1. CHAPTER 5: PROMOTING ACCOUNTABILITY THROUGH MEASUREMENTS Jamie Duffy ETM 568/ Dr. Burtner

2. Presentation Summary Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz 2  Acronyms  Levels of Accountability  Case Example: Self-Extubation  Getting the Doctors on Board  Analyzing Errors  Overview

3. Acronyms 3  ACS- American College of Surgeons  AHRQ- Agency for Healthcare Research and Quality  APACHE-Acute Physiology, Age and Chronis Health Evaluation  CEO- Chief Executive Officer  CMS- Centers for Medicare and Medicaid Services  ED- Emergency Department  ICU- Intensive Care Unit  JCAHO-Joint Commission on Accreditation of Healthcare Organizations  LOS-Length of Stay  NYS DOH- New York State Department of Health  OR- Operating Room  PDCA-Plan Do Check Act  PIGG- Performance Improvement Coordination Group Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

4. Levels of Accountability 4 Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz Board of Trustees Committee on Quality System Performance Improvement Coordinating Group (PIGG) Site-Specific PIGG Site Service Line Meeting Unit-Specific Review of Data System Medical Executive Committee Site-Specific Medical Boards System and Site Administration System and Site Nurse Executive Figure 5.1. Levels of Accountability High level management Middle level management Low level management

5. Case Example: Self-Extubations 5  Decrease patient self-extubation in ICUs  PDCA methodology  Specific goals for improvement: Standardize critical care quality indicators for monthly collection and analysis Develop admission and discharge criteria for the ICU Improve and monitor nursing competency Formalize protocols  Leadership support was crucial Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

6. Getting the Doctors on Board 6  Mortality rating has an impact of doctor reputation.  Financially punished for never events.  Held to national standards of patient safety. Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

7. Analyzing Errors 7  Continuously measuring care allows for data to alerts leadership when a process is beginning to fail.  A root cause analysis is used to identify the causes of the event and processes can be implemented in place to improve.  Cause and effect (fishbone or Ishikawa) diagram illustrates how various factors impact a result.  Must mandate that the hospital present a corrective action plan to alert the problem. Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

8. Overview 8  Accountability is promoted when leadership can evaluate the delivery of care.  Physicians must be held to an objective standard.  It is important that even nonclinical staff must understand their role in the process of care.  The use of measurements must determine gaps in patient safety and then monitor improvements. Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz

9. THANK YOU! 9 Measuring Health Care: Using Quality Data for Operational, Financil, and Clinical Improvement by Yosef D. Dlugacz