Measurement: Why & What

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En provenance du cours de The George Washington University

Leading Healthcare Quality and Safety

167 notes

The George Washington University

Leading Healthcare Quality and Safety

167 notes

Ensuring patient safety and healthcare quality is critical and should be a key focus of everyone in healthcare practice. This course provides healthcare practitioners and others with an introduction to the knowledge and skills needed to lead patient safety and quality improvement initiatives at the micro and macro levels. Participants will explore the foundations of health care quality and the science underlying patient safety and quality improvement, design and select effective health care measures, analyze patient safety problems and processes using tools such as human factors analysis, apply systematic approaches including the Plan-Do-Study-Act (PDSA) model to address quality improvement challenges, and learn strategies to lead a culture of change. The course takes a world view of patient safety and quality, linking participants to research and resources from the World Health Organization (WHO), the US Agency for Healthcare Research and Quality (AHRQ), the Joint Commission and other international organizations. Course highlights include personal stories, lessons learned from other industries and interviews with the President of the National Committee for Quality Assurance (NCQA) and other leaders in quality movement. About The George Washington University School of Nursing Ranked among the top nursing schools by U.S. News & World Report, the George Washington University School of Nursing educates and inspires nurses to provide high-quality, compassionate person-centered health care. The school develops leaders actively engaged in health promotion, patient advocacy and healthcare innovation, and prepares exceptional nurse educators who pursue quality and advance the profession. The School of Nursing is committed to improving the health and wellbeing of people and communities locally, nationally and globally. The school values lifelong learning and its students advance nursing practice, leadership and education as they make a difference in the world.

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Measures & Measurement

Welcome to Module 3! This week we delve into measures and measurement. You'll learn to apply the basic Donebedian framework for measuring quality in healthcare in terms of structure, process and outcomes. We'll discuss the key attributes of useful (good) healthcare measures and the core concepts of validity and reliability. You'll also learn the most critical elements to consider in choosing and applying a measure or measures to measurement in a given health care setting or situation, and the key characteristics of a measurement process that must be present to provide information that is a valid and useful reflection of quality of care.

Introduction7:42

A Framework for Measures14:52

What Makes a Good Measure?16:09

Measurement: Why & What8:36

Use & Reporting of Measures4:41

Rencontrer les enseignants

Jean Johnson

Professor, GW School of Nursing and Executive Coach
Gregory Pawlson

Clinical Professor of Medicine and Adjunct Professor, GW School of Nursing and Executive Coach

Welcome to episode four, Measurement- Why and What.

The choice of what area or areas to measure is clearly a critical step.

Even if the measures are being imposed from the outside,

there may be some leeway in choosing which parameters or

which areas to focus most of your effort and time on.

Besides situations where measures are an imposed requirement from outsider

practice, or reporting measures provides an opportunity for extra payment.

Starting a program of measurement is usually directed

towards gathering information.

That might guide future quality improvement efforts or

at least shed some light in a concern or a problem area that you've identified.

Ideas we put into measurement areas may come to light through many different

channels, including your own observation and the potential area of concern.

From comments or concern raised by patients, by family members or your staff.

If you were planning a measurement effort and you have a full latitude

in choosing measures, it's usually best to resist the initial temptation

to create a new measure specifically for use in your setting.

While this sometimes may be necessary, given the lessons we've learned in episode

three about what constitutes a useful measure.

It's not easy to develop a measure that will actually get you the answer

you need or intend.

The good news is it that there are number of good sources for potential measures.

One very useful and very easily searchable site

is the national quality measures clearing house but you all call the clearing house.

The clearing house is a publicly accessible resource reported by the US

agency for healthcare research in quality or ARQ.

While the clearing house is the most readily accessible site, there are other

resources available such as the European Commission's healthcare indicator site.

Also the World Healthcare Organization periodically produces monographs and

other publications of indicators that are helpful in measurement of diseases

like tuberculosis or other global health issues.

The listing on a clearing house includes a searchable function that allows searching

by disease or problem.

Includes a full description of a measure, the type of measure, the organization

that developed and manages the measure, the evidence based for the measure and

other information critical to potential use of measure in your site.

It cannot be overstated that for

most situations, using measures that were well constructed and

fully documented is a critical early step in successful measurement.

Performance Measures listed on the clearing house,

have clearly stated specifications.

So that if applied and very careful and precise manner, there is

a reasonable probability that the same data will be collected in the same way.

Which in turn increases the chances that the information will in fact be

useful and comfortable.

There are additional issues to consider as you move forward

within a grading measuring into your own practice.

Most of these considerations are looking at how some of the desirable attributes or

measures apply directly to your own site and interest in measurement.

And how the measures you are contemplating are likely to actually perform

in your practice.

Is the data that you will need likely to be accurate, accessible, and

complete in your own medical records?

Will there be a sufficient number of cases in the practice to draw reliable and

valid conclusions?

Making valid comparisons from data collected at a prior date or

to data from bench marking outside your practice

is very dependent on having a sufficient sample size.

In other words, having enough patients or

instances of a problem that's actually being studied.

For example, if you are in an outpatient practice and

are concerned about the care of patients with rheumatoid arthritis.

You will need to ask yourself whether or

not you see a sufficient number of patients with RA to

have an adequate sample size to answer the question that you wish to answer.

While there are power tables available that indicate the number of patients

needed to have a certain probability of finding a significant difference between

two groups of patients.

It is rare that valid comparisons can be done with fewer than 30 patients.

In order to directly compare one practice to another, it may take several hundred

patients to find significant differences using most measures.

In the example we used,

the prevalence of rheumatoid arthritis is estimated at about 1%.

So that in a family practice of 2000 patients, one might expect about

20 patients with RA, likely not enough for valid measurement.

You will also need to think about whether you will be able to attribute

the variation that you find in the measure, to the care you actually provide.

In other words can variation that you find be associated with the healthcare

practice, that is actually controllable within your practice.

In the example of rheumatoid arthritis, interventions made by consultants may have

a much larger impact than any intervention that you might do in your own practice.

In addition to sample size and variation,

there are a number of issues related to the data itself that must be considered.

First do you have access to the data you'll need to actually collect?

Is the data readily available in existing medical records, either paper or

electronic?

Or are you going to need to create and enter new data, or

even enter existing information in new ways to the patient records?

How expensive will it be to add data versus just using

the data that's already available.

Second, how will the data actually be collected?

What's the source of the data?

Hard copy charts, electronic health records or other data sources?

Will the data also be collected through observation and interview?

While electronic heath records or EHRs can provide a useful and

efficient way of collecting data for measures, there are major challenges.

To mention just two, the completeness of data and

the accuracy of the algorithms setup to extract and organize the data.

There may be inconsistencies across systems in how EHRs

are organized that may affect the data extraction.

Potentially, these sort of details will ensure that the data obtain

as relevant to what you are trying to measure.

Another factor to consider is the quality of the data,

are the data entered in the same way by all providers, are there many omissions?

Who will collect and organize data?

If hospital based you need to get a hospital quality improvement group

together to do this?

Or ambulatory care based, do you have someone with the skills to collect and

analyze the data?

What steps will need to be taken to collect the data?

Minimizing the number of steps will reduce the likelihood of problem analyze.

You also will need to consider how much will the data collection and

analysis cost.

Are there potential unintended consequences of using these measures?

As you can see there is a lot to think about to not only select the right

measures but to apply the measures and actual practice in the right way.

The questions we have posed will hopefully help you participate in deciding or

at least influencing, which measures to use in monitoring care,

in any practice setting, discipline or geographic location.

While the questions may seem extensive, they often can be addressed fairly easily,

especially if you are only gathering data for a project within your own practice.

Note that it almost always gets better and easier after the initial project.

Among your resources you will find a measured selection checklist

that you may find helpful.

Being thoughtful in your approach will help you avoid the pitfalls of

choosing the wrong measure, or applying the wrong measure in the wrong way.

Remember that the immediate goal is choosing the right measure and

applying it to the right issue in the right way.

Note finally, that measures and measurement is only one critical step

along the path to actually improving the care provided.

Final observation in this regard measuring quality doesn't improve anything,

just as weighing a steer does not add any beef.

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