Outcomes and Measures

1. Outcomes and Measures Kim Erlandson, RN, MPH, CPHQ University of Iowa Hospitals & Clinics Clinical Quality, Safety and Performance Improvement Free Clinics of the Great Lakes Region Conference - September 27, 2007

2. Objectives • Brief measurement overview • Differentiate process measures from outcome measures • Identify sources for outpatient standards and use these to create meaningful measures

3. Measurement Basics • Baseline Data • Measures the process prior to interventions • Setting objective measures • Must be measurable • Closing the gap • From where you started (baseline) to measurement after project implementation • Process vs. Outcome • Operational Definitions • Continuous vs. Discrete • Data Collection

4. Process Measures • Voice of the workings of the system • Is the system performing as planned? • For diabetes: Percentage of patients with hemoglobin A1c level measured twice in the past year • For access: Average daily clinician hours available for appointments • For medication systems: Use of adverse drug event chart review

5. Outcome Measures • Voice of the customer or patient • How is the system performing? What is the result? • For diabetes: Average hemoglobin A1c level for population of patients with diabetes • For access: Number of days to appointment • For medication systems: Adverse drug events per 1,000 doses

6. Balancing Measures • Looking at a system from different perspectives • Are changes designed to improve one part of the system causing new problems in other parts of the system? • Reduce time patients spend on a ventilator after surgery • Make sure reintubation rates are not increasing • Reduce length of stay in the hospital • Make sure readmission rates are not increasing • Decrease HbA1c • Make sure not increasing episodes of hypoglycemia

7. Operational Definitions • Operational Definitions • Specify how the concept is measured and applied • Everyone on team agrees with specifications • Must be clarified before data collection\ • 50% Wool Blanket • Interpretations • Foot Exam • Interpretations What does 50% wool Blanket mean????

9. Continuous Data • Often obtained from use of a measuring system • Measured on an infinitely divisible continuum or scale • Things that occur regularly should be looked at as continuous data • Examples: • Time (hours, minutes, seconds) • Height (feet, inches, fractions of an inch) • Temperature (degrees) • Money (dollars, yen, euro) • Sound Level (decibels)

10. Discrete Data • Measures that can be sorted into distinct, separate, non-overlapping categories • Examples: different types of vehicles, types of credit cards, types of lab tests • Includes artificial scales like ones on a survey • Examples: 5 point scales, likert scales • Sometimes called attribute measures because they count items or incidences that have a particular characteristic that sets them apart from other items • Examples: Is the patient male or female? Was the procedure on time or late? Is LOS better or worse than our target?

11. Data Collection • Meaningful data • Sufficient • Enough data to confirm that patterns you see are real • Relevant • Has to be able to help you understand or pinpoint your problem • Representative • Full range of process conditions or problems are seen in the data • Contextual • To give you a complete picture of what is happening throughout the entire process

12. Is it measuring what you want?

13. Convincing Funding Sources • Scorecards • Charts and graphs

14. Scorecards • Report card – measurement by an outside group • Example: Core Measures • Grades your performance • Thermometer – simply records performance

15. Dashboard • Internal tool • Align organization vision, mission, values with performance • Select Key Performance Indicators (KPI) • Some may be at goal, but continue to monitor so can be proactive in response to negative trends • If below target – drives Performance Improvement (PI) projects • Thermostat – driving reaction in response to a change in temperature

16. Scorecard Example

17. KPI related to Type II diabetes management

18. KPI related to Type II diabetes management

19. Guidelines Translated to Measures • Adapting your practice: treatment and recommendations for homeless children with otitis media • Antibiotics • Recommended for homeless; may not get follow-up • Simpler regimen better – consider lack of refrigeration. Consider one time injection • What measures would you use? http://www.guideline.gov/summary/summary.aspx?doc_id=4855&nbr=003496&string=otitis+AND+media

20. Measures for Otitis Media • Process Measures • Outcome Measures

21. Guidelines Translated to Measures • Standards of medical care in diabetes. • VI. Prevention and management of diabetes complications. • Foot Care • Perform a comprehensive foot examination and provide foot self care education annually on patients with diabetes to identify risk factors predictive of ulcers and amputations. (B) • The foot examination can be accomplished in a primary care setting and should include the use of a monofilament, tuning fork, palpation, and a visual examination. (B) • How would you measure this? http://www.guideline.gov/summary/summary.aspx?doc_id=5062&nbr=003546&string=diabetes+AND+foot+AND+care

22. Measures for Foot Care • Process Measures • Outcome Measures

23. Measures Translated to Scorecards/Dashboards Organization Mission/Vision/Values Quality Care/Patient Safety Practice Guideline Implementation Type II Diabetes Management Measure Benchmark Target Baseline Performance

24. Questions Contact Kim Erlandson 319-353-7222 Kimberly-erlandson@uiowa.edu Sources http://www.uihealthcare.com/depts/cqspi/index.html http://www.ihi.org/ihi The Team Handbook, Scholtes, Peter R., Jointer, Brian L., Streibel, Barbara J. Oriel Incorporated, 2001