicaid
  Services (CMS).
• The contents presented do not necessarily reflect
  CMS policy.
• 7SOW-MN-GEN-05-14 2.2005