Process and Outcome Measures Lynne Hall

 State why Process Measures are important to data gathering  Outline the use of Process Measures Process and Outcome Measures Objectives

 CMS has changed the format of what is expected from Critical Access and Small Rural Hospitals  GHAREF HEN must submit evidence of participation in all 10 Core Events  CAH’s and Small Rural hospitals will now need to change their focus to include the 10 Core Events What is expected for Measures for GHA HEN:

Z Hospital does not provide services related to this HAC 0 Providing services to which the HAC is relevant, but is not participating 1 Engaged in work related to HAC, but not submitting data 2 Engaged in work related to HAC AND submitting data 3 Outstanding improvement or sustained high performance (data for validation submitted to HEN) 4 Potential mentor hospital - achieved highest possible level, now pushing for related care improvement Scoring of HEN CAH’s and Small Rural Hospitals

PERCENT OF RURAL HOSPITALS AT STATUS 2, 3 or 4 Participating and Submitting Data

PERCENT OF RURAL HOSPITALS AT STATUS 0 OR 1 Not Participating or Not Submitting Data

Percent of Rural Hospitals at Status 3 or 4 Outstanding Performance

 Understanding process and outcome measures is one key factor  Getting your teams together to look at problem areas  Know your data and how to collect and access it  Celebrate success  All teach – all learn How can we move forward?

 Processes lead to Outcomes  Both are important  Measure both in healthcare How do you determine what is a process measure and what is an outcome measure?

 To determine if a process is stable  Manage the process measures  To determine if the processes that lead to the outcomes are functioning effectively and efficiently  Process measures tend to be real time Process Measurement

 There will always be inherent variation in every system component  Because all the work is accomplished in processes, it is possible to obtain measurements of key performance indicators Process Measurement

 By definition it is the results of processes  Offers findings that can used to adapt, improve, and become more effective  Outcome measures tend to tell us if our process is working Outcome Measures

 Process: How the system works  Outcome: The final product, results Quick Version

I drive to work:  Process Measures:  What route did I take to work?  How did I arrive: bus, train, car?  When did I leave? Simple Example

I drive to work:  Outcome Measures:  How many times did I make it to work on time?  How long did it take me to drive to work? Simple Example:

Diabetic Patient  Process Measures:  How often does the patient correctly give themselves insulin?  Does the diabetes team visit all in-patient diabetics? Clinical Example

Diabetic Patient  Outcome Measures:  Is A1C within range for diabetic patient?  How often are the readmitted for the same diagnosis? Clinical Example

The following are either process measures or outcome measures: 1.Number of CHF patients that visit the ED? 2.What percentage of staff have received their flu vaccine? 3.How many of your diabetic patients receive yearly foot exams? 4.How many of smokers have quit smoking? Test your knowledge:

 Process and Outcome measures are both important in looking at your measurements  There will always be variability with your system – this is normal to an extent  Watch for outliers or special causes for data variance Conclusion:

1.Go to Hover over Quality and Health 3.Click Hospital Engagement Network Submitting EED Data

1.Click on Learning Collaborative Submitting EED Data

1.Click on OB Adverse Events Submitting EED Data

1.Click on meetings Submitting EED Data

1.Click on Data Measurement collection tool Early Elective Deliveries Submitting EED Data