1 Building a Measurement System That Works Session B7 13 April 2016 1330 – 1500 Robert Lloyd, Ph.D. Vice President, Institute for Healthcare Improvement Gary Sutton, BSc (Honors) Statistician International Forum on Quality and Safety in Healthcare Gothenburg Sweden The presenters have nothing to declare IHI Faculty (bio sketches can be found at the end of this presentation) Gary Sutton, BSc (Honors) Scottish Government, Statistician Improvement Advisor; Scotland [email protected]@scotgov_ia Robert Lloyd, PhD Vice President, Institute for Healthcare Improvement [email protected]@rlloyd66
51
Embed
Building a Measurement System That Worksaws-cdn.internationalforum.bmj.com/pdfs/2016_B7_Robert_Lloyd_Gary_Sutton.pdfApr 13, 2016 · Building a Measurement System That Works Session
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Building a Measurement System That Works
Session B713 April 20161330 – 1500
Robert Lloyd, Ph.D.Vice President, Institute for Healthcare Improvement
Gary Sutton, BSc (Honors) Statistician
International Forum on Quality and Safety in Healthcare
Gothenburg Sweden
The presenters have
nothing to declare
IHI Faculty(bio sketches can be found at the end of this presentation)
Gary Sutton, BSc (Honors) Scottish Government, Statistician
From a food science perspective, it is difficult to define a food product that is 'natural' because
the food has probably been processed and is no longer the product of the earth. That said,
FDA has not developed a definition for use of the term natural or its derivatives. However, the
agency has not objected to the use of the term if the food does not contain added color,
artificial flavors, or synthetic substances.
What is the definition of 'natural' on the label of food?
September 23, 1999An expensive operational definition
problem!
NASA lost a $125 million Mars orbiter because one engineering team used metric units (newton-seconds) to guide the spacecraft while the builder (Lockheed Martin) used pounds-second to calibrate the maneuvering operations of the craft.
Information failed to transfer between the Mars Climate Orbiter spacecraft team at Lockheed Martin in Colorado and the mission navigation team in California. The confusion caused the orbiter to encounter Mars on a trajectory that brought it too close to the planet, causing it to pass through the upper atmosphere and disintegrate.
16
How do you define the following healthcare concepts?
• Medication error• Co-morbid conditions• A healthy life style• Cancer waiting times• Health inequalities• Asthma admissions• Childhood obesity• Patient education• Health and wellbeing• Adding life to years and years to life• Children's palliative care • Safe services• Smoking cessation• Urgent care• Complete history & physical• Surgical Screening
• Delayed discharges
• End of life care
• Falls (with/without injuries)
• Childhood immunizations
• Complete maternity service
• Patient engagement
• Moving services closer to home
• A well-baby visit
• Ambulatory care
• Access to health in deprived areas
• Diagnostics in the community
• Productive community services
• Vascular inequalities
• Breakthrough priorities
ExampleMedication Error Operational Definition
Measure Name: Percent of medication errors
Numerator: Number of outpatient medication orders with one or more errors. An error is defined as: wrong med, wrong dose, wrong route or wrong patient.
Denominator: Number of outpatient medication orders received by the family practice clinic pharmacy.
Data Collection:
• This measure applies to all patients seen at the clinic
• The data will be stratified by type of order (new versus refill) and patient age
• The data will be tracked daily and grouped by week
• The data will be pulled from the pharmacy computer and the CPOE systems
• Initially all medication orders will be reviewed. A stratified proportional random sample will be considered once the variation in the process is fully understood and the volume of orders is analyzed.
17
• Select one measure for your project (outcome or process) and write a clear and specific Operational Definition.
• Is the measure clearly defined? If you gave the definition of your measure to another person would they know precisely what you are attempting to measure?
• Are you clear about the name of the measure, what is to be included and the measurement steps required to obtain data?
• Use the Operational Definition Worksheet to record your responses.
ExerciseBuilding Your Operational Definitions
34
Measure Name: ________________________________________(Remember this should be specific and quantifiable, e.g., the time it takes to…,the number
of…, the percent of… or the rate of…)
Operational DefinitionDefine the specific components of this measure. Specify the numerator and denominator if
it is a percent or a rate. If it is an average, identify the calculation for deriving the average.
Include any special equipment needed to capture the data. If it is a score (such as a patient
satisfaction score) describe how the score is derived. When a measure reflects concepts
such as accuracy, complete, timely, or an error, describe the criteria to be used to determine
“accuracy.”
Operational Definition Worksheet
See Appendix D for a detailed Operational Definition worksheet
18
� Operational definitions are not universal truths!
� Operational definitions require agreement on terms, measurement methods and decision criteria.
� Operational definitions need to be reviewed periodically to make sure everyone is still using the same definitions and that the conditions surrounding each measure have not changed.
Conclusions:Developing Operational Definitions
36
AIM (How good? By when?)
Concept
Measure
Operational Definitions
Data Collection Plan
Data Collection
Analysis ACTION
Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004.
Milestones in theQuality Measurement Journey
19
Stratification
• Separation & classification of data according to predetermined categories
• Designed to discover patterns in the data
• For example, are there differences by shift, time of day, day of week, severity of patients, age, gender or type of procedure?
• Consider stratification BEFORE you collect the data
Common Stratification Levels
� Day of week
� Shift
� Severity of patients
� Gender
� Type of procedure
� Unit
� Age
What stratification
levels are appropriate
for your data?
20
Sampling
When you can’t capture data on the
entire population (an enumeration), you can estimate its characteristics
Four run rules are used to determine if non-random variation is present
How do we analyze a Run Chart
“How will I know what the Run Chart is trying
to tell me?”
It is actually quite easy:
1. Determine the number of runs.
2. Then apply the 4 basic run chart
rules decide if your data reflect
random or non-random variation.
33
What is a Run?• One or more consecutive data points
on the same side of the Median
• Do not include data points that fall on
the Median
First, you need to determine the Number of Runs
Me
as
ure
Time
X (CL)~
How many Runs on this chart?
Points on the Median (don’t count these when counting the number of runs)
Run = a series of consecutive data points above or below the median.
Ignore points on the median.
34
Me
as
ure
Time
X (CL)~
Draw circles around the individual runs
Did you identify 7 runs?
Now apply the Run Chart Rules to Identify any non-random patterns in the data
• Rule #1: A shift in the process, or too many data points in a run (6 or more consecutive points above or below the median)
• Rule #2: A trend (5 or more consecutive points all increasing or decreasing)
• Rule #3: Too many or too few runs (use a table to determine this one)
• Rule #4: An “astronomical” data point
68
35
Rule 1 – A Shift
A shift in the process is six or more consecutive points either all above or all below the median. Values that fall on the median do not add to nor break a shift. Skip values that fall on the median and continue counting.
Data line crosses only onceToo few runs: total of only 2 runs
Rule #3: Requires a reference table
72
Use this table by first calculating the number of "useful observations" in your data set. This is done by subtracting the number of data points on the median from the total number of data points. Then, find this number in the first column. The lower number of runs is found in the second column. The upper number of runs can be found in the third column. If the number of runs in your data falls below the lower limit or above the upper limit then this is a signal of a special cause.
# of Useful Lower Number Upper Number Observations of Runs of Runs
It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system.
For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who would gain by the new one.
A closing thought…
Machiavelli, The Prince, 1513Machiavelli, The Prince, 1513Machiavelli, The Prince, 1513Machiavelli, The Prince, 1513
96
Appendices
•Appendix A: General References on Quality
• Appendix BC: References on Measurement
• Appendix C: Operational Definition Worksheet
• Appendix D: Faculty Bios
49
97
Appendix AGeneral References on Quality
• The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996.
• Quality Improvement Through Planned Experimentation. 2nd edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998.
• The Improvement Handbook. Associates in Process Improvement. Austin, TX, January, 2005.
• A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.
• “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,”Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997.
98
Appendix BReferences on Measurement
• Carey, R. and Lloyd, R. Measuring Quality Improvement in healthcare: A Guide to Statistical Process Control Applications. ASQ Press, Milwaukee, WI, 2001.
• Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004.
• Nelson, E. et al, “Report Cards or Instrument Panels: Who Needs What?Journal of Quality Improvement, Volume 21, Number 4, April, 1995.
• Provost, L. and Murray, S. The Health Care Data Guide. Jossey-Bass Publishers, 2011.
• Solberg. L. et. al. “The Three Faces of Performance Improvement: Improvement, Accountability and Research.” Journal of Quality Improvement23, no.3 (1997): 135-147.
50
Team name: _____________________________________________________________________________
WHAT SPECIFIC MEASURE DID YOU SELECT FOR THIS PROCESS?
OPERATIONAL DEFINITIONDefine the specific components of this measure. Specify the numerator and denominator if it is a percent or a rate. If it is an average, identify the calculation for deriving the average. Include any special equipment needed to capture the data. If it is a score (such as a patient satisfaction score) describe how the score is derived. When a measure reflects concepts such as accuracy, complete, timely, or an error, describe the criteria to be used to determine “accuracy.”
Appendix COperational Definition Worksheet
Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett, 2004.
DATA COLLECTION PLANWho is responsible for actually collecting the data?How often will the data be collected? (e.g., hourly, daily, weekly or monthly?)What are the data sources (be specific)?What is to be included or excluded (e.g., only inpatients are to be included in this measure or only stat lab requests should be tracked).How will these data be collected?Manually ______ From a log ______ From an automated system
BASELINE MEASUREMENTWhat is the actual baseline number? ______________________________________________What time period was used to collect the baseline? ___________________________________
TARGET(S) OR GOAL(S) FOR THIS MEASUREDo you have target(s) or goal(s) for this measure?Yes ___ No ___
Specify the External target(s) or Goal(s) (specify the number, rate or volume, etc., as well as the source of the target/goal.)
Specify the Internal target(s) or Goal(s) (specify the number, rate or volume, etc., as well as the source of the target/goal.)