Measuring

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• Measuring
• Medical Quality
• Developing a Medical Quality Scorecard
  Physician Performance Reports
• Mike Heenan
• St. Josephs Healthcare Hamilton

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Background

• Previous MAC performance reporting was not
  strategic
• Numbers after numbers after numbers
• Compass 2012 Strategic Plan
• How do we engage MAC in quality to advance
  strategic plan?

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RealityWhats all this Gobbledygook?
HSMR
Strategic Planning
HAPS
NRCPicker
CCHSA
Physician
Falls
Hospital Report Card
Med Errors
Wait Times
Hay Benchmarking
MCC
Readmission Rates
QWL
Sick Time
RIW
ALC Days
CMG
ALOS ELOS
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Desired StateWere all on the same team
Mission, Vision, Values
Strategic Plan
Measurement Tool Scorecard
Patient Safety
Appropriate Care
MAC
Resource Utilization
Wait Times
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Aim

• Engage Chiefs to work collectively towards
  Strategic Plan and improve corporate quality
  issues
• Frame the work of the MAC as the work of the
  hospital
• Select 2 - 3 projects where results could drive
  further discussion

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Barriers to Improvement

• Physician Skepticism
• Operational Bandwidth
• Engagement once an issue was identified

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5 Steps to Success

• Step 1 MAC vision statement
• Step 2 Scorecard has 4 quadrants but framed
  in MD language
• Step 3 Indicator target development Throw
  it on see what sticks
• Step 4 Consulted every Chief on targets
  through use of target document
• Step 5 Action QI projects on Hot
  issues (HSMR RIW)

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HSMR - How do we get to 76?
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Trends in HSMR Deaths
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RIW - How do we increase our bill to the Ministry?
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Project Complexity
Model for Quality Improvement

• Increase Weighted Cases
• Better Reflect Expected Length of Stay
• Improve Documentation

1. What are we trying to accomplish?
2. How will we know that a change is an
improvement?

• Increase in RIW
• Reduction in Conservable Bed Days

Act
Plan

• Identify Willing Services
• Educate MDs on Need for increased Documentation
• Develop Check-Lists that highlight key conditions
• Audit process post 6-months

3. What changes can we make that will result in
improvement?
Study
Do
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Gaining Momentum

• Process Results
• Medical Quality Scorecard presented 4 times
• Standing agenda item quarterly
• Outcome Results
• HSMR Project on Septicemia
• Project Complexity Physician Documentation
  Project
• Cascade Results
• Physician Performance Reports
• 25 Clinical Program Scorecards

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Physician PerformanceHow do we lead and improve
as a team?
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5 Key Success Factors

• Supportive Chief of Staff
• Performance Improvement Consultant for MAC
• Paper Scorecard Report sent to all physicians
  created awareness and branding
• Chiefs have performance/quality results tied into
  contracts
• Competition

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Lessons Learned

• Medical Quality Scorecard
• Involve support system from beginning medical
  quality started with inpatient and outpatient
  data but also requires DI, Lab and Pharmacy
• Resource the process
• Physician Performance Reports
• Early adopters raised credibility
• Its about trend, HR planning and team work

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Next Steps

• Medical Quality Scorecard
• DI, Lab, Pharmacy data
• Annual target setting
• Physician Performance Reports
• Alignment with credentialing
• Its about Quality
• Fulfill HSMR and Project Complexity mandates

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• Mike Heenan
• Director, Quality Planning Performance
  Improvement
• St. Josephs Healthcare Hamilton
• Tel [phone], ext. 32218
• Fax [phone]
• Email mheenan_at_stjoes.ca