SVtY QUALITY INDICATORS - University of Michigan
Contents
1. Ambulatory Care Executive Director lJohnFosyh 1 0 everly Jones L David N Southwell B Information Services Division aul R Vegoda R Page 5 2 3 Table 2 CRITERIA for QUALITY INDICATORS 4 Request Quality Indicators from Departments The quality indicators which were available at the start of the project had been submitted a year earlier in September 1991 In order to re initiate the quality indicator collection our client communicated with the departments through memos and our team communicated by telephone with the departments requesting that the they submit or update their indicators Our team also requested that the departments send in any current data they have available or if they had none were currently monitoring them As the information throughout the project was returned to our client s office the team continued to update the final list of quality indicators We also found that some of the indicators from the original forms were not included on the initial log of quality indicators We added the appropriate indicators to the log of indicators Develop Criteria for Evaluating Quality Indicators As seen in Table 2 seven criteria were developed and defined for evaluating the usefulness and appropriateness of the indicators This list was sent by memo to each department so that they could better understand the evaluation process and use it as a guideline f2. ith B 4t 2070 qe 4490 7041102060189 Tul 59 zu um EINEN A Te ER ae Pe an Sea d om sita a 2205 ay satu zu in f rear Toit SEO fola ve ni rabia v zn m ats lors oh o Ei 43 zum ara BL yr ISTE di ji i ays T uni Tus S UE aX AL ES act am sequ va dreamed el mane rots or valo 55 p allt woody en dim lt t 310 H rt air 2 ia Satie na suis bo do Jh Lr ia GL etnies a Seng qd iude d pa na SRY 2214 ESSI FAT MAI las 2 rtg a nel el ROS Wo Sy ae my ech gt sahen 1888 nA atts 17 Sia 2 17 pe il ES Ken P 14 ud usw utu 1174 Lad T Sites Dux Chen ge ee Wu Deb 1 14 7 gant cheep y I hath esu aro mi yoy pati iv bW oi rs Zn sai ane ef sit esp oath 8 lo fe gs ums Tb vr In Id I A 6 8 9 Evaluated the updated log of quality indicators which consists of 144 indicators We also made comments regarding how the indicators might be improved Once evaluated the log was sent to our client for review and for further modifications of the indicators that did not fully meet all
3. QUALITY INDICATORS Final Report for Administration Department University of Michigan Medical Center Dy Management Systems Department Total Quality Management Team Peter Giordano Patrick Herzog Christina Tatting December 17 1992 FIM eet Tabl nten 2 Quality Indicator Development eere eere eee enne 2 Reporting Mechanism 2ues00e2000000020000000000n0000neunssonsnonssonsnnssnsssnsssnnsnsenennnene 2 Introduction and Background eee eee 3 InitialiSituatlon 265 ii ET eds ie onda a aae Edna 3 Approach and Methodology eese eese eese eese eee eene eese entente ense nnne tenen nennen 4 Findings and Conclusions eere 8 Quality Indicator Development eere eere eene einen ennt nnns 8 Reporting Mechanism e eeeeeeeeee 9 Method 1 Decentralized 5 Lore eee 9 Method 2 Centralized 1 crece ee 2 2 9 252222 22000 9 Method 3 Combination Centralized Decentralized 9 Recommendations c eee eese eese so enean n nne seas ases sees sae a 10 Quality Indicator Development 10 Reporting Mechanis
4. Oo CON HD CQ Interval Avg Interval Max Interval Min c6 LV 6t 1 21 91 2 21 91 3 21 91 4 21 91 5 21 91 6 21 91 7 21 91 8 21 91 9 21 91 10 21 91 11 21 91 12 21 91 1 21 92 2 21 92 3 21 92 4 21 92 5 21 92 6 21 92 OT GI 05 09 SIWI eM Appendix C Information and Networking Services Departments on the U of M Medical Center s Banyan Network 1 Administration Office of the Executive Director 2 Ambulatory Care Services xecutive Sue xecutive Suite M Care Health Center Northeast Ann Arbor M Care Health Center Northville Northville M Care Health Center Plymouth Plymouth Nutrition Counseling Center utrition Svcs U of M Medical Group Briarwood Campus NetSvcs 3 Attorney Executive Suite 4 Biomedical Communications Wolverine5 Biomedical Engineering olverine5 6 Bone Marrow Transplant Program 0160 Cancer Cony Bone Marrow Transplant Clinic ott Cancer Cen 7 Facilities Administration acAdminl Capital Budget Program FacAdminl Design and Construction olverinel Environmental Health amp Safety olverine3 Facility Engineering FacAdmini Infection Control FacAdminl Maintenance PlantSupport Planning and Design Plant Operations l A Project Support acA Utilities Management lantSupport olverine5 8 Finance Administration l IB Finance Billing and Third Pary Collections NI
5. EXGRPH lt ver gt Instructions for entering and updating your own data are as follows Entering Data for the First Time Make sure you have the appropriate software application This could be either Microsoft Excel for the Macintosh Microsoft Excel for DOS or Lotus for DOS The following list of file formats are included on 3 5 floppy disks packaged with the Log of Departmental Quality Indicators Quality Indicators Tabular and Graphical Data Macintosh Format m f Version EXTAB 3 0 Microsoft Excel ver 3 0 EXGRPH 3 0 Microsoft Excel ver 3 0 INDITAB 3 0 Microsoft Excel ver 3 0 INDIGRPH 3 0 Microsoft Excel ver 3 0 EXTAB 4 0 Microsoft Excel ver 4 0 EXGRPH 4 0 Microsoft Excel ver 4 0 INDITAB 4 0 Microsoft Excel ver 4 0 INDIGRPH 4 0 Microsoft Excel ver 4 0 DOS Format 1 m ftware Version EXTAB WKS Lotus 1 2 3 wks file type INDITAB WKS Lotus 1 2 3 wks file type EXTAB3 XLS Microsoft Excel ver 3 0 EXGRH3 XLC Microsoft Excel ver 3 0 INDITAB3 XLS Microsoft Excel ver 3 0 INDIGRH3 XLC Microsoft Excel ver 3 0 Open the file INDITAB ver 9 This file will be used to update all of your subsequent data for one of your indicators Use IND2TAB lt ver gt for data entry for the second indicator If you want to keep a copy of this in its original form make a copy of both IND1TAB lt ver gt and IND1GRPH lt ver gt before making any modifications to the files 9 The spreadsheet already has some information on it including the dat
6. department Internal Medicine is on a local network that is connected to a Health Sciences Network which in turn is connected to the Banyan network The workstations on the local net in Internal Medicine can still access any Banyan server Shared File Implementation Creation and Access A shared file is a file that is accessible by many different workstations over a network Permission to access the shared file is determined by administration and enforced by access lists The creation of a shared file on the Banyan file servers is a minimal task It requires but a few minutes for an INS system administrator to set up the file Access privileges to the shared file are just as easily resolved To define access privileges a list of people who are allowed to access certain files is needed by INS To access a Banyan file server one would simply log on using a Macintosh or PC and select the correct server From a PC a user would execute the BAN COM file to open a connection to a Banyan server From a Macintosh a user would open the chooser and click on the Banyan server icon Format of Shared File A standard format for storing the data should be established The Banyan file servers are PC compatible computers that can run DOS applications Almost every PC or Macintosh throughout the departments can run either DOS Lotus 1 2 3 DOS Microsoft Excel or Macintosh Microsoft Excel All of these applications can read in import text files These softwa
7. eu 8182 1 10121113 uopnquisig Aiddng 32IAM3S T31H3 LVW SOAS IVYNOISS1IOUY4 A V euren Juswpeder jueurejnseeqyw more ejeje wog 1 1L 91 9 Uo 9583 5 0 10 5 5 yBjem eyejidoidde 51 Aq pejidpnu euejuo yoea 10 581095 eu Jo WNS eui sp BIOL peju6reA eu p T W101 031H9I3A 4 91 6101 peiubjeAA 10J eiqeeunseayy 8109S 550 156 eiqepuejsJepun ejqeuoseeu 19112 Seyses Aejeiduoo z 5 3 1euJ0 5n2 JEUMBWIOS Bled SefjSqeS BANIISOd lspes jou seog 0 918A Z 10 0 JO 81098 9 6806 eq Aew BLEND ueA es eui jo 553 SIONEOIPL 10 GHAND 10 SiuDI M 553 xipueddy Appendix B Instructions for Reporting Quality Indicators using Macintosh Excel The enclosed disk includes a blank format to use for entering data for your quality indicators Once you enter the data you can easily print out a copy of it in tabular form as well as graphically This instruction sheet assumes basic knowledge of the software application Excel or Lotus In the following instructions substitute ver with the appropriate extension listed in the table of file formats below Examples of each are included on this disk To view the tabular form open the file EXTAB lt ver gt While this file is still open choose the command OPEN under the File menu and open the file
8. on Excel for Macintosh versions 3 0 and 4 0 Excel for DOS versions 2 2 and 4 0 and Lotus 1 2 3 wks file type It will be made available to the departments along with directions for its use through our client s office Example tabular and graphical reports and the instructions are included in Appendix C Research Future Automation Alternatives The future success of a quality indicator performance monitoring system rests with the ability to accurately store and report quality indicator data While much of this project focused on establishing the framework for collecting information about the progress of establishing quality indicators within the departments it was also aimed at gathering information about possibilities of creating a computerized reporting mechanism The project team took the following steps in researching this topic e Met with Joyce Miller of the Quality Assurance department regarding their monitoring software Spoke to John Ellison of the Information Networking Systems department about mainframe software availability and graphing capability and other options for recording the data e Met with Joan McCollum and Roger Wilfong of the Information Networking Systems department regarding access to the Banyan network and possible ways to incorporate the local area network into a reporting mechanism e Discussed various alternatives to developing a reporting mechanism based on the usefulness to the departments Issues
9. relating to report frequency centralized vs decentralized reporting and computer program architecture were addressed Develop and Report Recommendations The results of our research and project work was combined into a final report Our findings and recommendations follow n ion Quality Indicator Development Based on the fact that some departments are still in the process of developing and refining quality indicators not all the data are currently available Because of the large number of departments expected to submit indicators it is often difficult to accurately communicate Page 8 to them and follow up with them Although the structure is now in place to record the information it is important for the departments to understand the requirements of reporting quality data and how to monitor it We found that not all departments are aware of the significance of establishing quality indicators and feel it is important to focus on increasing communication and awareness on the subject Reporting Mechanism The project team evaluated each of the three methods of storage and retrieval of departmental quality indicator measurements listed in the Current Situations section of this report Each method and its advantages and disadvantages are listed below Method 1 Decentralized Advantages e A spreadsheet used on each different type of PC would make it very easy to enter data and generate graphs e A macro on the spreadsheet coul
10. up with the departments to ensure that they understand the requirements of reporting quality data and how to monitor it Not only is it important to maintain communication with the departments regarding this effort but it is also necessary to have strong support from management At the current level of support this project may not have enough strength to continue The departments must see the importance of monitoring quality indicators through examples set by management Based on our recommendations we propose that the following steps be taken in order to continue the project to monitor quality indicators Continue requesting data from the departments and updating the appropriate information in the notebook and evaluation structure Communicate to the departments The importance of establishing quality indicators The requirement that each department submit the descriptions of two quality indicators along with monthly data in both tabular and graphical form The evaluations for the current indicators The availability of example reporting formats The support by upper management 9 Prepare monthly reports indicating which departments have or have not submitted quality indicators Reporting Mechanism In researching possible ways to store and retrieve all quality indicator data for current and future use we have proposed that the data be placed on a shared file on a server on the Banyan network system This allow
11. B Finance Financial Information Services NIB Finance Food and Nutrition Services Administration Food Procurement Non Patient Food Services Nutrition Services Patieat Food amp Nutrition Services 10 Gift Shops FRIENDS of University Hospital 11 Housekeeping Services utrition Svcs Nutrition Svcs Nutrition Svcs Nutrition Svcs Nutrition Svcs Executive Suite Wolverine2 12 13 14 4 13 16 17 18 19 20 21 22 23 24 29 I D Key Office Information Services Division Information amp Networking Services Information Center _ Medical Information Services aternal Medieine 7 Caere Brighton Health Center Learning Resource Center Management Systems Materiel Managment Materiel Management Information Systems UARCO M Line Nursing Services Educational Services Nursing Scheduling P P P Nursing Administration UH amp Kellogg Nursing Administration Obstetrics and Gynecology Administration Labor amp Delivery Office of Clinical Affairs Ophthalmology Otolaryngolo Administration Pediatric Otolaryngology Administration Vestibular Testing Lab Patient Staff Relations Risk Management Pediatrics Newborn Services Pediatric Cardiology Pulmonary Services Wolverine4 xecutive Suite IS Department S Banyan Mac LAN Development edical Info Brighton Student Carrel Executive Suite at Mgmt Dept at Mgmt M at Mgmt MIB NIB Marketiug ursing E
12. ant to report on a different set of data points As long as the data you want to report is 18 successive points this can be easily done 3 Highlight the 18 data points in columns G and H that you want to report and graph In most cases this will be the last 18 data points in columns G and 4 Choose Copy from the Edit menu 5 Highlight the cells in columns C and D which correspond to the tabular reporting form These are the bordered cells C18 to C36 and cells D18 to D36 All 38 cells should be highlighted at the same time 6 Choose Paste from the Edit menu 7 Your new numbers will now appear Print this now 8 Before closing this file open the IND1GRPH lt ver gt document Your new numbers should be graphed here as well Print the graph 9 Be sure to save each document before quitting the application 10 Each time you have new numbers to add just continue to add them underneath the data that is already there in columns G and H and paste them into cells C18 to C36 and cells D18 to D36 Reporting Form for Quality Indicator Measurements Date 12 17 92 Major Department Department Account Number Dept Head Manager Quality Indicator Average wait times in minutes Description if necessary Target Value less than 10 1 21 91 2 21 91 3 21 91 4 21 91 5 21 91 6 21 91 7 21 91 8 21 91 9 21 91 10 21 91 11 21 91 12 21 91 1 21 92 2 21792 3 21 92 4 21 92 5 21 92 6 21 92 I
13. atisfies the criteria somewhat and 2 means it completely satisfies the criteria e Because some criteria are or may become more important than others we established a weighting system for the seven criteria Currently the Customer Focus criterion has a weight of 2 and the others have a weight of 1 These weights can be easily changed on the spreadsheet if necessary We defined the weighted score based on the criteria as the sum of each criteria score multiplied by its appropriate weight The total possible points for this weighted score is currently 14 e We also added another type of score which relates to the status of the data This score reflects whether each indicator currently has data available 2 points if the data is being monitored graphically 4 points and whether that information has been submitted to the appropriate source the Corporate Lead Team or your office 6 points e A total score for each indicator is defined as the sum of the weighted score based on the 7 criteria and the score based on the monitoring status The total possible points for this score is 20 An example format of this evaluation structure is included in Appendix Evaluate Quality Indicators The updated list of quality indicators and their evaluations consists of 144 indicators The project team evaluated each indicator comments were made regarding how the indicators might be improved This information was not sent directly to the departme
14. d NIB IS Development CHC Nursing Nursing CHC Nursing IB Nursing 6 GYN MPB etal Monitor MIB OCA KEC Ophthy MIB OTO IB OTO MIB OCs Suite IB OCA IB OTO Newborn Svcs Peds Cardiology Newborn Svcs 26 Physical Medicine amp Rehabilitation Electromyography lectromyograph Phys Med Rehab MedRehab m ed Rehab Occupational Rehabilitation amp Health CORH Orthitics and Prosthetics Orthotics Rehabilitation Engineering lectrom opraph l hys Me aang Spinal Cord Injury Center Spinal Cord eelchair Seating Service Orthotics 27 Planning and Marketing Referring Physician Communications IB Marketing Referring Physician Computer Network IB MNET Research and Planning NIB Marketing 28 Security Services Wolverine4 wee AS INpsTie7T7T 6 7 On fone SA PSB f micro h170 depts wp l lan_docs tomforms dept wp original 09 16 91 amended 01 20 92 amended 11 16 92 So Pharmsey Or Vie Ha ce as QUALITY INDICATORS PROJECT Interim Report Peter Giordano Patrick Herzog Christina Tatting November 9 1992 fr a gt gt Introduction The Quality Indicators project focuses on gathering and evaluating quality indicators submitted by the departments at the University of Michigan Hospitals and establishing a reporting mechanism for monitoring their performance Purpose Based on the progress up to this point our purpose remains to develop a framew
15. d data Page 10 The project team has researched the use of a shared file on a Banyan file server as a repository for Quality Indicator Measurement data A discussion of the Banyan file servers and the implementation of a shared file follows In the discussion workstation is a generic term referring to either a Macintosh or a PC Banyan File Servers There are currently 41 file servers attached to the Banyan network These 41 file servers are directly attached to 30 departments see Appendix C In order for workstations to be connected to a Banyan file server the file server must be on a token ring method of networking workstations and must have Vines 5 0 networking software used with Banyan networks installed INS is presently moving all of the Banyan file servers onto token rings and upgrading them with Vines 5 0 networking software When this is accomplished workstations on the Banyan network and other networks will be permitted to access the Banyan file servers in their own department and other departments attached to the Banyan network Outside of the 30 departments directly attached to Banyan file servers other workstations in other departments can still access a Banyan file server if that department is on the Banyan network or a network that is attached to the Banyan network workstation within a department meeting these requirements is said to have access to a Banyan file server An example of this would be the Internal Medicine
16. d ensure consistent graphical and tabular displays of data The responsibility for entering and tracking the data would lie with the individual departments Disadvantages The disparity among the types of personal computers and versions of software available in each department makes it nearly impossible to design a macro for each type of system e The use of this method would also keep all of the information decentralized in each department making it difficult for management personnel to review the data from different departments Method 2 Centralized Advantages e All of the data would be centralized and available to anyone who may need to access it The data would be processed centrally facilitating consistent reports e Nearly every department has some means of accessing the mainframe Disadvantages Centralization of data and data processing takes the responsibility away from the individual departments The mainframe is a transactional driven system It is not intended to run applications for tracking quality indicator measurements e There is no facility on the mainframe for creating graphical displays of data May add a level of bureaucracy and substantial delay in completing reports Method 3 Combination Centralized Decentralized Advantages e The responsibility for tracking and entering the data would lie with the individual departments Page 9 The data would be processed at each department a
17. d in the proposal we need to gather data in order to put together a notebook of quality indicators Although the departments have been asked to submit their indicators not all of them sent in the actual data The original log of indicators dated September 1991 contained some indicators for which data was not available That data might be available now Therefore we should establish how to gather the data and in what specific format if any Graphical Display of Data A clear definition of the format of the graphic representation of the data is required It has been suggested that the monitoring system should chart some quantitative value over time An example would be the number of records processed per day over a month s time period The frequency i e monthly quarterly bimonthly with which the data should be entered has to be determined Can it differ between departments Should there be a standard sample size of dates to enter Should each graph for each department display data over the same time frame A method for testing the graphical data has to be determined Should the graphs be control charts or should departments chart their progress against target values Plan For The End Of the Semester 1 Meet with client 2 Evaluate the new indicators 3 Gather the available data from the departments 4 Finalize the reporting mechanism and prepare a user manual for it 5 Finalize the note book 6 Prepare a draft of the final repor
18. e and spaces for you to input information specific to your department In the cells next to each of the following titles type in the appropriate information Major Department Department Account Number Indicator This should be a simple one line title for the indicator Description Additional space is provided for you to provide more detail on the indicator Target Value You may enter a target value for the indicator if you prefer 9 You may also add a short 10 character title to your data In Cell D18 replace Data Value with this title This title will then appear on the graph This first page is linked to a document that will graph the data The columns labeled Date and Data Value in cells C18 and D18 are used to print the tabular data and to relate the appropriate information to a graph It has been decided that 18 data points are sufficient for each reporting period Therefore only up to 18 data points will be printed on the tabular and graphical reports at a time Data entry will be made only in columns G and H labeled Date and Input Data Data should be entered chronologically most recent data last and the dates should be the same distance apart preferably every two weeks or monthly 3 For each data point enter the date in column G and the appropriate number in column H NOTE Column G is already formatted for dates and column H is formatted for numbers Feel free to format the number column to correspond to
19. he data Banyan the Local Area Network within the Hospital or the mainframe could also be used to make a tabular form of the data available for storage and for use by the appropriate people Approach an hodol Diagram 1 illustrates the general approach followed to obtain the project goals The key steps completed are described below 1 Obtain Department List The initial list of departments was organized around eleven major departments based on the accounting structure at the hospitals See Table 1 for the departments and their current directors Then each major department director was asked to indicate which departments are expected and should be required to submit new customer focused quality indicators We have updated the list for all major departments with the exception of Ambulatory Care and Professional Services Professional Services has indicated that they will submit the list in January 1993 Page 4 Diagram 1 Approach Develop Criteria for Evaluating Qualit Quality Indicators Project ludicaiors Key Steps Create Evaluation Structure for Quality Indicators Obtain aie Evaluate List Indicators from Ioa yt Departments Prepare Notebook of Quality Indicators Research Future Develop and Report Automation Altern lives Recommendations Table 1 Major Departments and Directors Professional Services John Gialanella Treatment Services P Senior Associate Director Ellen Gaucher
20. m eese tne en ette enonue 10 Banyan File Servers 11 Shared File Implementation eee tenen tenete nennt 11 Limitations of the Banyan Network eee eene 12 Action 1332 o La a 12 Quality Indicator Development eere eere eene eee nnne 12 Reporting Mechanism eese eee eee 13 E IV mm Quality Indicator Development Approximately 150 quality indicators have been submitted by 75 departments throughout the hospital Although not all departments have sent in the descriptions of their indicators or data representing current performance the structure is now in place to record that information when it is available A notebook is available for collecting tabular and graphical quality data from each department Also an evaluation structure is set up which evaluates current indicators based on meeting the criteria for good indicators and monitoring the data This structure is also useful for determining which departments have or have not submitted their descriptions and or data for two quality indicators In order to continue with this quality improvement effort it is necessary to establish good communication lines to the departments We have recommended that a person within the hospital be placed in charge of continuing to update the current information and follow
21. menting a quality indicator measurement tracking mechanism is the need to have all of the tabular data from each department available to management Method 2 accommodates this aspect but at the expense of relieving the departments of the responsibility of processing and monitoring their own data It is important for each department to be able to graph its own data so that trends within that department are clearly evident and can be acted upon Method 3 allows each department to graph its own data and allows management to easily review all of the tabular information in a central location It is necessary to construct consistent tabular and graphical displays of data so that management can easily interpret the information from each department Method 3 allows each department to format their data to create consistent yet tailored reports By following the examples of tabular and graphical displays of data the departments will be able to generate consistent reports that can be easily reviewed by management There are a few problems associated with using the mainframe as means of centrally locating the data First the amount of information that needs to be accessed is not large enough to warrant allocation of file space on the mainframe Secondly the mainframe 1s largely a transactional driven system and is not intended for storage of raw data files The structure of the mainframe system does not facilitate the use of individual accounts to access store
22. nd the tabular information would be centralized accessible from the network and or mainframe e Each department could create consistent graphs by following the example graphical reporting structure Disadvantages Management must ensure that the departments follow a standard form for reporting the data It must be ensured that the data reported in the tabular and graphical form is the same as the data put in a central location e Notevery department is connected to the Banyan network Recommendations Quality Indicator Development To continue the quality improvement effort our team suggests that a person be assigned to be in charge of following up with the departments and updating the quality indicator information This would include updating the notebook and the evaluation spreadsheet as well as preparing reports to indicate which departments have or have not been submitting or monitoring quality data This person might also provide feedback to the departments including making use of the evaluation scores that are in place Not only is it important to maintain communication with the departments regarding this effort but it is also necessary to have strong support from management At the current level of support this project may not have enough strength to continue The departments must see the importance of monitoring quality indicators through examples set by management Reporting Mechanism One very important aspect of imple
23. nnected to a Banyan token ring To connect an Appletalk network the Appletalk network routing change would cost about 900 and the installation of a local talk card would cost about 350 For the above reasons the project team believes that there should be a system in which a shared file is located on a server on the Banyan network system that is accessible by the appropriate people This would provide a sufficient means for monitoring reporting storing graphing and retrieving data Action Plan Quality Indicator Development Based on our recommendations we propose that the following steps be taken in order to continue the Total Quality Management project Continue requesting data from the departments and updating the appropriate information in the notebook and evaluation structure Communicate to the departments The importance of establishing quality indicators The requirement that each department submit the descriptions of two quality indicators along with monthly data in both tabular and graphical form The evaluations for the current indicators The availability of example reporting formats The support by upper management Prepare monthly reports indicating which departments have or have not submitted quality indicators Page 12 Reporting Mechanism In order to establish a reporting mechanism utilizing a shared file on the Banyan network we propose the following actions 9 Establish a connection bet
24. nts but is available for use in the future It has not yet been decided how to best utilize this information Although the spreadsheet will not be complete until all indicators are developed and put in place the framework exists for including them when they are available The most current list of these indicators is available in the Log of Quality Indicators Quality Indicator Tabular and Graphical Data This spreadsheet is available on a computer disk Prepare Notebook of Quality Indicators In addition to providing a list of indicators and their evaluations we have prepared a notebook which will contain the data in both tabular and graphical form of all current indicators Our original goal was to have this notebook complete by the end of the project However its completion depends primarily on the departments submitting the required information Not many departments have submitted data so we have prepared the shell for this notebook to be completed when more information is obtained Page 7 7 8 9 indi Create Example Reporting Structure for Data In order to make it easier for departments to tabularly and graphically submit their data we have created a sample blank spreadsheet for their use The spreadsheet contains a specified area for inputting data In addition it includes a tabular reporting format which is directly connected to a graphical format Both formats can easily be printed This spreadsheet is available
25. of the Quality Indicators team is to set in motion a reporting and monitoring process that can be maintained in the future By establishing the initial framework little effort will be required to add more indicators and data at a later time The scope of the project was to collect and evaluate the available indicators and explore the possibilities of presenting data in both tabular and graphical form We also investigated the development of an automated system for future use nitial Si ion At the onset of the project in September 1992 129 quality indicators had been submitted from 70 departments and only a few were being tracked However not all of the indicators were clearly defined and their graphical formats were inconsistent In addition there were many departments which had not developed indicators One of our first goals was to coordinate this information and establish a formal structure by which departments could define and communicate their indicators Another main consideration involved developing and implementing a tracking mechanism for departmental quality indicators In particular we explored the method for storage and retrieval of information in tabular and graphical forms A tabular form of the information is required so that individual departments may easily add and store the historical quality indicator data This tabular form of data should be made into a standard form so that there is consistency in reporting across depa
26. of the criteria Spoke to Joyce Miller of the Quality Assurance department regarding their monitoring software Spoke to Information Networking Systems about mainframe software availability and graphing capability Discussed various alternatives to developing a reporting mechanism based on the usefulness to the departments see Problems and Issues 1 Created an example reporting structure on Excel Problems and Issues to be addressed at the Interim Meeting with the client scheduled November 11 1 Decentralization or Centralization of Data We have defined two possibilities for collecting the data from the departments and noted advantages and disadvantages of both ways The first is decentralization Each department would enter their own data into a spreadsheet and produce a graphical representation of it The report would be submitted to our client s office This method is advantageous because the departments are responsible for measuring and monitoring their own data However because there are various software packages being used by the different departments it may be difficult to ensure that each department can use the software that the reporting mechanism is built on Itis possible to make the spreadsheet available on several versions of Excel and Lotus but without knowing how many different packages are being used it may be difficult to accommodate every department Another alternative is to let the departments use whate
27. or updating their indicators Included with this memo was a copy of the most recent list of indicators that had been submitted Customer Focused The indicator should relate to a service that focuses on the customer of the department Positive The indicator should aim toward increasing customer satisfaction instead of focusing on decreasing dissatisfaction For example the number of infections is a negative indicator A positive indicator would be the scores on patient pain relief The indicator should follow RUMBA guidelines Reasonable relating to a critical process worth measuring Understandable clear and concise Measurable can be represented numerically and tracked over time Believable do able a goal that can actually be reached Achievable can help achieve quality improvement in the department Create Evaluation Structure for Quality Indicators An Excel spreadsheet was created based on the final department list which lists the the name of each department required to submit quality indicators their corresponding division and accounting numbers of the department the description Page 6 5 6 of quality indicators that have been submitted and evaluation scores for each indicator The evaluation scores are based on the following information e For each indicator each of the seven criteria is rated on a scale of 0 to 2 A score of 0 means the indicator does not satisfy the criteria 1 means it s
28. ork for the departments at the University of Michigan Hospitals to consistently track and report their progress based on customer focused quality indicators Status The following steps have been completed 1 Developed a complete list of departments within the hospital that should submit quality indicators This list is organized around eleven major departments based on the accounting structure at the hospitals It will be used to track which departments have submitted indicators and which departments are measuring their performance 2 Developed a list of criteria for evaluating the indicators This includes developing operational definitions for the criteria We submitted this list to the client for final approval The final list is included in Appendix A 3 Drafted a memo to the departments through our client s office which introduced our group and the project The memo requested that the departments submit any new or updated indicators We also included the list of criteria so that they could better understand the evaluation process and use it as a guideline for updating their indicators Included with this memo was a copy of the most recent list of indicators that has been submitted 4 Developed an evaluation structure for the indicators based on the seven criteria developed The structure is an Excel spreadsheet which shows the department their quality indicators and their evaluation scores The scores represented are a weighted
29. re applications can also write export text files If the shared file on the file server were a text file workstations could read and write the files on the server without any problems Page 11 Limitations of the Banyan Network The Banyan file servers must be running Vines 5 0 and be networked via a token ring in order for workstations to access a shared file Not every department has a file server It would be easy to set up a separate shared file for a department that does not have a file server on the file server of another department However this may cause a cost allocation problem as a result of one department using another department s disk space and file server It is difficult to determine the exact number and location of workstations that can connect to Banyan Workstations are connected to networks that are connected to Banyan and are not counted as workstations with direct access to Banyan Workstations are added to the Banyan network without being accounted for in an overall list The most effective way to determine which departments are connected to the Banyan network is through direct communication with each department There are costs associated with connecting workstations to the LAN Local Area Network There is an internal price listing for making these connections INS can provide LAN connection for about 750 per workstation Any of the stand alone Appletalk networks network of Macintosh computers would have to be co
30. rtments A standard tabular form would also allow consistent construction of graphical displays of the data Page 3 graphical form of the information is required so it is easier to track trends in quality indicator measurements over time Graphical display of time related data easily depicts out of control or outlying points The project team researched three methods for storage and retrieval of the quality indicator measurement data The three methods are listed below 1 Decentralized Reporting Each department enters its own data in tabular form into a spreadsheet package on Macintosh or DOS compatible personal computers macro within the spreadsheet package generates a graphical display of the data These reports would then be sent to a central location to be collected and ordered into a notebook This information would be used to asses and communicate progress as measured by the quality indicators 2 Centralized Reporting The data are entered into the mainframe at the hospital and mainframe applications are used to process and display the information in tabular and graphical form The departments would submit their data then a central location would perform all of the tasks of entering and reporting data 3 Combination Reporting Following guidelines and examples of tabular and graphical reporting forms the departments may use their own means software packages to create consistent tabular and graphical displays of t
31. s each department to be responsible for tracking and graphing its own data and allows management to easily review all of the tabular information in a central location Page 2 It is necessary to construct consistent tabular and graphical displays of data so that management can easily interpret the information from each department Our recommendation allows each department to format their data to create consistent yet tailored reports By following the examples of tabular and graphical displays of data the departments will be able to generate consistent reports that can be easily reviewed by management Total Quality Management is one of the most important changes in health care management today With this in mind a significant goal for the University of Michigan Medical Center UMMC is to establish a continuous monitoring system for the departments to report and monitor quality indicators Currently quality indicators have not been established in all departments and there is no system in place for tracking performance As a step toward achieving continuous quality improvement we have proposed to develop a framework for the departments at the UMMC to consistently report and track their progress based on new customer focused quality indicators This Quality Indicators project focused on gathering and evaluating quality indicators submitted by the departments and providing a reporting mechanism for monitoring their performance The goal
32. t 7 Complete the final report 8 Final presentation Work Plan 1 Meet with client on November 11 to discuss the following The methods needed to resolve the current problems and issues as discussed above Interim report 2 Evaluate the new indicators which are received before the deadline of November 14 Submit these new evaluations and suggestions to client 3 Gather the available data from the departments in the current log of indicators Contact those departments which were monitoring their indicators Obtain data through our client in tabular and graphical form 4 Finalize the reporting mechanism and prepare a user manual for it Reporting mechanism Supply software systems to those departments needing a system Supply user manual available for software systems used Excel and Lotus versions Finalize the notebook of quality indicators to be submitted at final presentation Includes the following Departmental names and structure based upon the accounting structure At least two indicators and their measurements Tabular representation of data when available Graphical representation of the tabulated data where applicable Prepare a draft of the final report e Submit draft to client for review and modifications Complete the final report e Review and modify any changes from draft Final presentation to be done For client on December 11 9 For class on December 16
33. value based upon the seven key issues of evaluation At the present time each of the seven criteria has a weight of one 5 Updated the log of indicators based on the original submitted forms During the evaluation process we found that some of the indicators from the original forms were not included on the initial log of quality indicators This log entailed a preliminary list of 64 departments which had previously submitted their indicators to our client at the onset of the project We added the appropriate indicators to the log of indicators TLS m GOP AW n be OY anie NL 0509 E Tf daro 2151 MUT E 3 57 uU aT n5 u savon a anton ogee bir uan eg lt pa bentes il 40 lo 33x 7 manda en vum er Eu ul Mte an iti ge mua p am Y Tfzuith 7 XH h Ira alae i b dott ir v reor cm iod fig 1886 1316 Jus Len zv guy Pot gd i IP Vim OLD on 11 uer SMOG oic one 6073 MIL M oes gei t att sE E ges ye A VE we nahra a Ma aa of 4 u gt 6 eed su A Lum s fi a AE ac SG Ab ig tr Me gg su od aningid qub cs cards af few dE spoke rcx srt 75 ET vel j MUR eed SERO 5 l ag aero Oe
34. ver graphing software they are currently using Our reporting mechanism would be made available to those departments that are not currently graphing their progress The departments would be responsible for obtaining the necessary software The disadvantage is that the graphics may not be consistent between departments see 2 Centralization of the data is the second possibility The departments would send the data to a central location where it would be input to the mainframe This would make all data available to anyone who might need it However graphing capabilities are minimal on the mainframe In addition the departments would be further removed from their data 2 3 4 Consistency of Reporting Some of the departments are already monitoring and graphing their quality indicators They are using different formats i e bar charts pie charts scatter plots as well as different software Lotus Excel etc It was originally decided that a consistent format should be used However we should consider the impact of asking some of the departments to change the format they have already established In addition our original intention was to gather what data is available and create a notebook for it Because some data has already been submitted in tabular and graphical form it would take considerable time to convert it all into one consistent format We need to decide on a final format for reporting Gathering Data As state
35. ween each department and a Banyan file server A department would need to either have its own file server capital investment of 6 000 to 20 000 or use file space on another department s file server Each department should create a shared file on a Banyan file server an INS administrator will do this Provide INS with the names of personnel who should have access privileges to each shared file INS will create access permission lists for each shared file 9 Agree upon a standard format for saving tabular data most likely a text file and communicate this to the departments Page 13 c6 Zl ME i 9 zi m o 3 m 8109S Sneis Beg et PUB 8095 jo WNS euj eJo2s 1 OL 3HOOS WLOL e oqe peqiosep se snyers ey UO peseq 81095 eui S eJoos SNES VLO OUL JYS SNLVIS V1VQ BONO 0 26J 20SSV JO 1109 penjuqns yeyo pueg pue eeg 9 ejqeje g yeyo pue peudeij Gujeq s Beg p pep2ejoo Dujeq sj veg Z paloy uow painseew Bujeg 0 SIUM peJojuoul pue pesnseeui Bujeq jo snes S 196j61 8109S ueAJB OSIY 1 SNOLLVYI4O NINGY NAD SNOLLVYAdO NINGV 7 NID SAOIAUTS TARILVW 181080 BIAS eu siewosno 5 doy sejjddns jo SUING PUB Jels 10 ewh Punoseuung Ue peu ey sewn punong pel Ayejdwos siepso pue swai au Jo
36. your data if necessary When you enter up to 18 data points this way the spreadsheet will automatically copy the information to the first page of the document the one which is used for reporting It will also report the average maximum and minimum data values for the time interval When you are finished entering the data choose Print under the File menu and the tabular form will be printed Under the File menu choose Open and open the file INDIGRPH ver A graph of the data you just inputted will appear You may customize the graph by adding text if you prefer or add any other information you would like Then choose Print under the File menu to print the graph 8 Before closing this document be sure to update your changes by SAVING it After you close this document Save the IND1TAB lt ver gt as a text file as well You can then QUIT out of the application Updating Data 1 When you have additional data to input continue entering it in columns G and H as before Enter all data chronologically adding to the data that was previously input You will not write over any data but will simply add to it This way you can keep a record of past data Start inputting data in the rows directly beneath the previous data 2 Once you have input all of your data you must copy this new data into the appropriate section on the tabular reporting page You may want to report the most recent 18 data points now or you might w
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