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

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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

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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

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CCDHB Readmissions (within 28 days)

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Signal – run of 8 above the mean (bad)

INVESTIGATIONS (April 2014)• Investigations into signals

• Readmissions• Safe Staffing• Peri-operative Care

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INVESTIGATIONS (April 2014)• Initial analysis using existing tools

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

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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%)

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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

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General Medicine

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General Surgery Haematology

Oncology Renal Medicine

Histogram of LengthOfStay60

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General Surgery Haematology

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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

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I P 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

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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 1164165141134103 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

indexdrg3

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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

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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

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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