A Balanced Set of Clinical Measures

and the discussions they have provoked

Bruce GeorgeExecutive Director (Operations)

Quality, Improvement and Patient SafetyCapital & Coast DHB

SITUATION (September 2013)• Lots and lots of bar graphs• Many providers of “data” and “charts”• Multiple systems from which data is extracted• Some data extracted and turned into charts without

any internal oversight

0100200300400500600700800900

Num

ber E

vent

s

Month

Events Reported by Month/Year

2009

2010

2011

2012

2013

SITUATION (September 2013)• Inconsistent definitions• Some very complex denominators to “enable”

comparisons• Multiple (connected?) committees where insight from

data or charts is discussed

CURRENT STATE (April 2014)• Standard Balanced Set of Clinical and Quality Measures• Clear definitions of “counts” to drive improvement• Discussion, agreement and action at Clinical

Governance meetings

70

75

80

85

90

95

100

01Ap

r13

15Ap

r13

29Ap

r13

13M

ay13

27M

ay13

10Ju

n13

24Ju

n13

08Ju

l13

22Ju

l13

05A

ug13

19Au

g13

02Se

p13

16S

ep13

30Se

p13

14O

ct13

28O

ct13

11N

ov13

25N

ov13

09D

ec13

23D

ec13

06Ja

n14

20Ja

n14

03Fe

b14

17Fe

b14

03M

ar14

17M

ar14

31M

ar14

14Ap

r14

28Ap

r14

12M

ay14

26M

ay14

09Ju

n14

23Ju

n14

Cou

nt

Week ending

ED 6hr target

Green Amber Red

Value X Center Line Natural Process Limits

CURRENT STATE (April 2014)• Balanced Set includes:

• Patients Discharged Deceased (monthly)• SAC 1 & 2 events (monthly)• Placements to Aged Residential Care (monthly)• ED 6 hour target (weekly)• Hospital Occupancy at 4pm (daily)• All Reported Events (weekly)• Readmissions (monthly)• Complaints (weekly)• Falls (monthly)• Medication / Fluids errors (monthly)• Pressure Sores / Ulcers (monthly)• Peri-operative Harm (quarterly)• Restraints / supportive Devices (monthly)• Safe Staffing (monthly)

INVESTIGATIONS (April 2014)• Investigations into signals

• Readmissions• Safe Staffing• Peri-operative Care

050

100150200250300350400450500

01Ja

n11

01M

ar11

01M

ay11

01Ju

l11

01S

ep11

01N

ov11

01Ja

n12

01M

ar12

01M

ay12

01Ju

l12

01Se

p12

01N

ov12

01Ja

n13

01M

ar13

01M

ay13

01Ju

l13

01S

ep13

01N

ov13

01Ja

n14

01M

ar14

01M

ay14

Cou

nt

Month and Year

CCDHB Readmissions (within 28 days)

Red Amber Green

Value X Center Line Natural Process Limits

Signal – run of 8 above the mean (bad)

INVESTIGATIONS (April 2014)• Investigations into signals

• Readmissions• Safe Staffing• Peri-operative Care

1

5 1

2

2

6

2

2

2

2

2

Mean CL: 350.47

293.69

407.26

270.00

280.00

290.00

300.00

310.00

320.00

330.00

340.00

350.00

360.00

370.00

380.00

390.00

400.00

410.00

Indi

vidu

als:

Val

ue

INVESTIGATIONS (April 2014)• Initial analysis using existing tools

• Unforeseen readmission – new problem• Unforeseen readmission – existing problem

Vasc

ular

Urolo

gyPa

in Mg

mts

Paed

Sur

gPa

ed O

ncolo

gyPa

edea

trics

Orth

opae

dics

Opth

amolo

gyOb

stetri

csNe

uros

urg

Neon

atal

Gyna

ecolo

gyGe

nera

l Sur

gery

ENT

Dent

alCa

rdiot

hora

cicRe

spira

tory

Rena

lAT

ROn

colog

yNe

urolo

gyIm

muno

logy

Olde

r Adu

ltsHa

emot

ology

Gene

ral M

edici

neGa

stro

Endo

Emer

geng

yDS

SCa

rdiol

ogy

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Read

mis

sion

Rat

e

Readmit Rate per month by Specialty

• Haematology (24%)

• Oncology (22%)

• Renal (19%)

• General Medicine (14%)

• Older Adults (14%)

• ATR (13%)

• General Surgery (12%)

• Paed Oncology (15%)

24%

22%

13%

19%

14%14% 12%

15%

Avg readmit rate

By Specialty: Monthly Readmit Rates (Jan12 to Jan14)

• Three specialties highlighted as higher rates – understandable as likely to be complex cases

By original visit LOS

• Distributions of LOS resulting in a readmission are in synch with those of all admissions

Readmissions All Admissions

60

45

30

15

02824201612840

2824201612840

60

45

30

15

02824201612840

General Medicine

Days

Perc

ent

General Surgery Haematology

Oncology Renal Medicine

Histogram of LengthOfStay60

45

30

15

02824201612840

2824201612840

60

45

30

15

02824201612840

General Medicine

Days

Perc

ent

General Surgery Haematology

Oncology Renal Medicine

Index LOS

By Clinician: General Medicine

Readmisisons 50 49 48 47 45 42 32 31 29 2391 22 9386 69 60 60 56 56 55Percent 5 5 5 5 4 4 3 3 3 29 2 98 7 6 6 5 5 5

Other

Marion

Leigh

ton

Nicola

Smith

Adel E

kladio

us

Consu

ltant

Emerg

ency

Colin

Feek

Sinead

Donn

elly

Christi

na Ca

meron

Phil ip

pa Sh

irtcliff

e

Kyle P

er rin

Ange

la Sote

riou

Darren

Bowle

s

Luatup

u Ioan

e-Clev

erley

Rupa

l i Shar

ma

Nigel

Raym

ond

Ketna

Parek

h

John M

urray

Wilson

Dorot

hy Din

esh

Peter

Robe

r ts

Elaine

Barr i

ngton-

Ward

120

90

60

30

0

Read

mis

ison

s

IP Admissions 354 354 301 300 287 274 273 219 189 173523 124 111 658510 465 436 433 432 417 398Percent 5 5 4 4 4 4 4 3 3 27 2 2 97 6 6 6 6 6 6

Other

Marion

Leigh

ton

Mark

Weathe

rall

Nicola

Smith

Consu

ltant

Emer g

ency

Colin

Feek

Kyle P

errin

Dar ren

Bowles

Christi

na Ca

meron

Ange

la Sote

riou

Sinead

Donn

el ly

Luatup

u Ioa

ne-Cl

everle

y

Adel E

kladio

us

Rupa

l i Shar

ma

Ketna

Par ek

h

Phil ip

pa Sh

irtcli ff

e

J ohn M

urray

Wil son

Nigel R

aymon

d

Dorot

hy Din

esh

Peter

Robe

rts

Elaine

Barri

ngton-

Ward

600

450

300

150

0

IP A

dmis

sion

s

Readmissions

All Admissions

• Readmit rates largely in synch with the overall admission rates per clinician

Doctors names

Doctors names

By DRG: General Medicine

Count 68 66 63 63 56 56 55 51 51 49183 47 46 44 44 43 1164165141 134103 96 77 69Percent 2 2 2 2 2 2 2 2 2 26 2 2 1 1 1 406 5 5 4 3 3 2Cum % 35 38 40 42 44 46 48 49 51 536 54 56 57 59 60 10012 17 21 25 28 31 33

indexdrg3Othe

rF60X60Q61E75I68B76L64G66K60F73E69T60J64G67G70F76B77L63F74E62F62X62E65

3000

2500

2000

1500

1000

500

0

100

80

60

40

20

0

Coun

t

Perc

ent

Pareto Chart of indexdrg3 by IndexSpecialtyIndexSpecialty = General Medicine

Count 102 96 78 75 74 70 66 62 62 58287 56 54 53 53 1483231164 156 156 125111 103Percent 3 3 2 2 2 2 2 2 2 28 1 1 1 1 396 4 4 4 3 3 3Cum % 38 41 43 45 47 48 50 52 53 558 56 58 59 61 10014 18 22 26 30 33 35

DRG3Othe

rT63I71B76B81D63Q61F76F63G47G70E69K60F74G67E75J64T60L63F62F73E65E62

3500

3000

2500

2000

1500

1000

500

0

100

80

60

40

20

0

Coun

t

Perc

ent

Pareto Chart of DRG3 by HealthSpecialtyNameHealthSpecialtyName = General Medicine

• Readmission DRG’s in synch with total IP admission DRG’s, except X62 & G70

Readmissions All Admissions

Outcomes of Readmissions analysis• Has driven development and deployment of new

charts, insight from data and discussion at Clinical Governance

• No clear single reason for increase but two DRGs to investigate further

• Progress with internal clinical audit• Include Primary Care in investigations

Visibility of data and analysis of signals has driven• Greater use of Central Dashboard• Planning for Operations Centre to optimise flow & safety

CURRENT STATE (April 2014)

CURRENT STATE (April 2014)Visibility of data and analysis of signals has driven• Greater use of Central Dashboard• Planning for Operations Centre to optimise flow & safety

FUTURE STATE (December 2014)• Standard Balanced Set of Clinical and Quality Measures• Clear definitions of “counts” to drive improvement• Discussion, agreement and action at Clinical

Governance meetings

6

6

6

2Mean CL: 94.09

88.77

99.41

78.00

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

Indi

vidu

als:

Val

ue b

y Ph

ase

FUTURE STATE (tbc)• Charts (Statistical Process Control) accessed via intranet

dashboard.• Proactive not reactive - act upon early warning from

signals not trends.• Analysis for improvement (count) and comparison (rate).• Full DHB perspective not just Hospital.• Integrated Operations Centre

Monthly Balanced Scorecard Month & YTD vs targetsMonth YTD Month YTD

Patient Experience Process EfficiencyED Target 94 94 Length of Stay 2.8 3.2Complaints 65 564 Acute vs Elective 74 68

Clinical Measures DOSA 71 73Falls 72 641 Bed utilisation 89 93SAC 1-2 2 88 Theatre utilisation 77 87Reported Events 342 4536 Outpatient DNA 6 7Peri Operative 54 345 Value For MoneyMedication 32 432 Caseweight 6533 6565

Healthy Workplace Acute vs Elective 678 765Staff Turnover 1.3 0.9 FTE costs 45999 654336Engagement 4.3 4.1 Operating Costs 34555 665458