Annotating Reports and Demonstrating CQI

Annotating Reports and Demonstrating CQI Examples from Both New Zealand and Australia

There is no doubt that many aged care facilities are becoming more and more sophisticated in the analysis of their KPI results and this is being reflected both in what is being added in the comment boxes at the time of data entry and also the word reports after being sent back to the facilities. The two examples below come from the Presbyterian Support South facility, Vickery Court, in the deep south of New Zealand and also from UPA Murray Vale Shalem Hostel in the NSW / VIC border town of Albury-Wodonga.

Vickery Court Hospital (High Care)

Principal Nurse Manager Sherwyn Parmenter understands the important of good breakdown data'. It helps with the analysis of results and the identification of improvement opportunities. As Sherwyn explains "whilst it is important for us to understand our outcomes in relation to others, it is just as important for us to understand the specific detail behind these outcomes so that we can continually look for improvement opportunities". Consequently after collecting benchmarking data for over a year it was decided to document the specific detail of our incident data in the online data entry system. The benefits of doing this are numerous. Firstly it imparts on the management and staff a responsibility to collect good information on the incident report forms. Secondly it ensures that the organization periodically reviews its data collection forms to ensure that appropriate information can be efficiently collected. Thirdly, it ensures that the organization routinely reviews what is happening in all KPI areas even before the benchmarked results are returned.

In the two examples below it can be seen that a few minutes of documentation at the time of data entry can add substantial value to the understanding of the report and what might be happening in the facility. A review of this information indicates that the facility is aware of times that accidents might commonly occur, the reasons for the accidents and specific residents that might be considered at highest risk.

As Sherwyn explains "we are building a good set of information that is linked to our benchmarked outcomes that will help us in our understanding of where to focus our energy to achieve improvement".

Skin Tears Analysis

Benchmarked Report for Quarter 4 2010/2011 All High Care & ; No. of Facilities: 152

Analysis / Action Taken / Outcome

Falls Analysis

Mr PD 15 April = 6, May = 5, June = 6

This gentleman has Parkinson's disease and attempts to remain independent. He also gets very disorientated at night

Mrs T DB 11 April = 3 May = 4 June = 4

This lady has metastatic disease in her spine which has affected her balance but she attempts to remain independent

UPA Murray Vale Shalem Hostel

Following their enlightening article in last quarter's newsletter on how to achieve high resident and relative satisfaction, UPA Murray Vale manager Jaqui Hastings shares with us how she uses the QPS Benchmarking Word Based Report to track continual improvement initiatives and shares these with staff and residents.

Jaqui explains that after all the hard work in collecting good data, analyzing it and taking action it is sometimes easy to forget to close the quality cycle around the many improvement strategies that we employ. One of the great benefits of having a benchmarking report in a flexible word format is that it is extremely easy to periodically summarize strategies and work them into a 'track change' chart. Creating these charts is easy to do if you routinely annotate your data quarter by quarter. It is then quite convenient to go back and summarize this work into a track change chart.

The track change charts help us to communicate with staff and residents on the work that underpins the great service delivered by the staff. The charts help to build staff confidence in the overall continual improvement program and make it easier for staff to describe improvements to relatives, the community and accreditation assessors.

The following information has been extracted from UPA Murray Vale Shalem Hostel's last benchmarking report.

Jaqui and the staff at UPA Murray Vale Shalem Hostel contend, with justification, that their improving rate in the area of skin tears over the past three years has not been accidental, but rather from the constant vigilance and strategies as outlined in the track change chart above ???.and it would be hard to disagree. Another benefit of the 'track change' charts is that they are a constant reminder to staff of the numerous quality initiatives that are undertaken. It also helps the staff to explain quality initiatives to accreditation assessors.

A Quick Guide to Creating Track Change Charts