Performance measures in ambulatory care. (Perspectives in Ambulatory Care).
* Healthy People 2010 (DHHS)
* ANA Advisory Committee for Community Based Nonacute Care
* AHRQ: Agency for Healthcare Research and Quality (formerly AHCPR)
* NLHI: National Library of Healthcare Indicators
* Centers for Disease Control (CDC)
* American Academy of Pediatrics (AAP)
Ambulatory care organizations can achieve higher quality at lower costs by implementing an effective performance improvement (PI) program. An overview of a performance improvement model, sample performance measures, and resources to create a credible and sustainable ambulatory care performance measurement program will be provided.
Balanced Scorecard/Report Card
A need exists for organizations to assess and monitor performance in a variety of areas. In 1992, departmental operational indicators were first developed as a means of identifying efficiency opportunities within the professional revenue cycle at the Cleveland Clinic Foundation (CCF) Division of Medicine (Kaatz, Sargeant, Kay, Ahmad, & Stoller, 2000). Kaatz et al. (2000) explained that these first-generation tabular displays were "busy" and did not permit identification and display of acute points or review, leading to the development of a second-generation performance review instrument known as a balanced scorecard. Katz et al. (2000) show how inquiry into several operational aspects of health care delivery at CCF related to financial operations, service/quality, utilization/productivity, and access has effected change and improvement. The data are displayed on a performance wheel that summarizes the identified indicators, allowing easy comprehension of performance in various operational aspects and a visual appreciation of the interaction among these operational aspects.
A trend for report cards became popular with the increase in managed care. Castaneda-Mendez, Mangan, and Lavern (1998) state that health care organizations should develop a balanced scorecard with measures that reveal the interdependency of the business values, employee values, and patient values. The balanced scorecard or dashboard concept can assist leaders in developing and monitoring a strategic plan by creating a vision of the future behavior, performance, and perception of the organization using performance-improvement principles (Castaneda Mendez et al., 1996). Management must review the balanced scorecard periodically to evaluate and take corrective and preventive action on planned initiatives that do not contribute to the strategic plan. Felix and Pyle (2001) note that "tools that document data on the health status, which can be affected by nurses, will begin to illuminate the value nurses add to the health care equation. These data, in turn, will provide recognition for the role nurses can play" (p. 419). The dashboard or balanced scorecard, which is commonly presented in a graphic format, is a way to view relationships among separate indicators of cost and quality that together, give an indication of overall performance. Varying types of report cards have been created by organizations with specific indicators or measures identified by management that are considered important to track or to identify information important to the consumers they serve.
Performance measures commonly identified by organizations in the literature are generally classified into the following categories: access to care, utilization and productivity, financial operations and quality/service (see Table 1).
National Organizations and Quality
Accreditation from a national organization such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), Accreditation Association for Ambulatory Health Care (AAAHC), the National Committee for Quality Assurance (NCQA) and the Community Health Accreditation Program (CHAP) provide a framework for assessing performance-improvement systems within ambulatory care organizations aimed at evaluating the administrative and clinical aspects of their operations. By requiring the application of a performance-improvement system, accredited organizations are evaluating their key systems in a routine, systematic, and continuous manner and that ownership of this must be at all levels in the organization. There must be active participation at the physician, executive, and line staff levels for the program to be effective.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines performance measurement in health care as representing what is done and how well it is done. The goal is to accurately understand the basis for current performance so that better results can be achieved through focused improvement actions. Performance improvement ensures that the organization designs processes well and systematically monitors, analyzes, and improves its performance to improve patient outcomes (JCAHO, 2002). The customer we serve is always concerned and increasingly more aware of the basic structures that exist to measure quality, as well as the health care organizations' reports cards of quality that become public record.
UCSF Performance-Improvement Model
The University of California, San Francisco (UCSF) is an academic medical center that includes more than 900 physicians, a 500-bed hospital, and outpatient clinics in more than 75 specialties. A nationally designated Comprehensive Cancer Center and the UCSF Children's Hospital are recognized centers of excellence. The mission, vision, and values at UCSF are integral to staff performance and the development and implementation of all PI activities.
The PI program at UCSF Medical Center measures performance indicators using an aggregate quality dashboard. Performance indicators are measurable characteristics of products, processes, services, and systems used to track and improve performance. A dashboard is a tool that consists of the indicator, the actual performance, a performance benchmark, an indicator value, a data source, a benchmark source, trends, and comments. Information is collected and reported on a quarterly basis.
A problem or process in need of improvement may be noted from the dashboard's trended data or from other sources in the organization. The process for addressing these issues is the UCSF Medical Center's PI Model, called IMADIM, which stands for: Identify, Measure, Analyze, Design, Implement, and reMeasure. A summary of the IMADIM PI model is provided in Table 2. An example of an ambulatory PI project utilizing clinical-performance measures in the IMADIM format is shown in Figure 1.
The PI process is crucial for health care leaders to improve outcomes and adapt to change as well as to deliver cost-effective and high-quality patient care. Regulators, payers, and patients will continue to demand performance-based data that documents compliance with quality standards and benchmarks. Using the dashboard as a tool to track organizational performance measures and the progress of critical indicators as well as having a strong PI program can assist organizations to cope with the changing health care environment.
Figure 1. Performance Improvement Program Example Ambulatory Pediatric Dialysis Clinical Performance Measures Performance Improvement Program created by James D. Cooke, RN, CNN, Manager and Anthony A. Portale, MD, Chief of Pediatric Nephrology Overview Clinical Performance Measures 2002 is the performance improvement (PI) program of the Ambulatory Pediatric Dialysis Unit (PDU). This PI program is a comprehensive, continuous process that is adapted quarterly to the clinical needs of the PDU's patients. The goals of this program include: 1. Provide adequate, effective and safe treatment for End Stage Renal Disease (ESRD) 2. Provide accurate monitoring of patient laboratory values 3. Provide effective nutrition counseling to improve growth and nutritional status and to promote general well-being 4. Provide effective patient education to improve adherence to the dialysis prescription 5. Vaccinate all ESRD patients for hepatitis B infection Identify The Pediatric Dialysis Unit has identified 7 major components of medical, nursing and nutritional care for continuous monitoring and intervention: 1. Anemia status 2. Bone health 3. Adequacy of dialysis treatment 4. Nutritional status 5. Cardiac/PVD status 6. Growth status 7. Hepatitis B Vaccination Measure Clinical measurements (indicators) for both the hemodialysis and peritoneal dialysis programs of the PDU are collected monthly and include: Hemodialysis 1. Hemoglobin 2. Ferritin 3. Transferrin saturation 4. Ca/PO4 product 5. Parathormone 6. Potassium 7. Albumin 8. Hepatitis B vaccination 9. Urea reduction ratio 10. Urea kinetics 11. Interdialytic weight gains 12. Diastolic blood pressure 13. Growth status (indicators) 14. Access/blood infection rate Peritoneal Dialysis 1. Hemoglobin 2. Ferritin 3. Transferrin saturation 4. Ca/PO4 product 5. Parathormone 6. Potassium 7. Albumin 8. Hepatitis B vaccination 9. Urea kinetics 10. Growth status (indicators) 11. Access/blood infection rate Measurements are taken of each indicator monthly for each patient eligible to participate in the PI program. Most chronic kidney disease (CKD) patients admitted to the PDU for more than 60 days participate. Ineligible patients include: first 30 days of CKD admission, acute renal failure patients temporarily dialyzing in PDU while awaiting recovery of renal function, CRF patients with stay less than 60 days, and guest CKD patients less than 60 days. Data, along with factors for individual outliers, are collected by hemodialysis and PD registered nurses. Analyze Raw data is collected by clinical staff, provided to the patient care manager (PCM) and plotted on a spreadsheet. Line and bar graphs illustrate trending of the data. Most data is organized by the monthly mean/median and the number of the number of patients achieving the established goal. This varies by the indicator, see attached graphs and charts. The PCM analyzes the data and outliers to create recommendations for consideration by the PDU PI Committee. Design PI Committee membership consists of the PCM, Chief of the Division of Pediatric Nephrology, Medical Director of Pediatric Renal Transplantation, Pediatric Nephrologists, Renal Nutritionist and any other interested party. The PI Committee meets quarterly and considers year-to-date (YTD) data including: trending, patient outliers, staffing issues, equipment, and medical supplies. The PI committee recommends changes in PDU interventions, policies, procedures, protocols, equipment and medical supplies. PI reports are shared with the Medical Center Department of Infection Control and their input is integrated into the design and implementation phase of the PI program. Implement Possible strategies for responding to negative trends and outliers include: 1. Revision of policies, procedures and protocols 2. Review of patient education program 3. Revision of and/or creation of new patient education materials 4. Review of validity and applicability of targets and goals 5. Review of updated national benchmarks for adjustment of targets and goals 6. Creation of incentive based programs for pediatric patients in which adherence to the treatment prescription is the critical factor for certain PI indicators PI committee recommendations are implemented by the PCM, physicians clinical staff, and the nutritionist. Measure Clinical performance measures (indicators) will continue to be collected monthly and analyzed quarterly. The PI committee will review the YTD PD data quarterly and will make recommendations to address negative trends and outliers. Table 1. Key Performance Measures in Ambulatory Care Utilization and Access to Care Productivity Financial Operations Appointment availability; Space/Exam room Charge timeliness for example, next vs 2nd utilization and accuracy or 3rd available Visits per exam room Charge lag Bumped/rescheduled Number of specialty Co-payment and cash appointment rate referrals collection rate No show appointment Number of ED visits Rejection/Denial rate rate Wait time Number of visits Accounts receivable Exam room conforming to CPT days Waiting room codes Cancellation rate Staff mix per visit Insurance/ registration accuracy Referral request Staff turnover rate Total visit volume turnaround New patient Urgent/walk-in visits % change to prior year visit variance to budget Consult request Support staff FTEs Total direct cost turnaround per MD per visit Availability of urgent or Expenses per visit Revenue and expense walk-in appointments per visit Telephone access Relative Value Units Billing timeliness Abandonment rate (RVUs) and accuracy Average time before RVUs per visit Billing lag answered Total RVUs Total number of calls RVU variance to by agent budget Response time for clinical triage Access to Care Quality and Service Appointment availability; Patient satisfaction for example, next vs 2nd or 3rd available Bumped/rescheduled Staff satisfaction appointment rate No show appointment PI projects; site specific rate Wait time Sedation outcomes Exam room Waiting room Cancellation rate Immunization rates Referral request Diabetes compliance turnaround Hgb A1C Annual eye exams Foot care Consult request Point of care testing turnaround compliance Availability of urgent or Population-specific walk-in appointments guidelines, e.g. CHF, COPD, CF Telephone access Prevention of tobacco use
IMADIM: Performance Improvement Model at UCSF Medical Center
I = Identify the Problem or Process for Improvement
1. Define the problem being addressed by the project. What trended data or anecdotal evidence do you have to indicate a need for improvement or suggests concerns over quality of care/service (report baseline data)?
2. How/why was this problem selected?
a. Targeted population is high dollar, high volume/high risk, low volume/high risk, and/or problem prone.
b. Project is consistent with mission, values, goals, and patient priorities of the organization.
c. Issue is a key theme for accreditation or other regulatory body e.g. JCAHO, NCQA.
d. Sentinel event or near miss incident identified a process for improvement.
e. Other practical considerations: Costs: Can you pay for it? How much time will it take? Is it under your organization's control? Are staff members resistant to change? Are staff overloaded?
3. Who are the members of the PI team? Ensure adequate representation from all involved disciplines.
M = Measure the Current Performance of the Problem
1. Was the baseline data sufficient to understand and/or further define the problem or did you need to collect additional data?
a. Are your data Quantitative: expressed in time, dollars, patient expectations?
b. Are your data Accurate: record keeping must be organized?
c. Are your data Informative: can it be translated into information that will guide change?
d. Are your data Graphic: can it be expressed in data run charts, control charts, histograms, dashboards?
e. Are your data Comparative: are you able to compare performance using internal benchmarks, comparable organizations, standards, and best practices?
2. What, if any, additional data were collected to further define the problem? Provide/attach results.
3. Indicators you use must be SMART: Specific, Measurable, Attainable, Relevant, and Time based.
A = Analyze the Current Process for Improvement
1. Examine all the steps in the process you have selected for improvement.
2. Make certain that input from all disciplines involved in the process are represented.
3. Describe the method(s) used to analyze the process or processes of care that you are trying to improve? (Use flowcharts, fishbone diagrams, or other graphic tools).
4. What did you learn from this analysis? Summarize distinct points that can be addressed in a redesigned process. What conclusions did you draw to help further refine your problem statement and provide a basis for targeting improvement strategies?
D = Design the Improved Process
1. Based on your analysis and baseline data, what areas were targeted for improvement and/or redesign and how did you select them?
2. Describe improvement strategies or the new process using a flow chart.
3. Highlight new process steps.
I = Implementation of the Improved Process/ Improvement Strategies
1. How are you planning to implement the improvement strategies? What are the steps involved and timeline for implementing the new process? Use Gantt chart, MS project task list, or activity network diagram to display. Who is responsible for each of the steps? Do you have "buy in" from the key stakeholders?
2. If you have already implemented improvement strategies, how are things going and when will the outcomes be reviewed (for example, frequency)?
3. Did you build in a "pilot period" to check your group's assumptions?
M = Measure Performance after Implementation
1. How do you plan to measure the effectiveness of your improvement strategies and monitor response to your implementation, including additional costs, if any? Provide a timeline for completion.
2. If you have remeasured, what are your results (show trends)? What conclusions can you draw from your analysis of the remeasurement process?
3. What modifications have you made, if any, to your original plan?
4. How will you sustain the improvements? What are the project team's next steps?
Performance Measurement Publications
Joint Commission on Accreditation of Healthcare Organizations
Cost Effective Performance Improvement in Ambulatory Care. (2003).
Tools for Performance Measurement in Health Care. (2002).
Using Performance Improvement Tools in Ambulatory Care. (2001).
For more information on these publications visit: www.jcrinc.com or call (630) 792-5800.
Organizations and Web Sites
* Agency for Healthcare Research and Quality www.ahrq.gov
* American Academy of Ambulatory Care Nursing (AAACN) www.aaacn.org
* American Nurses Association www.nursingworld.org
* American Society for Quality www.asq.org
* Center for Clinical Effectiveness Loyola University www.luhs.org
* Institute for Healthcare Improvement www.ihi.org
* Institute of Medicine www.iom.edu
* International Council on Nursing www.icn.ch
* Joint Commission on Accreditation of Healthcare Organizations www.jcaho.org
* Leap Frog Group www.leapfroggroup.org
* Medical Group Management Association www.mgma.com
* National Association for Healthcare Quality www.nahq.org
* National Center for Patient Safety (NCPS) www.patientsafety.gov
* National Committee on Quality Assurance www.ncqa.org
* National Guideline Clearinghouse www.guideline.gov/index.asp
* National Institutes of Health www.nih.gov/icd
* National Institute of Nursing Research www.nih.gov/ninr
* President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry www.hcqualitycommission.gov
* University Healthsystems Consortium www.uhc.edu
NOTE: This column is written by members of the American Academy of Ambulatory Care Nursing and edited by REBECCA LINN PYLE, MS, RN, Regional Nursing Guidelines Coordinator, Kaiser Permanente, Denver, CO. For more information about the organization, contact: AAACN, East Holly Avenue, Box 56, Pitman, NJ 08071-0056; (856)256-2300; (800)AMB-NURS; FAX (856)589-7463; E-mail: email@example.com; Web Site: http://AAACN.inurse.com
Castaneda-Mendez, K., Mangan, K., & Lavern, A. (1998). The role and application of the balanced scorecard in healthcare quality management. Journal of Healthcare Quality, 20(1), 10-13.
Felix, K., & Pyle, R.L. (2000). Clinical performance improvement. In J. Robinson (Ed.), Core curriculum for ambulatory care nursing (pp. 419). Philadelphia: W.B. Saunders Company.
Joint Commission on Accreditation of Healthcare Organizations. (2002). Tools for performance measurement in healthcare: A quick reference guide. Oakbrook, IL: Author.
Kaatz, T., Sargeant, M., Kay, R., Ahmad, M., & Stoller, J. (2000, September/October). Balancing the perfect scorecard. MGM Journal, pp. 30-40.
Roski, J., & Gregory, R. (2001). Performance measurement for ambulatory care: Moving towards a new agenda. International Journal of Quality Healthcare, 13(6), 447-453.
SHIRLEY M. KEDROWSKI, MSN, RN, is Consultant/Interim Patient Care Director, Ambulatory Services (2002-2003), UCSF Medical Center, San Francisco, CA; and Past President (2000-2001) of the American Academy of Ambulatory Care Nursing. For more information, e-mail firstname.lastname@example.org
CINDY WEINER, RS, RN, is Manager, Endoscopy Department, UCSF Medical Center, San Francisco, CA; and Masters Student, Nursing Administration, UCSF School of Nursing.
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|Author:||Kedrowski, Shirley M.; Weiner, Cindy|
|Date:||Jul 1, 2003|
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