Make the most of publicly reported quality data

Comparative data help to identify best practices

Quality professionals are making great gains using free resources to compare their performance against other hospitals, and publicly reported data can be a powerful tool to get "actionable" data for decision makers.

At Freeport, IL-based FHN, a balanced scorecard is used to track quality indicators that are aligned with the organization's strategic plan. Progress is monitored by using state and national data from the Hospital Compare web site (, which was created jointly by the Centers for Medicare & Medicaid Services and the Hospital Quality Alliance.

"The identified targets are the organizations nationwide that are doing the best in selected indicators," says Glenda Koeller, vice president of performance excellence. "Those organizations may or may not be represented on Hospital Compare. We may have to look other places to find the best one in the nation."

The same process is used with data from core measures and a health care ratings, information, and advisory services company.

"What would make me choose one over another is the time element. We want the most recent data that is updated most often so we have a timely snapshot, not something that happened 12 months ago," says Koeller. "We want the most recent data that reflects the most accurate results, since we are striving to continually improve."

Once comparative data are obtained, areas of opportunity for improvement are identified, and decisions are made on what resources will be allocated for each. "By working with organizations achieving benchmarking status, we are able to share best practices to improve those identified areas of opportunity," says Koeller.

For example, results for antibiotics administered within four hours of admission were above state and national benchmarks but below comparative organizations.

"We then work with other organizations such as VHA and our QIO to determine who has the best practice and adapt their practices," says Koeller. "We are in the process of working on changes that can be sustained."

Another area for opportunity identified by comparative data is pneumococcal vaccination, with changes made pertaining to standardization and automation.

"Sharing of forms and processes has led to improvement in this indicator for us," says Koeller. The number of patients vaccinated increased 11% from 2005 to 2006 to date, she reports.

Information also is shared with the medical staff by department and individually, which is a strong motivator for improvement. "The indicators are shared via balanced scorecard with all the medical staff departments, the executive team, and the board," says Koeller. "In addition, each physician is provided his or her data to see where they are compared with other medical staff members."

Quality professionals at Quincy, IL-based Blessing Hospital use JCAHO's Quality Reports ( to benchmark against, with applicable indicators shared with hospital staff, medical staff, and administrators. Benchmarking with other organizations has given measure-specific information, which is used to establish organizational goals for performance.

"We include the average and 90th percentile reporting at the measure level to best put our performance into perspective," says Tena Jones, director of quality management.

"We utilize a standardized format to assure consistent reporting. We use the average as a minimum expectation, with the 90th percentile as the benchmark." Reports are shared with the board of trustees, and nursing, administration, and physician committees.

At OSF St. Joseph Medical Center in Bloomington, IL, JCAHO's Quality Reports and Hospital Compare data are used to compare core measure indicators for congestive heart failure, acute myocardial infarction, pneumonia, and surgical infection prevention. "We select the site that gives us the information we are seeking or has data about a topic we are comparing," says Kathy Haig, director of quality resource management at OSF.

For example, Hospital Compare is used for mortality data on certain product lines such as cardiac surgeries, whereas the Leapfrog Group's web site ( is used to see how the organization compares on many safety indicators.

Benefits include comparison with state and national averages, determining the top percentile scores, and sometimes the names of other facilities to contact. "We have networked with other organizations to share ideas about process improvement on a variety of topics, including the core measure indicators, rapid response teams, and surgical infection prevention," says Haig. However, the downside is that the data can be very old — usually not less than nine months, she adds.

Once comparative data are obtained, they are presented using a table format showing the organization's own scores alongside the comparison data. "It is helpful if we can download the data already formatted into a table or matrix showing our hospital's results with that of others, to avoid rework," says Haig. "This data comparison assists us in setting goals and defining best practice."

For core measure indicators, the top 10th percentile is determined based on the comparative data, and the organization sets a goal to meet or exceed that number. "This information is shared with medical staff and hospital staff, as all are members of the same team trying to achieve the same goal," says Haig.

[For more information, contact:

Kathy Haig, Director, Quality/Risk Management/Patient Safety Officer, OSF St. Joseph Medical Center, 2200 E. Washington Street, Bloomington, IL 61701. Telephone: (309) 662-3311, ext. 1347. E-mail:

Tena Jones, Director, Quality Management, Blessing Hospital, Broadway at 11th and 14th Streets, PO Box 7005, Quincy, IL 62305. Telephone: (217) 223-1200. E-mail:

Glenda Koeller, Assistant Vice President, Performance Excellence, FHN, 1045 W. Stephenson St., Freeport, IL 61032. Telephone: (815) 599-6125. Fax: (815) 599-6125. E-mail:]