BY

Mahmoud Alserafy Eman Konsowa

Quality & Accreditation Consultants

August 7, 2020 [email protected] [email protected] 1

Kindly

August 7, 2020 [email protected] [email protected] 2

 Chapter 5

Information Management

8/7/20 [email protected] [email protected] 3

Information Management

August 7, 2020 [email protected] [email protected] 4

Information Management

Ø Empowerment

Ø Transparency

Ø Key of Integration?

Ø DM according to quality principles

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Information Management

q Definitions:
§ Data: un-interpreted observations of facts.
§ Information: data transformed through analysis and
interpretation into a form useful for decision making.

q Goal: to support the decision making to improve:

§ Patient outcomes
§ Safety
§ Documentation
§ Performance

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Information Management

Essence of leadership
is
Decision making

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Pressure for better information system

q Proof of quality:
§ Purchasers (report cards)
§ Customers

q Integration of QM/UM/RM information.

q Reporting responsibility and comparisons.

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Data management process steps

1) Identify the current available data sources.

2) Identify the critical information needs.
3) Define data elements. (e.g., UTI)
4) Determine data collection plan.
5) Collect, aggregate, and display data.
6) Analyze and interpret data/information.
7) Act on information/knowledge.
8) Report decisions.
9) Collect more data to monitor decisions.
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Data management process steps

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Quality Management model

q Traditional clinical model of decision making:

§ Decisions depend on opinions, rationalization, or
intuition, not on good data.
§ No defined process for decision making.

q QM model:
§ Data-based model (scientific method).
§ In QM, decisions fall into three categories of activity:
.QP .QC .QI

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 1) The most important time to collect and use data is

a) before the QI project begins, to prove a problem exists.

b) during the QI project, to answer questions about cause.
c) during the QI project, to help prioritize the implementation of improvements.
d) after the implementation of the improvement, to maintain the gain.

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Quality data sources

INTERNAL SOURCES EXTERNAL SOURCES

-Patient/client records -Reference databases
-Patient surveys, interviews, questionnaires -Accreditation reports
-Staff surveys -Third party payers and employer reports
-QI team reports -CDC reports
-Indexes, registers, and logs -Recent literatures
-RM reports -Sentinel event alerts
-Infection control reports -Evidence-based practice guidelines
-UM reports -Identified best practice
-Patient safety reports and FMEAs -Validated clinical pathways
-Patient bills -Comparative report cards
August 7, 2020 -Financial reports
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Quality data sources

q Indexes: Permanent topical collections of medical record

data required by state laws and logic to locate cases for record
maintenance, statistics, and research.

q Registers: permanent chronological listings for maintaining

certain statistics.

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Indexes

§Master patient index (MPI): a permanent file of all patients seen in the
organization, with dates, names of attending physicians, and medical
record numbers.
.The most accurate index of patient information. ABCD…….

§Physician index: a file of cases attended by individual physicians,

maintained for a minimum of 10 years.

§Disease index: a file of principal diagnosis codes with individual patient

information, maintained at least 10 years.

§Surgery index: a file of principal procedures similar to the diagnosis

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index. [email protected] [email protected] 17
Registers

§ Births register.
§ Deaths register.
§ Emergency register.
§ Surgical log
§ Number register 1,2,3,…..

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Management of the legal aspects

q Information in the medical record:

§ The physical medical record is the property of ????
§ The owner of the information in the medical record is ???
§ Who is responsible for safeguarding both the record and the
informational content?????
§ Well-defined policies on the use and disclosure of medical information
must be in place.
§ Confidentiality agreement: for whom?????
§ For psychiatric cases, psychotherapy information is maintained
separately and made available as necessary.
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Management of the legal aspects

q Internal use: generally, written authorization by patient is NOT required for use of
their personal health information by the provider organization in HC operations.
§ Those in provider organizations permitted access to medical record
information for organization operations without authorization of the patient
include:
• GB
• CEO
• HC personnel involved in the care
• Clinical department directors
• Information management personnel
• QI teams of the organization
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Management of the legal aspects

qAuthorization and outside disclosure of health information:

§ Written authorization (permission) by the patient or his legal representative is
required for release of medical record information outside of the
organization, unless permitted or required by law or regulation.
§ Written authorization is NOT required when disclosure is:
1) law or statutory regulation, e.g.:
Reporting of communicable diseases, births, deaths, etc.
Fraud and abuse detection and compliance.
2) Medical emergency.
3) For the conduct of research, under certain circumstances.
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Management of the legal aspects

q Patient access: In the U.S., HIPAA (Health Insurance Portability and

Accountability Act) recognizes the patients’ right to access, inspect, and copy
their health information.
§ The right to amend (add corrections, but not delete) their medical
records.
§ HIPAA health information privacy rule:
It is unlawful to use patient information in ways that are inconsistent with the
patient’s original authorization.
access is limited to persons who need to know in order to carry out their roles
and responsibilities. ( +++ confidentiality)

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Management of the legal aspects

2) Confidentiality of information is best accomplished by:

a) Limiting access
b) Obtaining proper consent to release
c) Having all staff sign a confidentiality agreement
d) Removing all patient and practitioner identifiers from documents

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Management of the legal aspects

3) Requiring peer reviewers to sign a confidentiality agreement helps

protect review information from legal discovery and

a) Is necessary for releasing the medical record for peer review

b) Is necessary for proper informed consent
c) Enhances the privacy of medical record information
d) Releases the organization from liability for the quality of medical care

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Informed consent

qDefinition: providing the patient/legal representative with adequate

information to make a rational, informed decision to permit medical-surgical
treatment. The patient is free to reject recommended treatment.
qTypes:
§ General admission or treatment consent: information provided by
the organization, but not necessarily by the practitioner.
§ Special consent: for highly technical testing, medical, or surgical
treatment (information provided by the practitioner ).

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Informed consent

qProcess:
§ Information for special procedure must be provided by
the practitioner performing the procedure and must
include:
• The full extent of the treatment plan.
• The side effects and risks involved.
• Alternative treatments available.
• The risks of non-treatment.

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Informed consent

q To constitute proof of consent: a valid written consent must contain the

following elements:

§ The exact name of the procedure under consent.

§ The consenter’s understanding of: the nature of the procedure,
alternatives, risks and benefits, and probable consequences of
non-treatment.
§ Date of consent.
§ Witness.
§ The patient’s signature.
§ Oral consent is difficult to prove in court.

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Meeting minutes

q Content and format of minutes

§ Content:
• Meeting date.
• Meeting time.
• Attendance: members present,
absent, excused, and guests.
• Old business.
• New business.
• Authorized signature, approving
content.
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Exercise 1

1- Before meeting send …………. + …………

2- Ground rules … when???

3- First step in meeting …………………….

4- In first meeting ….. Yes ….. + …. No ….

5- Someone is late ???????????

6- Last step ………………….

7- Issue outside the agenda ??????

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 4) During the QM/UM Committee meeting of the Atlantic Medical Group,
one physician takes the opportunity to express hostility over the contract
health plan's performance measures and practice guidelines, an issue not on
this month's agenda nor pertinent to the meeting topics. The Committee
Chair defers the complaint to the quality professional, whose best response is
to
a. suggest that the issue be placed on next month's agenda.
b. defend the health plan's right to measure and assess the quality of care provided
to its members.
c. express sympathy with the concerns and offer to discuss the issue in detail after
the meeting.
d. take this opportunity to educate the physician and Committee about evidence-
based practice and measuring performance.
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The Medical Record

q It is the primary legal document as well as the primary data source for
recording and ascertaining the quality of HC delivery to patients.

qPurposes:
§ Continuity of care.
§ Communication among practitioners.
§ Legal protection.
§ Identify the patient.
§ Support for the diagnosis and justification of need for
treatment.
§ Documentation of the course and results of care.

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The Medical Record

qTypical completion requirements for hospitals:

§ History and physical examination
§ Verbal orders
§ Informed consent
§ Progress notes
§ Operative report
§ Reports
§ Discharge summary: what + when + by whom???
§ Discharge instructions
§ Deaths autopsy report
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The Medical Record

qThe medical record as a monitoring/review tool; It is useful for

measuring/reviewing:
§ Medical necessity and appropriateness of hospital, level of care,
admission, and continued stay. (UM)
§ Variance and outcome monitoring based on clinical paths or practice
guidelines.
§ Timeliness of care delivery.
§ Continuity of care delivery.
§ Adequacy of the medical record as a clinical, communicative record.
§ Completeness, timeliness, and legibility.

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The Medical Record

q Both concurrent and retrospective review involve:

§ Trained clinical review staff to screen/interpret information.

§ Trained health information management/medical record staff to screen

for completeness, timeliness, legibility, and compliance issues.

§ Trained physician advisor/medical directors for individual case review

and, if concurrent, immediate action as necessary.

§ Appropriate action/recommendation by committee/team.

§ Reporting to all parties who need to know.

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Frequency comparisons

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Frequency comparisons

q Rate: Comparison of the frequency of events in one population

(numerator) with the frequency of the same events in a comparable
but different population (denominator) in a specified time period.

§ expressed as whole number, decimal, or percentage.

§ example: 5 visits per week, 8 falls/1000 patient days = 0.8 %

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Frequency comparisons

q Ratio: a fixed relationship between similar measures-different

populations, but in a like or similar group.

Example: ratio of nurses to patients.

q Proportion: a type of ratio in which the events included in the

numerator must also be included in the denominator. It is a part
of/whole relationship within the same population.

example: 3 SSIs/60 surgical procedures performed = 5 %.

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Exercise 2

Rate, Ratio or Proportion?

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Exercise 2

1- 1 PHYSICIAN / 100 PATIENTS

2- 10 PATIENTS / DAY
3- 10 SENTINEL EVENTS / YEAR
4- 10 pt. HAIs / 100 PATIENTS

5- 10 HAIs / MONTH
6- 10 INFANTS / 3 MOTHERS
7- 10 INFANTS / 50 POPULATION
8- 10 HCV / WEEK

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 § Incidence: rate during a specified time period.
e.g., during a one-year period: # new cases of transfusion reaction/# of
patients receiving blood.

§ Prevalence: proportion in a defined population, regardless of onset,

calculated at one specific point in time, e.g., on a particular day.
e.g., all infants immunized/total # eligible infant members in the HMO.

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Sampling

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Sampling

q Definitions:
§ Sampling: a subset of a population; a group drawn from a
larger population.
§ Population: a complete set of individuals, objects, or
measurements having some common observable
characteristics.
§ Sample: a subset of a population.
q Purposes:
§ To measure only a portion of a total group.
§ To achieve accurate representation of the entire population.
§ To generalize the results to the larger population.

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Sampling

qProbability sampling: each case in the population has a

chance of being selected and is, therefore, truly representative
of the entire population being sampled.

qNonprobability sampling: an intentionally-biased way to

sample, involving qualitative judgment about an issue that is
suspected to be common or widespread, thus the results can’t
be generalized to the entire population without further study.

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Sampling

PROBABILITY NONPROBABILITY
SAMPLING SAMPLING
Ø Simple random Ø Convenience

Ø Stratified random Ø Quota

Ø Systematic Ø Purposive
random
Ø Snowball

Ø Voluntary

August 7, 2020 Ø Expert

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Probability sampling

§ Simple random: using a table

of random digits to select the
persons/cases from a list of
every case in the defined
population.
• Inappropriate for non-
homogenous populations.

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Probability sampling

§ Stratified random: creating

two or more homogenous
groups of a population and
selecting an appropriate
number of cases that are
representative of the whole.

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Probability sampling

§ Systematic : randomly
selecting the first case
and then selecting
every nth case
thereafter based on
fixed intervals.

e.g., every fifth referral to

a specialist by a primary
care physician after
random selection of the
first case.
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Non-probability sampling

§ Convenience: using data

most readily available.

e.g., all patients seen

in the ED in a given
week.

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Non-probability sampling

§ Quota: portions or
percentages of cases
in a stratified
population.

e.g., 10% of male

patients with both
diabetes and
heart failure.

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Non-probability sampling

§ Purposive: cases selected

because they
demonstrate a desired
characteristics and can
be measured against
specific, predetermined
criteria.

e.g., all patients over 60

years with total hip
replacement.

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Non-probability sampling

§ Snowball: a subtype of
convenience sampling. It
involves subjects suggesting
other subjects for inclusion
in the study, so that the
sampling process gains
momentum.
Used when subjects
are difficult to
identify, but are
known to others
because of an
informal work.

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Non-probability sampling

§ Expert: This is a type of purposive

sampling that involves selecting
experts in a given area because of
their access to the information
relevant to the study.

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Non-probability sampling

§ Voluntary: the sample is self-selected.

The sample consists of people who choose

themselves by responding to a general
appeal

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August 7, 2020 [email protected] [email protected] 55
Exercise 3

Sample type?

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Exercise 3

Ø All cases of C.S this week.

Ø Every third case of C.S this month.

Ø C.S cases above 35 years with hypertension.

Ø 10% of cases of C.S and hypertension.

Ø Representative # of C.S cases in three shifts.

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 5) When using a check sheet to measure the types of medication
errors that occur in a large acute care facility, why is simple
random sampling of all the patients in the facility not
appropriate?

a) The patient population is non-homogeneous.

b) The patient population is large.
c) The number of patients in the various units differs significantly.
d) Check sheets should be used on the entire patient population, and
not a sample.

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Sampling

q Confidence level:
§ A level of probability that the sample is truly representative of the population,
usually set at 95% (the 0.05 level).

§ A confidence level, statistically calculated, involves a test for significance, and is

generally represented by the “p-value”.

§ e.g., p = <0.05.as the p-value decreases, significance increases.

§ A p-value of < 0.05 means that the data is significant statistically, therefor the team
members have more confidence that they can trust the data and make decisions
accordingly.

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August 7, 2020 [email protected] [email protected] 60
 TYPE CATEGORICAL CONTINUOUS
Also known as Attributes, Discrete, Variables, Quantitative
Nominal, Qualitative

Can be Counted and categorized Counted, categorized, and

only measured
Examples # members, patients, gender, Age, height, weight, time, LOS
occurrences
Reported as % in each category (whole Mean, median
numbers) Percentiles
(whole and fractional units)

Statistical test of Chi square test t-test

differences
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between groups
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Exercise 4

Which type of data?

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Exercise 4

1- Age
2- body weight
3- Number of visits
4- Blood pressure
5- Blood groups
6- Causes of errors
7- Height
8- AlOS (Average Length of Stay)
9- Number of falls
10- Waiting time

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 6) Focus groups provide patient/customer input or
feedback. What type of information do they offer?

a) Qualitative
b) Quantitative
c) Measured
d) Opinionated

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 Freq. distr.
Ordering Ratio
Proportion
Mean
Averaging Median
Handling of Mode
numbers Range
Variability variance
SD
T-test
Comparison Chi square test
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Reg. analysis67
Ordering

q Frequency distribution:
§ Simple frequency
§ Grouped frequency
§ Cumulative frequency

q Relative frequency/percentage/proportion

q Ratio

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Frequency distribution

qSimple frequency: all possible values between the highest and the lowest
reported measures are listed in one column. The number of times each
numerical value appears in the set of data is listed in an adjacent column.
LOS ( days ) FREQUENCY
2 5
3 7
4 7
5 9
6 6
7 5
August 7, 2020 8 3
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Frequency distribution

qGrouped: when the range of values is wide, group the single measures
together in blocks (class intervals), each containing an equal number of possible
values . CPHQ SCORES FREQUENCY
121 : 125 6

116 : 120 9

111 : 115 15

106 : 110 22

101 : 105 26

96 : 100 33

August 7, 2020 91 : 95 39
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Frequency distribution

q Cumulative: at each value or point in the distribution column, the cumulative frequency
is calculated as the sum of the frequency of the value or point plus the frequencies of all
points or classes of similar values.
CPHQ SCORES FREQUENCY CUMULATIVE

121 : 125 6 6

116 : 120 9 15

111 : 115 15 30

106 : 110 22 52

101 : 105 26 78

96 : 100 33 111
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95 [email protected] 150 71
 Freq. distr.
Ordering Ratio
Proportion
Mean
Averaging Median
Handling of Mode
numbers Range
Variability variance
SD
T-test
Comparison Chi square test
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Reg. analysis72
Averaging

q Measures of central tendency: statistical indexes that describe

where a set of scores or values of a distribution cluster. Central
refers to the middle value, and tendency refers to the general
trend of the numbers.

q Measures:
§ Mean (M)

§ Median (Mdn)

§ Mode (Mo)

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Averaging

q The “average” or “mean”(M): the sum of the measures, scores, or values

divided by their number.
§ M is a point of balance between the highest and the lowest
measures, scores, or values in a distribution.
§ e.g., 6, 3, 8, 5, 3.
M = 6+3+8+5+3 / 5 = 25 / 5 = 5

qMedian (Mdn): The middle score value in a set of rank-ordered measures .

§ The position of the median is determined by the formula:
i = (n + 1 )/ 2
§ In the set of rank-ordered data 3, 3, 5, 6, and 8 (n = odd number):
i = 5 + 1 / 2 = 3rd position (median = 5)

qMode (Mo): the score that occurs most frequently.

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Averaging

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Averaging

q Comparison of Mean, Median, and Mode:

§ The more stable value from sample to sample is M, and the least
consistent is Mo.

§ In unimodal symmetrical distribution, the values of M, Mdn., Mo. are

the same.

§ In an asymmetrical or skewed distribution or curve, Mo. falls at the

highest point, M someplace towards the tail, and Mdn. lies between
the Mo, and M.

ü Which measure is not affected by extreme values ????

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Averaging

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Frequency distribution curve

SYMMETRICAL +VE SKEWED

18
M
25
Mdn
16 Mo
Mo
20
14

12
15
10

8
10 Mdn
6

4
5
M
2

0 0
0 2 4 6 8 0 1 2 3 4 5
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Frequency distribution curve

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Exercise 5

Mean, Mode or Median?

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Mean, Mode, Median

1- 50th percentile.
2- The more stable value from sample to sample.
3- The score that occurs most frequently.
4- A point of balance between the highest and the
lowest.
5- The middle score value in rank-ordered measures .
6- The highest point in asymmetrical curve.
7- The sum of the values divided by their number.
8- The least consistent from sample to sample.
9- The nearest point to tail in asymmetrical curve.

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Exercise 6

Mean, Mode, Median?

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Mean, Mode, Median

ØN

Ø MEAN
6,9,4,9,2,5,7,6,9,3
Ø MEDIAN

Ø MODE

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 Freq. distr.
Ordering Ratio
Proportion
Mean
Averaging Median
Handling of Mode
numbers Range
Variability variance
SD
T-test
Comparison Chi square test
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Reg. analysis84
Variability indices

q Range (R): the distance from the lowest to the highest

value in distribution.

§ Its value is totally dependent on the two

extreme values.

§ For the data set 3, 3, 5, 6, and 8, the range is:

R=8–3=5

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Variability indices

q Standard deviation (SD): a measure of the spread of a

distribution; a computed value describing the amount of variability
in a particular distribution.

§ The square root of variance.

§ In a normal distribution, 68% of the values will fall
within 1 SD of the mean, 95% of the values will fall
within 2 SDs of the mean, and 99.7% of the values will
fall within 3 SDs of the mean.

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Variability indices

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 Freq. distr.
Ordering Ratio
Proportion
Mean
Averaging Median
Handling of Mode
numbers Range
Variability variance
SD
T-test
Comparison Chi square test
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Reg. analysis88
Comparing

q Chi-square test: Is there a significant difference

between the groups or conditions being compared in the
counts or rates of a particular occurrence, event, or
outcome?

q t-test: It compares two sets of like things, using means

(averages) to see if they indicate real (significant)
difference, or a difference likely to have occurred by
chance.

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Comparing

q Regression analysis:
§ Comparing the entire distribution of observations of one
measurement (or variable) with the entire distribution of another
measure.
§ It determines how strongly the two sets of variables are interrelated
(correlated).
§ It is a way of evaluating the kinds of data found in scatter diagrams.

§ A correlation coefficient (r): is the computed value in regression

analysis that expresses the strength of the relationship between the
two sets of measures.
The numbers associated with (r) range between 0 and +/-1.
To display; scatter diagram.

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Comparing

+VE
TYPE
-VE

CORRELATION
STRONG
SIGNIFICANC MODERATE
E
WEEK
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 +20 100 1544036 & +20 100 0692392

[email protected] & [email protected]

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