Feedback, Data Systems, and Monitoring Identify Data Sources to Analyze Performance, Identify Areas of Risk and Solicit Feedback/Input Organizations must effectively identify, collect, and use data and information from all departments and the facility assessment. Identify data sources, the frequency of data collection/analysis, targets/benchmarks you will use and establish a plan to communicate data analysis. Choose data sources your organization will use to develop and monitor performance indicators that will track your ongoing performance. Data Benchmarks to Who will Data Data will be Communicate Frequency of collection analyze this analyze analysis communicated data analysis communication frequency data source the data? frequency with via applicable clinical guidelines board meetings board members identified best bulletin boards Data caregivers practices HR dashboards Sources* weekly weekly community weekly national data Leadership newsletters monthly monthly executive monthly corporate data Team posters quarterly quarterly leadership quarterly state data QAPI QAPI annually annually families annually facility identified committee interdisciplinary Suggestions residents performance meetings volunteers indicators/goals/ staff meetings thresholds/targets Choose a data source Choose a data source Suggested Data Sources: Advanced care planning audits Family Satisfaction Near Misses (incidents w/out serious Staff retention CMS Quality Measures (long-stay; Fire safety deficiencies harm) Staff satisfaction short-stay Infection Prevention and Control Nursing Assistant staff hours/resident State survey results Case Mix Program day Staff turnover CASPER report Info from providers, physicians, Occupancy rates Volunteer hours Community activities contractors, vendors Performance Indicators Other Consistent assignment Licensed nurse staff hours/resident day Rehospitalization rates Discharged resident surveys Medication administration audits Resident council minutes Drug regimen review summary Medication errors Resident satisfaction surveys Falls Medication room audits Revenue payer sources mix
Feedback, Data Systems, and Monitoring Identify Data Sources to Analyze Performance, Identify Areas of Risk and Solicit Feedback/Input Organizations must effectively identify, collect, and use data and information from all departments and the facility assessment. Identify data sources, the frequency of data collection/analysis, targets/benchmarks you will use and establish a plan to communicate data analysis. Choose data sources your organization will use to develop and monitor performance indicators that will track your ongoing performance. Data Sources* Data collection frequency Benchmarks to analyze this data source Who will analyze the data? Data analysis frequency Data will be communicated with Communicate data analysis via Frequency of communication Suggestions weekly monthly quarterly annually applicable clinical guidelines identified best practices national data corporate data state data facility identified performance indicators/goals/ thresholds/targets HR Leadership Team QAPI committee weekly monthly quarterly annually board members caregivers community executive leadership families residents volunteers board meetings bulletin boards dashboards newsletters posters QAPI interdisciplinary meetings staff meetings weekly monthly quarterly annually Choose a data source Choose a data source Suggested Data Sources: Advanced care planning audits CMS Quality Measures (long-stay; short-stay Case Mix CASPER report Community activities Consistent assignment Discharged resident surveys Drug regimen review summary Falls Family Satisfaction Fire safety deficiencies Infection Prevention and Control Program Info from providers, physicians, contractors, vendors Licensed nurse staff hours/resident day Medication administration audits Medication errors Medication room audits Near Misses (incidents w/out serious harm) Nursing Assistant staff hours/resident day Occupancy rates Performance Indicators Rehospitalization rates Resident council minutes Resident satisfaction surveys Revenue payer sources mix Staff retention Staff satisfaction State survey results Staff turnover Volunteer hours Other