quality reporting and improvement using technology mike hindmarsh hindsight healthcare strategies...
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Quality Reporting and Improvement Using
Technology
Mike Hindmarsh
Hindsight Healthcare StrategiesCincinnati, OH
June 18, 2010
How Do We Know That a Change is an Improvement?
“When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it,
when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind.”
Lord Kelvin, May 3, 1883
Measuring Performance for Improvement
We cannot improve what we cannot measure IT is a critical success factor in gather
improvement data Understanding how to get data out of your
EMR is essential Garbage in, Garbage out “Why bother, I’m doing okay in practice!”
Different Purposes for MeasurementAspect Improvement Research
Aim Improvement of care New knowledge
Methods: Test Observability
Test observable Test blinded or controlled
Bias Accept consistent bias Design to eliminate bias
Sample Size “Just enough” data, small sequential samples
“Just in case” data
Flexibility of Hypothesis
Hypothesis flexible, changes as learning takes place
Fixed hypothesis
Testing Strategy Sequential tests One large test
Determining if a Change is an Improvement
Run charts or Shewhart control charts
Hypothesis, statistical tests (t-test, F-test, chi square),
p-values
Confidentiality of the Data
Data used only by those involved with improvement
Research subjects’ identities protected
Getting Started:Identify your population
Create a query that identifies the population (e.g., ICD-9 codes)
Be sure to code populations the same way. Don’t “over-worry” about the accuracy of case
finding: you can clean it up as you go. Get baseline data in the easiest, fastest fashion
possible…..if it’s hard to program, leave it for later! Don’t obsess about baseline data accuracy! Select measures that you can impact and have clinical
relevance
For Each Measure
Use measures from evidence-based guidelines Create concrete operational definitions to
capture data from you IT in a reliable, consistent manner
Use the reporting template to display your measures as quickly as possible.
Set goals based on evidence or best pratice Gather data monthly (quarterly at a minimum!)
Example of Improvement Measures: Diabetes
% with A1c<7 % with BP<130/80 % on ACE1 or ARB % with LDL<2.0 nmol/l % screened for microalbumen % with eye screen in last 24 months % with foot exam in last 12 months % with A1c in last six months % with documented self-mgmt goals in medical
record
Annotated Time Series
Percent of Patients with Documented Self-mgmt. Goals
0
10
20
30
40
50
60
70
80
90
100
Mar
-99
Apr
-99
May
-99
Jun-
99
Jul-9
9
Aug
-99
Sep
-99
Oct
-99
Nov
-99
Dec
-99
Jan-
00
Feb
-00
Mar
-00
Apr
-00
May
-00
Jun-
00
Jul-0
0
Aug
-00
Sep
-00
Per
cen
t of P
atie
nts
in R
egis
try
Goal=90%
Cycle 1: Dr. Smith/ 3 patients
Cycle 2: Test of Group Visit
Cycle 3: 8 patients self measuring blood glucose
“This type of data reporting isn’t reliable!!”
Yes it is….for quality improvement purposes! Trending is what you are looking for…not statistical
reliability. Your “goal” is to improve population outcomes over
your usual care by changing care for every patient: the annotated time series (run chart) will tell you if you are succeeding!
70
35
0
10
20
30
40
50
60
70
80
Before Change After Change
Per
cen
t o
f D
iab
etic
s in
Reg
istr
y
Improvement in Glycemic Control Percent of (Patients with HbA1c >9 in Clinic A)
Improvement in Glycemic Control (% of Population with HbA1C >9 in Clinic A)
0102030405060708090
100d
ate
Jan
Feb
Mar
Ap
r
May
Jun
Jul
Au
g
Sep Oct
No
v
Dec
Change Implemented
% o
f D
iab
etic
s in
Reg
istr
y
70
35
0
10
20
30
40
50
60
70
80
Before Change After change
Per
cen
t o
f D
iab
etic
s in
Reg
istr
y
Improvement in Glycemic Control (% of Population with HbA1C >9 Clinics B and C)
Improvement in Glycemic Control (% of Population with HbA1C >9 in Clinic B)
0102030405060708090
100
dat
e
Jan
Feb
Mar
Ap
r
May Ju
n
Jul
Au
g
Sep Oct
No
v
Dec
Change Implemented
% o
f D
iab
etic
s in
Reg
istr
y
Improvement in Glycemic Control (% of Population with HbA1C >9 in Clinic C)
0102030405060708090
100d
ate
Jan
Feb
Mar
Ap
r
May
Jun
Jul
Au
g
Sep Oct
No
v
Dec
Change Implemented
% o
f D
iab
etic
s in
Reg
istr
y
Month
Mar-99
Apr-99
May-99
Jun-99
Jul-99
Aug-99
Sep-99
Oct-99
Nov-99
Dec-99
Jan-00
Feb-00
Mar-00
Apr-00
May-00
Jun-00
Key Measur
e
0
10
20
un
its
Percent of Patients with 2 HbA1c's in Last Year
0
20
40
60
80
100
Mar-99 Apr-99 May-99 J un-99 J ul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 J an-00 Feb-00 Mar-00 Apr-00 May-00 J un-00
pe
rce
nt
Goal
Percent of Patients with HbA1c > 9.0%
20
30
40
50
60
70
80
90
100
Mar-99 Apr-99 May-99 J un-99 J ul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 J an-00 Feb-00
pe
rce
nt
Goal
Average HbA1c Values for Diabetic Patients
7
7.5
8
8.5
9
9.5
10
10.5
11
Mar-99 Apr-99 May-99 J un-99 J ul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 J an-00 Feb-00
ave
rag
e
Goal
Percent of Patients with Documented Self-Management Goals
0
20
40
60
80
100
Mar-99 Apr-99 May-99 J un-99 J ul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 J an-00 Feb-00
pe
rce
nt
Goal
Population and Currrent Size of Registry
0
50
100
150
200
Mar-99 Apr-99 May-99 J un-99 J ul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 J an-00 Feb-00
nu
mb
er
in r
eg
istr
y
Population size
Run Charts of Monthly Measures - Diabetes Population
Summary
Define your population with carefully thought out queries
Obtain baseline data on relevant measures through structured queries
Produce regular reports for improvement activities
Set targets/goals for imporvement based on best practice
Be ambitious!