Quarterly Reports for SHN’s Interventions

Understanding and Using the Data to Guide Performance

December 10, 2008Virginia Flintoft, RN MSc

SHN! Central Measurement Team

Goal• To understand how to enter YOUR data

into the Quarterly Reports (Monthly for ANC).

• To know how to use the Quarterly/Monthly reports to interpret performance and guide your QI initiatives.

SHN Performance Reports

Data In …

Sending your results to

Central Measurement Team

Submitting Data from a CoP Send you data from

ANY COP

Click on “SHN Data Submission Home “

button to get to data submission

screen

Save the url on this screen to your ‘favourites’ for easy access next month

Submitting Data from a CoP

1. Using ‘browse’ button select worksheet you want to send to CMT – 1 worksheet at a time.

2. Enter a message - include your name and phone or email.

3. Click on ‘Upload/ Télèchargement’ button to send worksheet to CMT

SHN Performance Reports

Data Out…

Reports you get from

Central Measurement Team

SHN Performance Reports• Quarterly Reports

• Apr-June, July-Sept., Oct.-Dec., Jan.-Mar

• By measure

• Distributed to Key Organizational Contact and Team Leaders

• Allows team to monitor their performance against national rates and by implementation stage

• Quarterly Performance • By individual team and measure

• Distributed to Node leads and SIAs

• Allows them to identify teams in need of support

Collaborative Performance Reports

Monthly Reports• Data in – 25th of each month

• i.e. December data sent in January 25th

• Data out – one week later

• Allows team to monitor their performance against Collaborative average rates

Oct. Data Submission

Cut-off

ANC ReportDistributed

Next ANC-Report

Dec.5

ANC ReportsANC-Report format

ANC – Report

#

Date data submitted

Months reported*

1 Nov’08 June ’08 – Oct.’08

2 Dec.’08 June ’08 – Nov.’08

3 Jan.’09 June ’08 – Dec.’08

4 Feb.’09 June ’08 – Jan.’09

* Cumulative report

Collaborative Performance Reports

Monthly Reports for ANC• Rate of Undocumented Intentional Discrepancies

• Rate of Unintentional Discrepancies

• Percent Residents Reconciled on Admission

SHN Monthly/Quarterly Reports

What to make of your results -

Interpreting the

Monthly/Quarterly Reports

The Basics

• Data submission cut off for ANC-Reports• 25th of each month

• ANC-Reports issued • Week following data submission cut off

• Sent to Dannie and Theresa for distribution to teams

ANC Collaborative Reports

Name and definition of

measure

Date of Data – months of data covered on this

report

Date Created – actual date when analysis

program ran

3 Worksheets within each Workbook –i.QR spreadsheet; ii.Chart – ANC vs Team Result; iii.Chart - Nodes vs Team (QR only)

Warning - Small Sample Size... 5 or less – results unreliable

Examples of Small Sample Size...

QR Data Analyzed & Presented:• Nationally• by Node –

Atlantic Ontario Quebec Western Paeds

• by Implementation Stage – Baseline Early (Working to Goal) Full

ANC• National will be called “Atlantic Collaborative” and data presented will be for ANC members ONLY• Nodes will be deleted• Implementation Stage as reported

Enter Goal for term of collaboration from your worksheet

Entering “Local Team” Data:• Copy values in “Final Calculation” row on Data Entry Sheet of Measurement Worksheet and • Paste into “Local Team” row (r7) on Quarterly Report

Definitions:

• “N (Teams)” = Number of teams reporting data for a specific month

• “Mean” = average score for the measure for the hospitals reporting data for that month.

• “SD” = standard deviation - a value indicating how widely dispersed the scores are around the mean; a measure of variation.

• Minimum – lowest score reported for a specific month

• Maximum - highest score reported for a specific month

• 25th – 75th percentile – of all teams reporting data for that month X% have a lower score than the specific percentile rank.

Comparator Group Descriptive Statistic Nov'05 Dec'05 Jan'06 Feb"06 Mar'06 Apr'06 May'06Score Score Score Score Score Score Score

Aspirin at Arrival Goal >90% >90% >90% >90% >90% >90% >90%Local Team (input own data) Final Calculation 75% 82% 83% 79% 88% 90% 90%

National N (Teams) 17 11 6 6 10 3 4Mean 94.06% 98.10% 98.15% 97.22% 98.89% 77.77% 95.50%

SD 6.66% 4.09% 4.53% 6.82% 3.51% 38.51% 5.47%

Quarterly Report format

Comparator Group Descriptive Statistic Nov'05 Dec'05 Jan'06 Feb"06 Mar'06 Apr'06 May'06 Jun'06Score Score Score Score Score Score Score Score

Aspirin at Arrival Goal >90% >90% >90% >90% >90% >90% >90% >90%Local Team (input own data) Final Calculation

National N (Teams) 27 19 15 17 18 11 11 10Mean 92.63% 93.91% 89.07% 92.09% 98.96% 93.94% 98.36% 97.90%

SD 8.39% 11.82% 27.03% 24.22% 3.10% 20.11% 3.76% 4.99%

QR #1 – data submitted for Nov ‘05 - June ‘06

QR #2 – data submitted For Nov ‘05 - Sept. ‘06

• Data becomes more stable as sample size increases

QR #7 – data submitted for Nov ‘05 - Dec. ‘07

Interpretation:

• Lower and Upper Bound = 95% CI

• Compare your performance (Local Team) to National mean month-over-month

• Compare your performance to CIo if score falls between upper and lower bound = statistically similar

(Jan.’08 – Jun.’08)

Interpretation:

• Lower and Upper Bound = 95% CI

• Compare your performance (Local Team) to National mean month-over-month

• Compare your performance to CIo if score falls between upper and lower bound = statistically similar

(Jan.’08 – Jun.’08)

Making Sense of Quarterly Reports

Quarterly Reports - Run Charts

Above ANC average (poor performance – Med Rec)

Same as ANC average (average performance)

Below ANC average (good performance – Med Rec)

Quarterly Reports

Interpreting and Reporting Your Results

Sharing the Quarterly Reports• With who do you (KOCs + Team Leaders)

share the QR info?• Team

• Staff

• Director / Senior Management

• (Board)

Making Sense of Quarterly Reports

SHN Performance Report – Example 1

Measure: 3.0 Medication Reconciliation Success

Index

Measure: 4.0 Medication Reconciliation at

Discharge

Poor GreatGood

Measure: 1.0 Mean Number of Undocumented

Intentional Discrepancies

Current Qtr = 0.64 Goal = 0.28# Mos. Reporting = 21

Node Qtr = 0.58Nat. Qtr = 0.54

Medication Reconciliation

No DataCurrent Qtr = 92%Goal = 90%# Mos. Reporting = 21

Node Qtr = 89%Nat. Qtr = 93%

Ventilator-Associated Pneumonia

Measure: 1.0 VAP Rate in ICU per 1000 Ventilator

Days

Measure: 2.0 VAP Bundle Compliance

Current Qtr = 0.64 Goal = 0.28# Mos. Reporting = 21

Node Qtr = 0.58Nat. Qtr = 0.54

Current Qtr = 78%Goal = 95%# Mos. Reporting = 10

Node Qtr = 85%Nat. Qtr = 83%

Element: Head of Bed

Qtr.= 97%

Element: Sedation Vacation

Qtr.= 60%

Element: Oral v Nasal

Qtr.= 77%

Element: EVAC TubeNo EVAC

Tubes

SHN Performance Report – Example 2

How to Get Answers to your SHN Measurement Questions

• Central Measurement Team

• Safety Improvement Advisors (SIAs)

• Community of Practice

• Faculty members• Clinical advisors

• Improvement advisors

• Conference calls on interventions

How to Get Answers to your Measurement Questions

• Safety Improvement Advisors (SIAs)

• Community of Practice

• Central Measurement Team

• Faculty members• Clinical advisors

• Improvement advisors

• Collaborative Conference calls

Questions or More Information

Virginia Flintoft

416.946.8350

virginia.flintoft@utoronto.ca

G. Ross Baker Alexandru Titeu

416.978.7804 416.946.3103

ross.baker@utoronto.ca shn.ea@utoronto.ca