Assessing Process and Audit Measures Jill A Marsteller

Assessing Process and Audit Measures Jill A. Marsteller, Ph. D, MPP May 24, 2011 © 2009

Learning Objectives • You will be able to: – Explain why measuring process is critical to success – Describe process measures planned for collection – Detail the planned collection process © 2009

Donabedian Model Structure Process How we organize care What we do during care delivery E. g. , presence of policies or committees E. g. , how often are evidence-based interventions performed © 2009 Outcome The results we achieve E. g. , how/ how many patients are harmed

Approaches to measuring process • Measures of perception – Accessible – Subject to bias • Regular process measures collection – More objective – Burdensome • Less frequent auditing – Less burdensome – Less reliable © 2009

Process measures you already collect • SCIP/STS – – – Abx selection Abx timing Abx stop w/in 48 hours Glucose measure Hair removal © 2009

New Measures/ Audit Topics • VAP process measures: – E. g. , HOB elevation – E. g. , sedation vacation • SSI: • CLABSI: – Insertion (OR, ICU) – Maintenance (ICU, Floor) • CUSP: – Daily goals; Am Briefing; LFD (ICU, Floor, universal) – Briefing/debriefing ; Huddle; LFD (OR) – Skin prep (type, appropriateness) – Antibiotic redosing; – Environment © 2009

Timeline-OR CLABSI Process SSI Audits Baseline Jul Aug Sep Oct Nov period 201 1 Wkl Wkl y y y Wkly Dec Jan Feb 2012 X (90) Wkly CLABSI Process Sep Oct Nov Dec Jan Feb 2012 2013 X (90) SSI Audits LFD Mar Apr © 2009 Jul X (90) huddle May Jun Jul Aug X (90) brief Jun X (90) X(90) May X (90) brief Aug 2012 CUSP Audits Apr X (90) CUSP Audits Mar X (90) huddle Sep 2013 LFD

Timeline-ICU CLABSI Process Baseline Jul Aug Sep Oct Nov 2011 Wkly Dec Jan 2012 X(90) VAP Process Mar Apr Wkly CLABSI Process Oct Nov X(90) LFD Jan Feb 201 3 X(90) VAP Process Dec 2012 Mar Apr Jun Wkly X(90) AMB May X(90) Jun Jul Aug X(90) Sep 2013 X(90) DGs AMB LFD © 2009 Jul 2012 X(90) DGs Aug Sep 2012 May X(90) CUSP Audit Feb

Timeline-Floor Baseline Jul period 2011 CLABSI Process— Maint. CUSP Audits Wkly Sep Oct Nov Dec Wkly Jan Feb Mar 2012 X(90) Apr May Jun X(90) CLABSI Process Sep X(90) Oct Nov Dec Jan Feb Mar 2012 2013 X(90) © 2009 AMB Apr May Jun X(90) DGs LFD Jul 2012 X(90 ) DGs Aug 2012 CUSP Audits Aug Jul Aug Sep 2013 X(90) AMB X(90) LFD

Timeline-Universal Bed Baseline Jul period 2011 CLABSI Process Wkly Aug Sep Wkly Oct Wkly Nov Dec Jan Feb 2012 X(90) VAP Process Mar Apr X(90) Wkly CUSP Audits CLABSI Process Sep Oct Nov VAP Process X(90) CUSP Audits Mar X(90) Dec Jan Feb 2012 2013 Wkly X(90) May Jun Jul Aug X(90) DGs © 2009 Sep 2013 X(90) LFD Jul AMB X(90) Apr Jun X(90) DGs Aug 2011 May AMB LFD

Audit data: “How To” • Reminder email will tell you what to audit for the coming month • Collect data once a week and report at end of month • Methods: Observations; counts with measure/ count total eligible; answer Qs • When you enter web tool, it will tell you what audit data is due this month • Web-based data entry forms © 2009

Examples • Daily Goal Audit—Once weekly count the number of patients that had a Daily Goals sheet filled for them during interdisciplinary rounds; also count total number of patients. Report: DG patients and total • LFD Audit—Count number of defects worked on in last quarter; number resolved; number posted; number evaluated for effects • AM Briefing or Huddle/ OR Briefing Audit—observe XX opportunities for briefings; Report: number of briefings conducted and number of opportunities; (Or observe briefings for recommended elements; Report: successes/observations for each element) © 2009

How process measurement helps you • Compliance is key to providing evidence-based practice • EBP allows you to meet your outcomes goals • Process measures provide a “map” to what’s working well and what’s not • Regular feedback on performance essential to performance and buy-in (transparency) • Use your data to inform, motivate, communicate laterally and upward © 2009