SKMC Experience In Selecting The

Clinical Indicators

.
Samer Ellahham,MD,EFQM,FACP,FACC,FCCP
Chief Quality Officer
Senior consultant
February 19, 2013
Purpose
Quality Improvement and Patient
Safety
Determine how well SKMC
Designs processes
Measures performance
Analysis performance
Improves on performance
2
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
JCIA Requirements
Quality Improvement and Patient Safety
Organization leaders must make the final selection for the clinical and
managerial processes and outcomes based on its mission, patient needs,
and services.
The process, procedure, or outcome to be measured.
how measurement will be accomplished.
how the measures fit into the organizations overall plan for quality
measurement and patient safety.
the frequency of measurement.Required monitor review.
the availability of science or evidence supporting the measure.
Pathway/guideline discussion
International library of measures
Data validation
3
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
Quality Improvement and Patient Safety Plan
Framework for planning/designing, measuring,
assessing, and improvement of all care and
services provided.

SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
2013 Quality Strategic Initiatives (needs to be updated)
SKMC has identified strategies that focus the efforts and energy of the organization on:

Clinical Areas
Managerial/Operational Areas
Governing Body Identified Areas
Clinical Guidelines, Pathways, Protocols
Failure Mode Effects Analysis (FMEA)
Quality Training Curriculum
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
Monitoring Process Prioritization
Data are collected that address required measures in support of the hospital mission, vision, values,
clinical priorities, patient safety priorities, managerial priorities and priorities identified by the governing
body.
Monitoring
Process
Prioritization
Patient
Safety
Clinical
Measures
Managerial
Measures
Governing
Measures
Mission
Vision
Values
1
Red - Green JCIA Dashboard
**
**
**
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
C. Governing Measure
Patient safety goals
Implementing surgical check
list
Hospital acquired infection
prevention
Hospital acquired pressure
ulcer prevention
Falls prevention
Sentinel events & adverse
events
Adverse drug events &
medication error
Patient Satisfaction
Admitted Patients That
Would Recommend SKMC
ER Patients That Would
Recommend SKMC
Outpatient Patients That
Would Recommend SKMC
UCC Patients That Would
Recommend SKMC

Clinical starter sets
Heart Attack (AMI)
SCIP Measure: Colon Surgery
SCIP Measure: Vascular
SCIP Measure: Hip and Knee
SCIP Measure: CABG
SCIP Measure: Other cardiac
SCIP Overall (surgeries,
antibiotics, VTE)
SCIP Measure: Cardiac control
glucose
VTE: ICU VTE Prophylaxis
Children's Asthma Care (CAC)
Stroke
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
INDICATOR:

Heart Attack (AMI)

* AMI -1: Aspirin at arrival
* AMI-2: Aspirin at discharge
* AMI-3: ACEI or ARB for LVSD
* AMI-4: Smoking cessation counseling
* AMI-5: Beta blocker at discharge
AMI-8a: Primary PCI within 90 min of arrival
AMI-9: Mortality
Governing Clinical Measures (Clinical starter sets)
* JCIA Library of Measures
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
INDICATOR:


Heart Failure (HF)

HF-1: Discharge instructions
* HF-2: Evaluation of LVS Function
* HF-3: ACEI or ARB for LVSD
* HF-4: Smoking cessation counseling
Governing Body Approved Clinical Core
Measures
* JCIA Library of Measures
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
INDICATORs:
Patient Safety Measures
Hospital Acquired Infection Prevention
Compliance with Hand Hygiene
Central Line-Associated Primary Bloodstream Infection (BSI) Rate
Central Line Bundle Compliance
Surgical Site Infections rate (per 100 surgeries) Class 1
Surgical Site Infections rate (per 100 surgeries) Class 2
CA-UTI per 1000 device days
VAP Rate per 1000 Ventilator Days
VAP Ventilator Bundle Compliance
MRSA Bloodstream Infections per 1000 Patient Days
Governing Body Approved Patient Safety
Measures
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013

INDICATOR:
Hospital Acquired Pressure Ulcer Prevention

Hospital acquired Pressure Ulcers incidence
Percentage of Patients Receiving Pressure Ulcer preventative care
INDICATOR:
Falls Prevention
Patient falls rate per 1000 pt days
Patient falls with harm rate (per 1000 pt days)
Patients with risk of falls receiving preventative care

INDICATOR:


Implementing Surgical Checklist (WHO)
Comprehensive Surgical Checklist Completed (based on WHO)
Governing Body Approved Patient Safety
Measures
SKMC Experience In Selecting The Clinical Indicators
February 19, 2013
Monitoring Validation Process
SKMC Quality and The Use of Data
February 19, 2013
Quality Measures Review and Validation Process- Quality Management Department
L
e
a
d
p
e
r
f
o
r
m
A
p
p
r
o
v
a
l
Data Quality Team Clinical Auditors Quality Statisticians Source
Receive ICD9 Code
Extract the data for the
required KPIs
Data verified by
extracting the same
data using same
methodology
Clinical Auditors
(Physicians, Nurses,
Pharmacists,...)
Quality Clinical Auditor
verifying results
Quality statisticians calculate
the data
Quality Clinical
Auditors checks the
calculated data
Data Published
on iShare
Data re-checked by data
quality team
Confirmed
Not Confirmed
10% for validation from
Quality Monitors
Confirmed
1
st
Quality
Statistician
2
nd
Quality
Statistician
Approved
Not Confirmed
Approved
ICD9
coding
completed
by HIMS
Data
Reconciliation
Discussion /
Reconciliation
Key Measures of Quality
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Outcome
Measure

Indicates the
result of
performance/non
performance


Process
Measure

Focuses on
process that is
designed to
achieve a certain
outcome
Structure
Measure

Assesses whether
organizational
resources and
arrangements are
in place to deliver
healthcare
Measure Selection and Data Collection
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QPS.3
QPS.3 The organizations leaders identify key measures
in the organizations structures, processes, and
outcomes to be used in the organization-wide quality
improvement and patient safety plan





Cont
15
Note:
oThe clinical areas identified in 1) through 11) of the intent statement
for standards QPS.3 through QPS.3 are included in the organizations
quality measurement plan
oAt least five (5) of the eleven (11) measures required in QPS.3.1 must
be selected from the JCI International Library of Measures. Data
collection, analysis, and use by all organizations will begin in 2011.
Submission of data to JCI for the five (5) measures is voluntary in 2011.
Mandatory submission will begin in 2012 or later.

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QPS.3
QPS.3.1 The organizations leaders identify key measures for
each of the organizations clinical structures, processes, and
outcomes
Note: The managerial areas identified in a) through i) of the intent
statement for standards QPS.3. through QPS.3.3 are included in the
organizations quality monitoring. Managerial measures will be added to
the International Library of Measures at a future date.

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QPS.3.1
QPS.3.2 , QPS.3.3
QPS.3.2 The organizations leaders identify key
measures for each of the organizations managerial
structures, processes and outcomes.

QPS.3.3 The organizations leaders identify key
measures for each of the International Patient Safety
Goals.


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Intent of QPS.3- QPS.3.3
Intent of QPS.3 through QPS.3.3
Effective use of data is best accomplished in the
broader context of evidence-based clinical practices and
evidence-based management practices.






Cont


19

Because most organizations have limited resources,
they cannot collect data to measure everything they
want. Thus, each organization must choose which
clinical and managerial processes and outcomes are
most important to measure based on its mission, patient
needs, and services.



Cont
20
Intent of QPS.3- QPS.3.3
Measurement often focuses on those processes that
are high risk to patients, provided in high volume, or
are problem prone.
An organizations leaders are responsible for making
the final selection of areas to target measurement
activities and the related key measures to be included in
the organizations quality activities


Cont..

21
Intent of QPS.3- QPS.3.3
Intent of QPS.3- QPS.3.3
The measures selected related to the important
clinical areas and include
1. patient assessments;
2. laboratory services;
3. radiology and diagnostic imaging services
4. surgical procedures
5. antibiotic and other medication use;


Conti
22
Intent of QPS.3- QPS.3.3
6. medication errors and near misses;
7. anesthesia and sedation use;
8. use of blood and blood products;
9. availability, content, and use of patient records;
10. infection prevention and control, surveillance, and
reporting; and
11. clinical research


Conti
23
Intent of QPS.3- QPS.3.3
The measures selected related to the important
managerial areas include:
a. the procurement of routinely required supplies and
medication essential to meet patient needs
b. reporting of activities as required by law and
regulation
c. risk management
d. utilization management


Conti

24
Intent of QPS.3- QPS.3.3
e. patient and family expectations and satisfaction
f. staff expectations and satisfaction;
g. patient demographics and clinical diagnoses
h. financial management; and
i. prevention and control of events that jeopardize the
safety of patients, families, and staff



Conti

25
Intent of QPS.3- QPS.3.3
For each of these areas, leaders decide:
the process, procedure, or outcome to be measured;
the availability of science or evidence supporting
the measure;
how measurement will be accomplished;
how the measures fit into the organizations overall
plan for quality measurement and patient safety; and
the frequency of measurement
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Intent of QPS.3- QPS.3.3
Measurable Elements of QPS.3
1.The organizations leaders identify targeted areas for
measurement and improvement.
2. The measurement is part of the quality improvement
and patient safety program.
3. The results of measurement are communicated to the
oversight mechanism and periodically to the
organizational leaders and the governance structure of
the organization
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QPS.3
Measurable Elements of QPS.3.1
1.The clinical leaders identify key measures for each clinical
area identified in 1) through 11) in the intent statement.
2. At least five of the eleven required clinical measures are
selected from the JCI International Library of Measures.

Conti..
28
QPS.3.1
3. The leaders look at the science or evidence supporting
each of the selected measures.
4. Measurement includes structure, processes, and
outcomes.
5. The scope, method, and frequency are identified for each
measure.
6. Clinical measurement data are used to and evaluate
the effectiveness of improvements.


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QPS.3.1
QPS.3.2
Measurable Elements of QPS.3.2
1.The managerial leaders identify key measures for
each managerial area identified in a) through i) in the
intent statement
2. The leaders look at the science or evidence
supporting each of the selected measures.



Conti..
30
QPS.3.2
3. Measurement includes structure, processes, and
outcomes.
4. The scope, method, and frequency are identified for
each measure.
5. Managerial measurement data are used to and
evaluate the effectiveness of improvements.

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Quality is a Journey,
not a Destination
Thank you!

Samer Ellahham, MD
971508113142

sellahham@skmc.ae