Center for Healthcare Governance Monographs 2005
Patient Safety and Quality Reporting for Governance: Data Reporting Guide for Hospital Staff
About the Authors: Sanjaya Kumar, MD, M.Sc., MPH is President & CMO and Chairman of the Board and Catherine Carson-Martin, RN, BSN, MPA is Director, Programs Management, at Quantros, Inc., a Miloitas, CA-based company that provides real-time knowledge solutions for benchmarking, patient safety, accreditation and compliance, and outcomes monitoring for health care providers, payers and pharmaceutical companies.
Preface:
Hospitals today have several disparate and centralized data sources that can be used to construct valid measures of performance, quality, safety, and service/product utilization. Application of standardized risk methodologies also allows for the computation of comparative metrics that can be used for outcomes monitoring. Faced with increasing demands from leadership, payers, and regulatory agencies to demonstrate and quantify improvement, hospital staffs are challenged to decide which measures need to be monitored and tracked over time. It is now widely acknowledged that measures are needed that can be computed at any given level within the organization. The measures being computed at the organization level need to be the same as those at the department/service line and practitioner levels to provide a common framework for understanding and communication.
Due to the diverse performance domain requirements of health care institutions and the current environment of increased accountability for governing boards, board members (trustees) need to be more vigilant than ever before in overseeing all of the activities of the hospital, including monitoring the quality and safety of care.While hospital board members do not direct daily operations or indicate to physicians and other health care providers how to treat their patients, they do need to monitor the quality and safety outcomes of care based on key indicators and metrics of performance.To this end, administrative staff or departments involved in preparing governing board reports need to utilize data visualization methods for selected measures that can be easily understood by board members. Performance data need to be presented in ways that allow trustees to easily pinpoint opportunities for improvement and gauge degree of improvement over time.
This data reporting guide provides a framework that can be used in synthesizing and making available data reports in formats that support review of progress toward meeting quality and safety improvement goals by the governing boards of hospitals.
Sanjaya Kumar, MD, M.Sc., MPH
President & CMO, Board Chairman
Quantros, Inc.
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