a balanced set of clinical measures and the discussions they have provoked bruce george executive...
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A Balanced Set of Clinical Measures
and the discussions they have provoked
Bruce GeorgeExecutive Director (Operations)
Quality, Improvement and Patient SafetyCapital & Coast DHB
SITUATION (September 2013)• Lots and lots of bar graphs• Many providers of “data” and “charts”• Multiple systems from which data is extracted• Some data extracted and turned into charts without
any internal oversight
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Nu
mb
er E
ven
ts
Month
Events Reported by Month/Year
2009
2010
2011
2012
2013
SITUATION (September 2013)• Inconsistent definitions• Some very complex denominators to “enable”
comparisons• Multiple (connected?) committees where insight from
data or charts is discussed
CURRENT STATE (April 2014)• Standard Balanced Set of Clinical and Quality Measures• Clear definitions of “counts” to drive improvement• Discussion, agreement and action at Clinical
Governance meetings
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01A
pr13
15A
pr13
29A
pr13
13M
ay13
27M
ay13
10Ju
n13
24Ju
n13
08Ju
l13
22Ju
l13
05A
ug13
19A
ug13
02S
ep13
16S
ep13
30S
ep13
14O
ct13
28O
ct13
11N
ov13
25N
ov13
09D
ec13
23D
ec13
06Ja
n14
20Ja
n14
03Fe
b14
17Fe
b14
03M
ar14
17M
ar14
31M
ar14
14A
pr14
28A
pr14
12M
ay14
26M
ay14
09Ju
n14
23Ju
n14
Co
un
t
Week ending
ED 6hr target
Green Amber Red
Value X Center Line Natural Process Limits
CURRENT STATE (April 2014)• Balanced Set includes:
• Patients Discharged Deceased (monthly)• SAC 1 & 2 events (monthly)• Placements to Aged Residential Care (monthly)• ED 6 hour target (weekly)• Hospital Occupancy at 4pm (daily)• All Reported Events (weekly)• Readmissions (monthly)• Complaints (weekly)• Falls (monthly)• Medication / Fluids errors (monthly)• Pressure Sores / Ulcers (monthly)• Peri-operative Harm (quarterly)• Restraints / supportive Devices (monthly)• Safe Staffing (monthly)
INVESTIGATIONS (April 2014)• Investigations into signals
• Readmissions• Safe Staffing• Peri-operative Care
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01Ja
n11
01M
ar11
01M
ay11
01Ju
l11
01S
ep11
01N
ov11
01Ja
n12
01M
ar12
01M
ay12
01Ju
l12
01S
ep12
01N
ov12
01Ja
n13
01M
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01M
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01Ju
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01S
ep13
01N
ov13
01Ja
n14
01M
ar14
01M
ay14
Co
un
t
Month and Year
CCDHB Readmissions (within 28 days)
Red Amber Green
Value X Center Line Natural Process Limits
Signal – run of 8 above the mean (bad)
INVESTIGATIONS (April 2014)• Investigations into signals
• Readmissions• Safe Staffing• Peri-operative Care
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51
2
2
6
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2
2
2
2
Mean CL: 350.47
293.69
407.26
270.00
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350.00
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390.00
400.00
410.00
Ind
ivid
ua
ls:
Va
lue
INVESTIGATIONS (April 2014)• Initial analysis using existing tools
• Unforeseen readmission – new problem• Unforeseen readmission – existing problem
Vas
cula
r
Uro
logy
Pai
n M
gm
ts
Pae
d S
urg
Pae
d O
nco
logy
Pae
dea
tric
s
Ort
hopae
dic
s
Opth
amolo
gy
Obst
etrics
Neu
rosu
rg
Neo
nat
al
Gynae
colo
gy
Gen
eral
Surg
ery
EN
T
Den
tal
Car
dio
thora
cic
Res
pirat
ory
Ren
al
ATR
Onco
logy
Neu
rolo
gy
Imm
unolo
gy
Old
er A
dults
Hae
moto
logy
Gen
eral
Med
icin
e
Gas
tro
Endo
Em
ergen
gy
DSS
Car
dio
logy
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Readm
issi
on R
ate
Readmit Rate per month by Specialty
• Haematology (24%)
• Oncology (22%)
• Renal (19%)
• General Medicine (14%)
• Older Adults (14%)
• ATR (13%)
• General Surgery (12%)
• Paed Oncology (15%)
24%
22%
13%
19%
14%14% 12%
15%
Avg readmit rate
By Specialty: Monthly Readmit Rates (Jan12 to Jan14)
• Three specialties highlighted as higher rates – understandable as likely to be complex cases
By original visit LOS
• Distributions of LOS resulting in a readmission are in synch with those of all admissions
Readmissions All Admissions
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45
30
15
02824201612840
2824201612840
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02824201612840
General Medicine
Days
Perc
ent
General Surgery Haematology
Oncology Renal Medicine
Histogram of LengthOfStay60
45
30
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02824201612840
2824201612840
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45
30
15
02824201612840
General Medicine
Days
Perc
ent
General Surgery Haematology
Oncology Renal Medicine
Index LOS
By Clinician: General Medicine
Readmisisons 50 49 48 47 45 42 32 31 29 2391 22 9386 69 60 60 56 56 55Percent 5 5 5 5 4 4 3 3 3 29 2 98 7 6 6 5 5 5
Other
Marion
Leig
hton
Nicola
Smith
Adel
Eklad
ious
Cons
ultan
t Emer
genc
y
Colin
Fee
k
Sinea
d Do
nnell
y
Chris
tina C
amer
on
Phil ip
pa Sh
irtcliffe
Kyle
Per ri
n
Ange
la So
teriou
Darre
n Bow
les
Luatup
u Ioa
ne-C
lever
ley
Rupa
l i Sha
rma
Nige
l Ray
mond
Ketna P
arek
h
John
Mur
ray W
ilson
Doro
thy Di
nesh
Peter
Robe
r ts
Elaine
Barr i
ngton-W
ard
120
90
60
30
0
Rea
dmis
ison
s
I P Admissions 354 354 301 300 287 274 273 219 189 173523 124 111 658510 465 436 433 432 417 398Percent 5 5 4 4 4 4 4 3 3 27 2 2 97 6 6 6 6 6 6
Othe
r
Marion
Leighto
n
Mark
Weathe
ral l
Nicola
Smith
Cons
ultan
t Emer
genc
y
Colin
Fee
k
Kyle
Perri
n
Darre
n Bow
les
Chris
tina C
amer
on
Ange
la So
teriou
Sinea
d Do
nnel l
y
Luatu
pu Io
ane-
Cleve
rley
Adel
Eklad
ious
Rupa
l i Sha
rma
Ketn
a Par
ekh
Phil ip
pa Sh
irtcli
ffe
J ohn
Mur
ray W
ilson
Nigel R
aymon
d
Doro
thy D
inesh
Peter
Robe
rts
Elaine
Barri
ngton
-Ward
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150
0
IP A
dmis
sion
s
Readmissions
All Admissions
• Readmit rates largely in synch with the overall admission rates per clinician
Doctors names
Doctors names
By DRG: General Medicine
Count 68 66 63 63 56 56 55 51 51 49183 47 46 44 44 43 1164165141134103 96 77 69Percent 2 2 2 2 2 2 2 2 2 26 2 2 1 1 1 406 5 5 4 3 3 2Cum % 35 38 40 42 44 46 48 49 51 536 54 56 57 59 60 10012 17 21 25 28 31 33
indexdrg3
OtherF6
0X60
Q61E75I6
8B76L6
4G66K6
0F73E6
9T60J6
4G67G70F76B7
7L6
3F7
4E62F6
2X62E6
5
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0
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0
Count
Perc
ent
Pareto Chart of indexdrg3 by IndexSpecialtyIndexSpecialty = General Medicine
Count 102 96 78 75 74 70 66 62 62 58287 56 54 53 53 1483231164 156 156 125111 103Percent 3 3 2 2 2 2 2 2 2 28 1 1 1 1 396 4 4 4 3 3 3Cum % 38 41 43 45 47 48 50 52 53 558 56 58 59 61 10014 18 22 26 30 33 35
DRG3
OtherT6
3I7
1B76B8
1D63
Q61F76F6
3G47G70E6
9K6
0F7
4G67E7
5J6
4T60L6
3F6
2F7
3E65E6
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Count
Perc
ent
Pareto Chart of DRG3 by HealthSpecialtyNameHealthSpecialtyName = General Medicine
• Readmission DRG’s in synch with total IP admission DRG’s, except X62 & G70
Readmissions All Admissions
Outcomes of Readmissions analysis• Has driven development and deployment of new
charts, insight from data and discussion at Clinical Governance
• No clear single reason for increase but two DRGs to investigate further
• Progress with internal clinical audit• Include Primary Care in investigations
Visibility of data and analysis of signals has driven• Greater use of Central Dashboard• Planning for Operations Centre to optimise flow & safety
CURRENT STATE (April 2014)
CURRENT STATE (April 2014)Visibility of data and analysis of signals has driven• Greater use of Central Dashboard• Planning for Operations Centre to optimise flow & safety
FUTURE STATE (December 2014)• Standard Balanced Set of Clinical and Quality Measures• Clear definitions of “counts” to drive improvement• Discussion, agreement and action at Clinical
Governance meetings
6
6
6
2Mean CL: 94.09
88.77
99.41
78.00
80.00
82.00
84.00
86.00
88.00
90.00
92.00
94.00
96.00
98.00
100.00
Ind
ivid
ua
ls:
Va
lue
by
Ph
ase
FUTURE STATE (tbc)• Charts (Statistical Process Control) accessed via intranet
dashboard.• Proactive not reactive - act upon early warning from
signals not trends.• Analysis for improvement (count) and comparison (rate).• Full DHB perspective not just Hospital.• Integrated Operations Centre
Monthly Balanced Scorecard Month & YTD vs targetsMonth YTD Month YTD
Patient Experience Process EfficiencyED Target 94 94 Length of Stay 2.8 3.2Complaints 65 564 Acute vs Elective 74 68
Clinical Measures DOSA 71 73Falls 72 641 Bed utilisation 89 93SAC 1-2 2 88 Theatre utilisation 77 87Reported Events 342 4536 Outpatient DNA 6 7Peri Operative 54 345 Value For MoneyMedication 32 432 Caseweight 6533 6565
Healthy Workplace Acute vs Elective 678 765Staff Turnover 1.3 0.9 FTE costs 45999 654336Engagement 4.3 4.1 Operating Costs 34555 665458