1 Kathie Viers-City of Hope Eric Presson- Baylor Health Care Systems Jennifer Christian-Markay Cancer Center
2 Discuss Quality dashboards as auditing and Reporting Methods for Quality Management Provide examples of Administrative/ Operational and Clinical Dashboards in different size transplant organizations Discuss Auditing and Reporting Methods for Quality Management though use of Dashboards.
3 What is a Dashboard? What should it display? How do I use it? Why Now? What are common Issues Survey results How do other centers use Dashboards? What are Core measures for transplant programs?-what s going on?
4 Government and other regulatory reporting requirements- Show me the Data Payer and Accreditation organization requests for information and Standards compliance Show me the data Report to High level Administrative boards Show me the data Monitoring patient safety and quality of the care we provide our patients. WOW
5 Driving for Quality in Acute Care: A Board of Directors Dashboard Government Industry Roundtable On November 10, 2008, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services and the Health Care Compliance Association (HCCA) cosponsored government industry roundtable called Driving for Quality in Acute Care Dashboards were recommended as means to assess and oversee an organization s performance based on quality of care metrics.
7 A Dashboard is designed to display data, be intuitive and simple expanding data access from highly trained data analysts to the casual user. Insight from the dashboard is used to determine program viability, identify areas for improvement, make changes, and reallocate resources if necessary. Goals are to track data, improve operational and clinical performance and promote accountability and transparency
8 Data Display
9 Determine Key objectives or areas for display Develop Key performance indicators/measures for areas related to structure, process and outcomes. Select best practice benchmarks externally and or internally. Develop scorecard, monitor/audit overtime. Use Quality management principles to Identify areas which require Closer look exceed or below benchmark. Focus on High risk High volume indicators. Use Quality Management principles of process mapping and step analysis to develop an improvement plan or document acceptable outcome
10 1. Do you utilize a dashboard for monitoring key performance indicators Do you utilize a dashboard for monitoring key performance indicators 12.8% 5.1% Yes No 82.1% In development 2. Are you: an administrator/ quality specialist/ department manager/ Other 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 32.4% Are you % 10.8% 8.1% 0.0% an administrator a quality specialist a department manager other
11 3. What is the volume of transplants performed annually at your center? 5.3% What is the volume of transplants performed annually at your center? 15.8% 28.9% % 23.7% greater than Do you use a quality dashboard for reporting during quality meetings 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Do you use a quality dashboard for reporting during quality meetings 22.2% 66.7% 13.9% 5.6% monthly quarterly annually other
12 5. Describe your dashboard focus 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Describe your dashboard focus 67.6% 40.5% 8.1% Clinical Administrative/operational Combined What is the biggest challenge you feel in using the dashboard effectively 6. What is the biggest challenge you feel in using the dashboard effectively 28.2% 7.7% 17.9% Getting internal data getting external benchmarks selecting meaningful indicators 46.2% other
13 7. Do you feel the use of a dashboard has led to identifying a need for improvement or has led to improvements in your transplant program Do you feel the use of a dashboard has led to identifying a need for improvement or has led to improvements in your transplant program 44.7% yes 55.3% no 0.0% unsure
14 Getting external benchmarks 46.2% Selecting meaningful indicators 28.2% Getting internal data 17.9% Our Challenges continue to be: Developing Quality Management Programs which includes the selection of Key performance indicators based on regulatory and accreditation requirements and program needs. Working to develop internal quality reporting data systems Collaborating to identify core measures for transplant programs for external benchmarking
15 NMDP - National Marrow Donor Program CIBMTR Center for International Blood & Marrow Transplant Research-Stem Cell Therapeutic Outcomes Database(SCTOD) ASBMT-American Society for Blood and Marrow Transplantation C4QI Comprehensive Cancer Center Consortium UHC University Healthcare Consortium https://www.uhc.edu/ BMT Quality Roundtable Googlegroup
16 Kathie Viers RN,BSN,MS CPHQ HCT Regulatory/Quality Compliance Specialist Department of Quality, Risk, and Regulatory
17 City of Hope is a National Cancer Institute designated Comprehensive Cancer Center. Recognized for translating basic laboratory research into innovative patient care. The Hematopoietic Cell program is the largest provider of Blood and Marrow Transplantation (BMT) in California Over transplants completed, More than 600 BMT procedures performed annually. Adult and Pediatric transplant programs AUTO, ALLO, URD, CORD, Haplo Only center for 9th year in a row, to perform above expectations according to the Stem Cell Therapeutics Outcomes Database.(CIBMTR) transplant outcomes data.
18 Volume Length of stay Readmissions Cost/Payer contracts and reimbursement Staffing and staff competency Coding and documentation compliance Electronic Medical Record Development and use Utilization
19 Some Key Clinical Performance Indicators Total transplant volumes by type and cell type Other cellular therapy-dli, HPC., volume and outcomes Length of stay by transplant type Readmissions within 30 days of discharge Marrow collections volume, AE, product cell counts, recipient outcomes Mortality -30, 100, and 1year, Treatment related(non-relapse). Engraftment, by transplant and cell type, ANC and Platelet, median time to engraftment Patient satisfaction Press-Ganey-Transplant survey, case management discharge survey, donor followup reports. Critical event/quality reviews- Adverse events, ICU admits, data audits Trans Med Service indicators: collection, processing and administration and infusion, mobilization, positive microbial reports. Known Complications GVHD,ECP for GVHD, Infectious disease monitors. Chemo-verification procedure audits, ADR s. Donor and recipient screening and consent Support Service reports and focus compliance audits
20 Indicator Engraftment ANC Time to engraftment Autologous Time to ANC engraftment ALLO Sib/MRD Time to ANC engraftment MUD Benchmark >95% of HCT by Day % 10-11days 100% days 100% days
21 Treatment Related Mortality Benchmark Treatment Related Mortality- Autologous Scorecards Transplant Indicators related Mortality-ALLO- benchmarks SIB/MRD <5% day +100 Day <10% day +100 Day Overall TRM (Non-relapse Mortality)100 Days Dashboard Graphs TRM 100 Days
22 Do we need Core measures (Indicators)for Blood an Marrow Transplant Program Quality reporting and standardize for External Benchmarks? Does it matter how you display and or report your data internally? Do we need to collaborate and support each other?
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