Data Quality and Reporting Guide

Improving care and achieving your specific quality goals requires developing and utilizing reporting mechanisms that provide relevant stakeholders with access to timely and relevant data.

The Measure Calculation and Reporting for PHMI tool provides best practices to assist with the tracking and reporting of core measures.

You should be able to produce reports with the following best practice features:

• Rates segmented by subpopulations, such as patient race and ethnicity, clinic site and provider.
• Year-to-date (YTD) rates, in addition to 12-month rolling measurement. While rolling measurement is used to enable practices to track improvement throughout the year, YTD rates align with health plans and APM, and will allow for intervention planning and additional tracking throughout the year.
• Comparisons to benchmarks.
• Comparisons to prior time periods.
• Comparisons to peers (for providers) or similar organizations.
• Patient level drill down.
• Comparison tracking with cascading goals, which calculate the number of patient services (gaps) needed to reach goals.
• Tests of statistical significance to determine if change over time and/or rates by subpopulations are significantly different.
• Realistic internal targets for continuous improvement.

Consider the various audiences who need access to calculated rates, on what cadence, and how the data could be best displayed for that audience. For example, organizational leadership and your board of directors may need formal presentations aligning with their meeting cadence; care teams should have frequent at-a-glance access through tools such as dashboards to proactively monitor care and identify opportunities for improvement.

For most audiences, presenting complex sets of data in a visual, pictorial format will allow for a greater understanding of concepts and help people identify patterns. Using such data visualizations is a reporting best practice. The most effective data visualizations use the most appropriate structure or format for the data and are very simple. Tables, Graphs, Dashboards, & Reports: Data Visualization Best Practices, produced by HealthData Viz, offers tips for creating effective tables and graphs used in dashboards for healthcare professionals. 10 Best Practices for Building Effective Dashboards, designed for Tableau users, includes data visualization best practices and examples that apply, regardless of the platform you’re using. Both tools can help you create data visualizations that are easy for others to access, read and understand.

As you utilize robust and ongoing reporting to monitor care and identify opportunities for improvement, you will be able to formulate strategies to act upon those opportunities to improve population health and close gaps in care. Following are ways you can share data and engage staff in the collaborative work of improving care:

• Post measurement rates in shared areas and remind staff during daily huddles to use the data to underscore the collective focus on quality improvement.
• Have care teams examine and refine their workflows to ensure screenings and other key activities are being conducted.
• Use the data to inform small tests (change workflows, tweak processes, etc.) to improve performance.
• Identify patterns of gaps in care and develop strategies to address them (e.g., improving care delivery for patient subpopulations, reeducating staff with lower rates, etc.).
• Compare rates by subpopulation (e.g., different race and ethnicity or clinic site) to determine discrepancies, and develop interventions to address health inequities and health disparities between groups.