CPHQ Review Webinar

“Health Data Analytics Domain”

Part One
Eng. Nuha Y. Al Amin, MHHA, CPHQ, CPHRM
September 2019
BSc. Biomedical Engineering, 2008.

Masters of Hospital & Healthcare

Administration, 2018.

Certified Professional Healthcare Quality

(CPHQ)- NAHQ, 2017.

Certified Professional Healthcare Risk

Management (CPHRM)- AHA, 2018.

Certified Change Agent- NHS leadership

Academy, 2019.

CPHRM Exam Item Writer & Reviewer, AHA-CC.

Content
§ Data & Information.
§ Information Management System (IMS).
§ Data Sources.
§ Benchmarking.
§ Data Collection Tools.
§ Data Collection Process.
§ Population & Sample.
§ Types of Sampling.
§ Confidentiality Vs. Privacy Vs. Security.

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Quality Professionals are Information Literate!

ü Knows what information is needed.

ü Knows where and how to abstract & use it efficiently & effectively.
ü Critically evaluates the information and its source.
ü Adds the selected information to one's own database.
ü Understands the economic, legal, and social issues surrounding the
use of information.
ü Accesses and uses information ethically and legally.
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Data & Information
“Data” is the collection of uninterrupted observations or facts.
Assists in:
• identifying better and best practices.
• explaining patterns of care.
• identifying problems in the provision of care.
Clinical & Non-clinical data:
• Financial data, Patient data, Staffing data, etc..
• need to be combined to get to the necessary information that will guide
organizational decision-making.
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Relationship between Data & Information

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Information Management Systems (IMS)

1. Administrative Information System: financial, billing, inventory,

supplies management, human resources, risk management &
quality management information.
2. Clinical Information System: electronic medical record (EMR),
pharmacy & laboratory data.
3. Decision Making System: deals with strategic planning functions
(performance evaluation, monitoring, marketing, resource
allocation, product evaluation & services).

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Data Inventory

• Purpose is to identify & organize data needed so that information can

be accessed easily without duplication of efforts.
• It consists of: what data means & definitions, how and where it was
collected & analyzed, who owns the data, who has access to the data,
who manages the data, and how the data can be used and shared.

Inventory success will depend on the quality and accuracy of the information.

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A successful data inventory
Team members must:
• be trained on how to collect the data.
• determine exactly what is to be collected and in
what format. Avoid the DRIP
• determine if they are going to collect data used for Syndrome
internal and/or external purpose (Data Rich
Information
• determine why the data being collected Poor)
• determined with whom the data & information
must be shared for use in decision-making
processes.
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Data Sources

Internal Data Sources

• Available for analysis and use
as soon as they are collected.
• Are best utilized when there is a
desired change to a process or
an outcome.

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Data Sources

External Data Sources

gives facility an opportunity to
benchmark with other facilities
that are similar to the one
submitting the data.
(requires similar data definitions).

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Organization Measures/Performance Indicators

Structure: linked with

resources.
Must be
Process: linked with daily feasible,
operations. reliable &
valid.

Outcome: linked with service

outputs

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Benchmarking

A standard or point of reference against which data may

be compared or assessed.
•Example of benchmarking projects:
Internally: physician X vs. physician Y, fall rates in unit The goal is to
A&B in the same hospital. improve the
outcome not
Externally: CLABSI rates between hospitals. identifying
differences.
Zero incidence: wrong site surgery, CMS Healthcare
Acquired Infection rates (HAIs).

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Important considerations when benchmarking
outcomes

• Similarity between institutions(e.g. hospital size).

• Externally the populations of each organization are not similar so the
findings would not be comparable.
• Comparison between internal units(e.g. surgical vs. critical care units).
• Rate-based comparison is more accurate than percentage-based.

The most challenging part is to select the source of the organization’s

benchmarking comparative data.

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Data Collection Methodologies

Prospective Concurrent Retrospective Focused

• Collection occurs • collection occurs • Collection occurs • collection occurs

before a patient is while care is after care is when focusing on
accepted in being rendered. rendered. certain topics.
Facility (home • Medical record • Mortality data (high frequency/
healthcare) review, surveys/ Incidents volume, high risk,
• assess if the interviews. screening. also problem-prone)
patient meets the surveys/
requirements for interviews.
admission.

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Data collection tools

Adopted by H.S. Al Naimi CPHRM

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Tally Sheets: useful when you are Data/Work Sheets: for extracting
counting something to see data from the medical record.
how often it occurs .(limits details).

Focus groups: utilized in qualitative

Surveys: get feedback & assessment
studies. The analysis is limited, but
from a large group.
can be very valuable
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Important characteristics for data management

Validity: the ability to measure what is really desired to be measured. There must
be reliability of an indicator/tool before there can be validity of that indicator/tool.

Reliability: the ability to reproduce the same results if there are no interventions
or changes between measurements. ability of the indicator or collection tool to
measure in a reproducible way what it is supposed to measure.

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Data Collection Process

• Assessing what data are needed, and whether or not it is possible to

collect.
• Determine performance measures & the population of interest.
• Define & establish the sampling method(s) of the population,
inclusion & exclusion criteria. And your targets (benchmarked)
• Determine how data to be analyzed (statistical and non-statistical
analysis tools).
• Determine how to display the information(run charts, story
boards ,etc..)

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Data Collection Process - Cont’d

• Collect a baseline sample to determine the usefulness of the

collection tool ( to assure validity) This needs to be done to assure
that the tool collects the required data and the ease of recording the
collected data.
• Train the data collector. This will assure reliability of the data.
• After collection data it must be organized and scrubbed (validated),
Check for obviously incorrect (out-of-range) numbers.
• One way to validate the data collection is to have someone not
involved with the first data collection recollect data for a small
portion of the sample already collected.
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Issues with data collection

• Access to data/information (authority, securities, etc.)

• Availability of data/information in format needed
• Timeliness of data/information access (how close to real time is data
collected, downloaded, etc.)

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Leadership oversight
leaders to oversee the following:
• design of data collection methods
• minimize duplication of effort, maximize accuracy
• maximize the organization's computer capabilities
• coordinate data collection efforts across departments, services, and
QI Team activities.

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Population & Population (N) is 100% of the possible group to
Sample be studied, whether they are individuals,
objects, events and so on. Example: all cases
admitted for fever, all OB/GYN physicians in a
HCO.
Sample(n) is a subset of a population or a group
drawn from a larger population.
The purpose of sampling is to measure only a
portion of a total group or population and to
generalize the results to the larger population
based on sample findings.

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Types of Sampling

Adopted by H.S. Al Naimi CPHRM

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Probability Sampling

Simple random: each case having an equal

chance of being selected.

Systematic sampling: selecting sample from

population based on a certain order(every 9th
or 10th)

Stratified sample: divide the population into

homogenous groups called strata, then take a
random sample from each strata(age, gender,
education, etc..)

Cluster sampling: in which a sampling unit is a

cluster. Population is divided into
heterogeneous groups
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Non- Probability Sampling
Convenience: sample is most readily
available , all patients seen in ER on
Sunday.

Snowball sampling: subjects select other

subjects and so on..

Purposive(judgmental): selecting sample

based on researcher knowledge &
judgment.

Quota: divide population into strata, then

select sample from each based on a certain
percentage e.g.: 10% of female patients over
age 45 with breast cancer and diabetes.
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Confidentiality Vs. Privacy vs.
Security

Adopted by H.S. Al Naimi CPHRM

27
Confidentiality Privacy Security

Refers to personal information Refers to the freedom from Refers directly to protection,
shared with a physician, intrusion into one's personal and specifically to the means
therapist, etc. that generally matters, and personal used to protect the privacy of
cannot be divulged to third information. Activities health information. Example:
parties without authorization considered private include a locked file cabinets. Passcode,
and only with authorized medical examination, using a access to certain electronic
individuals. restaurant bathroom and files, back up plans.
generally any action for which
you have the reasonable
expectation of privacy.

Organizations are required by federal and state statues to maintain security & confidentiality
medical peer review and the monitoring and evaluation of patient care.

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Information Management Security and
Confidentiality
Policies and procedures in place containing:
Ø Who may have access to a medical record and to which part exactly?
ØUnder what circumstances in accordance with medical staff bylaws,
hospital policy, and applicable laws and regulations?
ØRequirements for removal of medical records.

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Release of Information

• The medical record is the primary legal document, as well as the primary data
source for recording and ascertaining the quality of healthcare delivery to
patients.
• Information may be released without written authorization from patients to
individuals and/or groups who have need for the information:
Internal use: Governing body, and designees, Physicians and healthcare personnel
involved in the care, Health information management/medical record personnel.
External use: for public health matters, law enforcement agencies, etc..

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Data Analysts are Quality Professionals!

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Resources

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