Decision Making

Scenario

 Downtown Hospital in Chicago, Illinois, is a leader in data-driven decision making to improve its organizational performance using measures based on the Institute of Medicine’s six “aims for improvement,” in turn promoting growth of the hospital’s reputation and patient encounters over time. As the patient quality and safety analyst, you work closely with many of Downtown Hospital’s managers to continuously monitor and analyze the organization’s performance data and to keep decision-makers well informed. The director of patient quality and safety has asked you to prepare a preliminary analysis of the hospital’s quality and safety data to improve patient satisfaction and to inform decision making on opportunities for growth.

Downtown Hospital uses a database that contains data on various quality and safety measures. Specifically, you have been asked to run a report and analyze the following measures for the hospital’s inpatient units over the past two years:

• Nurse staffing
• Average patient wait times
• Medication administration errors
• Healthcare-associated infections
• Patient satisfaction

The director of patient quality and safety is interested in receiving updates on how the hospital is performing compared to the internal performance targets set by the organization and other hospitals across the country, and identifying any key features and trends in the data that are evident and require further analysis. Your preliminary analysis will be presented in a report to the director of patient quality and safety to inform them on how to improve healthcare processes, delivery, and outcomes.

Directions

As the patient quality and safety analyst, you have been asked by the director of patient quality and safety to analyze the data to discover useful information, inform conclusions, and support decision making. Specifically, the director of patient quality and safety wants to know whether the hospital met its internal performance targets for nurse staffing and patient wait times. You have been asked to do the following:

• Compare actual data for nurse staffing and patient wait times to internal performance targets and determine data points that fell short of, met, or exceeded internal performance targets.
• Discuss the implications for Downtown Hospital regarding your findings. What do your findings mean? Did you meet your goals?
• Support your analysis with evidence from the data provided.

The director of patient quality and safety is also interested in examining the relationships among various measures at Downtown Hospital. Specifically, you have been asked to examine the data to do the following:

• Determine the relationships that exist among nurse staffing, patient wait times, and satisfaction. For instance, as one measure increases, do you notice the other measures increase, decrease, or stay constant?
• Discuss the implications for Downtown Hospital regarding your findings. What do your findings mean? Are these measures related to one another?
• Support your analysis with evidence from the data provided.

Safety is a high priority for Downtown Hospital. To see how it measures up to hospitals across the country, you will do the following:

• Compare outcome data for medication administration errors and healthcare-associated infections (HAIs) to the national average data and determine data points that fell short of, met, or exceeded the national average. Did your hospital’s percentage of medication errors and HAIs fall within the ranges for the national average?
• Discuss the implications for Downtown Hospital regarding your findings. What do your findings mean? How did the hospital’s number of medical errors and HAIs compare with the national average? How might this affect patient safety?
• Support your analysis with evidence from the data provided.

Over time, research has established new protocols and safety regulations at healthcare organizations across the country. If these protocols are followed properly, the number of medication errors should decrease. You have been asked to examine trends in medical errors to do the following:

• Determine how the number of medication administration errors has changed over time at Downtown Hospital. Has the measure increased or decreased over the past two years?
• Discuss the implications for Downtown Hospital regarding your findings. Given the various measures of data, does it appear that the hospital has improved its quality, safety, and patient satisfaction over the last two years?
• Support your analysis with evidence from the data provided.

Outliers in the data should always be explored to determine their source and possible meaning. Outliers can be weak or strong and result from such things as data collection errors, sampling inconsistencies, or variability in the measurements. You can compare individual values against the average to identify outliers. Specifically, the director of patient quality and safety is interested in any outliers that are evident in the data. You will do the following:

• Identify outliers in the data for average patient wait times and HAIs over the past two years.
• Discuss the implications for Downtown Hospital regarding your findings. Consider what each significant outlier suggests about quality, safety, and satisfaction. Does the outlier have positive or negative implications for your hospital?
• Support your analysis with evidence from the data provided.

What to Submit

Report to the Director of Patient Quality and Safety

Submit a report of your findings and supporting evidence to the director of patient quality and safety. Your report should present your findings in a clear and concise manner using Microsoft Word.

Although it is not required, consider including graphs or figures to refer to throughout your report by simply copying them from the Data Report_Graphs sheet in the data report provided. Cite all sources appropriately.

Spreadsheet: Data Report

Use this spreadsheet to access the data for Downtown Hospital. The report contains quarterly data on nurse staffing, average patient wait times, medication administration errors, healthcare-associated infections, and patient satisfaction. In each table, the measure is defined and accompanied by internal benchmarks or national averages for comparison. You may use the notes section to document your findings as you analyze the data. Be sure to transfer your notes into a Word document to report to the director of patient quality and safety.

• PLS SEE UPLOADED DATA REPORT

Project Rubric: Report to the Director of Patient Quality and Safety

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