D159 Task 2 Data Collection and Reporting Plan Example

Data Collection and Reporting Plan: Running the Measures for a Patient Blood Management Program as a Monthly Routine

Student Name

Leavitt School of Health, Western Governors University

D159: Evidence-Based Measures for Evaluating Healthcare Improvements, Task 2

Course Instructor

Month Day, Year

Data Collection and Reporting Plan: Running the Measures for a Patient Blood Management Program as a Monthly Routine

Scope

This plan describes how each measure in the patient blood management measure set will be collected, analyzed and reported for adult inpatients under the hospitalist and general surgery teams at the composite community hospital. It names the method, the responsible role and the frequency for each measure, explains how missing data will be handled, sets the analytic method and the rules for judging change, and defines who receives which report and when. The blood management nurse coordinator owns the plan; a quality data analyst builds and runs the reports.

Collection by Measure

Primary outcome, the share of red cell units given at or above 8.0 g/dL: an automated monthly report links blood bank issue and administration records to the last hemoglobin value reported in the day before each order, using the patient's medical record number and time stamps. The analyst produces it early each month, once the previous month's records are complete. Because automated logic can misclassify cases, such as a patient whose bleeding was documented in a note rather than as the order indication, the coordinator reviews a random sample of 20 units flagged above threshold each month against the chart and records any misclassification; if more than 10% are misclassified, the report logic is corrected and the previous month rerun.

Red cell utilization and single-unit orders: automated from blood bank records and the electronic order record, with patient days from the finance census report, monthly, by the analyst.

Order set use and alert override rate: automated from the order and alert logs, monthly, by the analyst, with the coordinator categorizing free-text override reasons.

Education completion: pulled quarterly from the learning management system for nurses and from department attendance records for clinicians, by the coordinator.

Structure measures: recorded quarterly by the transfusion committee secretary as yes or no.

Balancing measures: rapid response calls are pulled monthly from the rapid response team's log, and every call with anemia or hypotension noted is reviewed by the coordinator and a hospitalist champion within two weeks; readmissions are pulled quarterly by the quality department; order-to-transfusion time is automated monthly from blood bank and administration time stamps.

Cost: calculated quarterly by the finance analyst using the agreed method.

Missing and Incomplete Data

Transfusions without a hemoglobin in the 24 hours before the order will be counted in a separate category rather than excluded, because excluding them could hide a practice of transfusing without checking. If a month's automated report fails, the analyst reruns it within five business days; if records from one unit are missing because of a system downtime, that month is annotated on the chart rather than dropped. Any change to report logic is documented with the date, so the chart shows where definitions changed.

Analysis

Monthly measures will be displayed on run charts with the baseline median, and change will be judged using standard run chart rules for shifts, trends, the number of runs and unusually extreme points (Perla et al., 2011). After at least 20 monthly points are available for the primary outcome, the analyst will convert it to a p-chart, a type of control chart suited to proportions, which shows whether variation is within the expected range for a stable process or signals special cause (Benneyan et al., 2003). Control limits will be recalculated only when a sustained, explained shift has occurred, so that a new level of performance becomes the new baseline. Low-count measures, for example emergency team calls where anemia played a part, will be reported as counts with individual case review rather than as rates that swing widely from month to month. Clinician-level feedback will use at least six months of data or a minimum of ten transfusions, whichever comes later, to avoid unfair comparisons based on a handful of cases.

Reporting

Monthly dashboard: one page with the primary outcome, utilization rate, single-unit rate, override rate and balancing measures, each as a chart with a one-line interpretation, sent to the transfusion committee, the two service chiefs and the nurse managers by the tenth business day. Clinician feedback: each hospitalist and surgeon receives a private report setting their own above-threshold proportion beside the median for their service, with de-identified peer comparison; reports are sent by the service chief, not by the project team, to keep the message clinical. Nursing: charge nurses share the unit's single-unit rate and one recent example of good practice at monthly staff meetings. Executive: the sponsor group receives a quarterly summary including cost results and a recommendation to continue, adjust or expand. Patients: an annual summary is shared with the patient and family advisory council.

Each report ends with a short 'what we are doing next' line, written by the coordinator, so readers see how the data are being used. When the primary outcome reaches its target and holds for six months, reporting to clinicians will move to quarterly, and the monthly dashboard will continue for the transfusion committee as part of routine monitoring.

Data Governance and Privacy

Reports use the minimum necessary patient information; dashboards show only aggregate data, and case review worksheets are stored in the quality department's secure folder and deleted after two years. Clinician-level reports are treated as confidential peer review materials under the hospital's quality improvement policy. The analyst's access to linked blood bank and laboratory data is approved by the privacy officer.

Acting on the Data

The plan's purpose is action. If the primary outcome shows no shift after four months, the coordinator reviews process measures to see whether the order set and alert are being used; low use points to a build or workflow problem, while high use with persistent above-threshold transfusions points to alert design or to specific clinicians who need direct conversation. If any balancing measure signals, the transfusion committee reviews cases within one week and can pause or adjust the alert. Using data this way, as a guide to the next change rather than as a verdict, is the core of measurement for improvement (Provost & Murray, 2011).

References

Benneyan, J. C., Lloyd, R. C., & Plsek, P. E. (2003). Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care, 12(6), 458-464. https://doi.org/10.1136/qhc.12.6.458

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.