DATA ANALYSIS

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Policy No: QRM
DR BAKHSH HOSPITAL AL SHARAFIYAH
DBH-QPS-P-
003
Date Issued: Date
Function: QUALITY AND PATIENT SAFETY November Revised:
2008 July 2021
Date Effective: Next Review:
Title: DATA ANALYSIS
August 2021 July 2024
□ Hospital □
Category: □ Departmental:
wide Multidisciplinary
Applies HOSPITAL WIDE Version: 6
to:
Replaces: Policy : QUALITY IMPROVEMENT PLAN No.: QRM-Plan-01

1. PURPOSE:
0

1.1 To provide continuous feedback of quality management information to help

individuals make decisions and continuously improve clinical and managerial
processes.

1.2 To determine when intense data analysis is indicated in order to determine

where to focus improvement.

2. DEFINITION
0

2.1 Data is a set of values of qualitative or quantitative variables; restated, pieces

of data are individual pieces of information. Data is measured, collected,
reported and analyzed, whereupon it can be visualized using graphs or
images.

2.2 Qualitative data is a categorical measurement expressed not in terms of

numbers, but rather by means of a natural language description

2.3 Quantitative data is a numerical measurement expressed not by means of a

natural language description, but rather in terms of numbers.

2.4 Data analysis is the process of systematically applying statistical and/or

logical techniques to describe and illustrate, condense and recap, and evaluate
data. It is a process of inspecting, cleaning, transforming, and modeling data
with the goal of discovering useful information, suggesting conclusions, and
supporting decision-making.

2.5 Data aggregation is the process of transforming scattered data from

numerous sources into a single new one.

2.6 Information is the data that is accurate and timely, specific and organized for
a purpose, presented within a context that gives it meaning and relevance,
and can lead to an increase in understanding and decrease in uncertainty.

3. POLICY
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3.1 Dr Bakhsh Hospital leadership is responsible to select and prioritize the quality
measures throughout the hospital in coordination with the department /
service leaders.

3.2 Quality and Risk Management (QRM) Department provides support,

coordination and integration throughout the hospital for quality measures, i.e.,
clinical; managerial; patient safety; facility management & safety; contracts
management etc.

3.3 Quality measures’ details are determined by the department / service leaders
in coordination with QRM department. The measures’ details are as follows:

3.3.1 What will be measured

3.3.2 Who will measure it

3.3.3 When will it be measured?

3.3.4 Operational definition of indicator i.e., measure name, numerator,

denominator

3.3.5 Rationale for selection

3.3.6 Monitoring requirement i.e., accreditation, regulatory, payers, etc.

3.3.7 Data source

3.3.8 Data collection methodology

3.3.9 Audit tool

3.3.1 Data assessment frequency

0

3.3.1 Target
1

3.3.1 Sample size

2

3.3.1 Monitoring area

3

3.3.1 Data aggregation plan

4

3.3.1 Results dissemination plan

5

3.4 Data for the selected quality measures is collected by the concerned
department / service responsible staff in the prescribed audit tools (if manual
data is collected) or otherwise extracted from the computer system (if data is
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already entered in the system).

3.5 Data collection methodologies and tools are unified for the measures which
have been selected by more than one department / service such as medication
management, infection control, facility management, adverse events reporting
system, culture of safety measurement, etc.

3.6 Aggregate data is analyzed by the quality and patient safety department to
support patient care and management processes for effective decision making.
Analysis of data enables the hospital to compare its performance in the
following ways:

3.6. With itself over time, such as month to month, or one year to the next.
1

3.6. With other similar organizations, such as through reference databases.

2

3.6. With standards, such as those set by accrediting and professional bodies
3 or those set by laws or regulations.

3.6. With recognized desirable practices identified in the literature as best or

4 better practices or practice guidelines.

3.7 Appropriate statistical techniques (such as run charts, control charts,

histograms, Pareto charts, etc.) are used in data analysis especially in
interpreting variation and finding areas for improvement.

3.8 Intense analysis is conducted when adverse levels, patterns or trends occur
during data analysis and interpretation.

3.9 Intense data analysis shall be conducted for the following:

3.9.1 All confirmed transfusion reactions.

3.9.2 All serious adverse drug events.

3.9.3 All significant medication errors.

3.9.4 All major discrepancies between preoperative and postoperative

diagnoses.

3.9.5 Adverse events or patterns of adverse events during procedural

sedation.

3.9.6 Adverse events or patterns during anesthesia.

3.9.7 Adverse events related to patient identification.

3.9.8 Other adverse events; for example, health care–associated infections

and infectious disease outbreaks.

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4. PROCEDURE:
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4.1 QPS Committee shall prioritize and selects the areas for measurement and
areas for improvement through-out the hospital. Prioritization mechanism
considers the following:

4.1.1 High risk

4.1.2 High volume

4.1.3 High cost

4.1.4 Problem prone

4.1.5 Patient safety goals

4.2 QRM Department shall develop an inventory of the selected quality measures
as follows:

4.2.1 Clinical measures

4.2.2 Managerial measures

4.2.3 Patient safety measures

4.2.4 Facility management and safety measures

4.3 Concerned process owner shall:

4.3.1 Describes the indicator details and starts collecting data according to
agreed operational definition of the quality measure in a pre-defined
audit tool such as a check-sheet, log-book, etc.

4.3.2 Enters the collected data in mathematical / statistical database (such

as Microsoft Excel, SPSS, etc.)

4.3.3 Sends the collected data to QRM Department on agreed frequency such
as weekly, monthly, quarterly, etc.

4.4 QRM Department shall analyze and interprets the aggregate data to get useful
information and prepare quarterly reports.

4.5 The reports shall be discussed in DBH Board meeting, QPS committee, other
concerned committees and concerned departmental meetings for the
following:

4.5.1 To support patient care and managerial decision making.

4.5.2 To identify opportunities for process improvement.

4.5.3 To find opportunities for staff education and training.

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4.5.4 To compare the performance over time, benchmarking with other
similar organizations, with best practices and with the standards.

4.5.6 To appraise the performance of the departments / services and

individuals (healthcare associated infection rates, antibiotic utilization
rates, morbidity & mortality rates, average length of stay, surgery
complication rates, etc. are used during professional practice
evaluation and re-privileging processes).

5. RESPONSIBILITY:
0

5.1 The process owner is responsible to collect and aggregate the data for
analysis.

5.2 The QRM department is responsible to analyze and present the report to the
hospital leadership and concerned departments.

6. ATTACHMENT:
0

6.1 KPI prioritization matrix

6.2 List of KPIs

7. REFERENCE:
0

7.1 CBAHI Standards 3rd Edition 2016, LD.31, QM.6, QM.10, QM.11

7.2 JCI Standards 7th Edition 2021 QPS.8

7.2 Analysis and use of healthcare facility data, General Priniciple,WHO,2018

[Remainder of this page left blank intentionally. Signatures follow

on next page.]

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8.0 SIGNATURES:

Prepared & Revised by: Name: Signature: Date:

Clinical Review Analyst: Dr. Yasmin Hamdy

Patient Safety Specialist: Dr. Seema Afreen

Reviewed & Verified by: Name: Signature: Date:

Quality & Risk Management

Dr. Manar Gabr
Department Director:

Approved by: Name: Signature: Date:

Nursing Director: Dr. Randa Al Habahbeh

Administrative Director: Mr. Hattan Azhari

Medical Director/ Chairman,

Dr. Yahya Al Marhabi
ECOMS:

Chief Executive Officer-

Mrs. Rania Bakhsh
DBHG:

//qrmdocuments/Departmental Manual/JCI-QPS -2021

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