JHM Patient Safety & Quality Dashboard. Quick Start Guide

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1 JHM Patient Safety & Quality Dashboard Quick Start Guide

2 JHM Patient Safety & Quality Dashboard Quick Start Guide This guide will walk users through how to access and navigate the JHM Patient Safety & Quality Dashboard, drill down for enhanced details, and utilize third party resources for subject matter clarification. If additional assistance is needed, please submit a Technical Support Ticket. Launching the JHM Patient Safety & Quality Dashboard Access to the dashboard is only available within the JHM network. Click the Launch button on the Dashboard Landing Page to access the web-based dashboard. The dashboard will open in a separate window. Users will be prompted for their JHED authentication prior to accessing the dashboard. Other Resources found on the website landing page: Scope of the initiative Contacts Alerts and Updates Training Documentation Support and Feedback form General Tips for accessing data within the dashboard Click the buttons adjacent to the hospital names to toggle the visibility of a hospital s data within all four summary graphs Click Details to drill down and view more detailed information about a metric Click on links located within pop-up windows to view additional information and insight into a metric Hover over a data point on a graph to display the series name as well as x and y values Click Reset on the summary view to refresh the dashboard back to its initial state Print the dashboard by clicking on the Printer icon in the upper right-hand corner Access additional tips by clicking the blue i buttons located throughout the dashboard. 1

3 A Dashboard Walkthrough Hospital Level Summaries Upon entering the dashboard, users are presented with summary views of key metrics aggregated at the hospital level. 1. Hospital Core Measures a. For each of the five hospitals, the dashboard reflects the percentage of measures that have achieved or surpassed 96% performance for each month. b. More information on the Core Measures can be referenced directly from The Joint Commission's website. 2. Central Line-associated Bloodstream Infections (CLABSIs) in the ICU a. A Standardized Infection Ratio (SIR) is calculated for each hospital. b. The SIR is a comparison of the observed number of infections to the expected number of infections. The expected number of infections is calculated by multiplying the central line days in each unit by the NHSN benchmark (pooled mean infection rate) for that unit. The calculation is as follows: SIR Observed # of CLABSIs Expected # of CLABSIs Observed # of CLABSIs Unit s Device Days National Rate/1000 c. More information on CLABSI can be referenced directly from the CDC's website. 3. Inpatient Hand Hygiene a. The percent compliance with hand hygiene procedures, as collected by secret observers, is shown for all five hospitals. 2

4 b. More information on efforts to improve Hand Hygiene compliance can be referenced at Hopkins Hands. 4. Patient Experience of Care a. The results presented are extracted from the patient satisfaction surveys given to patients after being discharged from the hospital. The subset of questions within the survey required by the Centers for Medicare & Medicaid Services (CMS) are referred to as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). b. The percentage of patients that rated the hospital a 9 or 10 (on a scale of 1-10) are shown for all five hospitals. c. More information about Patient Experience of Care can be referenced at Service Excellence's Because We Care. Along the left side of the window is a sidebar that contains informational links and direct access to the Support and Feedback form. The Hospital Key located in the upper left-hand corner of the dashboard contains clickable buttons that toggle the visibility of a hospital s data on all four summary graphs. The color of the button corresponds to the series color for all four metrics. At any point the Reset button can be clicked to refresh the summary tables and drill downs to their original state. Each graph represents the key metric aggregated at the hospital level. Hovering over a series label will display the series name and values for that data point. Clicking on the Details button will allow users to see greater detail about the metric, including data at the service and unit level. Some graphs have blue i buttons for more insight about that metric. Details: Individual Metric Drill Downs The Core Measures Drill Down provides users with data across all hospitals down to the individual measure level. In the top left corner of this window, users are able to select the specific hospital for which they would like additional detail. This immediately updates the graph to the right, displaying a summary of the measure sets for the highlighted hospital. The selection labels located above the hospital summary graph allow users to Core Measures 3

5 toggle between how the Core Measures are presented at the measure set level. The screen initially defaults to Percentage of Measures Meeting 96% Performance Target, defined as the percentage of measures within a month that were at 96% or higher compliance for that month. By switching to Compliance Rates for Measures within a Measure Set users see the current percentage adherence within a month for each measure set. In the lower portion of the window users can select a measure set and the component measures will update within the adjacent table. This table displays each measure within a set along with its cumulative calendar year to date rate (%), the most recent month s rate (%) and a cumulative calendar year to date number of cases evaluated. By selecting a specific measure in the table, the lower right-hand graph is updated to display its results across a twelve month period. The green line represents the 96% benchmark all measures need to achieve. Users can click on Core Measure Descriptions to see more information about measure sets and the measures that make-up the set. The pop-up displays each measure set, its name, the measures within the set and the measure s description. Additional information can be accessed on The Joint Commission s website with the link provided in the lower left-hand corner. To get back to the Drill Down, click Close in the lower right-hand corner. Clicking the X in the upper right-hand corner on the Core Measures Drill Down, or any other Drill Down, will take the user back to the main summary view. Central Line-associated Bloodstream Infections in ICUs For the CLABSI drill down, after selecting a hospital, the ICU types within that hospital will be shown. The three potential classifications displayed are Adult, Neonatal, and Pediatric. Once a unit type has been selected, users can view the SIR or rate of individual units on the lower half of this drill down. A unit s rate will be calculated as follows: Rate Confirmed CLABSIs 1000 Device Days 4

6 Note: If users have drilled down to a unit or unit type, and then switch to a hospital where that unit or unit type does not exist, the selections will clear and no data will be shown. Select a possible unit type to continue the review. In the lower right-hand portion of the CLABSI Drill Down is a quarterly scorecard for the units within the unit type selected. Clicking the dropdown directly below the Unit Selection box displays the data for each quarter. The first column of the scorecard shows the unit name and a Performance Indicator that allows for a quick visualization of CLABSI performance. If a unit s rate for the selected quarter is above its NHSN benchmark the Performance Indicator will be red. If the unit s rate is at or below the NHSN benchmark, the Performance Indicator will be colored green. The final two columns of the scorecard show the numerator (confirmed CLABSIs) and denominator (Total Central Line Days) for the selected quarter. Inpatient Hand Hygiene Users can select a hospital to display that hospital s percentage compliance over a twelve month period. The green line represents the 85% system-wide goal. An additional feature for this metric are the fuel gauges on the righthand side of the drill down. By selecting a specific data point within either chart, the fuel gauge will update to reflect the percentage compliance for that month, as well as its performance relative to JHM benchmarks. The title and data within the fuel gauges will update for each data point selected. Located above the bottom graph are selection labels that allow users to toggle between viewing data at the Unit or Service level. Note: Howard County General Hospital does not have service designations at this time. The 85% system-wide goal will update to 88% for FY

7 This Drill Down shows Patient Experience of Care data at the hospital and unit level, as derived from the HCAHPS survey responses. Users select the hospital and unit of interest in the left most selection panes to update the scorecards in the middle of this drill down. Patient Experience of Care These tables reflect hospital and unit performance at a domain level. A domain is the aggregation of survey questions that target specific performance areas. To read more about the HCHAPS survey, users are encouraged to click the link or Domain Details button in the lower left-hand corner of the window. The Domain Details button will display more information about the domains and their respective questions. The two data sets graphed for a domain level are Percent Top Box and total responses. Percent Top Box represents the percentage of survey responses indicating the best answer possible on a given question. The data presented in this Drill Down are unadjusted. Survey results are based on the discharge date of the patient and reflect the patient s last unit prior to discharge. A patient has one year from the date of discharge to submit their survey and therefore values may change over time. 6

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