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Improving the flow of audit data - from collection, to analysis, to reporting back to the front line Team: Quality Improvement Consultants (QICs) from across Interior Health (Naomi Erickson; Ali Gregory; Allison Griffiths; Nial Helgason; Cindy O’Brien; Jody Pistak; Karen Leach-McLeod; Eleanor McCaughey; Reed Scott; Shelley Smillie; Jennifer Stieda; Julie Wootton.) Contact: Allison Griffiths, QIC IH West (firstname.lastname@example.org) Sub title Problem / Issue IH did not have a working, regional level system for data collection and reporting. QICs would enter their data into canvas for ministry submission but had to create their own system and re-enter the data if they wanted reports. What we ended up with was: Project Goals The “Finished” Project Challenges Faced & (mostly) Overcome The system of pulling a report has to be easy for all to learn and use, regardless of computer know-how. We want to give users the flexibility to add data and build reports but not accidentally delete data or formulas. We must use a computer program that all staff will have access to. There are differing reporting wants and needs for small sites vs. large sites as well as across sites in general (eg. while some sites want comparison graphs, for others it can lead to unhealthy rivalry). Lots of data, little real estate (no-one wants a 15 page report). Next Steps The program we currently use for data collection does not automatically sync with Excel so audits must be manually uploaded. A trial is currently underway, allowing direct data entry into Excel, thus enabling almost immediate access to these reports after data entry. CCM summary reports, which provide a quarterly snapshot of numerous CCMs all in one report, are currently in development. Promotion to Unit Managers and PCCs to do own auditing and pull own reports. Reports Context Approach Our Final Vision Report Creation PDSAs - Collaborative, iterative process of developing reports. Build something, try it, adjust, adjust, adjust. An initial ask went out to all QICs to consult their sites (and anyone else who might be on the receiving end of a report) to identify what they would like to see in future reports for Sepsis, Med Rec, and VTE. From this, an initial report was built. It was trialed and changes were recommended and made. It was then trialed and tweaked again. And again. Once everyone seemed happy with the reports, the workbooks were posted on our teamsite for all to use. To create: A safe and easily accessible location for CCM data; A standard and consistent template for reports; and An easy way that QICs (or unit managers) could pull their reports. 1 or 2 page 48/6 Report 1 or 2 page Sepsis Report Learnings / Results While our previous method of collecting, collating, and reporting back VTE, Sepsis, and Med Rec data to sites was getting the job done, there were areas for improvement. Delays, duplication, inconsistency, and opportunity for error were frequent. From just a couple clicks and drop down selections on the pages above, your report automatically populates (see examples below): This is a screenshot of the “home page” on the 48/6 Excel workbook. From this page you can select an IH level report, a site report, to see Ministry reports before they go off, or check to make sure you’ve submitted all your audits. Select site level or unit level, and which fiscal period or fiscal quarter you want for your report. Don’t know your fiscal periods? This gives you date ranges. Site champions can enter data and immediately print their report. QICs can see the data before it goes to the Ministry and make sure it’s accurate and complete. We can be more confident that the data we’re sending to the Ministry is representative of IH. Fewer missed fiscal periods Fewer duplicate entries of data …control charts, bar graphs, line graphs, comparison tables, and not a pie chart in sight! You can see a snapshot of how you did in the current fiscal’s audit as well as control charts of progress over time. Page 2 is optional – with either more detailed information or a comparison chart across units / sites. Each CCM is branded a different color so the reports can be posted side by side and stand out against each other! Quicker turnaround of data back to sites. Even those with little computer experience can create professional and detailed reports. Having all data in one spot makes additional one-off reports easier to build. Happier consultants with more time on their hands to consult! Duplication of data entry and report building (wasteful & increased chance of errors). No consistency to reports back to the sites / units. Several databases of CCM data spread across IH (potential safety issue as well as risk of errors). Potential for errors, duplicate, and forgotten entries in Ministry data due to not being able to review data once it was sent. Nov 2012 – Oct 2013 – 379 duplicate entries Nov 2013 – Oct 2014 - 6 duplicate entries Additional one-off reports can easily be built, with easy access to all sites’ raw data.