Intern Final Paper

FACILITY X Health System: Performance Improvement/Patient Safety

Student name

HCM 490: Healthcare Internship

Instructor Name

Date

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TABLE OF CONTENTS

Page #

Executive Summary .....................................................................................................3

Research Goals and Objectives ............................................................................... 3-4

Literature Review .................................................................................................... 4-5

Approach/ Methodology ..............................................................................................5

Implementation ...................................................................................................... 6-10

Data ....................................................................................................................6

Visual Element ............................................................................................... 6-7

Creating the Dashboard.................................................................................. 7-8

Skills Set ...................................................................................................... 9-10

Findings ................................................................................................................. 10-11

Conclusion ..................................................................................................................11

Works Cited ................................................................................................................12

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Executive Summary

From January 22, 2013 to April 18, 2013, I worked in the Performance Improvement/

Patient Safety department at Facility X Medical Center; I completed a total of 120 credit hours.

Facility X Health System has five hospitals, including Facility X Medical Center, with 765 beds

and many primary care physician offices located throughout Cumberland County and the

surrounding areas (About Facility X, 2012). The Performance Improvement/ Patient Safety

department commonly referred to as the PI department, works day to day to improve the overall

performance of the Facility X Health System.

During my time at Facility X, I worked under the supervision of Preceptor, the Director

of Performance Improvement/ Patient Safety, and daily with Preceptor, the Quality Engineer in

Performance Improvement/Patient Safety. The overall objective for my internship was to create a

dashboard for Facility X Health System. The dashboard will help executives and PI team

members to have a current idea of the essential indicator rates and where improvement is needed.

I developed the dashboard by using the Premier database and deciding on visual elements, key

indicators, and other essential factors.

The skills set that I used and obtained throughout completing the dashboard project

include: utilizing Premier, familiarizing myself with HCAHPS, and enhancing my knowledge of

fundamental computer concepts and tools. The dashboard project related to the Healthcare

Management degree program at Fayetteville State University within the following courses:

Quality Healthcare Management, Managed Care, and Healthcare Policy and Law.

Research goals and Objectives

The goal of my internship was to develop a quality/patient safety operations dashboard

for Facility X Health System. The purpose of the dashboard is to create a quick “snap shot” of

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current data that can help top leadership and PI team members to visually see the performance of

the hospital in specific areas and to see where improvement is needed.

Literature Review

A dashboard provides an overview of a company’s essential performance indicators

through the use of visual tools, such as graphs, charts, and tables. The following rates are used as

key indicators at Facility X Medical Center: hospital acquired conditions (HAC), mortality,

readmissions, evidence based care, and patient experience (HCAHPS). These specific indicators

are chosen because Facility X must report these rates to the Centers for Medicare and Medicaid

Services (CMS). CMS will then report these findings to the public to increase hospital care

transparency, provide valuable data to consumers who are deciding on care, and to assist quality

improvement efforts of hospitals (Outcome Measure, 2013). The hospital’s performance within

each category will also determine their payment provision from CMS, also known as CMS’s

“Value-Based Purchasing” (LaBresh, Jarret, & Lux, 2011).

I will briefly describe each key indicator and how the rates are determined. Hospital

acquired conditions (HAC) are medical conditions or complications, which are not present at the

time of admission, that a patient contracts during their hospital stay (Hospital Acquired

Conditions, 2012). CMS requires and publishes HAC rates based on four factors: catheter-

associated urinary tract infections (CAUTI), central line associated blood stream infections

(CLABSI), ventilator-associated pneumonia (VAP), and surgical site infections (SSI) (Kansas

Healthcare Collaborative). For mortality rates, CMS reports on the death rates of patients with

congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia (PN); the

window of death or survival is 30 days from the day of admissions. Readmission rates are

defined as patients who were readmitted for CHF, AMI, or PN within 30 days from the discharge

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date. Evidence based care rates determine how proactive a hospital is in using most recent and

top evidence based processes in decision making about the patient’s care or healthcare services

delivered. The last key indicator used was patient experience, which is based off the HCAHPS

survey. “The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

survey is the first national, standardized, publicly reported survey of patients' perspectives of

hospital care” (HCAHPS: Patients' Perspectives of Care Survey , 2013). HCAHPS captures the

patient’s individual satisfaction in several different areas including: communication with nurses,

communication with doctors, pain management, cleanliness and quietness of hospital

environment, etc. The Value-Based Purchasing model of Medicare’s payment will be partly

based on the hospital’s HCAHPS scores.

With Value-Based Purchasing and CMS reporting, it is crucial for Facility X’s corporate

officers (CEO, CFO, and CMO), board members, and PI team members to have updated and

current data available, essentially at a click of a button. This data helps to ensure that they are

satisfying patients’ needs and providing quality care to the community. The goal of developing

the dashboard is to ensure that these essential members have a “real time” idea of where the key

indicator rates are and where improvement is needed.

Approach/Methodology

I worked directly with my Preceptor, the Quality Engineer, to determine the dashboard’s

visual design, key indicators, and the most appropriate methods for obtaining data from various

sources and databases to utilize within the dashboard. I used Premier database, Microsoft Excel,

and Internet Explorer for research purposes.

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Implementation

Data

Facility X’s PI department uses several different sources and databases to obtain hospital

data. Some of the more popular sources they use are Premier/Quality Advisor, Partnership for

Patients, and Press Ganey. The source or database used is dependent on what data the individual

team member wants to pull and how they want to use it.

I, personally, was able to gain access to and utilize the Premier network and database.

Premier collaborates with Facility X to obtain their data/rates and stores them into a single

database. This allows the PI team members to gain easy access to current data and be able to

manipulate it; there is a vast amount of data to choose from when running reports. For instance,

when I was running a mortality report, I had to choose several different options including: the

time length, the population, and the row and column headings. I was unable to gain a lot

experience using Premier, due to confusion and delay of obtaining a username and password for

the database. Due to the delay in access to Premier, majority of the data pulled for the dashboard

was given to me by other PI team members.

Visual Element

The first step of designing the dashboard was to develop an idea of the visual aspects of

displaying the data. There are several different types of dashboards including:

Comparison Charts Gauge Charts Time Charts

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After several trial-and-error attempts, it was decided the best dashboard format would be

a scorecard (see figure below). This was the best format for the dashboard because it displays

crucial visuals, such as trends and symbols, as well as pertinent data, such as current and target

figures.

Creating the Dashboard

The dashboard was created to give a quick “snap-shot” of how Facility X is doing in each

key indicator (hospital acquired conditions, mortality, readmissions, evidence based care, and

patient experience). The initial dashboard I created included the following data of each key

indicator: name, color coded symbol, target value, current value, trend, change in current and

previous quarter, and a column explaining the desired value. The color coded symbol (see figure

below) is a quick visual that represents the change in previous quarter and the current quarter;

this allows individuals viewing the dashboard to quickly assess what key indicators have

improved positively or negatively.

indicates improvement from previous quarter

indicates no change from previous quarter

indicates negative change from previous quarter

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After input from the PI team members and the CEO of Facility X Health System, the end

result of the dashboard included the key indictor’s target value, current value, trend, and a color

coded symbol to show the change in quarters. Each section is automatically updated from data

that is directly linked to the indicator’s drilldown page. For instance, the readmission indicator

has a specific drilldown page that contains quarterly data and is linked directly to the dashboard

for automatic data updates. The final dashboard, after revisions and suggestions from several

individuals, is:

Skills Set TEST DATA

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The skills set that I used while developing the dashboard include: utilizing Premier,

familiarizing myself with HCAHPS, and enhancing my knowledge of essential computer

concepts and tools. As discussed previously, I was able to gain access to and utilize the Premier

database. The experience I received from using Premier will hopefully allow me to have a

competitive advantage within the healthcare industry job market.

Before interning in the PI department, I was familiar with the HCAHPS survey and the

Hospital Compare website. After creating the dashboard and researching HCAHPS, I have

gained more in-depth knowledge about how HCAHPS is now used to create payment incentives

and how hospitals focus on their HCAHPS scores. I also learned how Facility X Medical Center

is trying to capture and earn higher HCAHPS scores. For example, to ensure patients report

positively on the quietness of the hospital, each nursing station is equipped with a signal light

that displays the traditional green, yellow, and red colors. When noises are reaching an above

normal volume, the signal light will illuminate yellow and it cautions employees to reduce the

noise level. Similarly, when the signal light illuminates red, it allows employees to visually see

that the noise is too loud and needs to be reduced. These provisions allow Facility X to stay

proactive in ensuring their patient’s are satisfied with their experience during their stay.

With living in a technological world, it is extremely important for an individual to

continue to grow their knowledge in areas of computer programs. I am an advanced computer

user and even certified in Microsoft Word, but I was able to gain new skills within Microsoft

Excel when completing the dashboard project. I became familiar with creating trend lines,

conditional formatting, and hyper linking data. I took the initiative to research attributes and

procedures online, if I was unfamiliar with the process. For instance, when developing a

PowerPoint for displaying the dashboard with automatic data updates, I had to research the

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correct procedure and follow a step-by-step guide to ensure proper utilization. All of the new

skills I have acquired and used throughout my internship will be beneficial when I enter into my

future career.

Findings

The Healthcare Management degree program offers exceptional courses that help to

prepare students to enter into the healthcare industry. The Healthcare Management courses that

directly relate to the dashboard project of my internship are Quality Healthcare Management,

Managed Care, and Healthcare Policy and Law.

The PI department as a whole captures the core lessons and concepts that are taught

within the Quality Healthcare Management course. The Quality Healthcare Management

course’s main objectives were to study the vital principles of quality and the relation to

healthcare management, as well as examining the tools used to capture quality. The PI

department focuses on improving the quality and performance of the entire health complex

through essential tools, such as: daily Quality Care Control (QCC) meetings, various

performance initiatives, and failure modes and effect analyses (FMEAs.) The dashboard that I

helped to create will help Facility X to visually see exactly where they stand in terms of key

CMS indicators; essentially helping the PI department to lead quality initiatives to either improve

rates or to ensure rates stay satisfactory.

With CMS converting to a Value-Based Purchasing (VBP) program, Facility X must be

aware of their performance in key indicators. VBP was covered in detail, throughout the

Managed Care course. The Managed Care course highlighted what VBP was, the benefits and

risks associated with VBP for hospitals, and the initiatives that hospitals could focus on to ensure

repayment.

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Lastly, throughout any hospital department, it is crucial for team members to be mindful

of ethics, policies, and laws that protect patients and employees. In the Healthcare Policy and

Law course, students learned the principles of healthcare ethics, policies, and current laws. The

PI department goes through great lengths to ensure patient confidentiality and that each quality

project is adhering to ethical principles and the policies and laws that are currently in place.

Conclusion

My time at Facility X Medical Center was exceedingly informative, satisfying, and

rewarding. I not only learned a vast amount of new information, but I also put the skills and

knowledge, which I learned throughout the Healthcare Management program, to use daily. I

strongly believe that I could not have been placed in a better department then Performance

Improvement with Mrs. Preceptor and Mrs. Preceptor as my preceptors. I always felt included

within the department and within the tasks that were being performed. Mrs. Springer always

made sure that every task she assigned related to Healthcare Management and would be

beneficial to my future endeavors.

In my opinion, the most important aspect of my internship at Facility X was being

exposed to the different departments of the hospital and being able to decide on which

department I would like to be a part of in the future. Before my internship, I was unsure of what

department within the hospital, I would like to begin my career in. After being exposed to the PI

department, I really feel that my career niche would be to help the hospital better their policies

and procedures to improve their performance within a wide array of areas.

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References

About Facility X. (2012). Retrieved from Facility X Health:

http://www.capefearvalley.com/about/index.html

CAUTI, CLABSI, SSI, VAP. (n.d.). Retrieved from Kansas Healthcare Collaborative:

http://www.khconline.org/news/114-uncategorised/87-stay-fit

HCAHPS: Patients' Perspectives of Care Survey . (2013, April 10). Retrieved from Centers for

Medicare and Medicaid Services: http://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

Hospital Acquired Conditions. (2012, August 24). Retrieved from Quality Definitions and

Methodology: http://www.ahd.com/definitions/hqi_acq_cond_measures.html

LaBresh, K., Jarret, N., & Lux, L. (2011). Evidence-based Guidelines for Selected and

Previously Considered Hospital-Acquired Conditions. Research Triangle Park: RTI

International.

Outcome Measure. (2013, April 10). Retrieved from CMS:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/HospitalQualityInits/OutcomeMeasures.html