Volume 2, Issue 3
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INSIDE THIS ISSUE
Survey Data Analysis: Statistics Made Simple 2 (continued)
BHS Policy & Procedure Manual Now Available 3
HIPAA: What Does It Mean? 4
Addressing Medical Errors 5 - 6
Calendar of Events 7
How To Contact Us 8
Survey Data Analysis: Statistics Made Simple- Jonathan Rich, Ph. D.
Previous articles in this series talked about writing survey questions, selecting a sample, and administering your survey. All of these steps should be accomplished in ways that minimize bias and maximize the accuracy of your data. After the data are collected, the remaining task is to make sense of it. Statistical analysis is the tool that allows us to do this.
Most of us working in clinically related fields, particularly behavioral health, have been exposed to at least one class in statistics. Many students find the subject at best an irritating and irrelevant digression from clinical work. However, statistical analysis can readily reveal patterns in our work, which are otherwise hidden. It can clarify complex relationships, and help us to sort out what works and what does not.
There are two basic types of statistical analysis: descriptive and inferential. Descriptive statistics allow us to summarize data. For instance, we can take measurements or scores for many people and condense them into a single number. The most familiar descriptive statistic is the average or mean. If you take the age of all of your clients, add them up, and then divide by the number of clients, you will obtain the mean age of your clients. You could also describe your clients' ages by producing a graph, showing the number of clients in various age ranges, 20 to 29, 30 to 39, etc.
Descriptive statistics can provide interesting and useful information. However, they only provide information about a specific group of people. To derive information that can be applied to other people and situations, you need inferential statistics.
Think again about the statistic above: the average age of your clients. Suppose your average client is 35 years old. Now suppose that you survey your colleagues and find that they have an average client age of 38 years. Your average client is three years younger than your colleagues' clients, but you can not be sure that this difference is meaningful. You certainly would not expect the average to be exactly the same, so some difference is to be expected. Inferential statistics allow you to determine if the size of a statistic is large enough.
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To be considered stable and whether it can be generalized beyond your particular samples. In other words, is the finding "statistically significant"? Statistical significance is expressed as a probability. The conventional probability level for statistical tests is five percent or one-out-of-twenty. The statistical test determines the chance of getting the obtained result if there really is no difference between the groups being compared.
In the example above, we would start out by assuming that your clients and your colleagues' clients had all been randomly assigned to your caseloads from the general population of potential clients. Statistical analysis will tell us how likely a mean difference of three years would be, given that there is no reason, apart from chance factors, that they would differ. If we get a probability level of less than five percent then we conclude that
there is some factor other than chance operating. This "other factor" could be many things. It could be that you are better at retaining older clients, it could be that your referral sources cater to older clients, or it could be that you are sent or assigned older clients because some-one thinks you work better with them. There can be many reasons for a statistically significant difference; careful review of the research procedure, and sometimes further research, is needed to uncover the source of a significant difference.
COMMON STATISTICAL TESTS & THE QUESTIONS THAT THEY CAN BE USED TO ANSWER Survey Data Analysis: Statistics Made Simple (Continued from front page)
- Independent samples t-test Do the means of two groups differ from each other?
- Paired samples t-test Do pairs of scores (such as pre/ post) differ for individuals?
- Correlation What is the strength and direction of the relationship between two variables?
- One-Way ANOVA Do the means of several groups differ from each other?
- Multi-Way ANOVA What is the effect of 2 or more manipulated variables on a measured variable?
- Chi-Square Is there a relationship between 2 categorical variables (i. e., gender/ diagnosis)?
- Factor analysis What are the theoretical constructs that underlie a large number of variables?
- Regression What is the formula that can predict one variable from several others?
Dr. Rich, Ph. D. is a psychologist at Quality Management and Program Compliance. He has taught statistics and research design at CSU, Fullerton and other universities. Past employment included work as a psychologist at a Texas State prison and at County of Orange Alcohol and Drug Abuse Services. In addition to his County work, he maintains a private practice with specialties in psychological testing and research design and analysis.
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Begun as a project to integrate Divisional policies, the new BHS Policy and Procedure Manual is now available and is being distributed by the Quality Improvement and Program Compliance staff. This new manual, which will fill a gap between the broad Health Care Agency (HCA) Policy Manual and more narrow Division or Department policy manuals, will contain policies that will apply to all BHS Divisions and Programs.
Beginning in early 2000, representatives from all Divisions, Quality Improvement and Program Compliance, Patients' Rights and Advocacy Services, and Cultural Competency met to review scores of existing Division and Program policies to determine which could be revised or re-worded to apply throughout BHS.
New policies were drafted, reviewed, and re-worked by staff so that they met the requirements of numerous regulatory agencies and did not conflict with existing HCA and Division policy. Those policies that were approved by all Divisions were then sent to Deputy Agency Director Doug Barton for his signature. The manual is divided into six general sections and three expansion sections:
1. Care and Treatment 2. Client Rights 3. Human Resources 4. Administration 5. Information Management 6. Quality Improvement 7. Future expansion 8. Future expansion 9. Future expansion
The goals of this on-going project are to: a) Develop written procedures and policy useful to all BHS staff
b) Meet the requirements of State and Federal regulatory agencies
c) Coordinate new policy development among each of the BHS Divisions
At present, the Quality Improvement and Program Compliance staff have distributed over 120 of the estimated 200 manuals required. New or revised BHS policies will be distributed by e-mail when possible along with instructions.
Those service chiefs and program directors who have not yet received a manual are asked to contact Dan Ketchum at 714-834-5937 or Anthony Perera at 714- 834-2312 to obtain a manual.
BHS Policy & Procedure Manual Now Available!
Dan Ketchum, Quality Improvement & Program Compliance
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HIPAA is the Health Insurance Portability and Account-ability Act of 1996 (Public Law 104-191). It was en-acted as part of a broad Congressional attempt at incremental healthcare reform. The "Administrative Simplification" aspect of this law requires the United States Department of Health and Human Services (DHHS) to develop standards and requirements for maintenance and transmission of health information that identifies individual patients. These standards are designed to:
- Improve the efficiency and effectiveness of the healthcare system by standardizing the inter-change of electronic data for specified administrative and financial transactions; and
- Protect the security and confidentiality of electronic health information.
How Will HIPAA Effect HCA/ BHS?
HIPAA will require payers to use and accept specific transaction standards for electronic data information, claims/ encounters, eligibility verification, enrollment, and related transactions. This is meant to simplify and standardize electronic transactions across the nation.
HIPAA: What does it mean? Diana Mentas, Ph. D.
HIPAA will also require the County to protect the security and confidentiality of consumer health information whether it is in the form of data in a computer, information written in a paper chart, or verbal information. The County will take steps to protect the privacy of consumer health information in the following ways:
- Develop a security plan to protect consumer health information.
- Document formal procedures for protecting data integrity, confidentiality, and availability.
- Address staff responsibilities for protecting data. ° Put privacy procedures in writing and make it avail-able to all consumers.
- Limit the request for consumer records/ information from other providers to what is only necessary to accomplish the goal of treatment.
- Disclose only the "minimum necessary" amount of health information. This does not apply to the trans-fer of medical records for the purposes of treatment, since providers need access to the full record to provide the best quality of care.
- Develop practices that ensure the internal protection of medical records.
- Train and educate employees on privacy issues related to consumer health information.
- Provide a telephone number and a way in which consumers can file privacy complaints.
- Designate a Privacy Official to implement and manage privacy issues.
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Addressing Medical Errors by Dan Ketchum
1. Based on a study published by the Institute of Medicine, hospitals may wish to encourage staff to report errors by actively promoting a non-punitive culture. Which, if any, of the following actions has your hospital implemented to promote reporting?
- Focusing on product improvement instead of finger pointing 94%
- Retraining nurses and staff ................................... 66%
- Educating physicians about the non-punitive reporting culture 47%
- Minimizing disciplinary actions .............................. 46% Issuing warnings privately to individuals to allow them to save face ............................................................ 35%
- Reiterating during performance appraisals that there is no penalty for reporting errors .................................. 27%
- Other .................................................................. 9%
More hospitals and healthcare organizations are now focusing on medical errors and what they can do to help prevent them. Quality-improvement organizations have realized that many errors are due to "system" problems rather than individual performance. The May/ June 2001 edition of Healthcare Executive published a survey of 650 hospitals of what steps they have taken to address errors. The results of this survey are described below.
2. One factor that can thwart reporting of errors is the breach of confidentiality that potential reporters fear.
Which, if any, of the following has your hospital implemented to guarantee confidentiality for those who report errors?
- Educating staff about confidentiality policy.................................. 67%
- Establishing a non-punitive reporting policy .......................................... 62%
- Limiting access of reports to quality/ risk managers .......................................... 54%
- Educating physicians about confidentiality policy .......................................... 48%
- Establishing anonymous hotlines for event reporting .......................................... 32%
- Conducting electronic reporting via computer terminals to eliminate hard copy.............. 7%
- Other ................................. 3%
3. What steps is your hospital taking to reduce medical errors?
- Staff education ................................................... 95%
- Standardization/ simplification of processes............ 81%
- Peer review ....................................................... 73%
- Computerization of pharmacy dispensing process... 58%
- Computerization of physician order-entry............... 31%
- Other ................................................................ 11%
- None of the above .............................................. 1%
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- Obtain the consumer's "consent" for the use and disclosure of health information for the purposes of treatment, payment, and healthcare operations.
- Obtain a separate, specific "authorization" from the consumer for non-routine disclosures.
As you can see, there are going to be significant changes in the way we deal with consumer health information in the near future. Some of these changes have already taken place but most are currently being studied and will be implemented during the next two years. To address Agency-wide compliance regarding HIPAA, HCA has put together a workgroup that includes representation from Behavioral Health Services.
4. To what extent do the following factors represent obstacles to reducing the number of medical er-rors in your hospital? (Percent indicating major or moderate obstacle)
- Legal concerns about openly reporting errors..... 50%
- Cost of implementing improved processes......... 36%
- Shifting culture from punitive to non-punitive..... 25%
- Physician opposition ....................................... 17%
- Evaluating the effectiveness of recommended improvements................................................. 16%
HIPAA: What Does It Mean?
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Addressing Medical Errors
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Source: Healthcare Executive May/ June 2001 The Official Magazine of the American College of Healthcare Executives( ACHE) Used with permission
Additional reading:
1) "To Err Is Human: Building a Safer Health System" -Linda Kohn, Janet Corrigan, Molla Donaldson, Editors -National Academy Press 2000
Read it on-line at www.nap.edu/catalog/9728.html
2) "Medical Errors & Patient Safety" -Documents, Task Force news, speeches and hearings and Congressional testimony
Available at: www.ahcpr.gov/qual/errorsix.html
3) "Make No Mistake: Medical Errors Can Be Deadly Serious" -FDA Consumer Magazine
Available at www.fda.gov/fdac/features/2000/500 err.html 4)
"The Institute of Medicine Report on Medical Errors -Could It Do Harm?"
Available at: www.nejm.org/content/2000/0342/0015/1123.asp5) "Errors in Prescribing"-From Understanding and Preventing Drug Misadventures Conference
Available at www.ashp.org/public/proad/mederror/prob.html
Dr. Mentas is a licensed psychologist with the County of Orange Quality Improvement/ Compliance Division and AMHS Inpatient Managed Care Program. Dr. Mentas received her doctorate degree in clinical psychology from CSPP-Los Angeles in 1990. She comes to the County with private sector managed care experience in service delivery and quality management. Some of her responsibilities at the county include training AMHS staff in the administration of the Adult Performance Outcome Measures, conducting outcome studies and writing policies and procedures. In addition, Dr. Mentas currently serves as leader of the HCA HIPAA Privacy Subgroup.
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Volume 2, Issue 3
Event:August 1st
Adult Performance Outcome System Training
Time: 9am-12noon
Location: 405 W. 5th St. Room 512
Contact:Quality Improvement/ Program Compliance (714) 834-5601 or contact Diana Mentas by e-mail
Event:August 9
Community Quality Improvement Interdivisional Sub Committee Meeting
Time: 9: 30am -10: 30am
Location: 405 W. 5th St. Room 202
Contact: Dave Horner, PhD. (714) 834-6232
Event:August 10
Community Quality Improvement Committee
Time: 11am
Location: 405 W 5th St. Room 433AB
Contact: Dave Horner, PhD. (714) 834-6232
Event:September 13
Community Quality Improvement Interdivisional Sub Committee Meeting
Time: 9: 30am -10: 30am °
Location: 405 W. 5th St., Room 202
Contact: Dave Horner, PhD. (714) 834-6232
Event:September 14 -20
National Healthcare Quality Week
Event:September 11
Community Quality Improvement Interdivisional Sub Committee Meeting
Time: 9: 30am-10: 30am
Location: 405 W. 5th St., Room 202
Contact: Dave Horner, PhD. (714) 834-6232
Event: October
TBA Children's Performance Outcome System Training
Time: 9: 00 am-12 noon
Location: 405 W. 5th St.,
Room: To be determined
Contact: SMART (714) 796-0118
Event:October 2
Community Quality Improvement Committee
Time: 11am
Location: 405 W 5th St., Room 433AB
Contact: Dave Horner, PhD. (714) 834-6232
Event:October 8
Community Quality Improvement Interdivisional Sub Committee Meeting
Time: 9: 30am
Location: 405 W. 5th St., Room 202
Contact: Dave Horner, PhD. (714) 834-6232
Event:October 24
Adult Performance Outcome System Training
Time: 9am-12 noon °
Location: 405 W. 5th St., Room 433
Contact: Quality Improvement/ Program Compliance
(714) 834-5601 or contact Diana Mentas by e-mail
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JUNE/ JULY 2001 EDITION
County of Orange/ Health Care Agency
Behavioral Health Services
Quality Improvement &
Program Compliance
405 West 5th Street, Suite #410
Santa Ana, California 92701
Interim Division Manager Dave Horner, PhD. 834-6232 General Information Non-formulary Drug Treatment Authorizations (TAR's) Anthony Perera 834-2312 Eris Smith 834-5601 Diane Chang 834-2312
Performance Outcome System-Children's Services Heidi Nguyen-data processing 834-4087 Jon Rich, PhD.-data analysis/ reports 834-4043
Performance Outcome System-Adult Services Denise Martinez-data processing 834-4087 Jon Rich, PhD.-data analysis/ reports 834-4043
Quality Improvement Alan Edwards, MD 834-3081 Dan Ketchum, RPh. 834-5937 Diana Mentas, PhD. 834-3157 Sharron Williams, PsyD. 834-4043
Program Compliance Jeffrey Nottke 834-3042 Joe Churchin, MHS 834-5816
Division Liaisons Adult Mental Health Diana Mentas, PhD. 834-3157
Alcohol and Drug Abuse Services Sharron Williams, PsyD. 834-4043
Children and Youth Services Jon Rich, PhD. 834-3081
How to contact Quality Improvement and Program Compliance
The Quality Views newsletter is published bimonthly by the Quality Improvement & Program Compliance program of the County of Orange/ Health Care Agency.
If you would like to contribute an article, have some comments on the content, have ideas or other suggestions on how we can improve the newsletter, please contact us at:
County of Orange/ Health Care Agency
Behavioral Health Services
Quality Improvement &
Program Compliance
405 West 5th Street, Suite #410
Santa Ana, California 92701
Phone (714) 834-5601
Fax (714) 796-0194
Editor: Dan Ketchum
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