CPHQ Monitoring and Review Audit (Part 4) PDF

PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT Chapter 3 Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training Medical Record Review Process:  Usually begins with the determination of what should...

PERFORMANCE MANAGEMENT AND PROCESS IMPROVEMENT Chapter 3 Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training Medical Record Review Process:  Usually begins with the determination of what should be reviewed.  The content to be reviewed will depend on the utilization of the information.  In many cases, the data is screened by some predetermined criteria. If the documentation meets the criteria, further review is not required.  Reviewers usually include physicians, nurses, other relevant clinical professionals, health information management professionals (screening), and quality data abstractors.  It is not possible or feasible in many circumstances for all medical records to be reviewed due to time and other limitations. Therefore, sampling is often utilized. Type of clinical review: Prospective Before treatment During hospitalisation (open Concurrent MRD) Retrospectiv e After discharge (closed MRD) Revalidated Peer review  Multilevel review process 5th level: Monitoring and 4th level: evaluation Improve or design 3rd level: new process In-depth 2nd level: analysis. Initial analysis (Focus peer 1st level: & review) Screening & Confirmation data collection of variation by (Peer review) professionals in the point of care delivery Physician Monitoring: Medical staff departments generally meet quarterly to review summary reports of quality management activities.  The overall effectiveness of physician/LIP participation in organization wide quality management/performance improvement activities, leader involvement, and participation on teams should be evaluated along with the department specific and Medical Executive committee activities.  This evaluation can be integrated into an annual organization wide reappraisal of the quality management/performance improvement strategy and approach. Nursing Monitoring:  The nurse executive and other nursing leaders participate in and/or support all of the listed activities that impact the safety and quality of care provided to patients. We should have national Database of Nursing Quality Indicators (NDNQI) to promote and facilitate the standardization of information on hospital nursing quality and patient outcomes. Hospitals can compare their outcomes with others across the country. Patient Satisfaction Review:  Consumers now evaluate quality based on such criteria as: 1. Access to practitioners. 2. Geographical access. 3. Service. 4. Relationship/connectedness/affinity. 5. Cost.  As customers, the patients/members offer organizations vital information for validating quality of care and services, or for prioritizing needs for improvement in delivery processes.  Feedback is based on perceptive quality and it may take the form of complaints, positive or negative perceptions of care, or even innovative ideas for improvement.  Patient satisfaction survey is one of the key factors in quality management and performance improvement that provides perceptive quality information and helps measure outcomes of care and service. Patient/member feedback mechanisms include: 1) surveys/questionnaires (written and internet) 2) Telephone and face-to-face interviews 3) focus groups 4) internet email communications (questions, comments, etc.) 5) the complaint and grievance processes Patient/Member Satisfaction Surveys:  Patient /member satisfaction surveys are designed to measure performance and to diagnose sources of dissatisfaction.  The survey (questionnaires) should be developed with consideration given to 1. the length, language/reading level, layout, and size of type. 2. The survey should be offered to all patients all the time or on a periodic basis for example every 6 months for 30 days. 3. The survey could also be used with a representative sample of all patients all the time or all patients within certain categories, such as those on a specific unit, or having a particular treatment. 4. Use scale from (1 to 5) to assure that degrees of satisfaction or dissatisfaction.  The facility must be cautious about distributing the survey to be filled out prior to discharge of the patient, as the patients may feel less open while they are within the confines of the organization.  Patient experience: Focus on what they are thought and coordination of their health need.  Patient satisfaction: Focus on how satisfied the patients are with their care HCAHPS survey:  Survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience.  Importance of HCAHPS survey: 1. VOICE of patient (view patient perception). 2. Results are publicly reported (to see the impact of these result on our reputation) 3. Keep hospital financially strong. Patient will be surveyed 48hr till HCAHPS survey: Patient Interviews:  Used more and more to assess patient adherence to treatment plans and satisfaction with care , to follow up on discharge plans, and to determine health outcomes.  Patient interviews can be by telephone or in person (e.g. at time of follow-up office visit, home care visit, or planned return to Emergency Services).  Follow-up interviews are being used by teams implementing clinical paths to evaluate the care process, specifically asking patients and families for suggestions to improve both the care and  the process As with of care surveys, delivery. a face-to-face interview while the patient is still receiving treatment or prior to discharge may bias the patient to be less open about the answers. Focus Group:  Focus Groups are small groups of  The recommended pattern for introducing persons (6-10) with like conditions or the group discussion includes: experiences who are selected by a (1) Welcome sampling technique to interface with (2) Overview of the topic interviewers and each other, offering (3) Ground rules and input about a predetermined topic or (4) First question reactions to  Guidelines : an idea. 1. No right or wrong answers. 2. only differing points of view We're tape recording, 3. one person speaking at a time 4. We're on a first name basis 5. You don't need to agree with others, but you must listen respectfully as others share their views 6. Rules for cellular phones and pagers if applicable.( For example: we ask that your turn off your phones or pagers. If you cannot and if you must respond to a call, please do so as quietly as possible and re join us as quickly as you can. ) Patient Complaints & Grievances:  The patient has a right to register a complaint or file a grievance concerning the healthcare organization or the quality of care and a right to timely review and  resolution. The patient also has a right to multiple levels of appeal of denials of treatment, level of care, benefits, or coverage, and a right to timely review and resolution.  Both hospitals and managed care plans must respond to grievances in a timely manner and must maintain a written record for each grievance. Complaint: is defined as a minor verbal request that can be resolved quickly. Examples of a complaint include complaints about (( the room temperature, housekeeping issues, food and beverage preferences, or changing the bed.))  The patient must be informed as to how to file a grievance if the patient so desires.  If the complaint is a written complaint, it automatically becomes a grievance.  If the complaint is postponed for later resolution, referred to another staff member for later resolution, requires investigation and/or requires further actions for resolution, it becomes a  grievance. A complaint is resolved when the patient is satisfied with the actions taken.  If after the patient is discharged from the hospital, the patient or representative calls (verbal communication) regarding the patient care received, and it would have been treated as a complaint if it had been voiced as an inpatient, it should be treated as a complaint not a grievance. However, if it is in writing, or if the person voicing the complaint requests it be treated as a grievance, it must be treated as a grievance. Appe alAn : application to higher court. Complaint or dispute concerning organization determinations. The determinations by the organization to approve or not allow certain treatments, procedures, or medications prescribed in their plan to be utilized, are addressed through appeal procedures rather than grievance procedures. Organization determinations: Decision we make about your medical benefits and the amount that we will pay for medical service, include payment , provision of care and out of plan service payment.  Appeal and grievance: An appeal is a request that you make to Medicare or your Medicare Advantage or stand-alone Part D plan to reconsider its decision to deny coverage of an item, service, or medication. If your Medicare Advantage plan refuses coverage, it must send you a written notice that explains the reason for the denial and your appeal rights. A grievance is an official complaint filed with your Medicare Advantage or Part D plan if you are dissatisfied with the behavior or actions of your plan or its representatives. Ex: if your plan refuses to pay for a lab test that you received, then you should file an appeal. The appeal will ask your Medicare Advantage plan to reconsider its decision to deny coverage of the test. If your plan is covering the lab test but you were dissatisfied with the plan’s actions during the process (for example, a plan representative was unhelpful when you asked how to file an appeal), you can file a grievance.  Complaint Appeal Grievance An oral expression of A request to change a Formal expression of dissatisfaction(minor previous decision made dissatisfaction about and can be resolved by the organization. quality of care or quickly. (denial to pay) financial issue. A person “register” a (Usually written/may complaint ,generally be oral) about the process of care Resolved once pt is satidfied The analysis process:  The trick is to know what to do with the data. We need a systematic way to aggregate, display, and analyze the data, even once it is "organized," to turn it into good information for decision making.  First the data has to be submitted in a timely manner and delivered in the format that ensures it will be ready to use.  Without these steps, we will have no opportunities to improve and/or no evidence of improvement.  The analysis process operates most effectively when it is collaborative, with involvement of those most familiar with the process.  The analysis process answers one or more of the following questions: 1. What is our current level of performance? 2. Patient/family needs and expectations met? 3. Outcomes of care processes as expected? 4. What is the stability of our current processes? 5. Is there need for more intensive analysis? 6. Are there areas that could be improved? 7. Was a strategy to stabilize or improve performance effective? 8. Were design specifications of new processes met? 9. Are we consistent with our priorities for Theimprovement? process questions are asked in advance of the data collection.  The importance of analysis: The data that is essential to answer the questions is clearly identified and defined as the first step in the monitoring process. compare the aggregate level of actual performance for each indicator with the designated triggers /signals/benchmarks. Self compare. Comparison with others. Comparison with standard/guideline/regulation. Self- comparison:  Data monitoring over time is used by most of the healthcare  organizations. The internal patterns and/or trends over time are utilized to identify the organization's improvement processes through the use of the upper and/or lower control limits or design specification levels, pre- established criteria or performance expectations, and Comparison single sentinelwith event or total number of occurrences. others:  Assists the organizations in identifying how their data relates to the performance of similar processes and outcomes in other organizations (reference-based). Comparison with standards/guidelines/regulations:  Assists the organization with regulatory and accreditation compliance in designing new or redesigning old processes.  Comparison with best practices and benchmarks can be either internal or external to the organization.  The information on benchmarking assists the organization with identifying improvement opportunities and measuring the effectiveness of the improvements made. Initial Analysis:  For each process being monitored, the organization must first collect data to determine if the process is meeting the expected  outcomes. FIRST STEP: Identify the team, committee, Team department/service, or individual qualified Analyz and responsible for the aggregation, initial e data analysis or interpretation of the data and for in-depth/more intensive measurement and  SECOND analysis ifSTEP necessary. : Trigger The organization should secondly specify time tables for the data aggregation must be established. The data should be analyzed at regular, adequate intervals specified by the department/service/team/setting. This should be determined based on the volume of patients, services, or procedures and consider the degree of impact on direct patient care, including risk THIRD STEP: The analysis should be performed at the designated time intervals. The analysis should include a review for accuracy, validity, and reliability of data.  The organization should look for undesirable variation in data compared to baseline, previous measurement periods, or other appropriate comparisons and then determine if immediate action, continued measurement, or intensive analysis is necessary.  Lastly, the organization should identify any individual cases or sentinel events requiring in-depth analysis and identify any obvious problems, patient risks, or opportunities to improve.  Triggers for intensive analysis should be identified, including, but not limited to:  Sentinel events  Levels of performance or patterns/trends at significant and undesirable variance from the expected, based on appropriate statistical analysis  Performance at significant and undesirable variance from other similar organizations Performance at significant and undesirable Depending variance from recognized on the setting: standards Hazardous conditions (circumstances significantly increasing the likelihood of a serious Adverse outcome) Significant medication errors Major single or pattern discrepancies between preoperative and postoperative diagnoses, Including pathologic review Confirmed transfusion reactions Significant adverse drug reactions Significant adverse anesthesia-related events Intensive Analysis:  Additional investigation or special study is initiated when undesirable variation in performance has occurred or is occurring presently.  Intensive analysis is  These individuals must be able performed by those to evaluate appropriately individuals who are most aggregated and displayed familiar with, and can best data/information (totals, assess all facts of, the percentages, summaries, particular process or graphs), specific patterns and  When aspectprioritizing for of care or service.  Intensive analysis trends tracked seeks over timeto. intensive analysis the identify and/or clarify organization must opportunities to improve care include consideration of and service processes, real or potential effect significant on patient care and deficiencies/problems in care service, available and service processes, the organization resources, scope and severity of those and the organization's problems and possible causes mission and priorities. of problems/root causes of variations. Analysis Process Steps Run charts display summary and 1. Data is collected for prioritized performance measures and comparison data over is ongoing and with targeted studies. time 2. Ongoing systematic aggregation and initial analysis of data Control charts occurs with the frequency of aggregation and analysis display variation and predetermined/appropriate to measure(s). trends over time. 3. Utilization of statistical tools and techniques are Pareto charts 4. appropriate The comparisons, internal and external, should be prioritize where to start to the data collected. utilized to identify excessive or undesirable variability, work, and the type and cause of variation unacceptable levels of process and outcome performance, should be assessed. and best practices. ((External sources for comparisons can be found in literature, evidence-based practice guidelines, 5. performance Intensive measures, analysis occurs whenreference databases, indicated, if performance standards. varies significantly )) undesirably from the expected, other and similar organizations, recognized standards, if sentinel event occurs, and/or if specific clinical events are triggered. 6. Determine if there is a need for change determined and possible changes identified. 7. the change is selected, plans are made for pilot/implementation across the organization, and/or new performance expectations or measures are DISSEMINATION OF PERFORMANCE IMPROVEMENT INFORMATION After the analysis has occurred, the results need to be reported throughout the organization and to external users. Without communication, the actions taken will not be utilized and incorporated into the processes where the changes are needed. Any one must be provided enough information for decision-making, to meet their responsibilities for maintaining and improving the quality of patient care. Everyone in the organization has a right and a responsibility to know and respond to the results of QM/Pl activities, to which, they have committed. The governing body generally receives quarterly and annual summary reports. To reach the entire organization, summary reports of successful QM/Pl activities may be reported at management meetings and then disseminated by managers and supervisors through staff meetings. Leaders may present QI/Pl summary reports (e.g., balanced scorecard and strategic initiativ.es) at periodic and annual organization wide staff meetings. Outcomes of the Analysis Process: Analysis may result in opportunities to improve systems, knowledge, and individual behavior. Documentation of all monitoring and analysis activities must be completed and maintained for a period of time, as designated by the organization, accreditation standards, and/or state/federal laws. Reporting to the Governing Board:  A summary report of quality management activities must be provided to the governing body on a periodic basis as defined in the Quality Improvement Plan.  Most organizations report to the Governing board quarterly with goal/benchmark and previous year comparisons, and then provide an annual summary report.  Typical annual reports to the governing board include: All process and system failures The number and type of sentinel events All actions taken to improve safety, proactively and in response to actual