In a health care environment in which hospitals are encouraged to carefully monitor clinical metrics for a variety of reasons, tracking performance data and quality measures becomes increasingly important.


For hospital administrators, it has become essential to harness data to reduce errors and improve physician, departmental and hospital performance. One way to meet these demands is by pairing real-time performance data analysis with a collective quality review process that involves all hospital stakeholders.

University Medical Center of Princeton at Plainsboro offers a prime example of how to improve clinical care, patient safety and staff performance by collecting and analyzing key performance data day in and day out.

By consolidating data for regular analysis against a number of internal and payer metrics and industry requirements, UMCPP now provides accurate, timely and consistent performance reports. A unit of Princeton HealthCare System, based in Plainsboro, N.J., UMCPP recently earned recognition from the Joint Commission as a top performer on key quality measures. UMCPP was one of only 244 Joint Commission-accredited hospitals nationwide to earn the top performer designation two years in a row.

UMCPP's interdepartmental collaboration and data analysis has resulted in measurable benefits. First, it has offered hospital administrators valuable insights into how well they are meeting the measures necessary to solidify risk-based reimbursement. Second, and more importantly, it has significantly improved care for UMCPP patients.

Improving Safety and Outcomes

As risk-based payment models centered on care quality, patient safety and cost control continue to emerge, hospitals are under financial and regulatory pressure to reduce errors and improve patient care. For example, the Centers for Medicare & Medicaid Services no longer reimburse hospitals for care or readmissions due to a hospital-acquired condition or error.

Moreover, CMS now posts hospital and health system quality and error metrics on the agency's website, allowing prospective patients to view how well organizations follow certain evidence-based protocols, as well as their readmission rates, complication numbers and mortality rates for several conditions. As a result, the quality and outcomes metrics can affect a health care organization's reputation and, ultimately, its fiscal health.

UMCPP implemented an enterprisewide performance measurement process to monitor and analyze its publicly reported and internal care quality and safety data. In addition to supporting UMCPP's core value of delivering high-quality care, the process also helped the hospital proactively monitor quality metrics and make improvements whenever necessary.

UMCPP's Center for Quality and Patient Safety automatically collects and consolidates data required by CMS with Microsoft Access and performance measurement technology powered by Nuance Communications of Burlington, Mass. However, the organization tracks more than just the data required by CMS. The broader goal is to mine information in a way that enables continual quality and patient care improvement. To that end, other quality and safety protocols and metrics UMCPP studies include:

  • Agency for Healthcare Research and Quality guidelines;
  • Joint Commission criteria;
  • departmental benchmarks;
  • productivity metrics;
  • patient turnaround time.

Performance metrics from these studies are compiled by UMCPP and included in peer reviews for all of the hospital's departments, enabling physicians and other key staff to quickly examine, discuss and rectify issues to improve performance.

Ensuring Accuracy and Credibility

UMCPP also uses performance measurement to monitor patient encounters with safety or quality care issues — known as "fallout" cases — with the goal of improving patient safety. Every fallout case is reviewed by multiple departments. In line with the American Society for Quality's plan-do-check-act cycle, each case report includes an abstract that details patient severity, age, discharge status and other relevant facts that offer a quick summary of the outcome.

These reports are generated from data pulled on the same day and time — regardless of departmental or quality measure. This consistency ensures that physicians and others are not receiving conflicting performance results. Furthermore, physicians understand not only where the data come from, but also that the data have been vetted for quality and accuracy.

Once a report is compiled, analysts within the UMCPP Center for Quality and Patient Safety undertake the first review in every fallout case to check for irregularities. An analyst will examine the documentation and look for coding anomalies or unusual factors about the patient, such as morbidity or severity of condition. Anomalies are compared against original coding and physicians' documentation in the medical record.

In some instances, analysts might discover that a case simply has been miscoded. In those cases, the team pursues additional education or offers ways to improve coder-physician communication. In other instances, a quality-of-care issue might be revealed — such as a provider who fails to document adequately why he or she chose to deviate from a protocol. These issues can be addressed individually.

After this initial review, performance improvement analysts in the quality department present cases to each department's clinical and administrative leaders, who then meet with the relevant physicians, providers or billing staff to view data behind each case. They discuss how to improve coding for accuracy, as well as workflow and documentation changes necessary to reduce fallout cases. The process has enabled provider education opportunities that help organizations see how their documentation is coded. This, in turn, is expected to help drive future billing precision, quality and safety-report accuracy.

Visualizing Performance

On a day-to-day basis, UMCPP also supplies performance measurement dashboard reports to physicians and managers for each quality and safety measure they track. Since these are updated frequently, dashboards are color-coded so providers can understand performance at a glance: Green indicates quality benchmark attainment, yellow indicates quality benchmarks are on the border, red indicates improvement is needed.

UMCPP easily creates dashboards through a Microsoft Excel database, built and maintained internally, where the current month is compared with previous months. This visual tool offers providers an immediate assessment of current performance; it also suggests emerging trends — valuable information for clinical and senior leaders. Several months of yellow, or green into yellow, may indicate a gradual quality slide or issues with documentation or coding. Combined with the fallout case reviews, dashboards offer UMCPP's leaders constructive information to use for strategic planning, remediation efforts and resource allocation.

Reducing Hospital-Acquired Conditions

UMCPP's efforts definitely have paid off, and the proof is in the numbers: Through its comprehensive data reporting, analysis and education process, the organization has seen a reduction in costly hospital-acquired conditions.

Before implementing the performance improvement initiative, UMCPP's health information management and its quality and patient safety departments did not routinely share data, although both were involved in tracking and analyzing HACs. The performance-improvement initiative has combined the departments' efforts, and today they review each HAC case using the same database accessed on the UMCPP intranet.

Each HAC file contains the findings and notes from departmental analysis for follow-up and historical reviews. If they find a miscoded case, a health information manager follows up with coding updates or education for the relevant coding staff. If they find a bona fide HAC, the affected providers will review the case to discuss performance-improvement strategies.

Shared data and reporting have helped each department understand the other. The data-enriched teamwork approach has provided comprehensive and measurable results that are felt across the entire hospital.

Letting Data Drive Improvements

Government and commercial payers are introducing more risk-based payment models based on achieving quality benchmarks, following evidence-based protocols and controlling costs. These models require diligent data collection, real-time analytics and performance reporting among hospitals and health systems. In addition, because today's patients are responsible for more of their health care costs and care decisions, they are increasingly using the Internet and other means to research providers' clinical outcomes and to learn about hospital safety records.

All of this means that patient safety and quality data are now more transparent than ever to payers and the public. UMCPP has tackled these accountability issues head on by consolidating all of its patient care quality and safety performance data and sharing it with hospital leaders, physicians, coders and billers. These reports are delivered through a consistent, highly visible process that engages providers with color-coded performance dashboards for easy interpretation.

As the final step, open evaluation of each fallout case helps physicians and providers improve care and documentation quality, and helps coders improve billing accuracy. The result is safer, healthier patients and improved performance-based reimbursement.

Rachel Saxe, P.M.P., is a data analyst/project manager at the Center for Quality and Patient Safety at the University Medical Center of Princeton at Plainsboro (N.J.).