Tuesday, 08 December 2015 23:01

Leveraging Progress with the Flawless Care Scorecard

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HealthEast Care System is a community-focused, nonprofit healthcare organization that includes one long-term acute-care hospital (126 staffed beds), three short-term acute-care hospitals (500+ staffed beds), outpatient services, clinics, home care, hospice, and medical transportation. We have 7,300 employees, 1,200 volunteers, and 1,500 physicians on staff.

HealthEast has continued to discuss and define a global or organizational approach to measuring flawless care across the system. The discussions have now turned to what this number means and how we can determine if we are making improvements as we continue to create and refine the Flawless Care Measure and Scorecard.

Creating the Flawless Care Scorecard

In developing the Scorecard we used a quality measure matrix that included all regulatory, joint commission, and commercial pay-for-performance indicators to identify measures that could be included.

Each measure must have been reported during our 2015 fiscal year so we would have a baseline against which we could compare and calculate.

We also created an easy, familiar way for leaders to enter their monthly results and data. We chose to go with Excel, with the ultimate goal to use this as a database and put the filtering and re-calculating in Epic via WebI.

The Scorecard can be filtered by:

  •  Entity;
  •  Strategy deployment team;
  •  Pillar leader clinical quality;
  •  Data entry; and
  •  Measures

The Flawless Care Score then is recalculated based on the filters.

Challenges with The Flawless Care Scorecard

The biggest challenge was the need to measure performance across:

  • Multiple dimensions (structure, process, and outcome)
  • Multiple levels (business unity, entity, organization, and population)
  • Multiple clinical areas

Also, we asked ourselves, how do we get the Flawless Care Score to change with the many needs to report this number at varying levels of the organization?

Getting everyone to enter their data in a timely manner, without having to “chase” them for the data, was crucial. 

Measures such as readmission and infection rates can lag several weeks behind before we can get a final Flawless Care Score for the month.

The Flawless Care Score is a moving result based on who has entered data and for how many months. This is one of the reasons we needed to be able to break the data out by months, as well as compile a YTD report.

Flawless Care Score

This Flawless Care Scorecard made its debut at the Acute Care Clinical Quality Council and the HealthEast Board. The Scorecard is dynamic, meaning that every time a new result is added, the YTD number changes, not only causing confusion, but making it difficult to report/display the result to various audiences. The questions of what this number means and whether it is actually a meaningful number continue to be asked.  

The Flawless Care Score is made up of 60-plus measures that have been condensed to one number to monitor and measure the delivery of flawless care. Below is an example of the data, along with the formulas used to calculate the numbers.

We have added the ability to filter various columns and have the score recalculate based on the filter. The formula is subtotal = (1,BK3:BK67). The BK3:BK67 references the column of numbers included in the sort. If you choose not to sort and recalculate the score, it is an average of all the scores in the score column.

Example of The Flawless Care Scorecard

This is a very small example of what the Flawless Care Scorecard look like; it includes many hidden columns to make it printable. Work is being done in our reporting and analytics department to recreate the scorecard and have it accessable via Epic using WebI and to allow for greater access throughout HealthEast.

Learning

Understanding what the flawless care measures mean continues to be a major point of conversation and confusion. Moving to flawless care is a journey that does not have an end point. It has been really difficult for some analysts and reporting staff to wrap their heads around one measure, because we always wanted it to be statistically significant and to be able to tell if what we are seeing is normal variation or whether we really did make an improvement. The most basic question is the most important question: What does this number mean and how do we know if we are improving?  

Next Steps

We will continue our journey in uncharted waters, and it’s going to be rough going this next fiscal year as we continue to increase our understanding and refine our processes and reporting methodology.

Critical for sustainability is to start the discussion around how to create a flawless measure at the individual patient level and how to be able to report it by using data captured in the patient medical record.

About the Author

Kathleen Geier is the director of clinical and regulatory performance at HealthEast Care System in St. Paul, Minn. She leads the strategic planning and oversight of government-required pay-for-performance and commercial payor clinical and regulatory performance measures. She is also a member of the Minnesota Statewide Quality Reporting and Measurement Committee for 2014-2016.

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Last modified on Wednesday, 09 December 2015 05:20

Kathleen Geier is the director of clinical and regulatory performance at HealthEast Care System in St. Paul, MN. She leads the strategic planning and oversight of government-required pay-for-performance and commercial payor clinical and regulatory performance measures. She is also a member of the Minnesota Statewide Quality Reporting and Measurement Committee for 2014-2016.