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The Reason We’re All Here …

Welcome to HCA 622 Week Two, Session One Lecture

We spent our first week of HCA 622 introducing the key concepts and tools for CQI and Patient Safety, their history in health care, and some of the challenges we face in healthcare quality and patient safety today.

We also began our drill down into these concepts starting with a focus on the importance of leadership in the success of organizations working toward improving quality and safety. This is the primary focus of the “people awareness” leg of Dr. Deming’s three-legged stool and will be a theme that runs throughout our course work.

Everything Ties Together!

You are Quality champions!

Especially LEADERS!

HCA 622 Week Two Roadmap

√ Please read Chapters in the required text prior to our class

√ In order to get the most out of the course, pace yourself by completing something everyday

√ Catch up as needed over the weekend

√ All graded assignments must be turned in no later than Sunday at midnight PT each week

HCA: 622 Quality Appraisal and Evaluation– WEEK TWO ROADMAP
	Monday	Tuesday	Wednesday	Thursday	Friday	Sat/Sun
Themes		Variation for Medical Practice, Data Collection, Statistical Tools		IT, Dashboards and Scorecard: Tools for Creating Alignment, Quality Infrastructure
Readings		Read Chapters 3, 5, 6, 13, 10, 15 in required text
Film Festivals
Discussion Questions			Complete DQ3		Complete DQ4
Reflection Journal			Reflection Journal Entry #1		Reflection Journal Entry #2
Assessments						Complete Quiz #2
Case Studies						Week Two Paper Due
Course project

Week Two Individual Paper Assignment

What are the most important actions an organization (and their leaders) should take to create a Quality/Patient Safety Transformation?

As we have been going through the materials from the book, videos and other resources, a number of key leadership actions/behaviors have been identified to move an organization through a process to create a plan for improving Quality and Patient Safety within their organization.

In addition to the materials we have covered, it is also helpful to focus on key steps successful organizations, in this case, The Mayo Clinic, have taken to achieve superior quality and patient safety.

This paper should address what you believe are the most important actions and behaviors that leaders of an organization may take to accomplish the improvement of quality and patient safety within their organization.

Week Two Assignment Reminder:

Be sure to review the Week Two Case Study information in Week Two of Blackboard and let your professor know if you have questions regarding the assignment which is due at the end of the day, Sunday of Week Two.

Hints for Your Papers

Use APA Format – use your opinion and your references

Address all of the questions

Proof your papers carefully for grammar, spelling and punctuation errors

Submit the paper into Safe Assign - check your score – you can correct and re-submit

Be sure this reflects your ideas and opinions at a graduate level.

Complete instructions in Week Two - Blackboard

Questions?

Week Two – What is Next?

Chapter 3: Variation in Medical Practice and Implications for Quality Chapter Outline

Background and Terminology

Variation in Medical Practice

Scope and Use of Variation in Healthcare

Clinical and Operational Issues

Keys to Successful Implementation

Case Study: Baylor Health Care System

As we are aware, today’s health care model came from industry. Measuring and assessing key processes in industry was a mainstay for this model. In industry, data was gathered for every step in an assembly line process and any errors or issues on an ongoing basis.

The premise was, we must measure and understand out work before we can improve it.

Deming’s Three Legged Stool (Profound Knowledge)

Customer Focused

Systems Focused

Process focused

-Statistical Thinking

-Data

People

-Teamwork

-Empowerment

-Motivation

Culture of Excellence

Leadership

Variation in care!

Introduction

We will begin our work for Week Two with a focus on the “process awareness” leg of Dr. Deming’s stool with a focus on the importance of variation in healthcare.

THE ROLE OF VARIATION IN QUALITY IMPROVEMENT

What is variation?

Nature of process variation

Measurement and statistical analysis

Process capability

Interpreting process performance

Process requirements

Understanding

the process

Key things the

process must

Variation

The concept of variation in how care and service is delivered is a critical concept in health care.

What is variation?

Why is it important?

How do we measure and understand variation?

How do we use quality tools to help us in this process and in improving our work?

When I hear the word “statistics”!

We will focus on the over-all concept of how important statistical process control is to our work in understanding variation with a few examples of the key tools and some suggested resources for future drill-down into the tools.

The Role of Variation in CQI

The starting point for any QI is measuring and understanding the type and causes of system variation (Deming 1993; Nolan and Provost 1990)

Statistical control (or statistical process control) of stable or “in control” processes is the basis of CQI activities (Shewhart, 1931)

If a process exhibited variation, then the cause of that variation had to be discovered and removed

Key to TQM/CQI - Determining variation and analyzing its causes in order to remove them

We begin in our drill-down in CQI and Patient Safety first by measuring key processes to help us understand how they are working and what we need to do to improve them.

Just as industry measured every step in the assembly line, healthcare needs to understand and measure all of our key processes of care and service.

This includes administrative processes, like the steps to admit a patient into the hospital, as well as all of our key clinical processes such as medication administration or the key steps in the surgery process for a procedure.

What is Variation?

Variation is the extent to which a process differs from the norm

It is related to the statistical concepts of variance and standard deviation

Variation is like a band of output around the central measure of a process

Variation is the extent to which a process differs from the norm.

When a patient is admitted for a Radiology procedure, what steps are involved; how long do each of these steps take and are there standard procedures that we can use to improve how the process works?

Average time

X-ray

takes

10 mins

Variation

X-ray

takes

15 minutes

Variation

X-ray

takes

8 minutes

Practical Example

How long does it take you to get to work each day?

Monday – 32 minutes

Tuesday – 35 minutes

Wednesday – 58 minutes**

Thursday – 42 minutes

Friday – 33 minutes

All processes have some variation in them.

Let’s talk, for example, about how long it takes you to get to work in the morning?

Does it take you the exact amount of time every day?

If you collected data on how long it took, you would find that there would be some variation in the time it took each day, depending on traffic, or if you stopped for coffee or, in a rare case, a traffic accident.

The key question would be – How long should it take? If you mapped out each step in the process, could you identify some standard things you could do to get to work as close to the same time every day?

Healthcare

is a

Process

that leads to an

Output

We start to understand our care and services by breaking them in to steps and measuring them.

All of healthcare can be broken down into steps – think about the steps that a patient goes through to be admitted to the hospital or clinic.

Definitions

Process

A series of interconnected and interdependent performance steps designed to meet customer expectations.

System

A network of interconnected and interdependent processes designed to meet customer expectations.

Organization

A system of systems. A complex collective entity of interconnected and interdependent systems designed to meet customer expectations.*

The Einstein Consulting Group 1990

Healthcare is very complex!

People taking care of sick people!

If we put all of these processes together, we then have a system, such as the multiple processes involved in medication administration starting with the physician order, through the pharmacy and to the nursing unit.

When we put all of these systems together – they make up a health care organization.

Practical Wisdom!

“For every complicated

problem, there’s a

solution that is short,

simple, and wrong”

H.L. Menchen

If we do not understand our work, we are in danger of making quick decisions based on opinions instead of facts and we may make the process even worse!

What is Variation cont.?

The concept of variation in health care may be viewed from several different perspectives

From the national perspective variation highlights health care quality issues relative to access, medical errors, patient outcomes, and resource allocation

At the organizational management perspective variation provides insights on the links between variation and organization effectiveness and results

From the individual perspective may be considered from practitioner, employee, and customer points of view

We can view the variation in health care from various perspectives:

From a national perspective, is care for a hip replacement exactly the same in California as it is in South Dakota?

From an organizational perspective, how do each of the nursing units compare on the length of time it takes to do an admission assessment on a patient?

And lastly, from an individual perspective, do all of the orthopedic surgeons do a hip replacement in the same way, in terms of length of stay in the OR, the types of equipment they use, and how many infections they may have for their patients?

Variation in Health Care STATS!

World Health Organization (WHO) rates the United States as having the most individually responsive health care system in the world, while it ranks the U.S. in 37th place overall (among 191 countries)

In the U.S., studies published in leading medical journals consistently report findings that people with acute and chronic medical conditions receive only about two-thirds of the health care that they need - while 20 percent to 30 percent of the tests and procedures provided to patients are not needed or beneficial

*Unjustified variation not only has potential implications for patient outcomes, but also constitutes mismanagement of resources.

What we have learned in our first week of studies is that today, the U.S. health care system is ranked almost last when compared to other high- and middle-income countries as it relates to mortality, cost, and the variation for different procedures.

Variation

A study done in the 1990s by the Federal Government found that mortality rates varied by State and were different according to where you got a procedure.

There was also a difference in cost and outcomes depending on your state.

This variation got the attention of the payors in the U.S. including the Federal Government who, through Medicare and Medicaid are the largest payor of healthcare in the United States.

Nature of Process Variation

There are two general categories of variation, first described by Deming (1986), special and common.

Special causes of process variation: unnecessary variation associated with specific material(s), machine(s), or individual(s) (i.e.. Traffic accident!)

Common cause variation is the inherent variance in the process that is a result of how the process is performed

It is also referred to as systemic or internal variation

Can be addressed by those working directly with the process (i.e. The time it takes to get out of the house!)

There are two general categories of variation in processes:

Special cause variation – unnecessary variation associated with specific materials, or individuals that can be attributed to a particular source; (like the traffic accident) and

Common cause variation which is inherent in all processes and which requires a change in the process (usually by management) to reduce the variation. (think about the time it takes everyday to get to work – maybe you have to skip the coffee every day to get there on time!)

Nature of Process Variation

2. Common causes of variation: those associated with aspects of the system itself such as design, training, materials, machines, or working conditions.

Special cause (or externally caused) variations can be attributed to a particular source

Special cause variation may be traced to the source eliminated but common cause variation can only be reduced by improving the underlying process or system

Responsibility of management to correct, as management is responsible for correcting and preventing system problems

The Importance of Variation in CQI

Attempting improvement efforts in the absence of an understanding of variation puts the manager at risk of the following: (Carey and Lloyd, 2001):

Seeing trends where there are not trends

Blaming or giving credit to others for things over which they have no control

Building barriers, decreasing morale, and creating an atmosphere of fear

Never being able to fully understand past performance, make predictions about the future, or make significant improvements in the processes

It is very important to understand for managers to understand:

All processes naturally have some variation in them – we are people taking care of people and every patient has different symptoms and pre-exiting conditions – no two patients are alike – so it is warranted or acceptable variation to take care of every patient depending on their condition; and

If variation is not based on the patient’s condition – it is based on the physician’s training, his style, his personal preferences or standard procedures are not being followed – this is unacceptable variation or unwarranted variation and may account for differences in cost, quality and may cause medical errors.

We must understand our work, what kind of variation exists and if it is acceptable or unacceptable in order to be sure we are making the appropriate improvement to our processes to reduce unwarranted variation.

MEASUREMENT AND STATISTICAL ANALYSIS

Process Capability

Interpreting Process Performance

Process Requirements

As we learn to understand out work, there are three key concepts we must keep in mind:

Process Capability - what is the process cable of? In the OR , for example, depending on the staff and equipment and supplies, how many patients is it possible to operate on, safely , in a day?

Does the process have warranted or unwarranted variation in it?

Process requirements - How do we determine the key requirements for a process based on the needs of our customers?

Process Capability

Process capability studies are to understand the expected output of a process, or the behavior of the process (How long should it take you to get to work?)

This involves plotting outputs from the process on a histogram

The aim is to answer the question “Is the process inherently predictable or dependable?”

The next slide shows just such histograms

The first plots the turnaround time for 223 STAT blood tests during a 23-hour period at one large hospital

There is a tool kit that is used to understand our work, measure it and help us determine if variation is common cause, special cause, acceptable or unacceptable.

An example of this is a process control chart.

Figure 3.1: Process Capability

Laboratory Test Turnaround Time

Be measuring a process, using one of the statistical process controls tools, in this case a histogram, we can determine the questions that need to be answered about the process we are studying.

Process Capability

By plotting the variables over time, patterns or trends in data emerge which can signal:

a problem with the process

that it is time to identify the source of the problem

to prompt action to resolve the problem, and to monitor the impact of the solution.

The use of a process control charts helps us to determine:

Is there a problem with the process;

The source of the problem; and

What action can be taken to address it.

Interpreting Process Performance

Variation exists in every process

The key is to determine if the average level of performance and amount of common cause variation is acceptable

Acceptable variation depends on understanding the expectations or requirements for the process

Context (turnaround time (TAT) required by an ED department vs primary care)

Specific requirements of the task (e.g. differences in time taken to apply different tests)

Customer requirements

Technical requirements

Sources of unwarranted variation can include: how people are trained, poor communication, not using standardized or evidence-based processes, or role confusion.

Variation in Medical Practice: Warranted vs. Unwarranted Variation

Warranted (acceptable) variation is based on differences in patient preference, disease prevalence, or other patient-related factors.

Unwarranted (unacceptable) variation is variation that cannot be explained by patient preference or condition or evidence-based medicine.

Variation in Medical Practice: Sources of Unwarranted Variation in Medical Practice

Potential sources of unwarranted (unacceptable) variation:

Variation in how people are trained

Poor communication

Role confusion (lack of a standard process)

Inequitable access to resources

Misunderstanding and misapplication of clinical evidence

Clinician uncertainty

Process Requirements

Process requirements are the criteria from which the effectiveness of a process is evaluated

These requirements may be considered from three perspectives:

the customer

other stakeholders

market in general

The next slide illustrates the sequence of questions that should be asked in order to interpret process performance.

In order to understand our work, we must consider what is important about a particular process from the customer’s point of view (remember Dr. Deming’s stool).

Process Requirements

Process Requirement Determination Process: Sequence of Questions

We can learn this by asking a series of questions like “who are our customers; what do they expect from our services (think time waiting in the ED); how are our processes designed; and, how do we measure them?

Process Requirements

Who are the customers and what do customers require of your services?

What do patients require? Access? Competent, courteous providers?

What do payers require? A certain level of clinical results delivered in a cost-effective manner?

What do regulatory bodies require? Compliance?

What do markets require? A culturally diverse approach to delivering services?

We can then gather data to see if we are meeting those requirements at all times, is there variation in how often we are meeting them, is it unwarranted variation; and do we need to make improvements?

Variation in Medical Care: Tools for Quality Improvement

Where best practices have been identified:

Evidence Based Clinical guidelines

Benchmarking and report cards

Pay-for-performance

Transparency!

We also look outside our own organization to determine the best way to do things, based on evidence and research – evidence-based practices, benchmarking against other successful organizations and by the standards set by regulators or payors.

Scope and Use of Variation: Health Services Researchers and Healthcare Managers

Health services researchers answer the question “Other things being equal, does A cause B?”

Often take the long view to examine several years’ worth of data

Healthcare managers use data on variation to answer the questions “Where can we improve?” and “Are we getting better?”

“Just-in-time” performance data are essential

Keys to Successful Implementation

Administrative and physician views

Patience and a long-term vision

Engage physician champions

Organizational mind-set

EMRs

Economic incentives

IE. Mayo Clinic!

In order to be successful with our efforts to understand our work, we must:

Engage physician champions, create an organization mind-set that is open to change and make sure our incentives are aligned with these efforts.

Process Requirements

A process performance chart is the most effective way to measure, document, analyze, and understand the capability of a process.

Great Resource:

The Memory Jogger II:

A Pocket Guide of Tools for Continuous

Improvement and Effective Planning

by Brassard, Michael, Ritter, Diane (January 15, 1994)

Spiral-bound 1st Spiral-bound – 1600

by Michael, Ritter, Diane Brassard

This is a great resource that provides a leader with an explanation of quality and statistical tools and instructions on how to create and use them.

Case Study: Baylor Health Care System

Increasing use of evidence-based heart failure therapies

Each of the chapters from our text has case studies and examples that help us apply what we have learned and understand the key to success for applying these concepts and tools.

Conclusion

Keys to successful management (rather than elimination) of variation in pursuit of quality healthcare include the ability to

identify variation;

distinguish between random and assignable variation;

determine the meaning, importance, or value of the observed variation relative to some standard;

Acceptable or not? and

implement methods that will take advantage of or rectify what the variation reveals.

Contact Your Professor for Questions

Chapter 5: Data Collection Chapter Outline

Categories of Data

Considerations in Data Collection

Objectives for Success

Sources of Data

Once again, in order to understand our key processes, we must measure them.

Let’s begin our discussion of data and measurement with some key concepts and definitions.

Key Points

Data and Information are Different!

Data = Facts (A list of wait times for the ER)

Information = Answers to questions

(What is the best practice for ER wait times?)

“Information” includes “data”

“Data” do not necessarily

include “information”

Data = facts, information = the answers to questions; information includes data, but data does not include information.

This is an important concept, we have a lot of “data” in health care, but not necessarily a lot of useful information!

Without a clear understanding of our work, based on data, – we might find ourselves here!

Generating Information

Information Needs

Questions

Communication

Data

Analysis

Juran Institute, Inc.

In order to understand our work, we must identify our information needs, determine the data we need to answer the right questions and then be able to analyze the data.

Key Goals

Data created and captured in systems representing a treasure trove to be carefully stewarded and valued every step of the way.

Everything else we need to improve Quality and Patient Safety relies on these data.

Meaningful information that is relevant to someone who is doing the work of health and health care

The data created and captured in systems in health care is essential for us to understand our work and improve it.

Data Collection in Health Care

Quality measurements can be grouped into four categories or domains:

Clinical quality (both process and outcome measures)

Financial performance

Patient satisfaction

Functional status

Maintain a balanced perspective of the process of care when designing data collection efforts in all four categories.

The data that we use for quality and patient safety can be grouped into four categories: clinical date (both process and outcomes data); financial data, patient satisfaction data; and functional status data.

Data Collection

Keys to a Successful QI Project and Data Collection Initiative

Identify the purpose of the data measurement activity

Identify the most appropriate data sources

Identify the most important measures for collection

Design a common-sense data collection strategy providing complete, accurate, and timely information

When a project is identified for improvement, the following steps must be determined:

What data do we need and what is the purpose for the data?

What are the appropriate sources for the data? and

A data collection plan must be created.

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

The sources of data in health care include, but are not limited to: medical records data, administrative/financial databases, patient satisfaction surveys, health plan data bases and patient registries (where they exist.)

The following is a breakdown of each of theses sources.

As we move forward with technology in healthcare, planning for the future of data needs and measurement is a key priority so that we can automate these data sources and further understand our work and how to improve it.

Data Collection

Medical Record Review

Continues to be mainstay of data collection:

Seen by many as most accurate method

Has data elements not available in administrative databases

National quality improvement database projects have depended on retrospective medical record review

Primary tool for answering the “why” of situations

Downside:

Costly

Time consuming

EMR!

The future is near!

Data Collection

Administrative Databases

Administrative data refer to information collected, processed, and stored in automated information systems. These data include enrollment or eligibility information, claims information, and managed care encounters.

Patient Satisfaction Surveys

When patient satisfaction surveys are conducted on a continual basis using a proper sampling methodology, the organization can respond rapidly to changes in patients’ wants and needs.

Functional Status Surveys

A patient’s functional status usually is assessed before and at several points following a treatment or procedure.

Data Collection

Health Plan Databases

These databases can be an excellent source of data for quality improvement projects, particularly projects that have a population health management focus. They contain detailed information on all care received by health plan members.

Patient Registries - Registries are specialty or procedure specific.

Advantages:

Rich source of information

Collect most important data as determined by physicians

Can use data for quality improvement and research purposes

Do not have shortcomings of administrative databases

Provide complete picture of patient experience

Now What?

So, once we have our data and measurement plan set in place, what do we do next?

Chapter 6: Statistical Tools for Quality Improvement Chapter Outline

Fundamentals of Performance Measurement

Framework for Measurement

Selecting Performance Measures

Statistical Process Control

Control Chart Analysis

Comparison Chart Analysis

Statistical Assumptions About Data

Using Data for Performance Improvement

One of the most important toolkits for quality improvement are the statistical tools to measure, assess and improve our key processes.

We will provide a general overview of the toolkit, its importance and provide key additional resources for exploring these tools in more depth.

Deming’s Three Legged Stool

Customer Focused

Systems Focused

Process focused

-Statistical Thinking

-Data

People

-Teamwork

-Empowerment

-Motivation

Culture of Excellence

Leadership

As we have learned, one of the three legs of the stool is process/system awareness – understanding our key process of work so we can then improve them.

Statistical Tools for Quality Improvement

Purpose of Measurement – Quality and Safety!!!!

Performance measurement meets multiple internal and external needs.

Three fundamental purposes of performance measurement:

Assessment of current performance - process in control?

Demonstration and verification of performance improvement - Did we make a difference?

Control of performance – Overtime- sustaining improvements

Ongoing vs. CQI Teams

Performance measurement meets multiple internal and external needs:

assessment of current performance;

demonstration and verification of improvement efforts;

sustaining performance overtime; and

identification of the focus for current and future CQI teams.

Benefits

What gets measured get addressed!

Saving Patients lives!

Framework for Measurement

Performance improvement process – a strategically driven, values-based, systemic, organization-wide approach to achieving organizational improvements

Performance improvement plan – a detailed strategy for undertaking specific projects

Performance improvement projects – evolve from the establishment and articulation of the performance improvement plan

“Plan – what Plan?

I’m making it up as I go along!”

A cohesive CQI/Patient Safety program is comprised of three elements:

A performance improvement process – carefully chosen, values based, systematic organization-wide;

A performance improvement plan consisting of identified and prioritized opportunities for improvement, adequate staffing, expected time frames and resources; and

Performance improvement projects – focused initiatives that hospitals implement to achieve clearly defined, measurable improvement.

Statistical Tools for Quality Improvement

Framework for Measurement

A cohesive performance improvement program (plan) comprises three elements:

Performance improvement process

Performance improvement plan: a detailed strategy consisting of:

Identified and prioritized opportunities for quality improvement

Adequate staffing

Expected time frames

Necessary financial/material resources

Statistical Tools for Quality Improvement

Performance improvement projects:

Diverse, individual, focused initiatives that hospitals implement to achieve clearly defined, measurable improvements

4. Other components that support successful implementation of performance improvement programs:

Leadership commitment – Most critical element!

Staff training, understanding and participation

Establishment of partnerships with key stakeholders

Other key components include: leadership commitment; staff training, understanding and participation and involving key stakeholders at all levels.

Selecting Performance Measures

There are a number of ways that we can decide what is important to measure.

Dr. Avedis Donabedian, a major quality champion, provided a framework for measurement.

Statistical Tools for Quality Improvement

Selection:

Critical Performance Measure Characteristics

High volume, High risk, Problem Prone

Relevant

Reliable

Valid

Cost effective

Under the control of the provider

Precisely defined and specified

Interpretable

JCAHO/CMS

Requirements!

6 Aims!

There are several sources for ongoing measurement including structure, process and outcomes measures, the 6 aims as identified by WHO and the IOM, and those measurements required by regulators and prioritized patient safety measures for follow-up on organizational events and near misses.

Statistical Process Control (SPC)

Benefits of SPC in healthcare:

Increased quality awareness on the part of healthcare organizations and practitioners

Increased focus on patients

Ability to base decisions on data

Implementation of predictable healthcare processes

Cost reduction

Fewer errors and increased patient safety

Improved processes that result in improved healthcare outcomes and better quality care

The concepts and tools for measurement in health care have a number of key benefits as we strive to understand and improve our work for our patients.

Statistical Tools for Quality Improvement

There are a number of ways to use data for improvement purposes, all of which involve comparison.

There are a number of tools and references reviewed and provided in this chapter for your information and follow-up.

In later chapters we will review key toolkits for leaders to use to communicate the data and benchmark with other key indicators sets to provide for ongoing review and improvement.

Statistical Tools for Quality Improvement Example

Elements of a Control Chart

A control chart is a line graph with a centerline that represents the overall process average (or mean). It shows the flow of a process over time and is a dynamic presentation of data. The measure of the process being monitored appears on the vertical axis.

Control Chart Analysis

Common cause variation versus special cause variation

A control chart can tell us whether observed variation results from common or special causes.

Great Resource!!!!

On Amazon

under $18.00

This is another excellent reference for leaders.

Statistical Tools for Quality Improvement

Data can be used to compare:

An organization’s performance against itself over time

The performance of one organization to the performance of a group of organizations collecting data on the same measures in the same way

An organization’s performance against established benchmarks or guidelines

Samples

Hospital Compare.gov

Continuous Improvement

Getting the variation out of our key process!

Contact Your Professor for Questions

HCA 622 Week Two Roadmap

√ Please read Chapters in the required text prior to our class

√ In order to get the most out of the course, pace yourself by completing something everyday

√ Catch up as needed over the weekend

√ All graded assignments must be turned in no later than Sunday at midnight PT each week

HCA: 622 Quality Appraisal and Evaluation– WEEK TWO ROADMAP
	Monday	Tuesday	Wednesday	Thursday	Friday	Sat/Sun
Themes		Variation for Medical Practice, Data Collection, Statistical Tools		IT, Dashboards and Scorecard: Tools for Creating Alignment, Quality Infrastructure
Readings		Read Chapters 3, 5, 6, 13, 10, 15 in required text
Film Festivals
Discussion Questions			Complete DQ3		Complete DQ4
Reflection Journal			Reflection Journal Entry #1		Reflection Journal Entry #2
Assessments						Complete Quiz #2
Case Studies						Week Two Paper Due
Course project

In our next session we will focus on leadership tools to share data and create alignment in our organization.

750-words and include at least two references outside the assigned text and article. APA FORMAT

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