Case Study: Good Data Requires a Systems Approach

The respiratory therapy service of a large academic medical center received its patient care scorecard, and the hospitals quality assessment team was concerned by the findings. The scorecard provided performance benchmarks and improvement targets for the service. Patient satisfaction, process of care measures, and outcomes were among the performance benchmarks assessed. What troubled the quality assessment team were the poor marks for patient outcomes, specifically the patient mortality rate.

The respiratory service physicians questioned whether or not the data were correct when they reviewed the scorecard results. The results were summarized from the hospitals R-ADT system. To better assess the data, the data steward for the service requested a listing of all respiratory patients who had been admitted and discharged from the service for the period covered by the scorecard report. The listing was provided digitally and the data steward first reviewed the dates of admission and discharge for each patient, then the admission and discharge service for each patient, and compared the admission and discharge diagnosis for each patient.

On review of the data, the data steward found a significant number of discharge diagnoses were related to a cardiac rather than a respiratory diagnosis. Due to this finding, the data steward then studied a list of all the attending physicians for each patient. This review revealed that all of the patients with a cardiac discharge diagnosis had initially presented in the emergency department with respiratory symptoms and had been assigned to the respiratory service. However, during hospitalization, cardiac problems arose and each of these patients had been transferred to the cardiac service. During the transfer process, a change in service had not been noted in the service change menu in the patients EHR. Consequently, for these patients, the respiratory service was being evaluated with the wrong data. The data steward also reviewed who the responsible practitioner was for the transfer process. This led to determining that two individuals were responsible for 90 percent of the documentation errors.

Questions 1. In your own words describe the issue presented in this case. What is the cause of the issue?

These are not trick questions. They are designed to get you to think about the case, identify the problem and perform a root cause analysis to determine the underlying problem.

2. What procedure should have been in place to prevent this problem from occurring?

3. What should be done to ensure that this problem does not occur again?