DU Health & Medical Patient Satisfaction Scores Worksheet

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Health Administration Press Chapter 4: Data Collection Chapter Outline • Categories of Data • Considerations in Data Collection • Objectives for Success • Sources of Data Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 1 Health Administration Press Categories of Data • Clinical quality (including both process and outcome measures) • Financial performance • Patient, physician, and staff satisfaction • Functional status • The challenge is to collect as many data elements from as few data sources as possible with the objectives of consistency and continuity in mind. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 2 Health Administration Press Considerations in Data Collection • Time and cost • Medical record review and prospective data collection are considered the most time-intensive and expensive ways to collect information. • Administrative data sets are often considered cost-effective. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 3 Health Administration Press Considerations in Data Collection • Collecting the critical few rather than collecting for a rainy day • Syndrome of stockpiling “just in case” as opposed to fulfilling requirements “just in time” is ineffective and inefficient. • This approach provides little value to the data collection effort and is one of the biggest mistakes quality improvement teams make. • Collect only the data required to identify and correct quality issues. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 4 Health Administration Press Considerations in Data Collection • Inpatient versus outpatient data • Sources and approaches to data collection can be different. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 5 Health Administration Press Objectives The following objectives are essential to a successful quality improvement project and data collection initiative. 1. Identify the purpose of the data management activity (for monitoring at regular intervals, investigation over a limited period, or one-time study). 2. Identify the most appropriate data sources. 3. Identify the most important measures for collection (the critical few). 4. Design a common-sense data collection strategy that will provide complete, accurate, and timely information. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 6 Health Administration Press Sources of Data • Medical record review (retrospective) • Prospective data collection, data collection forms, and scanners • Administrative databases • Patient surveys: satisfaction and functional status • Functional status surveys • Health plan databases • Patient registries Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 7 Health Administration Press A3 Problem Solving • Developed by Toyota • Goals: • Solve problems • Report project status • Propose changes • Should give a 60 second illustrated view of the need for change. • Do not think of solutions until the last part of an A3. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 8 Health Administration Press A3: Problem Statement • What are you trying to solve? • Is it important? • What is at stake? • Do not think of solutions when writing the problem statement. Example: Patient Satisfaction Scores have decreased consistently over the last six months in our Gastroenterology clinic. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 9 Health Administration Press A3: Background • Background of what has happened and why it is important to address. • Background should give a very brief overview of the situation for someone that is not familiar with the area. Example: The Gastroenterology clinic consists of 25 physicians, seeing 1,600 patients a month. The GI clinic has one of the highest volumes of patient visits in the health-system. The GI specialty is experiencing fierce competition in the regional market. It’s decrease in patient satisfaction scores will be potentially detrimental to our growth in the market. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 10 Health Administration Press A3: Current State Condition • Illustrate the current measured performance • How do you know that there is a problem? • How is the problem currently measured? 75th percentile Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 11 Health Administration Press A3: Target Condition • What does ‘good’ look like? • What are the performance measures that the define success in an ideal state? • Current State condition and target condition should be comparable • Do not think of solutions when illustrating target condition 75th percentile Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 12 Health Administration Press A3: Root Cause/ Gap Analysis • After analyzing the problem, identify the key reasons for the problem. • Attempt to get down to the most essential problem (get down to the root of the problem). • Do not think of solutions or root causes until you do the analysis. Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 13 Health Administration Press A3: Counter-Measures • What solution(s) will specifically address the root-cause? Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 14 Health Administration Press Group Projects: Problem Assignments • Group 1: Access to services • Group 2: Patient prescription literacy • Group 3: Patient wait times • Group 4: Paper forms • Group 5: Access to care in urban communities • Group 6: Provider time with patients Copyright 2019 Foundation of the American College of Healthcare Executives. Not for sale. 15 BASICS Problem Statement: Patient satisfaction scores have decreased consistently over the last 3 months in the Cardiology Department Background: A3 Facilitator: Diamond Spikes Project Team: Alison Booher, Zainab Alfakhr Root Cause/Gap Analysis: (Describe the background of the problem in detail; indicate the importance of the problem to the organization) (List the problems; use root cause analysis to identify most likely direct cause of problem) The Cardiology Department consists of 30 Physicians and sees 2,000 patients a month. This department supports the greatest source of income for our hospital. The specialty of Cardiology is high in competition. Decreasing satisfaction scores will defer growth Metrics/ Process Map / Diagram / Picture of Area (indicate solutions that address the root cause of the problems) WHAT DO WE NEED TO DO TO GET THERE ? WHERE ARE WE AND WHERE DO WE NEED TO BE ? Current State Condition: Process Map / Diagram / Picture of area Target Condition: (What is the target process and specific outcomes desired?): Process Owner: Beau Karalis PDCA A3 Template Project Start Date: 9/24/19 Project Finish Date: Countermeasures: (Select the most practical and effective countermeasure to address the root cause): A3 Facilitator: BASICS Problem Statement: Process Owner: Project Start Date: Project Finish Date: Project Team: PDCA CYCLE Plan DO CHECK Act / Adjust Indicate who will do the plan and when it will be done. Do the plan. Measure the results. Describe the measured results and how they compared to the predictions. Highlight results in some manner. What is next? What lessons were learned? What modifications will be made for the next PDCA cycle? PROJECT IMPLEMENTATION What changes are to be made? List the steps to set up this test of change. Predict what will happen when the test is carried out. Standard work affected by this change? ☐ Yes ☐ No (If Yes, complete the steps below) Document standard work / process that is to be followed File Destination: File Name: File Revision Standard work / process review / approval Employee training to standard work / process PDCA A3 Template

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