Skip to main content

Developing a Hospital Quality Metrics System and Dashboard

  • Chapter
  • First Online:
Quality Measures

Abstract

Hospitals and health systems are responsible for reporting hundreds of distinct quality process and outcome measures to regulatory and accreditation agencies and to insurers. Organizations spend significant resources collecting and reporting a complex array of quality metrics, despite the fact that many metrics are of uncertain validity. To make sense of the proliferation of quality measures and to guide organizational performance goals, Tufts Medical Center and Floating Hospital for Children selected a subset of high-value measures to monitor and manage. The medical center’s quality leaders, with input from trustees on the board quality committee, developed a quality dashboard, dashboard summary, and “harm bubble” that captured and tracked measures that matter. We then tied the dashboard to the annual goal-setting process, using dashboard results to track the performance of key improvement initiatives. We also updated dashboard metrics to align with new goals. Presenting measures that matter in a quality dashboard was a productive way to bring coherence and focus to quality improvement and patient safety efforts.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Jha AK. Value-based purchasing: time for reboot or time to move on? JAMA. 2017;317(11):1107–8.

    Article  Google Scholar 

  2. Jha AK. Seeking rational approaches to fixing hospital readmissions. JAMA. 2015;314(16):1681–2.

    Article  CAS  Google Scholar 

  3. Joynt KE, Jha AK. Thirty-day readmissions – truth and consequences. N Engl J Med. 2012;366(15):1366–9.

    Article  CAS  Google Scholar 

  4. Zuckerman RB, Joynt Maddox KE, Sheingold SH, Chen LM, Epstein AM. Effect of a hospital-wide measure on the readmissions reduction program. N Engl J Med. 2017;377(16):1551–8.

    Article  Google Scholar 

  5. Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the hospital readmissions reduction program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542–52.

    Article  Google Scholar 

  6. Health Affairs Blog. Measures that matter – but to whom? 2016. Available at: https://www.healthaffairs.org/do/10.1377/hblog20160310.053833/full/. Last accessed 7 Mar 2019.

  7. Esposito ML, Selker HP, Salem DN. Quality over quantity: how the rise in quality measures is not producing quality results. J Gen Intern Med. 2015;30(8):1204–7.

    Article  Google Scholar 

  8. CMS. Hospital value-based purchasing. 2017. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Last accessed 7 Mar 2019.

  9. Agency for Healthcare Research and Quality. Patient safety indicators overview. Available at: https://www.qualityindicators.ahrq.gov/modules/psi_overview.aspx. Last accessed 7 Mar 2019.

  10. CMS. Medicare learning network hospital value-based purchasing booklet. 2017. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Last accessed 7 Mar 2019.

  11. US News & World Report. FAQ: how and why we rank and rate hospitals. 2018. Available at: https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals. Last accessed 7 Mar 2019.

  12. US News & World Report. 2018–2019 best hospitals procedures & condition ratings. 2018. Available at: https://www.usnews.com/static/documents/health/best-hospitals/BHPC_Methodology_2018-19.pdf. Last accessed 7 Mar 2019.

  13. Leapfrog hospital safety grade scoring methodology. 2018. Available at: https://www.hospitalsafetygrade.org/media/file/HospitalSafetyGrade_ScoringMethodology_Fall2018_Final.pdf. Last accessed 7 Mar 2019.

  14. National Quality Forum. Patient safety indicators: complications. Available at: https://www.qualityforum.org/Projects/n-r/Patient_Safety_Measures_Complications/Patient_Safety_Measures_Complications.aspx. Last accessed 7 Mar 2019.

  15. Winters BD, Bharmal A, Wilson RF, et al. Validity of the agency for health care research and quality patient safety indicators and the centers for medicare and medicaid hospital-acquired conditions: a systematic review and meta-analysis. Med Care. 2016;54(12):1105–11.

    Article  Google Scholar 

  16. Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.

    Google Scholar 

  17. Agency for Healthcare Research and Quality. Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) Fact Sheet: Patient Safety and Adverse Events Composite (modified version PSI 90) for ICD-9 CM/PCS, v6.0. 2016. Available at: https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ_v1.pdf. Last accessed 7 Mar 2019.

  18. Agency for Healthcare Research and Quality. CAHPS clinician and group survey. 2018. Available from: https://www.ahrq.gov/cahps/surveys-guidance/cg/index.html. Last accessed 7 Mar 2019.

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Saul N. Weingart .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Pavoll, A., Camenga, C.F., Weingart, S.N. (2020). Developing a Hospital Quality Metrics System and Dashboard. In: Salem, D. (eds) Quality Measures. Springer, Cham. https://doi.org/10.1007/978-3-030-37145-6_8

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-37145-6_8

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-37144-9

  • Online ISBN: 978-3-030-37145-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics