Problem: Quality metrics were collected laboriously through manual report reviews and validated with chart audits. Data were keyed into excel spreadsheets. Data metrics were sent to leaders quarterly by e-mail and did not stimulate significant change. Data collection and presentation was time-consuming, requiring hours of manual work without stimulating quality improvement.
Measurement: Gap analysis, fishbone diagram, key driver diagram, run charts, pie charts, and bar graphs.
Analysis: Based on our gap analysis, we identified opportunities for improvement with existing reports and organizational databases. Given the limited resources, we developed an interactive tool with drill down capabilities and trend analysis for improved data visualization. Data is now continually updated into a dashboard presented to surgeons and institutional leaders.
Implementation: We implemented a new process for data collection, collation, and distribution of surgical quality metrics and trends. There were multiple obstacles regarding low resources in surgery, quality, analytics, report writers, and EMR analysts. Multidisciplinary team brainstorming led to creative and innovative change ideas without requiring additional FTE support.
Results/Discussion: Organizing data allowed for clear visualization, real-time access, and reduced lag-time from 5- to 3-months. Data can be drilled down for trending and identification of projects for quality improvement and cost reduction. Advanced analytics allowed personnel to eliminate hours of manual data entry, allowing focus on leading projects for improvement.