Healthcare Information Management

5/13/2018
HEALTHCARE INFORMATION
MANAGEMENT
COURSE OBJECTIVES
At the end of this course, you’ll be able to:
Understand the major principles of

healthcare data analytics.
Understand data collection and designing

process.
Understand basic statistical and sampling

techniques.
Use basic statistical tools in describing data

elements.
Develop and interpret Run chart and

Control chart.
Interpret data to support decision making

and problem solving.
Healthcare Information Management
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AGENDA
Introduction and important definitions Bias and confounding factors
Information management principles KPIs
Confidentiality of records / reports Tools for displaying data
Data collection and tool designing Quality improvement process tools
Introduction to statistics Run charts and SPC
Sampling techniques Additional quality improvement tools
Descriptive statistics Pop Quiz
Inferential statistics
INTRODUCTION…
DEFINITIONS
Information management:
Is the collection and management of information

from one or more sources and the distribution of
that information to one or more audiences.
The 1ry purpose of information management system

is to allow an organization to evaluate data and the
ultimate purpose is proper decision making.
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HEALTHCARE ANALYTICS
Consists of the systems, tools, and
techniques that help healthcare
organizations gain insight into current
performance, and guide future actions,
by identifying patterns and relationships
in data and using that understanding to
guide decision making.
Analytics enable leaders, managers and

QI teams within healthcare organizations
to make better decisions and take more
appropriate actions by providing the right
information to the right people at the
right time in the right format with the
right technology.
First, no harm
INTRODUCTION… Doing the right thing right, 1st time and every time
HEALTHCARE Freedom from deficiency
QUALITY
Having high degree of excellence
Doing right things when no one is looking
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INSTITUTE OF MEDICINE
(IOM) DEFINED QUALITY AS
The extent to which health services provided to individuals
and patient populations improve desired health outcomes.
The care should be based on the strongest clinical evidence
and provided in technically and culturally competent manner
with good communication and shared decision making.
Appreciative Quality
ASPECTS OF
QUALITY (MAP) Perceptive Quality
Three Aspects Of Quality “MAP”
Measurable Quality
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ASPECTS OF
QUALITY (MAP)
Measurable quality: is equal to
compliance with or adherence to
standards, practice guidelines, or
protocols (provider’s aspect of care).
Appreciative quality: is the appraisal of

excellence beyond minimal standards
and criteria (expertise and skilled
person aspect of care).
Perceptive quality: is the degree of

excellence that is perceived by the
recipient of care (recipient’s aspect of
care).
INFORMATION MANAGEMENT
Quality must be defined in quantifiable terms to enable measurement,
monitoring, analysis, and most important, decision making and action.
Data vs. information:
❖ Data: abstract representation of facts, concepts and instructions.
❖ Information: data translated into results and statements useful for

decision making.
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Wisdom
Understanding, Integrated, Actionable
Given Insight
Becomes
Knowledge
Contextual, Synthesized, Learning
Given Meaning
Becomes
Information
Useful, Organized, Structured
Given Context
Becomes
Data
Signals, Know-nothing
GOAL
To support decision making to:
✓ Improve patient outcomes
✓ Improve healthcare documentation
✓ Improve patient safety
✓ Improve performance in patient care, treatment,

services and support processes.
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INFORMATION MANAGEMENT OBJECTIVES
Assure
Assure timely, easy access, accurate, comparable
data/information, balance with security
requirements.
Produce And Use

Produce and use aggregate, comparative and
external knowledge-based information to improve
patient safety and quality patient care, treatment,
and services.
Redesign
Redesign information-related processes for
efficiency and effectiveness then share it.
INFORMATION USES IN HEALTHCARE
Clinical / Service Organization Performance

Decision Making Decision Making Improvement
Education Research
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INFORMATION USES IN HEALTHCARE
What is measured What is acted on

gets noticed gets improved
What is noticed
gets acted on
Accurate
Timely
Relevant
Analyzed
“
Ensure that the information that is being used for
decision making and QI has the following attributes:
Visualized
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Identify current
Identify critical Define data
available data
information needs elements
sources
PROCESSES
Determine data Aggregate and
Acquire / collect data
collection plans display data
Interpret and Report data /

Act on information /
Analyze data / information /
knowledge
information knowledge
Collect more data to

monitor / analyze
the decision
DECISION MAKING
Traditional model
In the past, without good data, we relied upon
opinion, logic, rationalization or hearsay to lead us
to recommendations and hopefully appropriate
action or improvement.
Data - based model

The information management function closely
resembles scientific model in collection, designing,
interpretation and action.
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CONFIDENTIALITY
It is a fact to recognize that patient file is a
facility property while the information in the
file is a patient property.
Confidential information: is information that

one keeps or entrusts to another with the
understanding that it will be kept private and
not shared.
Protected information: is information that

cannot be obtained by others or used in a
court of law (e.g. psychiatric patient files).
It is a must to have a clear policy and

procedure to protect medical records.
CONFIDENTIALITY
Written authorization is needed for any purpose
unrelated to treatment (PTO); payment,
treatment, operations.
This written authorization includes:
✓ Patient name.
✓ Name of individual / organization

requesting information.
✓ Reason for release of information.
✓ Exact material required and period of valid
“
CEO, governing body, QPI responsible, and direct care
providers may use patient information without written
authorization.
release.
✓ Document indicates that this information

released only for mentioned organization.
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DATA COLLECTION
Data Collection Plan Data Collection Tools Reliability and validity
DATA COLLECTION PLAN
What information is Why is it

important to important?
collect?
How will the data Who will

(measures or collect
observations) be the data?
collected?
When will the Who will analyze

collection of data the data?
take place?
Where will data

be collected?
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DATA COLLECTION
TOOLS
Data sheet or work sheet

(Excel): form for recording data;
requires subsequent processing
for analysis and interpretation.
Check sheet or tally sheet: form

for recording data; designed to
TYPES OF
facilitate interpretation directly
from the form, collecting data
in real time and at the location
DATA where the data is generated.
COLLECTION Survey or questionnaire: form
TOOLS for getting input from a large

group.
Interview or focus group:

questionnaire format: can be
open ended discussion to
obtain qualitative input from
people.
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CONSIDERATIONS IN TOOL DESIGNING
KEEP PROVIDE
Keep the tool as short and simple as Provide appropriate definition of terms for
possible. using the tool.
CONSIDER INCLUDE
Consider computerizing whenever Include all data elements necessary to
possible. monitor the specified issue / indicator.
CHECKLIST FOR
ADEQUACY OF THE
TOOL
Does the tool really measure the
process or aspect of care and its
indicator?
Will you get more than you need?
Will the data you get interpretable?
Will data collection be a manageable

task with tool? Too much data? Too
much time? Can it be cut down?
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RELIABILITY
RELIABILITY
Types of reliability:
Inter-rater reliability: level of agreement between

assessments made by 2 or more assessors at the
same time.
3- Reliability and Validity
Intra-rater reliability: level of agreement between
assessments by one rater of the same material at
2 or more different times.
Test-retest reliability: the level of agreement

between initial test results and the results of
repeat measurement at a later date.
Split half reliability: describes reliability of the a

test that is divided in 2 with each half being used
to assess the same material under similar
circumstances (between 2 halves of a scale)
“
It’s the consistency of test results on repeat
measurement by one or more raters or over
time.
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VALIDITY
Types of reliability:
Face validity: the instrument appears to be an

adequate means of obtaining the data needed for
the research.
Content validity: the scope of item used to

measure the variable or if the instrument
adequately measures the universe of content. In
other words, are the number and type of items
adequate to measure the concept of interest?
Criterion validity: it is used to demonstrate the

accuracy of a measure or procedure by comparing
“
it with another measure or procedure that has
been demonstrated to be valid. It has different
types; predictive, concurrent, convergent and
discriminant. It’s the degree to which an instrument
measures what it is intended to measure.
VALIDITY
Types Of Validity:
Construct validity: the degree to which an

instrument measures the construct that is
supposed to measure. It is the most difficult
type to measure. It involves the measurement
of variables that’s not directly observable
(anxiety or depression)
Incremental validity: the extent to which the
“
test provides a significant improvement in
addition to the use of another approach. A test
has incremental validity if it helps more than
not using it. It’s the degree to which an instrument
measures what it is intended to measure.
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STATISTICS
BASIC TERMS
Population: A population describes a large set Sample: A portion of the population selected for
or collection of items that have something in study is referred to as a sample. Representative
common. It consists of all elements being sample contains the characteristics of the
studied. (N) population as closely as possible. (n)
Statistic: is a descriptive measure derived from Parameter: is a descriptive measure derived from
a sample. a population.
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BASIC TERMS
Variable: is a characteristic under study that Observation or measurement: is a value of the

assumes different values for different elements. variable for a single element. Example: systolic B.P.
Examples: diastolic B.P., heart rate… etc. is the variable; 120 is the observation.
Data set: is a collection of observation on a Bias: is the errors related to the ways targeted
variable. and sampled population differ.
REASON FOR USING

SAMPLES
Less expensive, time, resources and training.
More quick and more accurate.
From samples, you can estimate the error in

the resulting statistics.
A study of population is impossible in most

situations.
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Many factors affecting sample size. Generally, larger sample

result in more valid and accurate study since it’s more
representative. Furthermore, too large sample is waste of
time and resource.
SAMPLE SIZE Calculation od sample size depends on population size,

estimate of population SD, desired significance level, and
bounds of error estimation.
http://www.macorr.com/sample-size-calculator.htm
JOINT COMMISSION GENERAL GUIDELINES FOR

SAMPLING
Population Size Sample Size
< 30 cases 100% (All cases)
30 – 100 cases 30 cases
101 – 500 cases 50 cases
> 500 cases 70 cases
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SAMPLING
Probability Sampling
Simple Random
Systematic
Systematic
Cluster
Non-Probability Sampling
Purposive
Expert
Consecutive
Convenience
Quota
Snowball
PROBABILITY
SAMPLING
Simple Random Sample: Every element in
the population has the same probability of
being chosen for sampling as all other
elements in the population.
✓ Random Selection: every member of

the population has an equal chance of
being selected for the sample.
✓ Random assignment: every member of

the sample has an equal chance of
being placed in the experimental
group or the control group.
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PROBABILITY
SAMPLING
Systematic Sampling: divide population into
groups of K individuals: K= N/n. Randomly
select one, then select every Kth.
Stratified Random Sample: the population

is first divided into homogenous groups of
elements called strata. Each element in the
population belongs to one and only one
stratum. A simple random sample is taken
from each stratum (Example: gender,
location, age, job, patients with certain
disease, etc…)
Cluster sample: the population is first

divided into heterogenous groups of
elements called clusters. A simple random
sample of the clusters then taken. E.g. city
blocks, classes.
NON-PROBABILITY SAMPLES
(INTENTIONALLY BIASED)
Purposive or judgmental sampling: it involves hand-picking from the accessible population those individuals judged
most appropriate for the study. Means that selection will be based on a desired characteristic. E.g. All patients above
age of 60 with THR.
Expert sampling: a type of purposive sampling in which experts in a giving area selected because of their access to
relevant information. Used with Delphi technique.
Consecutive sampling: it involves taking every patient who meets the selection criteria over a specified time interval or
number of patients. It’s the best of non-probability techniques and one that is very often practical.
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NON-PROBABILITY SAMPLES
(INTENTIONALLY BIASED)
Quota sampling: portions or percentages of persons / cases in a stratified population. Examples:

✓ 10% of males patients over age 55 with DM and heart disease will be enrolled in the study.
✓ Review 5% of medical records of discharged patients.
Convenience sampling: it’s the process of taking those members of the accessible population who are easily available.
Example: all patient seen in ER in a given week (it’s widely used in clinical research)
Snowball sampling: it’s a subtype of convenience sampling involve subjects suggesting other subjects for inclusion in the
study. E.g. Drug addicts.
TYPES OF DATA
Data
Qualitative (Categorical) Quantitative (Numerical)
Nominal Ordinal Discrete Continuous
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TYPES OF DATA
Qualitative (Categorical) data:

Nominal and ordinal
Has no numerical value
Cannot be measured on a scale (Categorized only)
Can only have set values (i.e. no in-between values)
Quantitative (Numerical) data:
The data which has numerical value
Discrete and continuous
Variable that can be measured in the usual sense to

give information regarding amount
CATEGORICAL DATA
Nominal
Simplest level of measurement (e.g. gender)
Binary variables (e.g. sex, pre & post surgical) or multi-

category variables (e.g. anemia)
Generally described in terms of percentages or proportions
Ordinal
There is an inherent order among the categories (e.g.

tumor stages, qualification degrees)
Generally described in terms of percentages or

proportions
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QUANTITATIVE DATA
Discrete Variable
Numerical data that exist as count, that is, the frequency

of an event.
It can only take a discrete number of values

e.g. number of patients
Continuous Variable
It can have any value within the range of all possible

values.
e.g. Weight, blood pressure, temperature, age
TYPES OF DATA
Categorical
- Nominal Binary (Male / Female)
Nominal (Unordered) - Nominal Multi-category (Single,
married, divorced)
Ordinal (Ordered) Cancer stage I, II, III, IV
Quantitative
Discrete Number of patients
Continuous Weight, blood pressure
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QUANTITATIVE DATA
Although quantitative data has more statistical
power, It can be converted into categorical
data which is easy to analyze.
DESCRIPTIVE
STATISTICS
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DESCRIBING DATA FROM ONE SAMPLE
Descriptive statistics: deal with the enumeration, organization, central

tendency, dispersion and graphical representation of data.
According to the type of data.
Categorical Quantitative
Mode, Frequency
Normally distributed Non- normally distributed
Mean, Standard deviation Median, Range
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CATEGORICAL DATA
Mode
The mode of a set of values is that value which occurs
most frequently.
If all values are different, there is no mode.
A set of value can have more than one mode.
The only valid measure of central tendency for nominal

data.
The least frequently used measure of central tendency as

it does not lend itself to mathematical operations.
E.g. 20, 21, 20, 20, 34, 22, 24, 27 mode = 20

E.g. 25, 21, 29, 51, 34, 22, 24, 27 mode = No mode
Eg: 27, 21, 22, 20, 34, 22, 24, 27 mode = ?

CATEGORICAL DATA
Frequency
The number in each category
e.g. you received 10 incident reports, categorized as near

miss, minor event, and major event. The reports were in
this order:
Near miss, minor event, minor event, major event, near

miss, minor event, minor event, major event, minor
event, major event.
▪Near miss = 2
▪Minor event = 5
▪Major event = 3
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Mode, Frequency
NORMAL DISTRIBUTION
“Bell Curve”
Data can be distributed in different ways, but continuous data tends to be around a
central value with no bias left or right, and it gets close to a “Normal distribution”
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NORMAL DISTRIBUTION
It is symmetrical about its

mean. The curve on either
side of the mean is a mirror
image of the other side.
NORMALITY TEST
Use Minitab
P value Ho HA Distribution
< 0.05 Rejected Accepted Non normal
> 0.05 Accepted Rejected Normal
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DISTRIBUTED DATA
Mean
NORMALLY
The most commonly used measure of location.
Properties: uniqueness, simplicity, and affected by

every value (extreme values have an influence)
Example:
What’s the mean of the following? 5, 8, 22, 13, 16, 24,

12, 20 ----120 ÷ 8 = 15
What’s the mean of the following? 5, 8, 22, 13, 16, 24,

12, 140----240 ÷ 8 = 30

DISTRIBUTED DATA
The measure of central tendency do not reveal the whole

NORMALLY
picture of the distribution of a data set. 2 data sets with

the same mean may have completely different spreads /
variation.
Example:
MI patients weight: 53, 47, 60, 74, 66
Pneumonia patients weight: 20, 85, 67, 36, 92
The mean weight of the 2 groups is 60 years
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DISTRIBUTED DATA
Standard Deviation:
The most commonly used measure of spread.
NORMALLY
The SD is a measure of the spread of data about their
mean.
It tells us how far we are from the mean.
Easy to be calculated using Excel.
In which of the following data sets, the SD / spread

looks higher?
✓ MI patients weight: 53, 47, 60, 74, 66
✓ Pneumonia patients weight: 20, 85, 67, 36, 92
NORMAL DISTRIBUTED DATA

Standard Deviation
Suppose the exam score for 4 students are 82, 95, 67, and 92. Calculate SD
Mean (X)= 336 ÷ 4 = 84
2 2
Values X Mean X X-X (X – X) ∑(X – X) / n-1 √
82 84 -2 4 478 ÷ 3 = 159 12.6
95 84 11 121
67 84 - 17 289
92 84 8 64
∑ = 478
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Mode, Frequency
Median
The median is the middle number after they have been
NON-NORMALLY
sorted in ascending or descending order.
If after sorting, 2 numbers in the middle, then median
DISTRIBUTED DATA = average of these 2 numbers
Properties: uniqueness, simplicity, it’s not affected by

extreme values as in case of the mean.
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Median
E.g. what’s the median of the following?
NON-NORMALLY
5, 22, 13, 16, 24, 12, 20, 8, 10
Sort: 5, 8, 10, 12, 13, 16, 20, 22, 24
Median= 13
DISTRIBUTED DATA E.g. What’s the median?

5, 22, 13, 17, 24, 12, 20, 8, 27, 10
Median = ?

DISTRIBUTED DATA
NON - NORMALLY
Range:
Very simple, very rough, and the weakest
It’s the difference between the highest and lowest

values.
E.g.
MI patients weight: 53, 47, 60, 74, 66
Range = 74 – 47 = 27
Question: if you know that the following data set is

non normally distributed. How can you describe it?
2, 7, 9, 11, 13, 22, 27, 30, 49
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Interquartile Range:
DISTRIBUTED DATA
NON-NORMALLY
It’s the difference between the 75th and 25th percentiles.
Contains the central 50% of the observations.
IQR = Q3 – Q1
62 63 64 64 70 72 76 77 81 81
Median =
Q1 = 64
Q3 = 77
IQR =
STATISTICAL DATA DESCRIPTION
Measures of Central
Tendency
Mean
Mode
Median
Measures of Dispersion
Standard Deviation
Range
Variance
Interquartile Range
Coefficient of variation
(CV= SD/Mean%)
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STATISTICAL DATA DESCRIPTION
Measures of Position
Quartiles
Deciles
Percentiles
Ordering (Organizing)
Proportion
Ratio
MEASURES OF POSITION
Quartiles:
It’s the value which divides the distribution into 4 parts subsets of equal size, each comprising 25%
of the observations
E.g.: Weight of patients (165, 250, 140, 155, 160, 170, 180, 200, 200, 225, 230, 260)
Rank data and divide into 4 parts:

140,155,160 165,170,180 200,200,225 230,250,260
Q1 Q2 Q3 Q4
=(160+165)/2=162.52 =(180+200)/2=190 =(225+230)/2=227.5
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MEASURES OF POSITION
Deciles:
The values which divide the data into 10 equal parts are
called deciles and are denoted by D1, D2, …. , D9, D10
Percentiles
The values dividing the data into 100 parts are called
percentiles and are denoted by P1, P2, P3, …. P100. It’s the
most common used among measures of position.
E.g.: 70th percentile (P70) is the value such that 70% of the
observations are less or equal to.
ORDERING (ORGANIZING)
Proportion:
Is the number of observations with a given characteristic, “Part of a whole”
e.g. in hydrocortisone group, the proportion of died patients = P = a/a+b =
50/200 = 0.25
Hydrocortisone Group Placebo Group

Died 50 (a) 80 (c)
Survived 150 (b) 122 (d)
Total 200 202
Percentage:
Is a proportion multiplied by 100%, e.g. in hydrocortisone group, the
percentage of died patients = (a/a+b) X 100 = 25%
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Rate:
Died 50 (a) 80 (c)
Total 200 202
Is similar to proportions except that a multiplier (e.g., 1000,

10000, or 100000) called the base. Rate = (a/a+b) X Base.
E.g. in hydrocortisone group, the rate of death per 10000
patients per year = (50/200) X 10000 = 2500 / 10000
patients / year
Ratio
Is the number of observations in a given group with a given
characteristic, “ 2 different groups or population” e.g. in
hydrocortisone group, the ratio of died patients to survived
= a/b = 50/150 = 0.33
Died 50 (a) 80 (c)
Total 200 202
Example: Nursing staff to patient ratio = 1:5
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INFERENTIAL
STATISTICS
INFERENTIAL STATISTICS
Generalization
Inference
Inferential statistics: Concerned with reaching conclusion from incomplete

information that is, generalizing from specific sample
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There are 2 main methods used in inferential statistics:
Estimation: using CIs
Hypothesis Testing: Null hypothesis (HO) vs. Alternative
hypothesis (HA)
Confidence Interval (CI)

Mean age for a population of 20 persons:
➢ Sample size of 20: exact result
ESTIMATION
➢ Sample size of 10: less likely to be correct

➢ Sample size of 5: even less likely to be correct
Confidence Level: express how confident we

are that the sample mean reflect the population
mean. which usually 95%.
Confidence Interval: tells us the range within
which the true magnitude of effect lies with a
certain degree of assurance. Which usually
expressed as + or – (+).
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Confidence Interval (CI)

Example:
➢ Mean = 30
ESTIMATION
➢ Confidence level = 95%
➢ Confidence interval (CI)= 5
✓ We are 95% certain that the true population
mean is something between (25 – 35)
Note: Narrow CI = little variability

http://www.macorr.com/sample-
size-calculator.htm

HYPOTHESIS TESTING
Hypothesis Testing:
Is a branch of statistics that specifically
determines:
1- whether a particular value of interest is
contained within calculated range (CI).
2- whether you conclude that 2 things are
the same or different.
3- if 2 means are equal (or mean = target).
4- if differences you observe are likely due to
true differences in the underlying
populations or random variation.
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HYPOTHESIS TESTING
Null Hypothesis: HO
Is a statement being tested to determine whether
or not it is true.
HO: ϻ1 = ϻ2 or ϻ1-ϻ2 = 0
It means that the means from 2 sets of data are
the same.
We assume the null hypothesis is true, unless we

have enough evidence to prove otherwise.
If we can prove otherwise, we reject the null

hypothesis.

HYPOTHESIS TESTING
Alternative Hypothesis: HA
Is a statement that represents reality if there’s
enough evidence to reject Ho.
HA: ϻ1 ≠ ϻ2 or ϻ1-ϻ2 ≠ 0
It means that the means from 2 sets of data are
not the same.
If we reject the null hypothesis then practically

speaking we accept the alternative hypothesis.
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HYPOTHESIS TESTING
Statistical Significance:
Group A: Mean = 20
Group B: Mean = 40
Is the difference real or could be due to chance?
Use the appropriate test of statistical

significance to calculate the P-value (Minitab).
Note: When P value is < 0.05, the results are

statistically significant (Reject HO)
TESTS OF STATISTICAL SIGNIFICANCE
Parametric Tests Non-parametric Tests

Type of data Continuous scale Categorical data
Comparison Between means Between proportion
Tests Independent 2 groups: Student t-test Independent groups: Chi-square test
Dependent 2 groups: Paired t-test Dependent groups: McNemar test
> 2 groups: ANOVA (analysis of variance)
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TESTS OF STATISTICAL SIGNIFICANCE
P-Value Ho HA Difference
< 0.05 Rejected Accepted Statistically Significant
> 0.05 Accepted Rejected Statistically insignificant
TYPE I AND TYPE II ERRORS
Conclusion Drawn
Do not reject HO Reject HO

The True State
Correct Type I Error

HO is ture
(α risk)
Type II Error Correct
HO is false
(β risk)
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P-Value
If we reject Ho, the P-value is the probability of being wrong.
“The P-value is the probability of
making a Type I error”
It’s the critical α value at which the null hypothesis is rejected
BIAS &
CONFOUNDING FACTORS
IN
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Bias: any process at any stage of

inference, which tends to produce
results or conclusions that differ
(systematically) from the truth.
Bias cannot be measured or

controlled statistically. It must be
Bias reduced by good research
techniques.
They are introduced primarily by

researchers or by the subjects
themselves.
Bias types:
1- Selection
2- Performance
3- Observation
Types of Bias:
Selection Bias: occurs through the
identification and/or recruitment
of an unrepresentative sample
population, such that any drawn
conclusions cannot be generalized
to the target population.
Performance Bias: occurs when

individuals in the sample behave
in certain way because of
knowledge of the group they have
been allocated to. (if they prefer
the intervention or not)
Observation Bias: occurs as a

result of failure to measure the
exposure correctly. It can be due
to researcher or the subjects.
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Confounding Factors: where a

relationship between 2 variables is
attributable to (confounded by) a
3rd, relating to both but not on the
causal pathway.
Confounding Factors: are not

Confounding created by some mistake made by
Factors researchers. It arises from a real-life
relationship that already exist
between the exposure and the
outcome.
Confounding factors: can be

controlled:
1- At the designing time (by
restriction, matching,
randomization).
2- At analysis time (statistically)
Types of Confounding Factors:

Positive confounder: results in an
association between 2 variables
that are not associated. (e.g. the
association between coffee
drinking and lung cancer is
positively confounded by
smoking).
Negative confounder: makes an

association which is really
present. (e.g. the association
between poor diet and coronary
heart disease may be negatively
confounded by exercise. So,
people who exercise regularly
Exposure Outcome may compensate the effects of a
poor diet).
Confounder
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Definition: OR is a measure of association between

an exposure and an outcome.
The OR represents the probability that an outcome
will occur given a particular exposure, compared
to the probability of the outcome occurring in the
absence of that exposure.
Use: The odds ratio can also be used to determine

whether a particular exposure is a risk factor for a
particular outcome, and to compare the
Odds Ratio magnitude of various risk factors for that
outcome.
(OR)
✓ OR>1 Exposure associated with higher odds of
outcome.
✓ OR=1 Exposure does not affect odds of
outcome.
✓ OR<1 Exposure associated with lower odds of
outcome.
PERFORMANCE MEASURES
&
KEY PERFORMANCE
INDICATORS (KPIs)
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Performance Indicators: are quantitative measures of a specific part of
KEY
a process. By themselves, indicators do not directly measure quality.
KPIs: a set of measures focusing on those aspects of organizational
PERFORMANCE performance that are the most critical for the current and future
success of the organization.
INDICATORS (KPIs) Example:

# Average LOS
% CAUTI
$ expired medications Healthcare Information Management
Key Performance Indicators

Components:
1- Numerator: the number (in a
population) with disease, conditions
or events.
2- Denominator: either the number

of the whole population in the same
place at the same time (proportion)
or a comparable population (ratio).
Types:
1- Structure: e.g. % licensed
physicians.
2- Process: e.g. % documentation

completeness in medical records.
3- Outcome: e.g. % HAI.
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INCIDENCE VS. PREVALENCE

Incidence:
Incidence: is a measure of the risk of developing
some new condition within a specified period of
time (rate of occurrence of new cases).
Prevalence:
Is the proportion of defined population having a

disease at a given point in time, rather than rate
of occurrence of new cases.
Period prevalence: the proportion of a

population that has the disease during a given
time period
Lifetime prevalence: proportion of a population

that has or had the disease at a given point in
time.
Prevalence depends on incidence and
duration of disease.
“
To meet
customer needs
& expectations
To improve To manage the
the process organization
To measure To manage the

performance strategic plan
Why Performance Indicators
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IMPROVEMENT
“
If you can’t measure it,
you can’t improve it.
Lord Kelvin
Page 97
FOCUS:
WHAT GETS
MEASURED GETS
DONE
“Without measurement,
Sustained outcomes are
unlikely.”
Page 98
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CLARITY
Measurement is the glue

that makes it all stick.
Page 99
You have to
keep your eye
on the ball
or risk
getting hit!
50
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Target setting
Selection Documentation
Planning Implementation
How to Develop Performance Indicators
1- Planning
Identify the need / rational
Form a team
Identify the scope:

areas to be measured
Identify measurement
Objective
Identify the period /

duration
Clear definitions
102
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2- KPI Selection
Requirements: regulatory, accreditation.
Organizational Strategy (Goals & objectives): BSC
Operational Importance: Dashboard

✓ high risk,
✓ high volume,
✓ high cost &
✓ problem prone.
e.g. CLABSI rate is important in ICU, but it’s not in
OPD.
Selection Criteria:
✓ Relevant: Finding meaningful KPIs for what you
want to measure.
✓ Clearly defined: Concise, precise.
✓ Balanced: More than 1 KPI to reduce risk of
negative behavior.
KPI Selection techniques

1- Value flow analysis: cover all types, not only
outcomes:
✓ Input
✓ Process
✓ Output
✓ Outcome
2- KPI Balancing: > 1 KPI to reduce risk of negative

behavior:
✓ Leading vs. lagging
✓ Efficiency vs. effectiveness
✓ Quantitative vs. qualitative
✓ Subjectivity vs. objectivity
3- KPI Expo: collecting and presenting relevant

examples of KPIs during the selection workshop.
4- KPI clustering: grouping KPIs in different

categories based on the purpose of the selection
process e.g. BSC & dashboards.
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Do not overburden
your self with
MEASURES
Science: literature, references,

guidelines
3- KPI
Target setting Best practices:
benchmarking
History
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5/13/2018
Non achievable
Target
✓ Challenging
✓ Achievable (Not impossible)
✓ Non conflicting
Target
Demotivating
Effort
Generate positive behavior
Frustrating
Employees
107
BENCHMARKING
Types of benchmarking:
Internal: e.g. time to antibiotic in sepsis, (ER

vs. ICU) at X hospital.
External: e.g. CLABSI, (ICU at X hospital vs.

NHSN).
Zero incidence: e.g. wrong site surgery, (X

hospital vs. zero incidence). 3- Reliability and Validity
Risk adjustment:
Technique used to control the fact that
different patients with the same diagnosis
may have additional conditions that can
affect how they respond to treatment
(comparing the outcome without risk
adjustment ca be misleading)
“
It’s the comparison of an organization’s or
practitioner’s results against a proper
reference point (Best practice) which give
shape for the shapeless raw data.
54
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4- Documentation:
109
Indicator Dictionary 2018
M02 Actual Medication Errors
General
Category Clinical
Standard(s)
What (area/ function) Pharmacy
Owner Chief Pharmacist
Data Administrator Outpatient Pharmacy Supervisor

To monitor medication errors that Actually reach the patient to ensure that safe practices
Rationale
are followed and check the efficiency of the drug distribution system
Performance Dimension (s) Effectiveness, Safety
Type
Add. Information / definitions

Outcome
Medication errors are classified into: Wrong dose, wrong frequency, wrong medication,
wrong route, medication duplication, drug-drug interaction, incomplete medication
Most common elements:
Calculations
74% Definition
Numerator Total number of Actual medication errors /
Denominator Total number of patient days

62% Calculation formula
Target/Threshold 0%
Measuring unit %
Source/Format Manual 49% Purpose & source of data

Collection method None
Target population
Sample size
All patients with prescribed medications
100%
34% Target / Threshold
Reporting
31% Unique identification code
Reporting time 11th working day
Reporting frequency Monthly
Communication Quality and Medical affairs Departments
Data aggregation & analysis Intital analysis by thePharmacy and the final analysis by Quality department.
Start date More than 7 years ago
Completion date Ongoing
Documentation date Sep-12
Revision date
110
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5- Implementation
Data collection & aggregation
Data analysis
Information reporting
Action plan
111
DATA COLLECTION
Data Collection Plan Data Collection Tools Reliability and validity
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DATA ANALYSIS
Compare to Target Trend Statistical Process Control
INFORMATION REPORTING
Achievements Opportunities to improve Recommendations
57
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ACTION PLAN
Action / Task Who is responsible Time frame
Attach
Measurement
to Coaching
58
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Performance Measurement tools
THE STRUCTURE OF PERFORMANCE MANAGEMENT

Vision Tools
1. Organizational identity Mission
Corporate value
Value driver Desired state of

2. Strategy formulation evolution
Goal
Strategy map
Objective
KPI Scorecard
3. Performance measurement
Target Dashboard
Program
Portfolio of
Initiative/ Project initiatives
4. Performance improvement
Milestone Initiative
description form
Task
118
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PERFORMANCE MEASUREMENT TOOLS
1. Scorecard
2. Dashboard
11
9
SCORECARD
12
0
60
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SCORECARD - SPORTS
12
1
SCORECARD - SPORTS
12
2
61
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STRUCTURE OF SCORECARD
• BSC views the organization from 4

different perspectives:
1. Financial: how do we look to

providers of financial resources?
2. Customer: how do our customers

see us?
3. Internal processes: at what must

we excel?
4. People, learning & growth: can we

continue improve and create value
for customers?
12
3
Strategic
objectives
12
4
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Strategic
objectives
KPIs
12
5
Strategic
objectives
KPIs
Targets
12
6
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Level of results
Strategic
objectives
KPIs
Targets
12
7
Analyze
• Departmental Scorecards on a weekly / monthly basis
12
8
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Analyze
• Corporate Scorecards on a monthly / quarterly basis during

Performance Review Meetings
12
9
Analyze
• Country Scorecards annually
13
0
65
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SCORECARD
• Report comprehensive view of

organizational performance in
a structured way
• Provide performance
measures in relation to
strategic plan (mission, vision,
goals & objectives)
• Indicates the extent to

which we are progressing
towards achieving our
strategy
13
1
DASHBOARD
13
2
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DASHBOARD
• Easy access computer

program integrates a
variety of performance
indicators into 1 display,
usually with graphs &
charts.
• Provide a running picture

of a departmental /
organizational status at
any point of time (real
time).
13
3
DASHBOARD
• Provide managers with

vital information
about key processes.
• Better decisions on a
daily / monthly basis.
13
4
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5/13/2018
DASHBOARD
• Data verification
• Data analysis
• Decision making
• Action
• Feedback
13
5
SCORECARDS
• Reflect on strategy
• Indicate level of performance in
reaching the strategy
• Monitor objectives
DASHBOARDS
• Operational tools
• Indicate the status of key processes
and Key areas of interest
• Monitor processes
13
6
68

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5/13/2018

Understand the major principles of

Understand data collection and designing

Understand basic statistical and sampling

Use basic statistical tools in describing data

Develop and interpret Run chart and

Interpret data to support decision making

Is the collection and management of information

The 1ry purpose of information management system