How to give the board the data it wants

Provide data in an understandable format

A typical hospital collects hundreds, if not thousands, of data points for reporting to state, federal, and accreditation agencies. It's so much information that trying to determine what is most important to share with a hospital board could become a tedious chore. What is useful? What is important? And what is accessible? And are all those mutually exclusive?

All are issues that Tricia Kassab, RN, MS, CPHQ, HACP, vice president of quality and patient safety at City of Hope Hospital in Duarte, CA, thinks about regularly. And what she thinks her board should know now is likely to change in the future. "We have always been responsive, not proactive in this area," says Kassab, who notes that historically, comprehensive cancer centers have been exempt from reporting much of the data that a standard hospital has to collect and report. But with health reform is the thought that such exemptions will end, and so cancer hospitals as a group are beginning to look at issues surrounding data collection to determine just what measures not only are important now, but will be important in the near future.

"We haven't had to worry about core measures like AMI," says Kassab. "But now our group of hospitals has a quality and value committee, and we are looking at the National Quality Forum [NQF] metrics pertaining to oncology, and other outcomes measures and process measures to determine what we should focus on."

City of Hope and the other comprehensive cancer centers had a group of physicians and quality specialists work to determine what was most important, and they came up with three buckets of metrics. First is the NQF-endorsed cancer metrics for breast cancer, lung cancer, and prostate cancer. The second bucket is of cancer metrics that weren't endorsed by NQF, but were endorsed by another group, such as the American Society of Clinical Oncology. "Many of these, we wonder why they aren't endorsed by NQF, but it can be a huge endeavor to do so — someone has to write a paper, including information on every data element, the usability, feasibility, and scientific applicability of the measure. It's a massive undertaking."

Among those measures are KRAS testing of colorectal cancer patients prior to inhibitor therapy. "It's very specific, but for our community, it's a critical measure." The cancer hospitals together have hired someone to work on the effort to get this particular measure endorsed by NQF.

Lastly, the hospitals are looking at completely new metrics. Kassab says one of the things they are looking at is patient perception with cosmetic reconstruction after surgery. "We do not measure that — how patients feel about having it done, or how they feel after. And individual physicians vary on whether or when they offer it."

Although all of these data points are of value to someone within City of Hope, not all of it is of use to the board. Kassab says she shares the five oncology metrics that will be required for public reporting in 2014 — two for breast cancer: combination chemotherapy for T1c N0 M0 or stage 2 or 3 hormone-receptor negative breast cancer and hormone therapy for T1c N0 M0 or stage 2 or 3 hormone receptor negative breast cancer; one for colon cancer: adjuvant chemotherapy for lymp-positive colon cancer; and two infection-related metrics: urinary tract infections and central line-associated bloodstream infections in the ICU.

Kassab also reports issues that affect risk management — falls, medication events, hospital-associated infections. Patient satisfaction is always on the list, too. In all cases, she makes sure that there is comparative data to other like organizations.

Be careful with that comparative data, says Cathy Newhouse, RN, BSN, MA, senior vice president of clinical programs and innovation at LHC Group in Lafayette, LA, which includes long-term acute care hospitals. "There might be a couple of quarters lag with CMS data, but you know yours in real time," she says. Make sure you are comparing like with like — not just in terms of kind of facility but the period studied.

Pillars of success

"We focus on our key drivers," explains Airica Steed, Ed.D, MBA, RN, vice president of professional services at Advocate Condell Medical Center in Libertyville, IL. These drivers fit into several buckets:

  • patient satisfaction, including HCAP scores;
  • physician and workforce satisfaction, including survey scores, turnover rates, time to hire, and vacancy rates;
  • financial data;
  • efficiency data, including length of stay, throughput, wait time, utilization, and capacity;
  • quality and health outcome data, related to CMS, Joint Commission, and other requirements, as well as facility goals.

Steed says her board gets a monthly scorecard on key metrics, with more in-depth data available if requested. The board receives education on the issues annually so they are engaged in what is presented to them.

Kassab agrees that it is a good idea to ensure you have a knowledgeable board that will understand the data you put before them. To that end City of Hope does some rounding with board members. But many of them are lay people without a scientific background. "We make sure we tell them why something is important. Then we show them where we are, how we compare, whether any change is statistically significant, and what we are doing around the metric." Statistical terms like confidence intervals are left out, unless someone specifically asks. "You do not want it too dumb, but also do not want it too complex."

Not everyone on a board has an understanding of clinical issues and statistics, Newhouse agrees. "The amount of data you can give them is overwhelming. There is the data by which we are evaluated and data we collect, but that isn't required. Then there is the data that is publicly reported and is supposedly of interest to the public, but may not be as important to them as we think."

Some of the more complex data are best saved for committees and subcommittees that deal with specific topics, says Newhouse.

Make sure you provide an analysis that makes sense of the information, says Lisa Snyder, MD MD, MPH, senior vice president and chief quality officer at Select Medical of Mechanicsburg, PA. "You can have a spike in a certain measure that looks alarming. Explain whether it is a true increase, or an increase in reporting. As the presenter, you have to know the data and its meaning backwards and forwards. You can't just take a trend graph and assume that's all you need to give them. You need to be able to tell the board members what makes up the trend and why it's important."

Over time, your board will become more educated and you'll be able to be more esoteric with the kinds of data you present and how you present it, says Snyder.

For more information on this story, contact:

  • Airica Steed, Ed.D, MBA, RN, Vice President, Professional Services, Advocate Condell Medical Center, Libertyville, IL. Telephone: (847) 990-5221. Email:
  • Lisa Snyder, MD, MPH, Senior Vice President, Chief Quality Officer, Select Medical. Mechanicsburg, PA. Telephone: (888) 735-6332.
  • Cathy Newhouse, RN, BSN, MA, Senior VP of clinical programs and innovation, LHC Group, Lafayette, LA. Email:
  • Tricia Kassab, RN, MS, CPHQ, HACP, Vice President of Quality and Patient Safety, City of Hope, Duarte, CA. Telephone: (626) 256-4673 ext. 68957.