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					SSM Health Care

Category 4:
Information and
Analysis
    Information and Analysis

   The MBNQA Information & Analysis
    criteria
   SSM’s approach to information
    management and measurement
    – Information systems infrastructure
    – Performance Management Process
    – Use of comparative data
MBNQA Categories

1. Leadership
2. Strategic Planning
3. Focus on Patients, Other
   Customers, and Markets
4. Information and Analysis
5. Staff Focus
6. Process Management
7. Results
Malcolm says…..
                                                                    Baldrige National Quality Program




                      1995 Average Category Scores
                 70
                 60
 Percent Score




                 50
                 40
                 30
                 20
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                                     HR                                         7
                                  4                                                                                         Health Care
                                                Categories                                                                  Education
                                                                                       Percent Score




                                                                                  20
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                                                                                                      60
                                                                                                           70
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                                                                                                                                                                                   Malcolm says…..




                                                        rc
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                                                                                                                                               Baldrige National Quality Program




                                                                      es
                                                                        ul
                                                                          ts
                                                                                                                1999 Average Category Scores




                              Service


Education
                Health Care
                           Framework
                         Organizational Purpose:
                 Environment, Relationships and Challenges




                   2: Strategic         5: Staff Focus
                     Planning

                                                             7: Organizational
1: Leadership                                                  Performance
                                                                  Results
                   3: Focus on            6: Process
                  Patients, Other        Management
                    Customers
                   and Markets



           4: Measurement, Analysis and Knowledge Management
MBNQA Category 4
INFORMATION AND ANALYSIS
Performance Measurement/Analysis
   Select and align measures
   Gather/integrate data to support daily
    operations/decision making
   Ensure effective use of comparative data
   Analyses to support leaders’ review and
    strategic planning
   Communicate results to enable effective
    decision-making
   Align results of analysis
MBNQA Category 4
INFORMATION AND ANALYSIS
Information Management
   Make needed information available
    to all stakeholders
   Ensure data integrity, reliability,
    accuracy, timeliness, security,
    confidentiality
   Ensure hardware/software
    reliability and user-friendliness
   Keep system current with health
    care needs
SSM Information Center (SSMIC)



    2002 recipient of the Missouri Quality Award
                                        Applications
               Client Response Center   development    Decision
                                                       support


 Information                                                       Compliance
  technology                                                      Administration
                                                                     Group
IS Planning and Management
 L
 I
 S
          Vendors /                SSMHC System Strategy
 T       Consultants
 E
 N
 I
          Network /
 N        Entity IMC                                                   Capital
 G                                        System
                                                                      Allocation
                                            IMC
 P          Nursing                                                   Committee
 O        Informatics
 S
 T   I
     N      Medical
 N   P    Informatics                                                  Entity
 E   U                                      SSM                        Service
     T
 E                                      Information                     Level
 D   S    e-Health /
                                           Center                    Agreements
 S         Web IMC
 A
 S
 S          HIPAA
 E                      Tactical        Operational        Project
 S                       Teams            Teams            Office
 S         Revenue
 M
            Cycle
 E
 N
                                                                       Plan / Check
 T
 S           ePMI          Entity Membership
                                                                         Do / Act
         Network/User
         Group Teams
Physician Connectivity
Access Anytime, Anywhere…
    Hospital 1




                                   E-mail access
     Hospital 2
                                       SSM Physician Portal
                     SSM Connect

                                       Lotus Notes access
   Hospital 3, etc

                                        Fax machine
                                   *
                                          Pager

                                          Hand-held PDA
              Our Mission




Exceptional patient, employee, and physician satisfaction
             Exceptional clinical outcomes
           Exceptional financial performance
Performance Management Process
                         Alignment of Indicators
                                       Through our exceptional health
                                        care services, we reveal the
                                         healing presence of God.



Exceptional                        Exceptional                                                  Exceptional
  clinical                     patient, employee &                                                financial
 outcomes                     physician satisfaction                                            performance



Unplanned re-    Inpatient           Overall             Overall                                 Operating
admission rate                      employee            physician                                 margin
                  loyalty
within 31 days                     satisfaction        satisfaction
 of discharge                                                                                       %




 Service &        Inpatient         Employee            Physician       Growth     Reimburse     Productivity/    Liquidity   Profitability
   quality         loyalty         satisfaction        satisfaction   indicators     -ment         expense       indicators   indicators
 indicators      indicators         indicators          indicators                 indicators     indicators
Gathering, Integrating and
Presenting Data
                     Performance Indicator
                     Reports (PIR)

                     Data Warehouse


                     Different Source Systems
                      - General Financial (ERP)
                      - Materials Management (ERP)
                      - Human Resources
                      - Clinical Systems
                      - Satisfaction Systems
Performance Indicator Report
(PIR) Rollup

       System-
    Level Indicators
     (SSMHC PIR)




      Operations
         PIR




        Hospital
       Operations
          PIR
Hospital Operations
Performance Indicator Report
Operations Performance Indicator
Report – System
  Performance Analysis – System-Level Indicators
                                                              Year to Date
                                                             Year to Date              Performance
                                                                                      Performance
 Initiative
Initiative             Indicators
                      Indicators                             Actual
                                                              Actual       Plan
                                                                          Plan           To Plan
                                                                                        To Plan
 Consolidated Operations
 Profitability        Operating Margin %                        1.5%        2.4%
 Liquidity            Unrestricted Days Cash on Hand            182         209
 Hospital Operations
 Growth               Acute Admissions                       137,656     136,884
 Reimbursement        Patient Revenue Per APD                 $1,410      $1,336
 Producitvity/Cost    Operating Expense Per APD               $1,402      $1,321
 Profitability        Operating Margin %                       3.7%        4.4%
 Clinical             31 Day Acute Readmission Rate            4.5%        4.2%
 Service & Quality    Inpatient Loyalty Index                 49.5%       52.9%
 Satisfaction         Employee Satisfaction Indicator         74.1%       71.8%
 Satisfaction         Physician Satisfaction Indicator        77.6%       73.6%
Skilled Nursing Home
Profitability        Operating Margin %                        1.4%        -1.9%
Service & Quality    Daily Physical Restraints Prevalence      3.9%         5.1%
Home Health                                                        .              .
Profitability        Operating Margin %                       12.0%        8.4%
Service & Quality    Homecare Patient Loyalty Index           56.9%       64.0%
Physician                                                          .           ..
Profitability        Net Revenue Per Physician               $35,074     $33,739
Productivity         Practice Direct Operating Cost %         66.6%       68.4%




                 > 5% favorable          Within 5% of plan             > 5% unfavorable
Corrective Action Plans

   Hospitals and networks use them frequently … for
    virtually every red light that exists on the PIR.
   Required by policy for certain indicators:
               Indicator                      Variance
      Inpatient loyalty index         < 70% of entity goal
      Operating margin %              > 5% unfavorable to YTD Plan
      31-day acute readmission rate   160% of entity goal
      Acute admissions                > 5% unfavorable to YTD Plan
      Employee satisfaction           < 60% of entity goal
      Physician satisfaction          < 60% of entity goal
Inprocess Measures
   Category 4: Gather/integrate data
    to support daily operations/
    decision-making
   Category 6: Inprocess measures
    used to manage day to day
    processes?
In-process indicators:
  Measurements that indicate how a process
  is working. Also called leading
  indicators. Provide early warning signals
  to tell us if we are moving towards/away
  from our goals.
Functional Groups’
Inprocess Measures
   ER – Time from door to treatment
    or physician time (whichever is
    earlier)
   Surgery - % limbs marked:
    – Correctly
    – Incorrectly
    – Not marked
   Radiology turnaround time
   Pharmacy- Drug cost/patient day
    (measured daily)
Deploying the Plan

 Departmental Posters
 Passport Program
Comparative Data


            Patient-level information
                                                  Improved
                                                   clinical
                                                  outcomes

 National                               Opportunities
  health
   care
 database                                            Cost
                                                   reduction
               Departmental-level
                  information
Clinical Indicators with Statistically
Significant Variation

                                                                                 Total       Total              Compare Compare       Stat      CI Perf Sign. In
                                                                                 Denominator Numerator HCO      Group 1 Group 1 % Significance Compare 2002 3
Indicator                                                                        Cases       Cases     Rate     Rate    Variance Comp Grp 1 Group 1 quarters
HBS900 Overall Mortality Rate                                                         18266    372     2.04%      2.28%    (10.63%)    S          +        0
HBS1512 Live born infants with a birth weight of less than 2500 grams                 1340      50     3.73%      5.95%    (37.27%)    S          +        1
HBS1620 MDC 04: Respiratory system medical readmissions within 31 days                 999      47     4.70%      7.01%    (32.86%)    S          +        0
HBS504 Patients with indwelling lines or central lines or arterial line with sepsis   414       20     4.83%      1.99%    142.35%     S          -        2
HBS814 Home Health Referrals For CHF Patients                                         346       12     3.47%      13.25%   (73.83%)    S          -        2
HBS815 Home Health Referrals For Pneumonia Patients                                   354       14     3.95%       9.55%   (58.58%)    S          -        1
HBS916 Intrahospital mortality of patients following isolated CABG                    356       14     3.93%      2.30%     71.00%     S          -        0
HBS1400 Post-op CNS complication for all Operating Room cases                         4705      27     0.57%      0.28%    101.99%     S          -        0
HBS1403 Carotid endarterectomy developing post OP CNS complications                    137       6     4.38%      1.43%    206.33%     S          -        0
HBS1619 MDC 01: Nervous system surgical readmissions within 31 days                   209       15     7.18%      2.56%    180.13%     S          -        1
HBS1623 MDC 05: Circulatory System Surgical Readmissions within 31 days                1978     91     4.60%       2.77%    65.90%     S          -        3
HBS1628 Readmits within 31 days of discharge                                          18266    2637    14.44%     10.49%    37.66%     S          -        3
HBS1629 Readmits within 15 days of discharge                                          18266    1946    10.65%     7.21%     47.78%     S          -        3
HBS1630 Readmits within 7 days of discharge                                           18266    1462    8.00%      4.75%     68.34%     S          -        3
Direct Cost Opportunities by
Service Line
Lessons Learned

    Measurement is essential to improvement
    Don’t compare yourself to just averages - -
     unless you want to be average
    Attention to inprocess (leading) indicators
     as well as to outcome (lagging) indicators
    Alignment of measures and strategic goals
     is essential
    Measure what is important

				
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posted:10/9/2011
language:English
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