How to collect monthly and quarterly quality indicators and enter data on-line Residential Care Program (click on the ▼button to continue this presentation)

Why collect indicators? An indicator is a sign or a signal. They provide us with warning about: –Changes with individual residents –Patterns that may be emerging in new or repeated incidents for individual and groups of residents –Impact of new processes, or changes in the environment (both positive and negative). Indicators do not tell us what to do. Their job is to send us a signal as to where and when to look further.

Why collect indicators? We need to collect indicators so that we can: –Monitor that our processes are effective –Address problems before they become critical issues –Demonstrate that improvements we have made are making a difference

Quality Indicators at IRT At IRT, we collect clinical (care) and management indicators on a monthly and quarterly basis. A group, or set of these indicators are then benchmarked to other like services within and outside IRT. Not all indicators we collect are entered into the MOA program-some are monitored within IRT only.

Quality Indicators QHow do I know what indicators are collected by IRT? 1. Read the MOA Continuous Quality Improvement Guide, which can be found in hardcopy in every service and on line via the MOA Resources page on the IRT Intranet.

2. Download the monthly printable package from the website Note-you can only do this if you have the appropriate authority from your manager, and your service’s password. The package can be downloaded by: –Going to My MOA once you are logged in –Select Data Entry –Select the service/unit you wish to download the package for –Select the appropriate month (eg March 2007) –Click on Printables, –Select Blank QI Data Collection Sheets –Click on Print Preview –The document will then download from the web for printing

See below

Example of the data collection sheet MOA Program Quality Indicators and Audits completed will be different from residential to community services

Quality Indicators Q How do I know how to collect the data, and where from? This information has been provided in the CQI Guide. See Section 3 and 4 of the manual.

Finding definitions of indicators

Example of an indicator definition How often What is included Why we collect it Where it can be collected from

Example of an indicator definition References and useful websites that can be used for further research, and for quality activities. This is updated annually.

Summary of Care related indicators The areas of collection of data for residential services are as follows: Aggression Falls Infection(plus additional quarterly data) Skin Integrity Medication Management (plus additional quarterly data) Restraints

Summary of Indicators collected quarterly The areas of collection of management data for residential services on a quarterly basis are as follows: Compliments and Complaints Suggestions for Improvement Resident/Rep involvement in care Review of Care Human Resources

How do we collect management indicators? See the CQI for guidance, but generally we use things such as: Letters or phone calls recorded regarding compliments and complaints. Completed suggestion forms, staff meeting minutes, resident meeting minutes. Resident meeting schedule and minutes Care plan review schedule and record of completed reviews More information can be found in Section four of your MOA CQI Manual.

Collecting Clinical (Care) Quality Indicators Clinical Quality Indicators are usually collected on one of the following forms: –Resident/Client Aggression Incident Form –Resident/Client Accident/Incident Form –Wound Reporting Form –Infection Incident Reporting Form –Restraint Monthly Summary Form –Medication Incident Report Form

IRT Clinical Indicator Database We enter the details of incidents into our IRT clinical indicator database for the following areas: –Aggression –Falls –Medication Incidents –Infections –Skin Integrity issues –Other care related incidents (eg burns, absconding etc)

IRT Clinical Indicator database

Enter the resident details

Enter the incident type and details-the same fields as the incident form

Collecting information for MOA At the end of each month and/or quarter, we run reports from the database so that we can enter the care related indicators into MOA.

Report generated This report can be generated at any time, so rather than looking through files, if incident forms are completed proomptly, supervisors and managers can log on to get a summary of what has been happening for the week or month per area, incident type, and individual resident.

So Be Prepared and don’t leave data entry until it is too late! Do you know who is responsible for data entry of incidents at your service?

IRT Clinical Indicator Database For further information about how to use the database, see your manager/supervisor about gaining approval for an access code. The database has an online guide which can be accessed once you log onto the program.

Before entering the data on-line Q Have all relevant incident reports for the month been reviewed by the relevant Manager? REMEMBER, the administration staff are not trained to interpret care incidents. Forms must be completed right the first time. QHas the data from these forms been entered into the IRT clinical indicator database (as relevant)?

Before entering the data on-line QIf quarterly data is due, has it been extracted from the quarterly report (for infection and medication management) and via other means as outlined in the CQI manual? QHas the relevant Manager or designated person reviewed the indicator data collected? If a number does not look “right” it might need to be double checked. QAny missed indicators on the data collection sheet? Even if the number is 0 for the month or quarter, this still needs to be entered.

On-line entry of indicator data 1.Log on with your logon name and password provided by MOA and go to the MOA website via the IRT intranet and go to My MOA. 2.Go to the relevant service that you wish to enter the indicator data for-make sure that the member number on the screen corresponds with the one on your data sheets if you enter for more than one service or unit. 3.Go to Data Entry (under Audit Program) 4.Select the relevant month’s package 5.Go to the Data Entry section at the top of the page

MOA on-line audit data entry Select the monthly clinical (care) indicators sheet. If quarterly indicators are due a separate sheet will be in this section. This column shows you % completed. You can save the data entered and come back to it later if you need to-this must be 100% before you sign off the package,.

MOA on-line indicator data entry Select the sheet Tells you the % complete-it should be 100% when you have entered all data.

MOA on-line audit data entry Enter data here, tab down to the next box Check the definition for the indicator by clicking on the question mark. Staff feedback about indicator improvements can be given by clicking on the star-the information goes straight to MOA and is used in its annual review of indicators.

MOA on-line audit data entry Remember to click on save! It will take you back to the beginning of the package. You can also click save at any time and come back to completing the data entry-it will save what you last entered.

MOA on-line indicator data entry Once you have completed data entry for all of the audits, and the quality indicators you need to “sign- off” the package. This tells the program that your data is ready to generate reports, and no more data till be entered. If you “sign-off” accidentally and have not completed entering all of the information, or you want to change it, contact MOA to unlock the package- before the 15 th of the month!

Signing off the package These should ALL be 100%

Problems with entering your data? Contact MOA during business hours on: | Phone:

Lets check what knowledge you have gained … What is an indicator? Why do we collect indicators? What indicators do we collect at IRT? How can I find out how to collect an indicator? How often do we collect indicators? What forms are used to collect clinical indicators? Where are the details of clinical (care) indicators entered? How do I enter indicator data on-line?

Printing Quality Indicator Reports If you would like to watch the powerpoint presentation for further instruction on Printing Reports, go to the MOA Resources page on the IRT Intranet.

Goodluck You can do it!