Example Data Sources to Analyze Performance, Identify Areas of Risk, and Solicit Feedback/Input 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 HR leadership team QAA committee weekly monthly quarterly annually board members caregivers community Executive. leadership families residents staff volunteers board meetings bulletin boards dashboard newsletters posters QAPI meetings staff meetings weekly monthly quarterly annually Abuse, Neglect, Maltreatment reports weekly Identified best practices Leadership team weekly Board members, QAPI committee, state reporting agency, Reporting requirements, meetings As needed, weekly CMS Quality Measures (long-stay and short-stay) monthly state and national data Leadership team monthly Executive leadership, board members, staff QAA and IDT meetings Monthly and quarterly Complaints weekly Identified best practices, organizational date Leadership team weekly Board members, QAPI committee meetings As needed, weekly Falls weekly Organizational data Leadership team, QAA committee weekly Residents, families, staff, Bulletin boards, dashboard, QAA and IDT meetings Monthly Medication errors monthly Organizational data Leadership team, QAA Committee Monthly or asap if adverse drug event Board members, staff Staff meetings, dashboard, QAA Meeting Monthly or sooner if needed Rehospitalization Rates monthly Organizational, state and national data Leadership team, QAA committee monthly Board members, Exec. leadership, staff Staff meetings, dashboard, QAA meetings Monthly
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 organizational (chain) data state data HR Leadership Team QAPI committee weekly monthly quarterly annually board members caregivers community executive leadership families QAPI committee residents volunteers board meetings bulletin boards dashboards newsletters posters QAPI interdisciplinary meetings staff meetings weekly monthly quarterly annually Resident/Family Council minutes monthly Organizational data Leadership team, QAPI committee monthly QAPI committee, residents families, board members meetings monthly Satisfaction Surveys annually Organizational date, national data Leadership team, QAPI committee annually Board members, staff, residents, families, QAPI committee Meetings, newsletters, board meetings annually Suggestion boxes weekly Organizational data QAPI committee, leadership team weekly QAPI committee, leadership team Meetings monthly
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 organizational (chain) data state data HR Leadership Team QAA committee weekly monthly quarterly annually board members caregivers community executive leadership families residents volunteers board meetings bulletin boards dashboards newsletters posters interdisciplinary meetings staff meetings weekly monthly quarterly annually