REPORT
Knowing your high risk, high volume when it comes to
data quality and patient safety
Odette Taylor and Kirrily Gilchrist
Monitoring of quality and safety within a health service is
paramount. Without this assurance, how do we know our
patients are safe from harm and adverse events? How do we
know what our problem areas are? Are we ensuring the same
standard of care for all of our patients all of the time?
high risk and high volume patient safety issues in the healthcare setting:
Governance for Safety and Quality in Health Service
Organisations
Partnering with Consumers
Preventing and Controlling Health Care Associated
The question ... how do we know?
Infections
Medication Safety
In health services, we monitor, we report, we trend, we analyse
Patient Identification and Procedure Matching
data from a number of different sources on a regular basis.
Clinical Handover
However, are improvements made to the quality of care we
Blood and Blood Products
provide to the patients from our monitoring of validated data
Preventing and Managing Pressure Injuries
such as Key Performance Indicators (KPIs) or patient safety
Recognising and responding to Clinical Deterioration
indicators? Do the data we report inform our staff of current
Preventing falls and Harm from Falls. (Australian
patient safety issues in a timely manner? Are the data we are
Commission on Quality and Safety in Health Care
reporting validated and accurate? How do we determine what
2012b:3)
should be monitored and reported?
Let’s examine one of the Actions of Standard 1 Governance
Accreditation can and should drive patient safety and
for Safety and Quality in Health Service Organisations. The
quality monitoring, but should not be the only driver. As
intention of this standard is to ‘Create integrated governance
noted in the Australian Commission on Quality and Safety in
systems that maintain and improve the reliability and quality of
Health Care (ACQSHC) Hospital Accreditation Workbook,
patient care, as well as improve patient outcomes’ (Australian
‘Accreditation is one tool, in a range of strategies, which can
Commission on Quality and Safety in Health Care 2012a: 51).
be used to improve safety and quality in a hospital. It is a way
In order to achieve this, health services must have supporting
of verifying:
governance systems. Does your health service have reliable
actions are being taken
and integrated governance systems? These will involve having
system data are being used to inform activity
KPIs or PSI reported, actioned and monitored through your
improvements are made in safety and quality. (Australian
governance systems.
Commission on Quality and
Action 1.6 of Standard 1
Safety in Health Care 2012a:
calls for the establishment of
4)
‘an organisation-wide quality
Does your health service have reliable and
The National Safety and
management system that
Quality Health Service Standards
monitors and reports on the
integrated governance systems?
(NSQHS Standards), produced
safety and quality of patient care
by the ACQSHC were endorsed
and informs changes in practice’
by Australian health ministers
(Australian Commission on
in 2011. A number of Victorian health services have been
Quality and Safety in Health Care 2012a: 59).
accredited under these new standards, and many are currently
This is required to ensure there is a systematic approach
leading up to accreditation. The primary aims of the NSQHS
within your health service around quality monitoring, underStandards are to protect the public from harm and to improve
taking quality activities, initiating improvements when required
the quality of health service provision. They provide a quality
and evaluating outcomes. This is where the overarching
assurance mechanism that tests whether relevant systems are
framework is required. Within this framework there needs
in place to ensure minimum standards of safety and quality
to be confidence that there are robust, concise data collecare met, and a quality improvement mechanism that allows
tion and validation processes embedded: ‘data out are only as
health services to realise aspirational or developmental goals
good as data in’. For many health services to meet this action,
(Australian Commission on Quality and Safety in Health Care
a system that monitors both clinical and non-clinical incidents,
2012b).
and reports on outcomes from the data put in, is required. For
There are 10 Standards that prescribe what should be
example, how many patient falls were there on your ward this
monitored and improved upon, all of which focus on areas of
month?
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We suggest the use of a data validation
tool to assist in regular review of
your indicators for safety and quality
monitoring.
What is your ‘source of truth’?
When it comes to reporting, we need to consider what
information we provide to our executive teams, our board
and our key stakeholders. Is it accurate, concise and timely
enough for them to make informed decisions and actions on
key patient safety issues? Do your staff delivering care at the
bedside understand what the patient safety issues are?
Data sources in the context of the
Standards
Each of the 10 Standards requires evidence of monitoring
and reporting. Where do you start? How do you ensure this
is embedded in your current quality and safety monitoring
framework?
If you have not already reviewed your indicators in line
with the national standards you will most definitely need to
undertake a review of all patient safety indicators and KPIs
across your health service. This will allow you to ensure you
achieve a manageable list of indicators that are meaningful and
relevant to high risk and high volume patient safety issues.
We suggest the use of a data validation tool to assist in
regular review of your indicators for safety and quality monitoring. The tool should include as a minimum key questions.
Examples of some key questions we see are:
1 Does the indicator have a clear definition? One person
could collect the indicator differently from another,
resulting in data inaccuracy. Will the Board or your target
audience misinterpret the indicator? There is nothing
worse than finding that after reporting an indicator to the
Board the indicator has been incorrectly reported.
2 Do you have a reliable data source from which to
extract the indicator data? If you are not able to extract
the indicator data in a timely manner and without
manipulation, the indicator will not assist in improvement.
Your indicators should be extracted from a reliable and
What does the Governance Standard
mean for you as a Quality Manager,
Quality Coordinator or HIM?
Standard 1, Action 1.2.1 which states: ‘Regular reports on
safety and quality indicators and other safety and quality
performance data are monitored by the executive level
of governance’, prescribes the requirements for this, and
provides opportunities for health services to demonstrate
evidence of how monitoring is achieved. Under this action,
it is important that the current monitoring and reporting
of patient safety indicators are reviewed to ensure the KPIs
relevant to your health service, along with the requirements of
the Standards, are monitored systematically and accurately.
When considering what to monitor, there are many tools,
data sets, references and guides that influence decision making.
Have a think about what you reference or use in your health
service. Do you use any of the following when monitoring and
reporting patient safety and quality: RiskMan (for incidence
reporting); Mortality Audit; ICD-10-AM/ACHI coding; Internal
KPI Monitoring; ACHS Clinical Indicators; DoH Reporting;
Statement of Priorities (agreements between health service
and government); National Health Agreements; My Hospital
Website; Maternity Services Performance Indicators;Victorian
Audit of Surgical Mortality (VASM); NSQHS Standards.
Table 1: Example of using the data validation tool for review of indicators
RECOMMEND
HEALTH SERVICE
1. CLEAR
INDICATOR
DEFINITION
2. RELIABLE SOURCE
3. ACTION TO IMPROVE
4. EXTERNAL BENCHMARK
OR CONTINUE
Medication errors
Yes
No – no system to collect
errors from
No
No
Cease
Falls with serious injury
Yes
Yes – RiskMan & patient
management system
Yes – implemented
falls strategies
Yes – ACHS/DoH
Continue with
reporting and
monitoring
Note:
COLLECTION CEASE
We would also suggest any new or proposed indicators be put through a data validation tool before being reporting to Board or Executive level.
HIM-INTERCHANGE Vol 4 No 3 2014 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)
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REPORT
robust source, for example ICD-10-AM/ACHI coded data
or RiskMan.
3 Have you taken action to make improvements as a
result of monitoring the indicator in the last two years?
This will tell you whether or not the indicator is driving
improvement: it may also mean that you are consistently
achieving excellent results so you should question the
need to continue monitoring if this is the case.You do
not want to drown in indicators or all you will be doing is
reporting.
4 Is there an external benchmark for the indicator to drive
the improvement and set the target?
Once you have reviewed your current indicators with
a data validation tool you can then move into ensuring the
indicators address high volume activity and high risk activity by
using your risk management systems to analyse risks, and your
activity monitoring tools for activity analysis. This should then
be combined with your reviewed indicators after validation to
make up your clinical governance indicators for patient safety.
These indicators need to be reported at least bi-monthly at
Board and Executive level and understood down to the clinical
staff delivering the care at the bedside. A quality improvement
tool should be used to document your improvements as a
result of monitoring the indicator. We would suggest an electronic improvement tool that references the Plan Do Study
Act Cycle (PDSA), which is also recommended by the national
standards. Regular review of your indicators is essential to
ensure you are continuing to achieve quality care at your
health service.
Summary
The Standards should complement the current safety and
quality monitoring within a health service. A thorough review
and gap analysis should be undertaken to identify what your
monitoring suite should consist of, and also what is required
by implementing the 10 National Safety and Quality Health
Care Standards.
Regular review of your indicators is essential to ensure
you are continuing to achieve quality care at your health
service. A data validation tool will greatly assist with this
process and will provide a clear framework in determining
and justifying what you are monitoring. The most important
element in this cycle is the improvement as a result of the
activity, and the impact it has on our patients throughout their
journey through the healthcare system.
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References
Australian Commission on Quality and Safety in Health Care (ACSQHC)
(2012a). Hospital accreditation workbook. Available at: http://www.
safetyandquality.gov.au/wp-content/uploads/2012/10/HospitalAccreditaton-Workbook-%E2%80%93-October-2012.pdf (accessed 2
June 2014).
Australian Commission on Quality and Safety in Health Care (ACSQHC).
(2012b). National Safety and Quality Health Service Standards. ACQHC,
Sydney. Available at: http://www.safetyandquality.gov.au/wp-content/
uploads/2011/09/NSQHS-Standards-Sept-2012.pdf (accessed 2 June
2014).
Odette Taylor, BMRA
Health Information Manager
Clinical Patient Folder, Client Data Management
Northern Health
(Formerly Manager Data, KPIs & Northern Health RiskMan
Administrator)
The Northern Hospital
185 Cooper Street
Epping VIC 3076
email: [email protected]
Kirrily Gilchrist, BHIM
CDM Manager
Emergency and Peri Operative Services
Northern Health
(Formerly Manager Quality, Data, KPIs & Accreditation)
The Northern Hospital
185 Cooper Street
Epping VIC 3076
HIM-INTERCHANGE Vol 4 No 3 2014 ISSN 1838-8620 (PRINT) ISSN 1838-8639 (ONLINE)