1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Auditing Your Care Armstrong Institute for Patient Safety and Quality Presented by: Jill A. Marsteller, PhD, MPP October 13, 2011

2. Learning Objectives You will be able to: –Explain why measuring process is critical to success –Describe process measures planned for collection –Detail the planned collection process Armstrong Institute for Patient Safety and Quality 2

3. 3 Donabedian Model Structure Process Outcome How we organize care What we do during care delivery The results we achieve E.g., presence of policies or committees E.g., how often are evidence-based interventions performed E.g., how/ how many patients are harmed

4. Approaches to measuring process Measures of perception –Accessible –Subject to bias Regular process measures collection –More objective –Burdensome Less frequent auditing –Less burdensome –Less reliable Armstrong Institute for Patient Safety and Quality 4

5. Process measures you already collect SCIP/STS –Abx selection –Abx timing –Abx stop w/in 48 hours –Glucose measure –Hair removal Armstrong Institute for Patient Safety and Quality 5

6. New Measures/ Audit Topics VAP process measures: –E.g., HOB elevation –E.g., sedation vacation SSI: –Skin prep (type, appropriateness) –Antibiotic redosing; –Environment CLABSI: –Insertion (OR, ICU) –Maintenance (ICU, Floor) CUSP: –Daily goals; Am Briefing; LFD (ICU, Floor, universal) –Briefing/debriefing ; Huddle; LFD (OR) Armstrong Institute for Patient Safety and Quality 6

7. Audit data: “How To” Reminder email will tell you what to audit for the coming month Collect data once a week and report at end of month Methods: Observations; counts with measure/ count total eligible; answer Qs When you enter web tool, it will tell you what audit data is due this month Web-based data entry forms Armstrong Institute for Patient Safety and Quality 7

8. How process measurement helps you Compliance is key to providing evidence- based practice EBP allows you to meet your outcomes goals Process measures provide a “map” to what’s working well and what’s not Regular feedback on performance essential to performance and buy-in (transparency) Use your data to inform, motivate, communicate laterally and upward Armstrong Institute for Patient Safety and Quality 8