What are the Good Quality Indicators to track and Why They are Important. Helena LI 15 October 2015

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1 What are the Good Quality Indicators to track and Why They are Important Helena LI 15 October 2015

2 Outline Quality Setting standards and quality indicators Selection of indicators Round up

3 Quality service Respecting a patient s values, preferences and expressed needs Access to care Emotional support Information, communication and education Coordination of care Physical comfort Involvement of family & friends Continuity and transition Nicholles et al 2000

4 Quality of Health Care Safe Effective With positive patient experience Lord Darzi 2009

5 All programmes on quality and safety cannot be considered a success if patients do not feel the care they have received has improved their health outcomes and quality of life as defined by themselves Tsang KP Chairman the Alliance for the Patients Mutual Help Organization

6 Exercise 1 How do we know patients appreciated the care? How do we know we have provided quality care? 6

7 Quality assurance Maintain standard of care Is formal process whereby the quality and appropriateness of patient care and/or departmental performance is documented and evaluated by the professional group responsible or within a multidisciplinary team

8 Quality Define standards Evidence Accreditation standards Benchmarking Select key measures Measure practices Observation Audit Survey Focus groups Analysis and take actions to close the gap Minor change/system change Monitor & evaluate NO YES Wolff & Taylor 2009

9 Newly Developed Pressure Sore Rates = Total No. of pressure sores Total No. of patient bed days X 1,000 Incidents per 1,000 in-patient bed days Pressure sore is defined as pressure sore(s) with skin break in patients developed 72 hours post admission into a hospital.

10 Observations & Issues At the Corporate Level Hospitals have been making reference to the overall rates over the years and implement measures to reduce the incidents as part of their continuous quality improvement activities Over the past yeas, there were declining rates of pressure sore in general

11 At the local Level Observations & Issues There were issues relating to the operationalization of data collection and definition in the early years Some hospitals have relatively stable rates Some hospitals have a declining trend in recent years Some specific analysis of pressure sore incidents were carried out by hospitals for local improvement measures

12 Is pressure sore a good indicator to track?

13 Accessed 2015/9/8 html

14 NDNQI Indicators Indicator Sub-indicators Measures Nursing Hours per patient day Staff Structure Patient falls Process & Outcome Patients with injury Injury level Process & Outcome Pediatric pain assessment, intervention, reassessment cycle Pediatric peripheral intravenous infiltration rate Pressure ulcer prevalence Psychiatric physical/sexual assault rate Restraint prevalence -community acquired -hospital acquired -unit acquired Process Outcome Process & outcome Outcome Outcome 14

15 NDNQI Indicators Indicator Sub-indicators Measures RN education/certification Structure RN Satisfaction survey options Skill mix: % of total hours supplied by Voluntary nurse turnover Job satisfaction scales Practice environment scale RN % of total nursing hours supplied by Agency staff Process & outcome Structure Structure Nosocomial infection -urinary catheter associated UTI -central line catheter associated blood stream infection - ventilator-associated pneumonia Outcome 15

16 Standard A standard is a statement of expectation or requirements. It addresses a hospital s level of performance in a specific area and set for the maximum achievable performance expectation for activities that affect quality and safety of care

17 Enhance Home Standard 1.7 Skin care and pressure ulcers Assessment of risk to pressure sores and detection and prevention of pressure ulcers Every nursing home shall assess residents upon admission for risk to skin breakdown and other skin conditions which require care, including pressure ulcers and wounds A skin review shall be conducted daily, in the process of providing care and assistance to each resident during bathing and other activities

18 Indicators Measurable variable (characteristic) that can be used to determine the level of performance of a system/ process, the degree of adherence to a standard, or the achievement of a quality goal To identify program weakness and measure program success Objective to detect areas being monitored Miller Franco 1997 Recited by Massoud et al

19 Indicators Standard Methodology to collect data Trending and analyzing quantitative measurement Identify problems/opportunities for improvement Compare cost Measuring measurable may not be an accurate reflection of the system 19

20 Enhance Home Standard 1.7 Skin care and pressure ulcers Assessment of risk to pressure sores and detection and prevention of pressure ulcers Every nursing home shall assess residents upon admission for risk to skin breakdown and other skin conditions which require care, including pressure ulcers and wounds A skin review shall be conducted daily, in the process of providing care and assistance to each resident during bathing and other activities Indicators:

21 Indicators Structure indicators Process indicators Outcome indicators 21

22 Indicators Structure indicators Related to context of care and the environment Process indicators Outcome indicators 22

23 Structure Indicators Staff Competence Satisfaction Mix of staff Organizational structure Work design Specialization Use of information technology Baars et al

24 Indicators Structure indicators Process indicators Related to actual care processes and the interactions between the health care providers, clients & carers Include access, appropriateness, continuity and coordination of care, prevention and safety Outcome indicators 24

25 Process Indicators Access Waiting list Timeliness Appropriateness Use of evidence-based guidelines Number of referrals Patient number treated Type of treatment Baars et al

26 Process Indicators Continuity/ coordination Presence of case management Number of no-show Prevention Screening attempts Preventive methods which are used Baars et al

27 Process Indicators Safety Number of medication errors Adverse side-effect Number of patient suicide Number of pressure ulcers Baars et al

28 Indicators Structure indicators Process indicators Outcome indicators Relate to the consequences of care Classified under effectiveness (include health status, quality of life, functional status and satisfaction with care) Efficiency & optimal use of resources (LOS, consultations, throughput, utilization, cost containment, financial measure) 28

29 Effectiveness Quality of life Satisfaction Functional status Outcome Indicators Baars et al

30 Outcome Indicators Efficiency Length of stay Number of consultation Economic Cost containment Financial measure Baars et al

31 Enhance Home Standard 1.7 Skin care and pressure ulcers Assessment of risk to pressure sores and detection and prevention of pressure ulcers Every nursing home shall assess residents upon admission for risk to skin breakdown and other skin conditions which require care, including pressure ulcers and wounds A skin review shall be conducted daily, in the process of providing care and assistance to each resident during bathing and other activities Indicators:

32 Safety Screen /reporting Clinical review Adverse event Record review Incident report Complaint Staff feedback Legal claims Critical pathway variances Coroner s report Consultative committee Satisfaction survey Insurers Alert from pharmacy, vendors Media report Accept risk Priority risks Wolff & Taylor 2009

33 FMEA A team based, systematic and proactive approach for identifying the ways that a process or design that can fail, why it may fail and how it can be made safer VA National Centre for Patient Safety 33

34 Healthcare FMEA A prospective assessment that identify and improve steps in a process thereby reasonably ensuring a safe and clinically desirable outcome Increase benefit Increase efficiency Cost reduction 34

35 Conduct hazard analysis List failure mode Determine severity and probability Use the decision tree List all failure mode causes 35

36 Risk priority numbers Occurrence score Severity coding scale Detestability scale Occurrence (1-10) x severity (1-10) x detestability (1-10) = Risk Priority numbers 36

37 Hazard analysis Severity rating 1. Catastrophe event 2. Major event 3. Moderate event 4. Minor event

38 What indictors can be measured for safety?

39 What indictors can be measured for safety? Fall Missing Wrong patient Exhibit unsocial behaviors

40 What are the Good Quality Indicators to track and Why They are Important Legislation requirement? Incidents? Hazard score? Organization?

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42 34 Safe Practices 1. Leadership structures and systems 2. Culture measurement, feedback and intervention 3. Teamwork training and skills building 4. Identification and mitigation of risks and hazards 5. Informed consent 6. Life-sustaining treatment 7. Disclosure 8. Care of the caregiver 9. Nursing workforce 10. Direct caregivers 11. Intensive care unit care

43 34 Safe Practices 12. Patient care information 13. Order read-back and abbreviation 14. Labeling of diagnostic studies 15. Discharge systems 16. Safe adoption of computerized prescriber order entry 17. Medication reconciliation 18. Pharmacist leadership structures and systems 19. Hand hygiene 20. Influenza prevention 21. Central-line associated blood stream infection prevention 22. Surgical site infection prevention 23. Care of ventilated patients 24. Multidrug resistant organism prevention

44 34 Safe Practices 25. Catheter associated urinary tract infection 26. Wrong site, wrong procedure, wrong person surgery prevention 27. Pressure ulcer prevention 28. Venous thromboembolism prevention 29. Anticoagulant therapy 30. Contrast media induced renal failure prevention 31. Organ donation 32. Glycemic control 33. Falls prevention 34. Pediatric imaging NQF 2010

45 Essence of care benchmarks for the care environment Agreed patient-focused outcome: People are confident that the care environment meets their individual needs and preferences

46 Agreed Patient-focused outcomes 1. Access to care environment 2. Culture- how it feels 3. Well-maintained environment 4. Clean environment 5. Infection control precautions 6. Personal environment 7. Linen and furnishings

47 Agreed Patient-focused outcomes 1. Access to care environment - People can access the care environment easily and safely 2. Culture- how it feels people feel comfortable, safe, reassured, confident and welcome 3. Well-maintained environment people experience care in a tidy and well-maintained area 4. Clean environment people experience care in a consistently clean environment 5. Infection control precautions people feel confident that infection control precautions are in place 6. Personal environment patients personal environment is managed to meet their individual needs 7. Linen and furnishings - patients care is supported by effective use of linen and furnishings

48 Enhanced Nursing Home Standards 2014 Nursing Homes to be homes away from Homes, Residents cared for safely with dignity Add life to days

49 Enhanced Nursing Home Standards 2014 Domain 1 clinical aspects of care Domain 2 social aspects of care Domains 3 governance and organizational excellence

50 Domain 1 clinical aspects of care 1.1 care planning 1.2 Medical service 1.3 Medication management 1.4 Advance care planning 1.5 Pain management 1.6 Falls prevention and mobility 1.7 Skin care and pressure ulcers 1.8 Oral hygiene and dental care 1.9 Continence management 1.10 Allied health services 1.11 Infection control 1.12 Food service

51 Domain 2 social aspects of care 2.1 Dignity of care 2.2 Psychosocial and Mental Health Care 2.3 Informed Care 2.4 Use of Restraint 2.5 Living environment - Premises 2.6 Living environment Facilities 2.7 Living environment Equipment 2.8 Ancillary services

52 Domain 3 governance and organizational excellence 3.1 General management duties and responsibilities 3.2 Duties and responsibilities of the Head of Nursing 3.3 Staff Organization and management 3.4 Staff training, competence and supervision 3.5 Financial management 3.6 Customer relations 3.7 Continuous improvement 3.8 Emergency preparedness

53 Mission statement Express purpose of the organization Define scopes of business Future oriented Contain core value that underpin organization behaviors and culture Provide staff with a sense of direction and common purpose

54 Abraham Maslow Self-actualization needs Esteem needs Love needs Safety needs Physiological needs

55 Exercise 2 1. Identify 1 standard from each domain 2. Why these are important for you 3. Develop at least one indicator from each standard to measure 4. How to track these quality indicators 5. How to share the quality indicators within the unit within the organization

56 Sharing of data It is information for staff to be aware of service performance Data can be shared by: Walk round management Quality Improvement Collaborative Benchmark Accreditation

57 Walk round management Demonstrate top level commitment Establish lines of communication about patient safety Provide opportunities for top management to learn about patient safety in the local settings Identify opportunities for improvement safety Encourage reporting Promote a culture for change Establish local solutions to minimize risk

58 Originated from IHI Quality collaborative Since 1995, IHI has sponsored over 50 [Breakthrough Collaborative) projects. Quality Improvement Collaborative (QIC) an approach emphasize collaborative learning & exchange of insights and support among a set of health care organizations

59 QIC QIC together study a specific health care quality problem Designing and implementing specific solution Evaluating & refining the solutions and disseminating the findings to other organization Adopt PDSA framework Mittman (2004) urged QIC has to acquire improved concepts of nature of quality problems, quality improvement processes through evidence-based approach

60 Benchmark An improvement process used to discover and incorporate best practices into operation The preferred process used to identify and understand the elements (causes) of superior or world-class performance in a particular work process

61 Accreditation A voluntary process by which a government or non-government agency grants recognition to the healthcare organization which meet certain standards that require continuous improvement in structure, process and outcome

62 References Barrs, I. J. Eevers, S.M. Arntz, A. & van Merode, G.G Performance measurement in mental health care: present situation and future possibilities. International Journal of Health Planning Management. Published online in Wiley InterScience DOI: /hmp.951 Department of Health Essence of Care Benchmarks for the Care Environment. Crown print. Lord Darzi (2009) High Quality Care for All. UK. Retrieved <10 May 2010> from Massoud, R. Askov, K. Reinke, J. Franco, L. M. Bornstein, T. Knebel,E. MacAulay, C. (2001). A Modern Paradigm for Improving Healthcare Quality. QA Monograph Series 1 (1). Bethesda MD: Published for the US Agency for International Development (USAID) by the Quality Assurance Project. Montalvo, L the National Database of Nursing Quality Indicatoes TM (NDNQI ). OJIN Online Journal of Issues in Nursing. Vol.12 No.3, Manuscript 2. National Quality Forum Safe Practice for Better Healthcare 2010 Update: A Consensus Report. Washington. DC:NQF Nicholls, S. Cullen, R. O Neill, S. & Halligan, A Clinical Governance: Its origins and its foundations. Clinical Performance and Quality Health Care, 8(3), Wolff, A. & Taylor, S. (2009). Enhancing Patient Care: A practical guide to improving quality and Safety in hospitals. Sydney: MJA Books. VA National Centre for Patient Safety. The Basics of Healthcare Failure Mode and Effect Analysis. Retrieved <31 August 2010> from