Tools for Performance Measurement in Health Care:

Tools for Performance Measurement in Health Care: A Quick Reference Guide Second Edition Includes CD-ROM

Senior Editor: Ilese J. Chatman Project Manager: Bridget Lillie Manager, Publications: Paul Reis Editorial Associate Director: Diane Bell Production Associate Director: Johanna Harris Executive Director: Catherine Chopp-Hinckley, Ph.D. Vice President, Learning: Charles Macfarlane, F.A.C.H.E. Joint Commission/Joint Commission Resources Reviewers: Stephen Anderson, Nancy Kupta, Nancy Lawler, Paul Reis, Laurel Shing, Frank Zibert Joint Commission Resources Mission The mission of Joint Commission Resources is to continuously improve the safety and quality of care in the United States and in the international community through the provision of education and consultation services and international accreditation. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of the Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission publication should not be construed as an endorsement of such organization, product, or services, nor is failure to include an organization name, a product, or a service to be construed as disapproval. 2008 by the Joint Commission on Accreditation of Healthcare Organizations Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), has been designated by the Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from the Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 permissions@jcrinc.com ISBN: 978-1-59940-191-1 Library of Congress Control Number: 2008925569 For more information about Joint Commission Resources, please visit http://www.jcrinc.com.

Table of Contents Introduction...v Using This Book...v The Accompanying CD...vi Acknowledgments...vi Chapter 1: Benefits of Performance Measurement Assessment...1 Using Performance Measurement in Performance Improvement... 1 Using Performance Measurement to Promote Improvement Initiatives... 12 The Joint Commission... 12 National Quality Forum... 14 Hospital Quality Alliance (HQA): Improving Care Through Information... 14 Hospital CAHPS (HCAHPS)... 15 Home Health Compare... 15 Nursing Home Compare... 16 Center for Mental Health Services (CMHS)... 16 The Leapfrog Group... 17 Institute for Healthcare Improvement (IHI)... 17 National Committee for Quality Assurance (NCQA)... 18 Using Performance Measurement to Be Proactive... 18 The Next Step... 19 Chapter 2: Navigating the World of Performance Measurement...21 Deciding What to Measure... 21 High-Risk, High-Volume, Problem-Prone Areas... 21 Other Measurable Processes... 23 Prioritizing Projects... 25 Establishing Goals... 28 Setting Up an Effective Team... 28 Composition and Responsibilities of the Team... 28 Team Training... 29 Choosing Measures... 30 Existing Measures from Outside Sources... 30 Understanding Data Needs... 30 Data Availability... 31 Data Accuracy and Completeness... 35 iii

Tools for Performance Measurement in Health Care: A Quick Reference Guide, Second Edition Time Frame for Data Collection... 36 Using Reliable Tools... 36 Using Comparative Data to Set Performance Goals... 38 Internal Benchmarking... 38 External Benchmarking... 38 Setting Your Goals... 40 Chapter 3: Measuring Up with the Right Tools...57 Tools for Team Planning... 57 Brainstorming... 57 Flowchart... 60 Cause-and-Effect Diagram... 63 Tools for Data Collection... 65 Checklist... 65 Check Sheet... 66 Survey... 70 Tools for Data Analysis and Presentation... 73 Boxplot... 73 Data Distribution... 73 Measures of Central Tendency... 73 Variation and Standard Deviation... 74 Comparison Chart... 76 Risk Adjustment... 76 Variation Across Units... 78 Control Chart... 79 The Types of Control Charts... 82 Histogram... 87 Line Graph... 89 Pareto Chart... 92 Run Chart... 94 Stratum Chart... 96 Balanced Scorecard/Dashboard Display... 99 Radar Chart... 100 Performance Matrix... 103 Stratified/Multivariable Display... 104 Chapter 4: Understanding Standardized Performance Measures and Future Goals... 109 ORYX and Accreditation... 109 Core Measure Sets...112 Requirements for Organizations...116 Quality Check...117 The Future...118 Glossary...127 Index...133 iv

Introduction There is an adage that says numbers don t lie, although in the case of preventable health care errors in the United States, many people wish they did. When the Institute of Medicine released its 2000 report on preventable medical errors and the need for a more comprehensive approach to patient safety, it estimated that 98,000 Americans may die each year due to such errors. 1 Data from other sources have not been encouraging. The Institute for Healthcare Improvement estimates that nearly 15 million instances of medical harm occur in the United States each year a rate of more than 40,000 per day. 2 Perhaps most disturbing of all are the recently published results from a study sponsored by the Commonwealth Fund and conducted by researchers from the London School of Hygiene and Tropical Medicine. Data from 19 countries, including the United States, Japan, Australia, New Zealand, Canada, and western European countries, were compiled and analyzed first between 1997 and 1998 and then again between 2002 and 2003 to determine the number of deaths in subjects under 75 years of age that could have been prevented by timely and effective medical care. In the first part of the study, the United States finished 15th, with a mortality rate of 114.7 deaths per 100,000 people; by the second part of the study, the United States had fallen to last place, with a rate of 109.7 per 100,000. The U.S. decline in preventable deaths was only 4%, whereas the other countries in the study experienced an approximately 16% decline (first place: France s rate was only 64.8 per 100,000). The researchers estimated that anywhere from 75,000 to 101,000 lives could have been saved in 2002 alone if the United States had achieved either the average rate of all the other countries or the average of the top three performing countries (France, Japan, and Australia). 3 The quality of care delivered by health care organizations has long been a subject of debate among facilities, clinicians, insurers, and patients. However, the 1990s saw this topic rise to national prominence due to a wide variety of factors, including the following: Skyrocketing health care costs The merging, acquisition, reorganization, and restructuring of all types of health systems and facilities Highly publicized reports of medical errors such as wrong-site surgery and medication overdoses Increasing demands from third-party payers and employers for increased efficiency, waste reduction, and reduced costs An increased emphasis on patient involvement in responsibility for care A public that was better educated than ever before thanks to the growing availability of health care related information via the Internet and other sources Government agencies, accrediting bodies, health care systems, professional associations, and private organizations all struggle with how to define high-quality care and how tp achieve it effectively and affordably. The interest in how well health care organizations provide clinical and support services has led to calls for greater transparency and better reporting of performance levels. Many government and private entities are working to facilitate the sharing of performance data and to establish standards of care to educate the field and the public. Using This Book Health care professionals are in the habit of collecting and interpreting medical data, such as red blood cell count or milligrams of a medication to use for patients, but when it comes to data related to processes and performance, vision v

Tools for Performance Measurement in Health Care: A Quick Reference Guide, Second Edition can be blurred. What is performance measurement? When is it used? How do you know what to measure? What good will measurement do? How do you go about setting up a measurement process? How does measurement relate to performance improvement? What are the best ways to collect and analyze data? This book will lead you through the sometimes confusing process of gathering and interpreting data, showing you the many tools and techniques available for each step in the process and providing guidelines as to which tools are appropriate at different stages. It will also help you see how performance measurement can be integrated into in fact, is probably already a part of your organization s existing improvement and quality activities. Chapter 1 introduces you to performance measurement and how it forms the basis of both internal and external performance improvement initiatives. The proactive use of measurement and the importance of involving leaders and clinicians in measurement and improvement activities are also illustrated. Chapter 2 examines the practical aspects of preparing for performance measurement, including identifying what should be measured in a process, setting goals, putting together a project team, and determining how to manage data. Chapter 3 is the heart of the book. Examples of tools for planning, data collection, and data analysis and presentation are presented, with details of how to use them, when to use them, and their benefits and drawbacks. Chapter 4 discusses The Joint Commission s current and future goals for performance measurement, including the ORYX core measure sets for hospitals, measures for diseasespecific care certification, and how Quality Check uses performance data in its reports on accredited organizations. Case studies showing how actual health care organizations use various tools as part of their measurement and improvement activities are scattered throughout the book. The Accompanying CD Many of the tools in this book are also available on the accompanying CD. The Check the CD symbol in the book indicates that the particular topic and tool can be found on the CD and can be printed or adapted for your own use. When you use the CD, you will also See the Text symbol which indicates that the topic is covered in more detail in the book. Refer to the appropriate chapter for additional information on how to use or re-create a specific tool. Acknowledgments Joint Commission Resources sends our thanks to Karen Steib for writing this book. We also thank Joint Commission reviewers Stephen Anderson (Joint Commission Resources consultant), Nancy Kupta, Nancy Lawler, Paul Reis, Laurel Shine, and Frank Zibrat for their indispensable knowledge and insight on this topic. A special thank you from Joint Commission Resources is extended to the following health care organizations that allowed us to feature their examples and tools in this book: Brattleboro Memorial Hospital 17 Belmont Avenue Brattleboro, VT 05301 Diversified Clinical Services 4500 Salisbury Road, Suite 490 Jacksonville, FL 32216 Pekin Memorial Hospital 600 South 13th Street Pekin, IL 61554 Riverside Methodist Hospital 3535 Olentangy River Road Columbus, OH 43214 References 1. Committee on the Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000. 2. Institute for Healthcare Improvement: Overview of the 5 Million Lives Campaign. http://www.ihi.org/ihi/ Programs/Campaign/Campaign.htm?TabId=1 (accessed Jan. 5, 2008). 3. Nolte E., McKee C. M.: Measuring the health of nations: Updating an earlier analysis. Health Affairs 27(1):58 71, Jan./Feb. 2008. vi