Managing Measurement Data 3

Question 1

what 4 decisions must be made for each measure to design data collection strategies.

Answer 1

Decide where data is locate; how to capture; whose responsibility to capture; and how often to capture

Question 2

Advance planning for data collection help ensure what?

Answer 2

Ensure Accurate, Reliable and Valid information is captured for measurement purposes.

Question 3

Define reliable

Answer 3

The consistency of data contained from the collection instrument

Question 4

Define valid

Answer 4

The soundness of the use and interpretation

Question 5

Before you start to the locate data step you must first ?

Answer 5

make sure the data elements necessary for creating a measure are clearly and objectively stated in the measurement specification.

Question 6

What should be done in situations when a department is already capturing data elements necessary for every performance measure used within that department.

Answer 6

You must confirm that data is reliable and matches measure specifications.

Question 7

True or false
In many situation data needed for departmental and medical staff service performance measure must be obtained from more than one location.

Answer 7

True

Example: rate of catheter-associated urinary tract infections in ICU patient per 1000 urinary catheter-days

Question 8

Why would you review your organization’s information management plan?

Answer 8

to search for Automated Data Sources

Because TJC requirement regarding information security liabilities. The infor mgmt plan will include a list of automated systems and types of data included in these systems.

Question 9

The Automated data Sources within an organization’s Information management plan support what type of activities/functions

Answer 9

enterprise-wide activities

department-specific functions

interfacing with network systems

non-network applications such as cancer registry data system

Question 10

by talking with the people who input the data.

in to the electronic database will help you to be sure of what?

Answer 10

you can be sure that the information put in the electronic database can be used to accurately measure the factor or parameter you want to evaluate.
Example: data definitions in a Billing database may be different than what is needed to construct a performance measure

Question 11

True or False
Using automated data sources for performance measurement purpose is of interest to national groups and federal regulators.

Answer 11

True
There is an effort to transform TJC core measure and those mandated by Medicare into electronic measures known as e-measures.

Question 12

E measures used to evaluate healthcare quality are sometimes called what?

Answer 12

e-quality measures or E-QMs

Question 13

True or False

EHR system should capture the measure data elements and also be capable of calculating the measurement results

Answer 13

True

Example: be able to electronicly transfer health information to CMS

Question 14

what is Non-Automated Data Sources

Answer 14

A quality measurement data element gathered by hand.

Example: abstraction administrative claims

Question 15

True or False

In some situations, only a non-automated data source can be used to obtain accurate information for measuring performance.

Answer 15

True

Example: gold standard for gathering accurate data for measuring observations such as people washing their hand.

data must be accurate, reliable, and valid

Question 16

Capture Data - How can you capture data?

The automated (electronic) data

The Non-electronic

Answer 16

electronic - transfer and query /would need to work out how best to get this info with individuals responsible for managing the automate systems.

Manual capture with checksheets, datasheets, surveys and other data gathering instruments.

Question 17

What is the name of the process of getting data from Standalone electronic systems that do not integrate easily

Answer 17

push or pull required data elements from one system to another.

assistance from HIM and IT needed to create interfaces and data exchanges

paper reports of the required data can be produce and manually shared

Question 18

Electronic systems can be less expensive than manual data gatherings

Answer 18

True but it is not without cost. in addition collecting and reporting cost EHR requires substantial validation to ensure data accuracy,

Question 19

Manual data collections involve the use of what instruments?

Answer 19

Check sheets,
Tabular checksheets
datasheets
surveys

Question 20

Checksheets

Answer 20

paper base structured forms enabling people to systematically capture and organize data about performance of a specific process.

Question 21

Tabular checksheets

Answer 21

A type of checksheet that is used to tally the frequency of events. (at time of performance)

Question 22

datasheets

Answer 22

form designed to manually collect data in a simple tabular or column format. Specific bits of data (numbers, words, marks) are entered in spaces on the form.

can be labor-intensive because must make several decision about pt care.

retrospectively because all info is more likely to be available

Question 23

What are the guideline for developing datasheets checksheets (easy to use paper based and electronic data collection tools)

Answer 23

• Involve workers who will use the tool
• Organize in same sequence as process flow
• everything on form well defined and easily understood by person capturing data
• include brief instructions on back or “pop-up”
• completed with the least amount of effort
• designate a place on form to record date time of collection
• allow sufficient space for narrative comments unusual events.

Question 24

Surveys questionnaires can be paper-based or electronic. What will help determine the design and method of dissemination of your survey.

Answer 24

The purpose of the survey

Question 25

To ensure the buy-in and credibility of a survey you should involve whom?

Answer 25

The stakeholders and audiences to be affected by the survey.

Question 26

What should you do to maximize return rates of a survey.

Answer 26

keep as simple as possible

Question 27

How can you ensure that a survey instruments yield actionable data.

Answer 27

Use survey questions about specific aspects of services.

“when I call the Center, the line is busy?” always usually sometimes never

Question 28

Why would you need to always check whether data need to construct performance measures are available electronically before creating a manual data gather system.

Answer 28

Cost.

Manual data gathering are higher than electronic database queries.

Question 29

What are you doing when you are determining:
Who will extract info from the databases
Who will regularly transfer info
Who will perform periodic database queries for paper reports

Answer 29

Identifying responsible people for data capture.

Question 30

What are the two distinct issues to be considered when discussing how often data will be gathered?

Answer 30

Frequency of reporting

Size of the measurement population.

Question 31

True or False

Performance results are often reported monthly or quarterly?

Answer 31

True

However to observe real-time trend in a processes will result reported daily or weekly.

Question 32

What will indicate the reporting time frame?

Answer 32

the measure specification

Example: Percent of new pt each month with incomplete or unsigned auth and consent for treatment forms follow first home visit.

Question 33

What is another consideration to determine how often to gather data?

Answer 33

Size of population

“all new pt”
“how clinic pt wait to be seen by a health professional”

Question 34

Define Sampling

Answer 34

The process of selecting a representative part of a population to estimate performance without collecting data from the entire population is called what?

Question 35

What are the common methods of selecting a population sample?

Answer 35

Simple Random Sampling
Stratified Sampling
Systematic Sampling
Cluster Sampling

Question 36

Simple Random Sampling

Answer 36

Every pt or event in the process has equal chance of being sampled.

Question 37

Stratified Sampling

Answer 37

Groups (strata) are identified and a random sample selected from each group.

“random sample for ped and a random sample from geriatric”

Question 38

Systematic Sampling

Answer 38

Events are periodically measured

‘wait time gather for every tenth clinic patient”

Question 39

Cluster Sampling

Answer 39

A typical group is selected and a random sample is taken from that group.

Question 40

When would the population and allowable sampling techniques be documented in the measurement specifications. These requirements must be consistently applied.

Answer 40

External mandate

measures required by CMS

Question 41

When there is no externally defined sampling requirement how would you to be sure to get statistically valid sample

Answer 41

only when the sample data truly represents the whole population can it be meaningful and useful.

Question 42

What are TJC suggested sample sizes?

Answer 42

< 30 100%
30-100 = 30
101 - 500 = 50
500+ = 70

Question 43

Because data sources and methods of data capture can change over time? what requirement must happen.

Answer 43

You should do a periodic evaluation of the data collections plans.

Example: the electronic data from the EHRs may not be useful for measurement purposes if the data definitions do not match the measurement data specifications.

Question 44

When planning strategy for collecting performance measurement data you must:

Answer 44

evaluate existing data sources to determine where information needed to create each measure can be found.

Question 45

Steps to locate data

Answer 45

First, determine if existing information system (automated or paper-base)
then check to be sure the data definitions are consistent with what is needed to create the measure.

Question 46

True or False

The accuracy and completeness of inform in the data source determine the level of confidence in measurement results.

Answer 46

True

Performance measurements results are only useful if the data collection yields valid information.

Question 47

What should be done before finalizing the data collection plan

Answer 47

assess the reliability and effectiveness of the data gathering process.

Question 48

True or false

It may be necessary to conduct periodic audits of the collected data to confirm its accuracy.

Answer 48

True

Example: every data source has advantages and drawbacks.

Question 49

What is a Survey

Answer 49

Data collection tool used to gather information from individuals

Question 50

What is a Data Source

Answer 50

Origin of the information you plan to collect.

Question 51

Example of
Data Collectons Plan
for
HIM Department Measures

Answer 51

Measure - % of ip records accurately coded

Measure specifications - n# accurately coded
d-# ip records reviewed

Data Source - n-coding audit form D-ip records that have been coded

Collection Frequency - Mntly random samples of 20% pf records

Responsible Person - Coding supervisor