FGCU Performance Measurement Reporting Video Transcript Capstone

Transcript

Capstone Video: Performance Measurement Reporting

[ Music ]

>> OK. So, who are we missing?

>> Paula Britter [phonetic].

>> I saw her two minutes ago. She said she was on her way.

>> And I don’t want to start without her. I do want to get this under way though.

>> Hi guys. I’m sorry. I’m sorry. The breakfast cart was calling me.

>> OK. So, we’re all here. Just for the record this is the first meeting of the performance measurement reporting committee for ORYX and CMS requirements. Barbara, you’re the new kid on the block. And I don’t know if this was a problem with your old job, but the primary goal of this committee is to monitor the hospitals reporting or performance measurement cases to JACO and CMS. This reporting is a major time eater. So, I think it worthwhile that we look for ways to make it as efficient as we can.

>> Amen to that.

>> The reason that I asked Paula here was, Paula, you’re here. Why don’t you just take it?

>> Oh, great. Make me be the heavy. Thanks Bill. Last week we got this letter from CMS dinging us for poor reporting.

>> Dinging? I think that’s quite an understatement Paula.

>> When I say dinging I meant raking us over the coals.

>> Wow.

>> So, in your opinion, do you think it was warranted?

>> There’s some truth in it. Sure. But it seems that it should be something that is not difficult to fix. And since JACO’s ORYX program and the CMS partnered on the performance measurement indicators, reporting should be easier than it used to be in the past when there were a different criteria. I don’t understand why we’re doing worse than we used to do or being cited for poor compliance. Where’s the weak link?

>> Wait, we’re not looking for blame. At least that’s my understanding. We’re just looking for ways to improve our methods of collecting and reporting.

>> Well, I did have to deal with problems in reporting ORYX and CMS data at my last job. And what we did then and need to do here I think is to check for gaps in the collection system. They’re not always obvious. That’s part of the problem.

>> OK. I think I have an example. In my department, the ORYX vendor trained my nurses on the ORYX system, right? And then one of them quit. Now, I doubt that the nurse that took over for her knows the system. I mean, she was kind of informally shown it by the other nurses, but she’s probably not as well trained on it as the ones that were trained directly by the vendor.

>> Thank you. That’s a perfect example of a possible gap in the process. I think moving forward, the best next step would be for each of us to go back to our respective departments and review the current process in place and then take some suggestions on ways to improve the quality of the data collection. Let’s say we meet next week, same time? Unless there are any conflicts or any disagreements. Feel free to contradict me. I won’t take it personally.

>> That’s fine.

>> Well, if people think it would be helpful, I still have the policies and procedures manual from my last job. There’s a section in it devoted to data collection procedures for ORYX CMS core measures. It might be helpful just to see how they handle it.

>> Thanks Barbara. If you could get that to us ASAP it would be great. So, if that’s all, I’ll call this meeting adjourned.

>> OK. Thanks.

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>> The committee chairperson should probably develop a smaller task force. Individuals can be assigned the following tasks, determining which vendor’s ORYX-approved system is being used to gather and report the data, gather any hospital established procedure, and ORYX CMS reporting requirements to review and compare them for discrepancies. Schedule the system vendor to conduct additional training for the staff on the utilization of the system for any of the staff currently assigned to collect and or report the data. Schedule a follow up meeting with all of the staff assigned to data collection and reporting in order to discuss the process. Identify potential problems and make suggestions for improvement. The committee will review policies and procedures from both facilities to look for gaps and errors. They’ll also review policies and procedures with any of the staff involved in data collection. To identify variances in processes and to gather suggestions for ways the processes might be improved. And the vendor should provide a follow up training sessions for the staff.

Watch the video entitled, “Performance Measurement Reporting”, and answer the following questions.