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Seniors’ Health Care Webinar 2: Digging Into the Data to Diagnose and Evaluate Issues

December 1, 2016 hspschool@cihi.ca

Seniors and Health System Performance Webinar Series

2

Session objectives

• Assess health system performance in seniors’ care including

drilling down into indicators using a systematic approach

• Discuss the value of comparisons and benchmarking

• Identify CIHI resources and tools for benchmarking and

comparing organizational and regional performance

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Why do we assess health system performance?

• Answers key performance questions

‒ How good is our care?

‒ Is our care getting better?

• Identifies and defines priorities for improvement

• Informs strategic directions and motivates stakeholders to act

• Highlights what is achievable by drawing comparisons and

benchmarking

• Facilitates best practice sharing

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How do we assess health system performance?

• Understand the population you serve and local health care context

• Review and monitor performance indicators that reflect a balance of

health dimensions and align with your strategic priorities

• Draw comparisons to averages, peers and benchmarks

• Set improvement targets

• Identify drivers and potential root causes of performance issues

• Examine clinical practice guidelines and gather best practices

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Taking a systematic approach

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  A case study example

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Identify the priority area Vancouver Island Health Authority (VIHA) Scorecard:

Source: CIHI. Your Health System: In Depth

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A systematic approach – step 1

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Why measure it?

• Falls are the leading cause of injury among older

Canadians: 20-30% of seniors experience 1+ falls each year

• Falls cause:

o 85% of seniors’ injury-related hospitalizations

o 95% of all hip fractures

o $2 billion a year in direct healthcare costs

Source: PHAC. Seniors’ Falls in Canada.

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Meet Lucy …

• Lucy is an 82-year-old retired teacher and a long-term care

resident. Last year, Lucy had a fall resulting in a fractured hip.

• Before her fall, Lucy:

• Walked with a cane

• Attended weekly exercise classes

• Was a member of the resident council

• Since her fall, she:

• Uses a walker or wheelchair

• Spends most of the day in her room

• Reports almost daily pain

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Connecting the dots: Big dots linked to small dots

Source: Adapted from Heenan et al.,2010. Figure 1, p.57

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Connecting the dots for falls in long-term care

Source: Adapted from Heenan et al.,2010. Figure 1, p.57

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A summary of big dot and small dot indicators

Big Dot Indicator Small Dot Indicator

How is it

defined?

• System-level measures

• Represents many aspects of

performance

• Outcome driven

• Program or unit-level measures

• Components of a Big Dot indicator

• Process driven

How is it

used?

• For quick, high-level comparisons

• To prompt you to dig deeper

• To operationalize Big Dots

• To drive specific improvements

Potential

limitations?

• Can mask smaller issues • Lose sight of the big picture

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A systematic approach – step 2

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Falls in the last 30 days in long-term care

What is being

measured?

Percentage of residents who fell in the 30 days leading up

to their most recent assessment

Numerator Residents who had at least one fall in the 30 days prior to

their most recent assessment

Denominator All residents

Exclusions None

Risk adjustment Facility: Case Mix Index

Individual: Not totally dependent in transferring; locomotion

problem; Personal Severity Index; wandering; unsteady

gait/cognitive impairment; age < 65

Performance Lower is better

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A systematic approach – step 3

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What is VIHA’s relative performance?

Source: CIHI. Your Health System: In Depth.

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How does VIHA compare to other regions in the province ?

Source: CIHI. Your Health System: In Depth.

Have there been any changes to the regional rate over time?

Source: CIHI. Your Health System: In Depth.

Falls in the Last 30 Days in Long-Term Care (Percentage)

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How are facilities within VIHA performing?

Source: CIHI. Your Health System: In Depth.

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Identifying peers for comparison

• A peer lets you compare to others that have a similar make-up to

your own facility

• Possible factors to identify peer long-term care facilities

― Facility characteristics

― Resident characteristics

― Others?

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Who are potential peers within VIHA?

Source: CIHI, CCRS 2015-2016

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How does Lucy’s facility compare with its peers?

Source: CIHI. Your Health System: In Depth.

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How does Lucy’s facility compare to other top performers across the province?

Top Performers

• Requires facility to be in the top

10% for three consecutive years

• Top facilities are indicator specific

• Encourages you to think about what

strategies or systems these long-

term care facilities have in place to

learn from

Learn from the best and strive to be among the best!

Source: CIHI. Your Health System: In Depth.

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Identifying benchmarks and improvement targets

Don’t strive to be average, strive to be the best!

Source: CIHI, CCRS 2015-2016; HQO (2012 & 2015)

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What do we know so far?

VIHA’s falls rate is significantly higher than the national average

There has been no significant change in the falls rate over the

past 3 years

Compared to other regions in the province VIHA has the highest

rate of falls

There is considerable variation among facilities and we see that

at Lucy’s facility there is room for improvement

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A systematic approach – step 4

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Key questions to identify performance drivers

What are the risk factors for falling in long-term care?

What does Lucy’s facility look like on certain risk factors?

What other related indicators could you look at?

What do the resident experience survey results look like in

Lucy’s facility?

What is happening to residents after they fall in long-term care?

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What are the risk factors for falling in long-term care?

Source: PHAC. Seniors’ Falls in Canada.

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What does Lucy’s facility look like on certain risk factors?

0 20 40 60 80 100

Physical impairment(ADL score 2 or more)

Cognitive impairment(CPS score 2 or more)

Diagnosis of dementia

Percentage of residents (%)

Resident Characteristics, 2015-2016

Lucy's Facility

Peer (Facility J)

VIHA

Notes.

ADL stands for “Activities of Daily Living” and represents a range from 0 (no impairment) to 6 (total dependence)

CPS stands for “Cognitive Performance Scale” and is scored from 0 (intact) to 6 (very severe impairment)

The VIHA rate is fictitious because these data are not publicly reported

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What other related indicators could you look at?

0

5

10

15

20

25

30

35

40

45

Has symptoms ofdelirium

Taken antipsychoticswithout a diagnosis of

psychosis

Daily physicalrestraints

Worsened bladdercontinence

Has pain

Pe

rce

nta

ge o

f re

sid

en

ts (

%)

Lucy's Facility Peer (Facility J) VIHA

Long-Term Care Quality Indicators, 2015-2016

Note.

The VIHA rate is fictitious in all instances where the data are not publicly reported.

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Some additional performance drivers

Internal (within the facility)

Physical environment

Polypharmacy

Staffing ratios

Family and resident experience survey

External (across the system)

Facility care provider model

Programs/services across the continuum of care

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Looking at resident experience information

Staff respond quickly when I ask for assistance.

19%

27% 41%

13% Never

Sometimes

Usually

Always

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What is happening to LTC residents in the region after they fall?

0

20000

40000

60000

80000

100000

120000

140000

0 2 4 6 8 10 12 14 16 18

Facilit

y r

esid

en

t d

ays

Number of ED visits for fall-related injuries

Number of ED visits from LTC for fall-related injuries in 2015-2016 by facility resident days

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Critical-thinking strategy for planning health system improvement

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A systematic approach – step 5

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What are some best practices?

ASSESS risk for falls and screen for cognitive impairment

REVIEW medications, corrective vision and hearing aids

OPTIMIZE and MAXIMIZE environmental factors to prevent falls

PREVENT through treating osteoporosis, establishing strength

and exercise programs

IMPLEMENT individualized toilet routines

USE hip protectors for high risk residents and mobility aids

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Monitor performance to ensure:

Performance improvements have intended impact

Performance improvements don’t result in unintended

consequences

Related process indicators are also being monitored

Transparency

― Report results to key stakeholders

― Tailor the information to different audiences

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  From data to action: Success stories

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Sienna Senior Living (Markham, ON)

• Completed a process map for those who sustained falls

• Reviewed collected data

• Audited resident care plans

• Based on findings changes made to process and care plans

• Process changes: team huddles where collected data is analyzed to prevent falls

cihi.ca

@cihi_icis

hspschool@cihi.ca

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  Appendix

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Appendix A. Taking a systematic approach

Why measure it? Consider the impact and relevance.

What's being measured? Define your indicator.

How to assess indicator performance? Assess relative

performance through comparisons and benchmarking.

How to drilldown and further understand your results? Identify

performance drivers and understand context.

How to action it? Use data to inform improvement strategies.

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Crude vs. risk-adjusted rates   Crude rates

  (good for internal monitoring):

• Represent counts

• Easy to understand and make use of timely data

• Limited use for comparisons

• Example: Hospital acquired infections

  Risk-adjusted rates

(necessary for comparisons):

• Represent comparative rate

• Accounts for risk factors that may affect indicator

outcomes (e.g. age, sex, comorbidities)

• Not able to control for all relevant risk factors

(hospital peer groups and contextual info.

facilitate meaningful comparisons)

• Example: HSMR (adjusted for age, sex, length

of stay, urgent admission, comorbidities and

transfer status from another hospital)

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Types of benchmarking

Internal monitoring:

- Within a facility/jurisdiction

- A great starting point

- Can use crude rates

- Example: performance scorecard

External Comparisons:

- Across facilities or jurisdictions

- Identifying and sharing best practices

- Uses risk-adjusted rates

- Example: top performers

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Setting improvement targets

• Consider different benchmark values to inform targets

• Set stretch targets (intentionally aspirational benchmarks)

to help achieve larger improvements

• Can set short-term targets when there is a large gap

between current performance and the desired benchmark

value

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  CIHI Resources

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CIHI’s Indicator Library

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Your Health System Tools

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CCRS eReports