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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Information Technology and Quality
Improvement

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I have selected a measure. How do I go about implementing it?

In planning for implementation, organizations select measures to determine the changes that will lead to quantitative improvement in quality.  The following steps will help guide you through the implementation of a quality improvement activity that utilizes health information technology.

Assess system capabilities.  In order to successfully implement a selected measure, it is important to understand system capabilities up front. Including technical leaders in the project discussion can be helpful to set realistic timelines and provide feedback on barriers encountered.  

Assess organizational readiness for change.  Determine the available staffing and resources. Consider developing a budget including percentage of each staff member’s time dedicated to implementation of the quality improvement activity and include an estimate of process completion financing.  Establish realistic timelines for completion of the implementation.  

Establish strong vendor relationships. Vendors are challenged to develop their products to meet national standards and the interests of all their clients. Two-way communication between vendor and client can help both parties understand the reasons for, and the methods by which, functionality is added and changes are made.

Develop target training programs.  Design training programs to educate users on the importance of implementing the measures and to train them on how to use the system. Training should be designed to meet the needs of the users.  The program may include individual or group sessions or a tiered approach using both types of training.  One approach is to begin by training principal leadership or “champions” to ensure buy in, followed by training mid-level staff. Depending on the size of your organization and the scope of the implementation, training can take anywhere from a few days to a few months. Work with the QI team closely to develop a training plan that will fit your organization’s unique needs, and continue to meet with the team throughout the implementation process to obtain feedback and make adjustments as needed.  After training, physicians are often supported by colleagues designated as advanced users, just-in-time training, and explicit standard operating procedures – all of which increase system proficiency and discourage variation.

Create a culture of quality. For successful implementation, leadership must understand the goals of quality improvement and buy into the QI plan.  

Determine data sources and clean up data if needed. While data from the practice management system is most easily accessible and can be pulled into an EMR or registry, this data is often inaccurate and needs to be cleaned up before commencing with quality improvement activities.  One method is to manually enter data into the systems from charts or paper records. While this is time-consuming and labor-intensive, it provides a clean state for quality improvement activities to begin. Another option is to pull laboratory data or other electronic sources of data for use in QI measurement.  Alternatively, some organizations have developed processes and policies to maintain data quality on an ongoing basis and to deal with issues that are discovered. Over time, higher quality data will yield results that are more likely to provide more accurate measurements of quality improvement.

Collect baseline data.  Information obtained from baseline data collection prior to implementation may demonstrate the need for improvement, thus encouraging buy-in from clinicians and key stakeholders. Additionally, it may help identify differences between pre-implementation processes and redesigned systems in order to determine the effect of QI efforts.  It is ideal to collect baseline data before the technology is implemented to avoid the hassle of reviewing old charts or pulling old data after go live.

Collect and analyze data. Once you have determined your measure and data sources, you are ready to begin collecting data.  This process will vary depending on the measures you have chosen, and more information can be found in the AHRQ Evaluation Toolkit.  For a quantitative study, you might consider what comparison group you will use. For a qualitative study, you might consider whether you will make observations or interview users.

Implement a new measure on a small scale.  Begin by measuring data in a population with a particular chronic condition, select a particular cohort of patients, or begin changes on one floor of a hospital. Select a small number of MAs or other staff to specialize in data entry for the particular measure.  

Share results.  Upon completion of analysis, results should be shared with clinicians and other staff.  Consider emphasizing the focus on coordinating quality patient care rather than evaluating individual performances.  Clinical dashboards are an effective way to share your results with the team, and these can take the form of feedback reports or electronic dashboards.

Introduce a QI effort to meet goals.  Discuss how your team will address the results and consider the most effective ways to improve quality without significantly interrupting workflow.  For example, if results indicate that diabetics are not getting their foot exams, implement a reminder sign in exam rooms for patients to take their shoes off.

Measure again. Once you have implemented a change to induce quality improvement, it is important to continually measure the progress and compare post-implementation results with pre-implementation conditions.  In the example used above, data should be analyzed to determine if the number of diabetics who have had foot exams has significantly increased since implementing the new quality improvement strategy. If results indicate quality has not improved, consider changing the QI effort or the measure.

Make adjustments and monitor progress. It is important to recognize that the desired aims of the quality metrics are often not achieved in one cycle, and you may need to repeat or adjust the QI effort.   Ongoing coordination with clinicians, stakeholders and the QI team is necessary to discuss progress and adapt processes if needed.  Additionally, new aims and goals may develop and lead to new measures and QI efforts.  In the above example, a change as simple as moving the location of a reminder sign for patients to remove their shoes to an alternative location where patients and clinicians are more apt to see it may increase the number of diabetics who receive foot exams. Once the change is either verified or rejected, you can expand to implement the change more broadly.  For example, a health center may have a QI goal of improving INR in all patients taking the high risk medication Coumadin through blood tests at regular monthly visits.  To address this goal, the health center team develops a search using their registry product to identify patients outside the parameters, and then develops a section in the charts just for these patients.  Results show that individual care improved, but not for those patients not following up. A new goal may be to achieve better response rates from patients, and a new PDSA cycle could be created to attain this.

Related Resources:

Implementing Changes go to exit disclaimer- Institute for Healthcare Improvement
Collaboratives Can Accelerate and Spread Improvement go to exit disclaimer- Institute for Healthcare Improvement
Roadmap for Quality Improvement: Guide for Doctors go to exit disclaimer- Institute for Healthcare Improvement
Improving HealthCare Quality Reporting go to exit disclaimer- California Health Care Foundation
Continuous Quality Improvement Worksheet go to exit disclaimer- National Association of County & City Health Officials

Evaluation Toolkit - Agency for Healthcare Research and Quality
Developed by the Health Resources and Services Administration as a resource for health centers and other safety net and ambulatory care providers who are seeking to implement health IT.
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