2016.04.

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主管會議 資料
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DEPARTMENT / SERVICE
QUALITY MEASUREMENT
TRACER

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 DEPARTMENT / SERVICE
QUALITY MEASUREMENT
TRACER
 How individual department/service leaders use quality
measurement to improve patient care and services.
 How clinical guidelines are selected and implemented
and used to decrease variances.
 The 5th edition standards place an increased emphasis
on the role and responsibility of department and service
leaders.
 Talking with the department or service leaders as well as
a variety of staff to understand the measurement
priorities for that particular department or service and
their participation in the hospital-wide strategic
priorities. 6
 NEEDED
FOR THE DEPARTMENTS /
SERVICES
 The performance measurement plan and
indicators.
 Copies of data collection tools, definitions,
and results for measures.
 Documentation of communication of
measurement activities for the department.

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 WHAT WILL OCCUR
 Discussion with the department or service leader and other
staff about their participation in the quality improvement and
patient safety program.
 Discuss their involvement in the hospital-wide strategic
improvements as well as what department-specific measures
are being collected.
 Review the measurement activities being done, data analysis,
and any improvements that were a result of their specific
measurement.
 Discuss how the specific department/service improvement
project has affected patient care and other improvements.
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 Sample questions :
1. How do the department's measures align with
hospital-wide priorities chosen by the leaders?
2. How does the Quality Department support you?
3. What measures do you collect that are specific
to your department/service area?
4. How did you pick your measures?
5. What are your results, analysis, and
improvements?
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 Sample questions :

6. How has all this been communicated to the

staff?
7. Do any measures from the Library relate to
your department/service?
8. Are there any measures you currently collect
that are applicable to physician and/or
professional staff evaluations?

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 Sample questions :

10. Which clinical guidelines are used in your area

and how were they selected?

11. What was the process for implementing the

guidelines?

12. How was the information communicated?

13. How was staff trained?

14. How is compliance with the guidelines

evaluated and how has this reduced variances?
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LEADERSHIP FOR QUALITY AND
PATIENT SAFETY INTERVIEW

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 How hospital leadership establishes and
supports an organizational commitment to the
quality and safety program.

 Leadership also implements a structure and

process for the overall monitoring and
coordination of the program throughout the
hospital, including how coordination occurs
among departments and services in
measurement and improvement efforts.

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 Avoid having the discussion gravitate towards
operational details of the quality program;
rather, keep it at the level of accountability
consistent with leadership.

 This will be more structured, and we will

expect more specific responses to questions, as
well as documentation evidence when
applicable to required reports, documents,
evaluations, etc.

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 Sample key standards : (Documents)
 GLD 1 — How is the governing board
evaluated, and is there one documented
annually ?

 GLD 1.1 — The operational responsibilities and

accountabilities of the governing entity are
described in a written document.

 GLD 1.2 — Those responsible for governance

approve the hospital’s program for quality and
patient safety, and regularly receive and act on
reports of the quality and patient safety program. 15
 Sample key standards :
 GLD 3 —ME 4— How do you ensure that policies
and procedures are followed ?

 GLD 3.1 —ME 1, 2, and 3: How did you determine

the clinical services ? How was the community
involved? Show us data you provide to your
stakeholders for ME 3 (Hospital leadership provides data and
information on the quality of its services to stakeholders).

 GLD 3.2 — How do hospital leadership ensure

effective communication ?
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 Sample key standards :
 GLD 4 — How has leadership been involved in the
development and monitoring of the QPS program ?

 GLD 4.1 — Ask to describe the flow of reports, and

then check the documentation. Review meeting
minutes. Ask for an example of a sentinel event that
was reported to governance.

 GLD 5//QPS 5 — What has been the process for the

development of hospital-wide prioritization ?

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 GLD.5
 Hospital leadership prioritizes which
hospitalwide processes will be measured,
which hospitalwide improvement and patient
safety activities will be implemented, and
how success of these hospitalwide efforts
will be measured.

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 INTENTS OF GLD.5
 Priorities may focus on the achievement of strategic
objectives; for example,
 To become the leading regional referral center for
cancer patients.
 Increase efficiency, reduce readmission rates,
eliminate patient flow problems in the emergency
department.
 Create a monitoring process for the quality of services
provided by contractors.

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 Hospital leadership considers priorities at a system
level; for example,
 Improving the hospital’s medication management
system.

 The priority-setting process includes the consideration

of available data on which systems and processes
demonstrate the most variation in implementation and
outcomes.

 Hospital leadership ensures that, when present, clinical

research and medical education programs are
represented among the priorities.

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 Hospital leadership also assesses the impact of
improvements. Measuring improvement in efficiency
of a complex clinical process, and/or identifying
reductions in cost and resource use following
improvement in a process, are examples. ( 舉例報
告)

 Measuring the impact of an improvement supports an

understanding of the relative costs for investing in
quality and the human, financial, and other returns on
that investment.

 “Overview of Measurement” (Singapore JCI

Education Participant Guide P195-209)
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 Hospital leadership supports the creation of simple
tools to quantify resource use of the old process and
for assessing a new process.
 Understanding both the impact of an improvement on
patient outcome and the relative cost and resulting
process efficiency contributes to improved priority
setting in the future, both at an organizational level
and at a departmental/service level.
 When this information is combined hospitalwide,
hospital leadership can better understand how to
allocate available quality and patient safety resources.
(Also see QPS.2, QPS.4.1, PCI.6, PCI.6.1, and
GLD.11)
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 GLD.5 MES
1. Hospital leadership uses available data to set collective
priorities for hospitalwide measurement and improvement
activities and consider potential system improvements.
2. Hospital leadership ensures that, when present, clinical
research and health professional education programs are
represented in the priorities.
3. Hospital leadership priorities include full compliance with
the International Patient Safety Goals.
4. Hospital leadership assesses the impact of hospitalwide
and departmental/service improvements on efficiency and
resource use. (Also see QPS.5) 23
 How do you ensure that these are valuable and
meaningful and useful to your hospital ? (Ask
how, not what the specific measures or areas
are.)
 Focus on measurement for systems
improvements and compliance with IPSG’s.
 What were you expecting to achieve ?
 Did follow-up evaluation confirm that you
achieved desired results ?
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QUALITY DEPARTMENT
INTERVIEW

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 How the quality program staff-members
support the overall program for quality and
patient safety including support for and
relationship with departments and services.

 How are quality department staff ( 品安會 )

chosen and trained, including the department
director; emphasis on data collection, analysis,
and validation; achieving and sustaining
improvements.

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 Standards Addressed :
 QPS 1: A qualified individual guides the program;
the program supports and coordinates activities.

 QPS.2: Quality and patient safety program staff

support the measure selection process throughout
the hospital and provide coordination and
integration of measurement activities throughout
the hospital.

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 Standards Addressed :
 QPS.4: The quality and patient safety program
includes the aggregation and analysis of data to
support patient care, hospital management, and the
quality management program and participation in
external databases
 QPS.4.1: Individuals with appropriate experience,
knowledge, and skills systematically aggregate and
analyze data in the hospital
 QPS.5: The data analysis process includes at least
one determination per year of the impact of hospital
wide priority improvements on cost and efficiency 28
 Standards Addressed:
 QPS.6: The hospital uses an internal process to validate data

 QPS 7: The hospital identifies and manages sentinel events

 QPS 8: The hospital analyzes data when undesirable trends

and variation are evident

 QPS 9: The hospital identifies and manages near-misses

 QPS 10: Improvement in quality and safety is achieved and

sustained

 QPS.11: An ongoing program of risk management is used to

identify and to proactively reduce unanticipated adverse
events and other safety risks to patients and staff 29
 Documents / Materials Needed
 Qualifications and training of the director, and the staff
 Evidence of supporting and assisting departments and
services, including performance measure results
 Example of data validation (~~ HR, Critical Supply)
 RCA from a sentinel event and the resulting action
plans
 Data from adverse events and near-misses
 Sample tools such as data collection tool, FMEA
sample, RCA sample, among others used to facilitate
functions 30
 Quality Program Interview Sample Questions
( 病安會 )
 How is the quality program organized to support
leadership in the implementation of the QI/PS
program ?
 How is support and coordination provided to
department/service leaders ?
 How are quality issues communicated to all staff ?
 How do you support measure selection and
measurement activities at the department/service
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level as well as hospital wide ?
 Quality Program Interview Sample Questions
 How is progress on data collection tracked for the
priorities selected ?
 How does quality staff help in the coordination of
department/service measures ? (Follow up on
tracer with front line staff)
 How do you use current scientific and other
information to support: Patient Care, Clinical
education, Research, and Management ? What
sources do you use for this information ?
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 Quality Program Interview Sample Questions
 Who does data collection ?
 How is data aggregated and analyzed, and
transformed into useful information ?
 How is this aggregated data/information used in
support of patient care ?
 What tools and techniques are used? How often is
data typically analyzed? How is this determined ?
 How is data analysis supported by benchmarking, best
practices and objective scientific sources ?
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 How is data provided to outside agencies when
required by law or regulations ?
 Do you participate in external data sharing
(databases) to allow
comparisons/benchmarking ?
 Discuss security/confidentiality when using or
contributing to outside databases.
 Provide an example of how a hospital wide
priority improvement impacted cost and/or
efficiency.
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 Describe how the QI/PS staff with other
departments (i.e. HR, IT, Finance) selected
QI/PS data.

 How have the results of data collection and

analysis been used to refine processes ?

 How does this get reported to leadership ?

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 How do you determine which data
needs to be validated ?

 What is your data validation

methodology ?

 Who is accountable for the validity of

publically reported data ?

 (Human Resource, Critical Supply)

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 Describe how undesirable trends,
patterns or adverse events are identified
and analyzed. Can you give examples ?

 Describe your reporting process for near

misses.

 Describe how the information/analysis

from near miss event examples have
been used to reduce future occurrences ?
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 How do you use data to demonstrate
that improvements are achieved and
sustained, including policy changes ?

 How are QI/PS improvements and

successes reported and documented ?

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 Describe your hospital’s risk
management framework as supported by
your policy.

 Describe your proactive risk assessment

process (done at least annually).

 Give an example of how, based upon

your assessment, high risk processes
were redesigned to reduce or eliminate
future risks.
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