How do I go about testing improvements? How do I interpret improvements?
Testing should be considered from the beginning of the decision-making process; choosing a clinical objective that is too broad (e.g. “improve patient safety”) or difficult to quantify will make any kind of assessment challenging.
The approach to testing improvements requires thoughtful planning in order to be effective. Suppose that your project has picked an objective that can be measured using data in an EHR, for example, periodic retinal exams for patients with diabetes. The relevant information is available in the medical record, but the way of applying it to a QI initiative needs to be carefully considered. If the practice acquires a new population of patients in the middle of the evaluation period, data comparing compliance across all diabetic patients from one year to the next will not be meaningful.
Also consider how data is going to be collected. In the above example, provider compliance could be measured at several points: when the provider educates the patient about the role of retinopathy in ongoing management of diabetes, when the provider orders a referral to an optometrist or ophthalmologist, or when a note from the specialist is added to the patient’s chart to indicate that they actually had such an exam. There are arguments for and against whether each of these points of measurement is a ‘fair’ standard, so it may be prudent to incorporate them in combination, particularly if providers are being assessed as individuals. A balance may have to be struck between how directly your choice of point-of-measurement corresponds to the clinical objective and how easy it is to collect the needed information.
Well-structured assessments of improvement are important to the project in other ways, as well. Funders appreciate quantitative proof that the project is making an impact. Good reporting makes it easier to identify the cause of any unexpected findings based on your data – in one study, starting a QI initiative caused a dramatic increase in reported medication errors because nurses had begun reporting errors that they used to correct without comment. Being thorough and thoughtful in constructing performance metrics could make a big difference in your understanding of the changes caused by the QI initiative.
Measures of Quality of Care – National Committee for Quality Assurance
Programs and Measures – Bridges to Excellence
Eliminating Serious, Preventable and Costly Medical Errors: Never Events – Centers for Medicare & Medicaid Services
Performance Measurement: Accelerating Improvement - National Academies Press
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