1. Quarterly Reports for SHN’s Interventions Understanding and Using the Data to Guide Performance December 10, 2008 Virginia Flintoft, RN MSc SHN! Central Measurement Team

2. 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.

3. SHN Performance Reports Data In … Sending your results to Central Measurement Team

4. Submitting Data from a CoP Send you data from ANY COP Click on “SHN Data Submission Home “ button to get to data submission screen

5. 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

6. SHN Performance Reports Data Out… Reports you get from Central Measurement Team

7. 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

8. Collaborative Performance Reports Monthly Reports Data in – 25 th 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

9. Oct. Data Submission Cut-off ANC Report Distributed Next ANC-Report Dec.5

10. ANC Reports ANC-Report format ANC – Report # Date data submitted Months reported* 1 Nov’08June ’08 – Oct.’08 2Dec.’08June ’08 – Nov.’08 3Jan.’09June ’08 – Dec.’08 4Feb.’09June ’08 – Jan.’09 * Cumulative report

11. Collaborative Performance Reports Monthly Reports for ANC Rate of Undocumented Intentional Discrepancies Rate of Unintentional Discrepancies Percent Residents Reconciled on Admission

12. SHN Monthly/Quarterly Reports What to make of your results - Interpreting the Monthly/Quarterly Reports

13. The Basics Data submission cut off for ANC-Reports 25 th of each month ANC-Reports issued Week following data submission cut off Sent to Dannie and Theresa for distribution to teams ANC Collaborative Reports

14. 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)

15. Warning - Small Sample Size... 5 or less – results unreliable Examples of Small Sample Size...

16. 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

17. 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

19. 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 25 th – 75 th percentile – of all teams reporting data for that month X% have a lower score than the specific percentile rank.

20. Quarterly Report format 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

21. Interpretation: Lower and Upper Bound = 95% CI Compare your performance (Local Team) to National mean month-over-month Compare your performance to CI o if score falls between upper and lower bound = statistically similar (Jan.’08 – Jun.’08)

22. Interpretation: Lower and Upper Bound = 95% CI Compare your performance (Local Team) to National mean month-over-month Compare your performance to CI o if score falls between upper and lower bound = statistically similar (Jan.’08 – Jun.’08)

23. Making Sense of Quarterly Reports Quarterly Reports - Run Charts

24. Above ANC average (poor performance – Med Rec) Same as ANC average (average performance) Below ANC average (good performance – Med Rec)

26. Quarterly Reports Interpreting and Reporting Your Results

27. 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

28. SHN Performance Report – Example 1 Measure: 3.0 Medication Reconciliation Success Index Measure: 4.0 Medication Reconciliation at Discharge Measure: 2.0 Mean Number of Unintentional Discrepancies Current Qtr = 0.09 Goal = 0.09 # Mos. Reporting = 21 Node Qtr = 0.68 Nat. Qtr = 0.63 PoorGreatGood Measure: 1.0 Mean Number of Undocumented Intentional Discrepancies Current Qtr = 0.64 Goal = 0.28 # Mos. Reporting = 21 Node Qtr = 0.58 Nat. Qtr = 0.54 Medication Reconciliation No Data Current 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 = 0.58 Nat. 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 Tube No EVAC Tubes

29. SHN Performance Report – Example 2

30. 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

31. 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

32. Questions or More Information Virginia Flintoft 416.946.8350 virginia.flintoft@utoronto.ca G. Ross Baker Alexandru Titeu 416.978.7804 416.946.3103 ross.baker@utoronto.ca shn.ea@utoronto.ca