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How To Measure Quality Improvement In Healthcare

How can a hospital assess and raise the quality of patient care? Learn the basic principles of quality improvement and how to measure the process.

Tricia, Senior Consultant at ClearPoint, leverages her 4+ years of performance management experience when working with customers to improve their reporting and strategy execution.

What’s the most important measure in healthcare? Speed is interesting and needed for urgent care, but not all healthcare is urgent. Cost is important as well, but varies widely and involves many complex factors. Quality—otherwise known as getting it right the first time—is the most important measure in healthcare because it directly influences speed, cost, and everything in between. Whether it’s patient lengths of stay and rates of readmission or hospital costs for additional treatments and system process errors, quality is the determining factor.

Once you accept it’s the most important measure, defining quality and figuring out how to measure it within your organization is the next challenge. Medicare has begun to offer guidance by introducing a hospital value-based purchasing program. The program assesses the clinical process, patient experience, outcomes, and efficiency of the hospital. In short, Medicare has started to define quality measures for reimbursement rates. But you’ll want to implement measures for more reasons than reimbursement rates. In this article, we’ll walk you through quality improvement principles, as well as best practices for developing healthcare measures for quality in your organization.

Principles Of Quality Improvement In Healthcare

Because healthcare is so personalized to the patient, it’s sometimes considered hard to apply quality improvement processes. And yet more and more hospitals are proving that theory wrong. Healthcare systems and processes can coexist with personalized care—the organization’s “back-end” operations can impact the individual patient’s well-being to an extent that quality improvement measures can be implemented.

Because healthcare is so personalized to the patient, it’s sometimes considered hard to apply quality improvement processes. And yet more and more hospitals are proving that theory wrong. Click To Tweet

As introduced by Health Catalyst, there are five guiding principles that healthcare organizations can use to successfully implement quality improvement initiatives:

Principle 1: Promote hands-on improvement projects.

High-level strategy discussions and ideas aren’t enough to promote quality improvement in healthcare. Hands-on work aids the adoption of quality improvement projects because staff and physicians can see the direct impact in real-life situations. It also incentivizes internal teams when the organization identifies an area that needs improvement, and encourages staff and physicians to play an active part in the strategy.

Principle 2: Get buy-in on what “quality” means.

Part of the difficulty in defining quality improvement stems from the word “quality” itself. It’s subjective, and organizations sometimes suffer from internal clashes on how to characterize those seven letters. It’s important to get buy-in across the organization on exactly what quality means so you can objectively determine if it’s improving. However you decide to define quality, it should be measurable and revolve around patients. Healthcare organizations are guided by a mission to improve the lives of patients, so your definition of quality should overlap with how you care for them.

Principle 3: Focus measures on improvement vs. accountability.

Since quality improvement in healthcare revolves around the patient, performance measures should focus on improvement rather than accountability. When accountability is overemphasized, the needs of the patient are superseded and quality improvement can’t be applied. For example, a typical accountability measure might collect data on the percentage of ER patients who waited more than 30 minutes, and hold management accountable for keeping wait times under 30 minutes. A better tactic would focus on the system and collect actual wait time data in minutes to measure performance, instead of just focusing on the person who’s held accountable for those wait times. By taking this approach, a process can be improved.

Principle 4: Use an established quality improvement framework.

There are plenty of quality improvement frameworks to choose from, but the most successful take an iterative, methodical approach rather than making sweeping changes all at once. Here are two popular framework examples:

Six Sigma DMAIC Model

The DMAIC model is used for Six Sigma projects, but is also a general framework healthcare organizations can apply to quality improvement projects. The data-driven strategy takes a cyclical approach to optimizing and stabilizing processes. It includes five phases that form its acronym:

  • Define: Outline the problem.
  • Measure: Quantify the problem.
  • Analyze: Identify the cause of the problem.
  • Improve: Implement and verify the solution.
  • Control: Maintain the solution.

Six Sigma DMAIC can be implemented as a standalone quality improvement project or as part of larger healthcare quality management initiatives.

Model for Improvement

The Model for Improvement was developed by the Associates in Process Improvement. Tongue-twisting names aside, this is one of the most commonly used quality improvement frameworks in healthcare. It asks three fundamental questions:

  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in improvement?

To answer these questions, an organization creates goals, aims (subsets of goals), and interventions (changes to the system or process). Interventions specifically address the third fundamental question above and follow a PDSA (plan, do, study, act) cycle, which tests changes to see their effect on outcomes. The Model for Improvement is successful because changes are always incremental—they start small, are tested, applied more broadly, tested again, and then implemented. And, as with the DMAIC, it’s an iterative process. The quality improvement framework repeats itself to ensure reliability of results and continual improvement efforts.

Principle 5: Understand intended and unintended data variation.

When making changes to processes or systems, there will be both intended and unintended results. Strong healthcare business management involves being able to recognize and understand these two types of data variation. Intended variation is purposeful change, whereas unintended variation is accidental change, which can sometimes impede your long-term quality improvement goals.

Realize from the outset that unintended variation is inevitable and naturally occurring. It’s impossible to control every result when making changes in your organization. If you have an unintended variation that doesn't align well with your overall goal, adjust that goal or create a new goal entirely.

This is also why the iterative frameworks mentioned in Principle 4 are so important—making small, phased manipulations in a repetitive manner allows you to more accurately measure the data and understand what change (intentional or unintentional) caused a certain result.

Best Practices For Measuring Quality Improvement In Healthcare

The specifics of how you weigh and measure quality improvement will vary, but these best practices are foundational:

Integrate quality improvement into your organization’s daily life.

Your quality improvement efforts should be fully integrated into your healthcare processes and procedures. If quality improvement is an afterthought, or seen as a divergent effort within the organization, it won’t be successful. Get everyone on board—quality must be an accepted and embraced part of your internal culture. You can create this culture of providing the best service to patients by forming quality improvement teams, holding regular quality improvement meetings, publishing goals and results, and more.

Identify potential areas for improvement.

A healthcare organization is a complex machine and it’s not easy to determine and prioritize areas that could be improved. What does your patient population data tell you? Where are stumbling blocks in your current operations? Several national forums can guide you in the process for identifying areas to apply quality improvement, such as the Agency for Healthcare Research and Quality. This federal agency outlines three types of quality measures:

  • Structural measures: The healthcare organization’s capacity, systems, and processes, such as number of physicians, types of technology, and physician-to-patient ratios.
  • Process measures: What is done to maintain or improve health, like percentage of people who received preventive services and length of patient wait time.
  • Outcome measures: The impact of healthcare services, such as results of care. (Risk adjustments are typically included to account for factors out of the hospital’s control.)

Collect and analyze data.

Data is the only objective way to prove whether your quality improvement efforts have been successful. It’s critical to have a team that collects data and tracks it against quality improvement measures and goals. Most importantly, the team will analyze and interpret the metrics so your healthcare organization can make better, data-backed decisions. This is a long-term commitment—data should be collected and analyzed prior to a project to set a baseline, during the project, and on-going after a project ends to assess lasting results.

Are you collecting the right data? Here are 108 healthcare KPIs and measures you might want to track.

Involve teams and share results.

Transparency is key to quality improvement in healthcare organizations. Include your staff, physicians, and even patients in the planning and implementing phases of quality improvement projects; then, share the results of your efforts with everyone. Also share your results with other healthcare organizations. Open communication will shorten your path to improvement and establish your facility as a leader in the industry.

Plan on continuous evaluation.

Quality improvement never ends. The best healthcare organizations have embedded quality into their culture and continually strive to improve their performance and patient care. This includes implementing new improvement processes and revisiting previous processes to ensure they are still helping your organization move forward. Plan to dedicate resources to this process on an ongoing basis.

An Example Of Quality Improvement In Healthcare

In 2011, the Cincinnati Children’s Hospital Medical Center was struggling with patient flow. Unnecessarily long patient stays, unpredictable discharges, and process delays were raising costs for both the hospital and patients. To address these challenges, the hospital’s quality improvement team developed standard discharge criteria for 11 common inpatient diagnoses and embedded these criteria in electronic medical records. Nurses could more easily track when patients hit discharge goals, doctors could better prioritize patients, prescriptions were filled faster, and overall discharge processes were smoother and tailored to patients’ needs.

By 2014, 80 percent of eligible patients were discharged within two hours of meeting the established criteria. More efficient discharges led to shorter lengths of stay and more beds for higher acuity patients. This resulted in an estimated $5.9 million in cost savings to the hospital and families.

This is just one example of how quality improvements can make a dramatic impact on patient lives and produce substantial savings. When implemented in an effective framework and measured properly, quality improvement initiatives can change the way your hospital works, from internal culture to patient care.

 

How To Measure Quality Improvement In Healthcare