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Quarterly Reports for SHN’s Interventions
Understanding and Using the Data to Guide Performance
December 10, 2008Virginia Flintoft, RN MSc
SHN! Central Measurement Team
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Goal• To understand how to enter YOUR data
into the Quarterly Reports (Monthly for ANC).
• To know how to use the Quarterly/Monthly reports to interpret performance and guide your QI initiatives.
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SHN Performance Reports
Data In …
Sending your results to
Central Measurement Team
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Submitting Data from a CoP Send you data from
ANY COP
Click on “SHN Data Submission Home “
button to get to data submission
screen
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Save the url on this screen to your ‘favourites’ for easy access next month
Submitting Data from a CoP
1. Using ‘browse’ button select worksheet you want to send to CMT – 1 worksheet at a time.
2. Enter a message - include your name and phone or email.
3. Click on ‘Upload/ Télèchargement’ button to send worksheet to CMT
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SHN Performance Reports
Data Out…
Reports you get from
Central Measurement Team
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SHN Performance Reports• Quarterly Reports
• Apr-June, July-Sept., Oct.-Dec., Jan.-Mar
• By measure
• Distributed to Key Organizational Contact and Team Leaders
• Allows team to monitor their performance against national rates and by implementation stage
• Quarterly Performance • By individual team and measure
• Distributed to Node leads and SIAs
• Allows them to identify teams in need of support
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Collaborative Performance Reports
Monthly Reports• Data in – 25th of each month
• i.e. December data sent in January 25th
• Data out – one week later
• Allows team to monitor their performance against Collaborative average rates
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Oct. Data Submission
Cut-off
ANC ReportDistributed
Next ANC-Report
Dec.5
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ANC ReportsANC-Report format
ANC – Report
#
Date data submitted
Months reported*
1 Nov’08 June ’08 – Oct.’08
2 Dec.’08 June ’08 – Nov.’08
3 Jan.’09 June ’08 – Dec.’08
4 Feb.’09 June ’08 – Jan.’09
* Cumulative report
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Collaborative Performance Reports
Monthly Reports for ANC• Rate of Undocumented Intentional Discrepancies
• Rate of Unintentional Discrepancies
• Percent Residents Reconciled on Admission
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SHN Monthly/Quarterly Reports
What to make of your results -
Interpreting the
Monthly/Quarterly Reports
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The Basics
• Data submission cut off for ANC-Reports• 25th of each month
• ANC-Reports issued • Week following data submission cut off
• Sent to Dannie and Theresa for distribution to teams
ANC Collaborative Reports
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Name and definition of
measure
Date of Data – months of data covered on this
report
Date Created – actual date when analysis
program ran
3 Worksheets within each Workbook –i.QR spreadsheet; ii.Chart – ANC vs Team Result; iii.Chart - Nodes vs Team (QR only)
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Warning - Small Sample Size... 5 or less – results unreliable
Examples of Small Sample Size...
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QR Data Analyzed & Presented:• Nationally• by Node –
Atlantic Ontario Quebec Western Paeds
• by Implementation Stage – Baseline Early (Working to Goal) Full
ANC• National will be called “Atlantic Collaborative” and data presented will be for ANC members ONLY• Nodes will be deleted• Implementation Stage as reported
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Enter Goal for term of collaboration from your worksheet
Entering “Local Team” Data:• Copy values in “Final Calculation” row on Data Entry Sheet of Measurement Worksheet and • Paste into “Local Team” row (r7) on Quarterly Report
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Definitions:
• “N (Teams)” = Number of teams reporting data for a specific month
• “Mean” = average score for the measure for the hospitals reporting data for that month.
• “SD” = standard deviation - a value indicating how widely dispersed the scores are around the mean; a measure of variation.
• Minimum – lowest score reported for a specific month
• Maximum - highest score reported for a specific month
• 25th – 75th percentile – of all teams reporting data for that month X% have a lower score than the specific percentile rank.
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Comparator Group Descriptive Statistic Nov'05 Dec'05 Jan'06 Feb"06 Mar'06 Apr'06 May'06Score Score Score Score Score Score Score
Aspirin at Arrival Goal >90% >90% >90% >90% >90% >90% >90%Local Team (input own data) Final Calculation 75% 82% 83% 79% 88% 90% 90%
National N (Teams) 17 11 6 6 10 3 4Mean 94.06% 98.10% 98.15% 97.22% 98.89% 77.77% 95.50%
SD 6.66% 4.09% 4.53% 6.82% 3.51% 38.51% 5.47%
Quarterly Report format
Comparator Group Descriptive Statistic Nov'05 Dec'05 Jan'06 Feb"06 Mar'06 Apr'06 May'06 Jun'06Score Score Score Score Score Score Score Score
Aspirin at Arrival Goal >90% >90% >90% >90% >90% >90% >90% >90%Local Team (input own data) Final Calculation
National N (Teams) 27 19 15 17 18 11 11 10Mean 92.63% 93.91% 89.07% 92.09% 98.96% 93.94% 98.36% 97.90%
SD 8.39% 11.82% 27.03% 24.22% 3.10% 20.11% 3.76% 4.99%
QR #1 – data submitted for Nov ‘05 - June ‘06
QR #2 – data submitted For Nov ‘05 - Sept. ‘06
• Data becomes more stable as sample size increases
QR #7 – data submitted for Nov ‘05 - Dec. ‘07
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Interpretation:
• Lower and Upper Bound = 95% CI
• Compare your performance (Local Team) to National mean month-over-month
• Compare your performance to CIo if score falls between upper and lower bound = statistically similar
(Jan.’08 – Jun.’08)
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Interpretation:
• Lower and Upper Bound = 95% CI
• Compare your performance (Local Team) to National mean month-over-month
• Compare your performance to CIo if score falls between upper and lower bound = statistically similar
(Jan.’08 – Jun.’08)
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Making Sense of Quarterly Reports
Quarterly Reports - Run Charts
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Above ANC average (poor performance – Med Rec)
Same as ANC average (average performance)
Below ANC average (good performance – Med Rec)
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Quarterly Reports
Interpreting and Reporting Your Results
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Sharing the Quarterly Reports• With who do you (KOCs + Team Leaders)
share the QR info?• Team
• Staff
• Director / Senior Management
• (Board)
Making Sense of Quarterly Reports
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SHN Performance Report – Example 1
Measure: 3.0 Medication Reconciliation Success
Index
Measure: 4.0 Medication Reconciliation at
Discharge
Poor GreatGood
Measure: 1.0 Mean Number of Undocumented
Intentional Discrepancies
Current Qtr = 0.64 Goal = 0.28# Mos. Reporting = 21
Node Qtr = 0.58Nat. Qtr = 0.54
Medication Reconciliation
No DataCurrent Qtr = 92%Goal = 90%# Mos. Reporting = 21
Node Qtr = 89%Nat. Qtr = 93%
Ventilator-Associated Pneumonia
Measure: 1.0 VAP Rate in ICU per 1000 Ventilator
Days
Measure: 2.0 VAP Bundle Compliance
Current Qtr = 0.64 Goal = 0.28# Mos. Reporting = 21
Node Qtr = 0.58Nat. Qtr = 0.54
Current Qtr = 78%Goal = 95%# Mos. Reporting = 10
Node Qtr = 85%Nat. Qtr = 83%
Element: Head of Bed
Qtr.= 97%
Element: Sedation Vacation
Qtr.= 60%
Element: Oral v Nasal
Qtr.= 77%
Element: EVAC TubeNo EVAC
Tubes
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SHN Performance Report – Example 2
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How to Get Answers to your SHN Measurement Questions
• Central Measurement Team
• Safety Improvement Advisors (SIAs)
• Community of Practice
• Faculty members• Clinical advisors
• Improvement advisors
• Conference calls on interventions
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How to Get Answers to your Measurement Questions
• Safety Improvement Advisors (SIAs)
• Community of Practice
• Central Measurement Team
• Faculty members• Clinical advisors
• Improvement advisors
• Collaborative Conference calls
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Questions or More Information
Virginia Flintoft
416.946.8350
G. Ross Baker Alexandru Titeu
416.978.7804 416.946.3103