Quality Dashboards: Measure What Matters

QAPI Dashboard

Quality Dashboards: Measure What Matters

By: Bridgette Diedrich

If your transplant center is anything like mine, there is endless consternation about what the QAPI team should measure, despite our familiarity with CMS guidance for indicators to monitor. In the QAPI Resource Guide for Transplant Surveyors (2010) it is explained that we are required to track both a process and an outcome in each of the three phases of donation and transplantation (pre, transplant/donation, and post). With that in mind, we still struggle to narrow down which key measurements these should be.

Here are a few things to consider when choosing which indicators to track for your program’s quality dashboard:

  1. Choose metrics to provide a big picture of your program’s overall performance

For example, measure how your program manages patients’ pre-transplant (i.e., waitlist mortality rate and transplant rate) as well as the one year post-transplant outcomes that we are all so heavily focused on.

Remember that transplant rate and mortality rate are provided for you in your SRTR Patient Specific Report. This makes it easy to measure, track trends, and gauge performance as you can benchmark against your own expected rates. If your program has stellar one-year survival but your waitlist mortality is high, it might help point to some opportunities to improve waitlist management or disease management programs. Also, if your transplant rate is low, it may prompt you to review organ offer reports as a part of regular QAPI oversight. Are you aggressive enough in your organ acceptance? Are your patients’ Status 7 periods too long and missing offers?

  1. Think first about what is clinically relevant to YOUR program, not just what every other program tracks

There may be specific challenges that you or your patients face. Perhaps you have phenomenal patient outcomes both pre- and post-transplant, but your patients and referring physicians complain about how long it takes to decide on transplant candidacy. If that is the case, track this as a pre-transplant process measure. It is an opportunity to not only be compliant with CMS QAPI requirements, BUT, also to improve in areas where you need. Indicators chosen for reasons like this give your dashboard or scorecard real relevance for your clinical team, and result in more meaningful engagement.

  1. Don’t just track the 100% metrics

To really get ahead and create true improvements in your program, track the ‘not-so-perfect’ stuff too. Displaying these less than favorable percentages on your dashboard will provide the visibility and motivation needed to help raise the bar.

I believe that transplant teams are generally made up of highly motivated overachievers who like to get straight A’s. Handing them a report card with anything less will inspire them to succeed.

  1. Engage the front-line

If you are a quality manager or staff member, you might be a little far-removed from issues that are occurring at the level of direct patient care. Engage them, and ask for issues to track. Maybe your pre-, post- or in-patient team is struggling from a lack of resources. Maybe there is a lack of beds or not enough staff to cover the needs of your growing transplant program.

If this is the case, you should be honing in on objective measures that paint a picture of how transplant patients are impacted. Sharing your regulatory-required reports with hospital leadership, armed with your dashboard data, will help justify resources. (Remember that pesky bi-directional requirement for communication between Transplant and Hospital QAPI, up to your governance? Here is how you can use it to your advantage).

Make sure to include the indicators and information that matters to the C-suite. Add things to your dashboard that translate into dollars for your hospital. This will only help your cause when establishing your program’s relevance to the bottom-line with hospital executives. Again, use that bi-directional requirement for all it’s worth!

  1. Include the publicly reported metrics too

In addition to choosing dashboard metrics that will drive continuous quality improvement, you should consider including information that others use to judge your program. This might include measures from the SRTR website (which are available to patients and payers), or it could include line-of-business data (potentially UHC/Vizient, or health system specific) used by hospital executives to judge your team’s performance.

Making data transparent to your team by way of your quality dashboard will prevent surprises. Your savvy patients may do their own research and ask questions of your transplant team members. Equip those team members with insight into the data so they have ready responses. Your Chief Medical Officer may reach out to your Surgical Director to ask why the UHC/Vizient Length of Stay index is higher on the transplant service than others. Know what others are looking at so your quality committee can be prepared with good responses to questions, or just so you can brag about how well you’re doing!

In summary, use your data to provide an overall picture of your program’s performance pre- and post- transplant. Be aware of the public data that your patients and colleagues could use to form opinions about your transplant center and be able to speak to it. Pick metrics that your associates are passionate about and provide value to your organization. Measuring indicators that matter allows you to have a single source of relevant information which can be used for a variety of purposes.

If composed of the “right stuff,” a quality dashboard can become more than just a tool for quality improvements. It can also serve as a tool for financial justifications, staff engagement, internal marketing, and education.


What do you think?

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About Bridgette Diedrich – Diedrich started in healthcare as a cardiac ICU nurse, was recruited to Heart Transplant Coordinator and worked up through the ranks to become Transplant Administrator as the Director of Advanced Heart Failure, Transplant, and MCS at MedStar Washington Hospital Center. She transitioned to Director of Quality, Regulatory Affairs, and Education at MedStar Georgetown Transplant Institute to focus more on quality and regulatory preparedness. She was officially ‘marked for life’ as the transplant bug bit her long ago and the ensuing genetic mutations have woven transplant into her DNA.

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