Measurement, Tracking,

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Measurement, Tracking, Reporting
National Nursing Home Improvement Collaborative
Donna M. Daniel, Ph.D., Qualis Health October
20, 2003 Prepared with assistance from Lloyd
Provost, Associates in Process Improvement and
the Institute for Healthcare Improvement
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Objectives

• Role measurement plays in this Collaborative
• Measuresrequired, additional, and balancing
• Pilot population
• Reporting
• Senior Leader Report components
• Registry and Run Charting Tool
• Customizing Run Charting Tool
• Other measurement strategies

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Using Measurement
You cant fatten a cow by weighing it.

Palestinian Proverb
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Measurement for Improvement vs. Research

• Clinical Research
• Aim New knowledge
• Methods
• Test blinded
• Eliminate bias
• Just in case
• Fixed hypotheses
• One large test

• Improvement
• Aim Improvement of care
• Methods
• Test observable
• Stable bias
• Just enough data
• Adaptation of the changes
• Sequential tests

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Different Types of Measurement

• PDSA cycle measurement
• Small-scale
• Qualitative and quantitative data
• Does not affect run charts, typically
• Key or global measures
• Affects entire population of focus, thus affects
  run charts
• Quantitative
• Spread measures
• Largest scale, generally
• May differ in style of measurement

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Key Measurement Guidelines

• Support teams aim statement.
• Use existing data collection systems, if
  available.
• Integrate measurement into the daily routine.
• Plot measures each month.
• Use a balanced set of five to seven measures.

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Tools
www.qualishealth.org/nnhic.htm

• National Nursing Home Improvement Collaborative
• Team-Shared Tools and Resources
• For Participants Only

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Outcome Measures

• of days between new nosocomial pressure ulcers
• Prevalence of pressure ulcers
• of pressure ulcers showing improvement
• Median days to healing

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Use time between for rare events
Instead of plotting the number of incidences each
month, plot the time (or number of cases,
patients, visits, etc) between incidences.
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Process Measures

• of admissions with prompt risk assessment
• of at-risk residents with daily assessments
• of pressure ulcers with PUSH score weekly
• of at-risk residents who have pressure-reducing
  support surface (bed and chair)

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Family of Measures Pressure Ulcer Prevention
Treatment
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Balancing Measures

• of residents with new nosocomial stage I
  pressure ulcers
• staff satisfaction
• resident/family satisfaction

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Population of Focus for Collaborative

• NH
• All Residents
• All Residents except specific subset (e.g.,
  residents on short stay unit)
• QIOP
• One Nursing Home in corporation
• QIO
• One (or two) Nursing Home(s) in state

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Population of Focus for Spread

• NH
• Other areas of care (e.g., pain management)
• Extend to subset (e.g., short stay residents)
• QIOP
• All other Nursing Homes in corporation
• QIO
• All other Nursing Homes in state

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Monthly Senior Leader ReportComponents

• Aim statement
• Description of population of focus
• Definition of key measures
• Brief description of key changes
• Annotated run charts
• Summary

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Minimum Standard for Monthly Reporting in the
Collaborative Annotated Run Chart
Wound Care RN
Staff not oriented to new process
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Patient Satisfaction Graphs
Overall Satisfaction
Respect
Comfort
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Examples

• Measure of pressure ulcers improved
• Residents on unit A
• Residents with stage IV pressure ulcers
• Residents with poor nutrition
• Residents with Braden score

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Methods for Addressing Competing Events when
Testing Changes (optional)

• Scientific evidence supports the change
• PresenceDocument rival explanations and use
  knowledge of the setting to attempt to rule them
  out
• Make observations more frequently
• Go beyond the simple time series design
• Remove the change, or a component of the change
• Stagger the change in multiple time series
• Add a control group