Health Administration Press
Chapter 4: Data Collection
Chapter Outline
• Categories of Data
• Considerations in Data Collection
• Objectives for Success
• Sources of Data
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Health Administration Press
Categories of Data
• Clinical quality (including both process and outcome
measures)
• Financial performance
• Patient, physician, and staff satisfaction
• Functional status
• The challenge is to collect as many data elements from as
few data sources as possible with the objectives of
consistency and continuity in mind.
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Considerations in Data Collection
• Time and cost
• Medical record review and
prospective data collection are
considered the most time-intensive
and expensive ways to collect
information.
• Administrative data sets are often
considered cost-effective.
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Considerations in Data Collection
• Collecting the critical few
rather than collecting for a
rainy day
• Syndrome of stockpiling “just in case” as
opposed to fulfilling requirements “just in
time” is ineffective and inefficient.
• This approach provides little value to the
data collection effort and is one of the
biggest mistakes quality improvement teams
make.
• Collect only the data required
to identify and correct quality
issues.
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Considerations in Data Collection
• Inpatient versus outpatient data
• Sources and approaches to data collection can be
different.
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Objectives
The following objectives are essential to a
successful quality improvement project and
data collection initiative.
1. Identify the purpose of the data
management activity (for monitoring at
regular intervals, investigation over a
limited period, or one-time study).
2. Identify the most appropriate data
sources.
3. Identify the most important measures for
collection (the critical few).
4. Design a common-sense data collection
strategy that will provide complete,
accurate, and timely information.
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Sources of Data
• Medical record review (retrospective)
• Prospective data collection, data collection forms, and
scanners
• Administrative databases
• Patient surveys: satisfaction and functional status
• Functional status surveys
• Health plan databases
• Patient registries
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Health Administration Press
A3 Problem Solving
• Developed by Toyota
• Goals:
• Solve problems
• Report project status
• Propose changes
• Should give a 60 second illustrated
view of the need for change.
• Do not think of solutions until the last
part of an A3.
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A3: Problem Statement
• What are you trying to solve?
• Is it important?
• What is at stake?
• Do not think of solutions when writing the problem statement.
Example:
Patient Satisfaction Scores have decreased
consistently over the last six months in our
Gastroenterology clinic.
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A3: Background
• Background of what has happened and why it is important to
address.
• Background should give a very brief overview of the situation for someone
that is not familiar with the area.
Example:
The Gastroenterology clinic consists of 25 physicians, seeing 1,600
patients a month. The GI clinic has one of the highest volumes of
patient visits in the health-system. The GI specialty is experiencing
fierce competition in the regional market. It’s decrease in patient
satisfaction scores will be potentially detrimental to our growth in the
market.
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A3: Current State Condition
• Illustrate the current measured performance
• How do you know that there is a problem?
• How is the problem currently measured?
75th percentile
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A3: Target Condition
• What does ‘good’ look like?
• What are the performance measures that the define success in an
ideal state?
• Current State condition and target condition should be comparable
• Do not think of solutions when illustrating target condition
75th percentile
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A3: Root Cause/ Gap Analysis
• After analyzing the problem, identify the key
reasons for the problem.
• Attempt to get down to the most essential
problem (get down to the root of the
problem).
• Do not think of solutions or root causes until
you do the analysis.
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A3: Counter-Measures
• What solution(s) will specifically
address the root-cause?
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Group Projects: Problem Assignments
• Group 1: Access to services
• Group 2: Patient prescription literacy
• Group 3: Patient wait times
• Group 4: Paper forms
• Group 5: Access to care in urban communities
• Group 6: Provider time with patients
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BASICS
Problem Statement:
Patient satisfaction scores have decreased consistently over the last 3 months in the
Cardiology Department
Background:
A3 Facilitator:
Diamond Spikes
Project Team:
Alison Booher, Zainab Alfakhr
Root Cause/Gap Analysis:
(Describe the background of the problem in detail; indicate the importance of the problem to the organization)
(List the problems; use root cause analysis to
identify most likely direct cause of problem)
The Cardiology Department consists of 30 Physicians and sees 2,000 patients a month. This department supports the greatest source of income for our
hospital. The specialty of Cardiology is high in competition. Decreasing satisfaction scores will defer growth
Metrics/ Process Map / Diagram / Picture of Area (indicate solutions that address the root cause of the problems)
WHAT DO WE NEED TO DO TO GET THERE ?
WHERE ARE WE AND WHERE DO WE NEED TO BE ?
Current State Condition: Process Map / Diagram / Picture of area
Target Condition: (What is the target process and specific outcomes desired?):
Process Owner:
Beau Karalis
PDCA A3 Template
Project Start Date:
9/24/19
Project Finish Date:
Countermeasures:
(Select the most practical and effective
countermeasure to address the root cause):
A3 Facilitator:
BASICS
Problem Statement:
Process Owner:
Project Start Date:
Project Finish Date:
Project Team:
PDCA CYCLE
Plan
DO
CHECK
Act / Adjust
Indicate who will do the plan and when it will be done.
Do the plan.
Measure the results.
Describe the measured results and how they compared to the
predictions.
Highlight results in some manner. What is next? What lessons were
learned? What modifications will be made for the next PDCA cycle?
PROJECT IMPLEMENTATION
What changes are to be made?
List the steps to set up this test of change.
Predict what will happen when the test is carried out.
Standard work affected by this change? ☐ Yes
☐ No (If Yes, complete the steps below)
Document standard work / process that is to be followed
File Destination:
File Name:
File Revision
Standard work / process review / approval
Employee training to standard work / process
PDCA A3 Template
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Formatting
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Citation
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