By James D. Perkins, MD, Professor and Vice Chair Department of Surgery
In the field of quality the mantra used to be, “If you can’t measure it, you can’t improve it.” The new mantra is “If you don’t show it, it doesn’t matter.” This new mantra is the focus of the relationship between the Divisions of the Department of Surgery and the UWMC Center for Clinical Excellence (CCE).
For over 15 years, select Divisions in the Department of Surgery have been collecting quality data and developing performance measures; however, only the Divisions’ care providers saw the data. The new relationship with the CCE allows the data to now be viewed on the intranet by all at UWMC with access, using Horizon Business Insight (HBI), a business intelligence software program for presenting performance data, including quality.
“A strong working relationship has developed between the Department of Surgery and the CCE in creating transparency for the performance measures,” states Julie Duncan, RN, MA, CPHQ, Director of the CCE. “The heart of this relationship is a team that includes a quality representative from each Division and a quality consultant from the CCE.”
The development of transparent performance measures starts with data collection. The Divisions collect clinical events from various sources, including specialty patient registries, mortality and morbidity conferences, and clinical reviews. The CCE collects clinical events from administrative database’s, University Hospital Consortium coded events, and directed searches. There are an increasingly overwhelming number of performance measures that could be reported. Specific performance metrics to be presented are selected by the team (described above) in association with each Division Chief.
The process will involve regularly scheduled data collection by each Division and the CCE. Then the CCE quality consultant collaborates with the HBI administrator to display data onto HBI. Once the data is in HBI, several different control charts are available for display. New software will soon allow development of a Quality Dashboard, resembling the dashboard of a car. The quality consultant and the Divisions’ quality representatives will review the display options appropriate for the data. Default options can be set for clear presentation of the performance measures.
Once the performance measures are selected and the control charts are formatted, these measures can be viewed on HBI by all with access through UWMC. Access is determined by the team with the Division Chief.
This collaborative data project is currently in development for display on the HBI website. A menu item, DEPT of SURGERY, will be placed on the HBI website, on which the Department of Surgery Divisions will display their performance measures. Watch for the activated site by mid-summer 2010.
The Department of Surgery shows its measures, and they do matter!