Not only have we all heard this saying, “Data Rich and Information Poor”, but so many organizations experience this. Throughout our travels across the country, we encounter organizations that struggle with the management of their data. We believe that CMS and the accrediting agency, The Joint Commission, may also be seeing the same thing.
The Joint Commission just recently concluded research into the design of successful performance improvement strategies and found two common themes in organizations with successful improvement programs:
1- These organizations adopted an established improvement methodology and the methodologies associated tools and used the methodology and tools consistently and relentlessly within the organization.
2- These organizations developed relevant and manageable plans for monitoring quality and prioritizing improvement initiatives and stuck with those plans.
The Joint Commission also announced this summer the revision to the Performance Improvement Chapter for all accreditation programs. These revisions and new requirements re-emphasize both themes identified within TJC’s research and take effect in all accreditation programs January 1, 2022. The Performance Improvement Chapter contains many revisions mostly rewording or movement in location to assist in the flow of the requirements. It also contains 3 new Elements of Performance. For ease of reading, the standards referenced herein come from the Hospital Accreditation Manual but should align with where they appear in the other manuals.
PI 02.01.01 EP 1 reminds us of the need for a written plan and defines new components for the written plan. The plans must address the following:
• The defined processes needing improvement
• Methods that will be used for measuring
• Analysis methods that will be deployed for identifying causes of variation and poor performance
• Methods that will be used for monitoring and sustaining improved processes
PI 02.01.01 EP 2 re-emphasizes the need for Leadership to review the plan at least annually and to update the plan to reflect any changes in strategic priorities and in response to any changes in the internal and/or external environment. It is here that surveyors will look for organizations to have revised their plan in response to things such as the Public Health Emergency/Pandemic, Wildfires, Hurricanes and potentially even the fluctuations seen within the supply chain.
Last but not least, the addition of PI 04.01.01 EP 3 sets the expectation that hospitals use improvement tools or methodologies to improve its performance.
This all brings us back to “Data Rich... Information Poor”. So often we will observe organizations that have volumes of data, but in the absence of a display of data over time, establishment of thresholds for expected performance, the organization truly does not know what information the data is telling them. Often the root cause of this can be contributed to the absence of a strong foundation for their Quality- Data Management processes. For instance, there is no process to orient new leaders to the operational expectations for managing data within individual departments. Couple this with a lack of data management and analysis skills and we have a perfect recipe for failure. Creating an orientation component for new leaders will create the opportunity to: (1) review the individual departments PI indicators, to ensure they are of value, contribute to the strategic goals of the organization and are well defined and performance expectations are set (2) create the opportunity to assess the new leaders understanding of the selected PI methodology and tools that the organization expects to be used and establish an education plan if needed and (3) assist the leader in establishing a simple worksheet with graphical display that can be used to compile data over time which will allow the organization to convert data to information. Remember, the team at C&A stands ready to help you advance your Quality-Performance Improvement Initiative. Reach out to us to learn how we can help.
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