Measurement Of Quality Indicators Research Articles

A Community Breast Center Report Card Determined by Participation in the National Quality Measures for Breast Centers Program

Measurement of quality indicators and peer comparison has been demonstrated to improve quality of care. The goal of this study was to determine whether a community breast center, in collaboration with the National Consortium of Breast Centers (NCBC), could voluntarily audit the quality of breast cancer care, confidentially transmit quality information to the NCBC, and receive peer performance comparisons. Quality indicator metrics from consecutive breast cancer patients undergoing care at a community interdisciplinary breast center were entered into a prospective database of quality measures that were defined by the NCBC. Retrospective review of patients from 2004 to 2006 was performed and subsequent quality indicator data was submitted electronically to the NCBC National Quality Measures for Breast Centers (NQMBC(TM) ) program. The percentage of new cancer diagnoses made by needle biopsy techniques was 94%, 95% and 96% from 2004 to 2006. Sentinel lymph node utilization in eligible patients was 93%, 96% and 91% from 2004 to 2006 and the immediate intraoperative pathologic frozen section false negative rate of the sentinel lymph node was 6.5%, 4.7% and 4%. Chart documentation of "patient participation in shared decision making for breast conserving therapy versus mastectomy" improved from 74% to 99% (p<0.05) from 2004 to 2006. Adjuvant systemic treatment for stage 2 breast cancer occurred in 76%, 89% and 77% of patients from 2004 to 2006. Neutropenia requiring hospital admission occurred in no patients in 2004 but in 4.8% and 2.9% in 2005 and 2006. The re-excision lumpectomy rates for stage 0, 1, 2, and 3 breast cancer patients from 2004 to 2006 was 14.2%, 22% and 24.8%. Quality indicator data was submitted to the NQMBC(TM) with successful confidential receipt of peer performance comparisons. Voluntary interdisciplinary institutional audits of breast cancer quality can be successfully submitted to the NQMBC(TM) with confidential peer performance comparison.

Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up.

BackgroundThe gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation.MethodsSix psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study.ResultsThe documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months.ConclusionsCompliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.

Evaluation of β‐Glucosidase Activity as a Soil Quality Indicator for the Soil Management Assessment Framework

The Soil Management Assessment Framework (SMAF) was developed to assess conservation effects on soil, and uses multiple soil quality indicator measurements to compare soil functioning. Our objective was to develop a SMAF‐compatible scoring equation for soil β‐glucosidase (BG) activity using published data sets representing different soils and management. The resulting equation was an S‐shaped curve: y = a/[1 + bexp(−cx)], where x is the measured BG activity (mg p‐nitrophenol [PNP] released kg−1 soil h−1), a and b are constants, and c is a factor modified by soil classification, texture, and climate. Data from a study conducted near Mandan, ND were used to test the model for sensitivity to crop management systems. Soil organic C (SOC) content at the site measured 247 to 687 g kg−1, while BG activity ranged from 33 to 675 mg kg−1 h−1 Using SMAF, SOC indicator scores ranged from 0.25 to 0.73, while BG activity scores varied from 0.17 to 0.93. As the work progressed, it became apparent that when BG activity values were normalized to the SOC content, the resulting ratio could indicate C sequestration trends, with ratios of 10 to 17 g PNP kg−1 SOC h−1 reflective of systems in equilibrium. Ratios &gt;17 were mostly from recently altered management systems with SOC contents trending upward, while ratios &lt;10 were generally from soils that were expected to continue to lose soil C. The application of a sensitive C cycling enzyme activity such as BG should improve the SMAF soil quality assessments for soil functions where soil metabolic activity or C‐cycle enzyme activity play a role.

Assessment of the quality of colonoscopy reports: results from a multicenter consortium

To improve colonoscopy quality, reports must include key quality indicators that can be monitored. To determine the quality of colonoscopy reports in diverse practice settings. The consortium of the Clinical Outcomes Research Initiative, which includes 73 U.S. gastroenterology practice sites that use a structured computerized endoscopy report generator, which includes fields for specific quality indicators. Prospective data collection from 2004 to 2006. Reports were queried to determine if specific quality indicators were recorded. Specific end points, including quality of bowel preparation, cecal intubation rate, and detection of polyp(s) >9 mm in screening examinations were compared for 53 practices with more than 100 colonoscopy procedures per year. Of the 438,521 reports received during the study period, 13.9% did not include bowel-preparation quality and 10.1% did not include comorbidity classification. The overall cecal intubation rate was 96.3%, but cecal landmarks were not recorded in 14% of the reports. Missing polyp descriptors included polyp size (4.9%) and morphology (14.7%). Reporting interventions for adverse events during the procedure varied from 0% to 6.5%. Among average-risk patients who received screening examinations, the detection rate of polyps >9 mm, adjusted for age, sex, and race, was between 4% and 10% in 81% of practices. Bias toward high rates of reporting because of the standard use of a computerized report generator. There is significant variation in the quality of colonoscopy reports across diverse practices, despite the use of a computerized report generator. Measurement of quality indicators in clinical practice can identify areas for quality improvement.

Strategic Initiatives to Ensure Sustainability of a University Health Center

A university health center was faced with the challenge of ensuring long-term sustainability. A project was undertaken to assess and implement administrative and financial strategic initiatives that would support and ensure sustainability. As a result of these initiatives, primary care services reflective of the mission of the University would continue to be provided to students, faculty, staff, and community members in a fiscally responsible manner. Client outcomes were also identified through the measurement of quality indicators and patient satisfaction. Financial stability was a major impact of the project. After several years of experiencing significant financial loss, a cost assessment was conducted; as a result, the operations of the Health Center now demonstrate fiscal responsibility.

Hospital quality of care

Hospitals have been slow to adopt information technology (IT) largely because of a lack of generalizable evidence of the value associated with such adoption. To explore the relationship between IT adoption and quality of care in acute-care hospitals. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between various measures of IT adoption and several quality indicators after controlling for confounders. Adoption of IT was measured using a previously validated method that considers clinical, administrative, and strategic IT capabilities of acute-care hospitals. Quality measures included the Inpatient Quality Indicators developed by the Agency for Healthcare Research and Quality. Data from 98 hospitals were available for analyses. Hospitals adopted an average of 11.3 (45.2%) clinical IT applications, 15.7 (74.8%) administrative IT applications, and 5 (50%) strategic IT applications. In multivariate regression analyses, hospitals that adopted a greater number of IT applications were significantly more likely to have desirable quality outcomes on seven Inpatient Quality Indicator measures, including risk-adjusted mortality from percutaneous transluminal coronary angioplasty, gastrointestinal hemorrhage, and acute myocardial infarction. An increase in clinical IT applications was also inversely correlated with utilization of incidental appendectomy, and an increase in the adoption of strategic IT applications was inversely correlated with risk-adjusted mortality from craniotomy and laparoscopic cholecystectomy. Hospital adoption of IT is associated with desirable quality outcomes across hospitals in Florida. These findings will assist hospital leaders interested in understanding better the effect of costly IT adoption on quality of care in their institutions.

Ontario, Canada: Using Networks to Integrate Palliative Care Province-Wide

Ontario, a Canadian province, identified the lack of coordination, integration, and consistency of end-of-life care services as barriers to quality palliative care. To address these barriers, various governmental, organizational, and community-level initiatives were implemented. The Ministry of Health and Long-Term Care enacted an End-of-Life Care Strategy in 2005 aimed at shifting care from acute settings to appropriate alternate settings of care; enhancing client-centered and interdisciplinary service capacity; and improving access, coordination, and consistency of services. Crucial to accomplishing the strategy was the establishment of End-of-Life Networks within health care planning regions. The networks were instrumental in developing end-of-life care service delivery models in the various regions, bringing key stakeholders together toward a common vision, and building strong collaborations across providers and settings. Cancer Care Ontario, an organization dedicated to improving cancer care at the regional and provincial levels, also leads improvements in palliative care through the implementation of a palliative strategy for cancer patients aimed at improved measurement of quality indicators, increased use of evidence and standards, and increased efficiency and access to care. A regional network of organizations in Southeastern Ontario created a quality improvement project, the Palliative Care Integration Project (PCIP), which disseminated common symptom assessment tools, collaborative care plans, and evidence-based guidelines across the continuum of care. The PCIP was embraced by key stakeholders across the province as a model intervention to better coordinate, integrate, and standardize palliative care service delivery, and is currently being spread across all regions of the province.

The quality dilemma

In the language and logic of the free market, providers of health care will have to demonstrate the quality of their work. However, in this setting quality is only interpreted in quantitative ways and consequently does not necessarily do justice to good physicians. Moreover, both outcome measures and process measures have serious drawbacks. An emphasis on outcome measures will disadvantage physicians working in deprived areas and doctors managing more complicated cases. Although process measures give the most direct information on the physician's performance, their evidence base is not always as straightforward as commonly supposed. Finally, measurement of quality indicators is complicated and time consuming. Physicians should be aware of the drawbacks of quality measurement and of the poor effects of quality improvement strategies on patient outcomes.

Health information technology: will it make higher quality and more efficient healthcare delivery possible?

Holding a new promise for improving efficiency and quality and reducing cost, Health Information Technology (HIT) has become the latest national priority. Selecting three evidence-based national quality indicator systems/models as examples, this paper examines relationships between quality of care and HIT as well as their economic implications. The analysis focuses on the three systems' overall goals; targeted healthcare facilities; data sources; quality indicator measures; data format/standardisation; stages of development; levels of adaptation; and complexity of IT infrastructure including inter-operability, patient involvement, resource requirements, and potential financial gains. The discussion concludes that although enormous challenges are ahead, through joint efforts by all partners and players relating to the healthcare system, the Electronic Health Record (EHR) information system has a potential to fundamentally transform the healthcare delivery to a high-quality and efficient system, which will ultimately benefit patients.

Improving quality of care: Challenges to implementing quality indicators

16030 Background: To assess the overall quality of cancer care, efforts seek consensus quality indicators that crosscut health services. Although pilot programs have collected and analyzed relevant clinical data, they have been unable to collect radiation oncology (RO) data detailed enough to assess the quality of services or to inform key decision makers. Quality Research in Radiation Oncology (QRRO) conducted retrospective surveys of national practice since 1973 with major positive impact on the quality of practice through recursive processes. Methods: From Donabedian’s model of quality assessment, QRRO analyzes crucial quality components by conducting Facilities, Process, and Outcomes Surveys. Survey design allows calculation of national averages for patients treated with RO and comparisons by key factors. Evolving data collection methods allow assessment of modern technologies. Methods start with definition and measurement of evidence-based quality indicators but allow greater detail and specification than most other quality measurement efforts. Results: QRRO showed that radiation dose affected outcomes for prostate cancer patients. Higher radiation doses were associated with improved local tumor control rates and treatment techniques affected toxicity rates. These results, presented widely in numerous venues, stimulated dose escalation clinical trials. Trials conducted in the USA all used QRRO results as critical data, providing the major impetus to test new directions in dose escalation and new methods to target delivery more precisely. National practice shifted to higher doses and use of conformal techniques. The dataset is unique in providing cross-sectional information on practice patterns with a wide variety of treatment approaches from many institutions and sufficient details of treatment delivery to allow examination of questions about quality and effects of techniques. Conclusions: Mounting societal demands for improvement in the quality of care, ever increasing complexity of radiation therapy, and escalating use of multi-modality treatment make continuing to measure, report, and improve quality of care in RO crucial to patients and the profession. Methods must keep pace with new technologies and techniques in radiation therapy. [Supported by NCI grant CA 65435]. No significant financial relationships to disclose.

Comparison and Verification of Bacterial Water Quality Indicator Measurement Methods Using Ambient Coastal Water Samples

More than 30 laboratories routinely monitor water along southern California's beaches for bacterial indicators of fecal contamination. Data from these efforts frequently are combined and compared even though three different methods (membrane filtration (MF), multiple tube fermentation (MTF), and chromogenic substrate (CS) methods) are used. To assess data comparability and quantify variability within method and across laboratories, 26 laboratories participated in an intercalibration exercise. Each laboratory processed three replicates from eight ambient water samples employing the method or methods they routinely use for water quality monitoring. Verification analyses also were conducted on a subset of wells from the CS analysis to confirm or exclude the presence of the target organism. Enterococci results were generally comparable across methods. Confirmation revealed a 9% false positive rate and a 4% false negative rate in the CS method for enterococci, though these errors were small in the context of within- and among-laboratory variability. Fecal coliforms also were comparable across all methods, though CS underestimated the other methods by about 10%, probably because it measures only E. coli, rather than the larger fecal coliform group measured by MF and MTF. CS overestimated total coliforms relative to the other methods by several fold and was found to have a 40% false positive rate in verification. Across-laboratory variability was small relative to within- and among-method variability, but only after data entry errors were corrected. One fifth of the laboratories committed data entry errors that were much larger than any method-related errors. These errors are particularly significant because these data were submitted in a test situation where laboratories were aware they would be under increased scrutiny. Under normal circumstances, it is unlikely that these errors would have been detected and managers would have been obliged to issue beach water quality warnings.

OPPORTUNITIES TO MEASURE CONSUMER PREFERENCE AND RETAIL SHELF PERFORMANCE USING INDIVIDUAL PRODUCT ID

Modern value chains are constantly seeking improved methods for information management and data capture. A major focus is track and trace technology. To increase the rate of adoption of this technology information should have multiple uses. This paper discusses an approach that uses individually identified product and a range of quality indicator measurements to infer consumer preferences for product at the point of sale. The technique is also useful to provide feedback on product performance on the retail shelf. Two products have been studied, tomatoes and flat mushrooms. Consumers show a preference for intense red tomatoes and will show this preference over a small band (L-value of 40.6 over 41.1 and hue angle of 51.0o over 49.0o). For mushrooms there is a preference for larger product (>55g), which moves more quickly off the shelf. The technique also enables demonstration of product deterioration on retail shelves. For example firmness and colour change in tomatoes is significant, and mushrooms can lose over 30% of their weight over 3.5 days on a retail shelf.

Comparison of beach bacterial water quality indicator measurement methods.

Three methods (membrane filtration, multiple tube fermentation, and chromogenic substrate technology kits manufactured by IDEXX Laboratories, Inc.) are routinely used to measure indicator bacteria for beach water quality. To assess comparability of these methods, quantify within-laboratory variability for each method, and place that variability into context of variability among laboratories using the same method, 22 southern California laboratories participated in a series of intercalibration exercises. Each laboratory processed three to five replicates from thirteen samples, with total coliforms, fecal coliforms or enterococci measured depending on the sample. Results were generally comparable among methods, though membrane filtration appeared to underestimate the other two methods for fecal coliforms, possibly due to clumping. Variability was greatest for the multiple tube fermentation method. For all three methods, within laboratory variability was greater than among laboratories variability.

Development of an instrument to measure strategic and clinical quality indicators in postoperative pain management.

To develop and evaluate psychometric properties, that is reliability and validity, of an instrument to measure strategic and clinical quality indicators in postoperative pain management. Strategic and clinical quality indicators in postoperative pain management were previously developed from a tentative model of important aspects of surgical nursing care and assessed to have content validity, that is to be essential for the quality of care, realistic to carry out and possible for nurses to use to influence management. The quality indicators were converted to items suitable for a patient questionnaire and were scored on a 5-point scale, with higher scores indicating higher quality of care. Inpatients from five surgical wards took part in this study on their second postoperative day. The response rate was 96% and the average ages of the female (n=120) and the male (n=78) respondents were 62 and 63 years, respectively. Items in the total scale had an average inter-item correlation >0.20 and an item-total correlation >0.30. Cronbach's coefficient alpha was 0.84 for the total scale. Four factors entitled 'communication', 'action', 'trust' and 'environment' emerged from an orthogonal factor analysis, with a cumulative variance of 61.4%. Patients who received epidural analgesia had higher scores on the total scale compared with those who did not receive epidural analgesia. Patients who reported more pain than expected had lower scores on the total scale compared with those who did not report more pain than expected. Correlation between the total scale and an overall pain relief satisfaction question was 0.53. The results suggest initial support for the new instrument as a measure of strategic and clinical quality indicators in postoperative pain management, but it must be further refined, tested and evaluated.

Effectiveness of simple ventilation strategies and partitioning in mitigating the effects of passive smoking

Pubs, bars and restaurants are places where smoking policy is still left to the discretion of the manager and where smoking is often permitted. However, there is demand to take measures to eliminate or reduce the effects of environmental tobacco smoke (ETS) to non-smoking occupants. This paper reports the results of a field study in which ETS markers and air flow patterns were monitored in a number of occupied spaces. The measurements included CO concentrations as a marker of ETS, CO2 concentrations as a general indoor air quality (IAQ) indicator and air flow measurements to estimate ventilation and infiltration rates. The findings indicate that shared-space smoking needs action beyond that of simple ventilation, segregation of occupants or simple partitioning to minimise the potentially harmful effects of ETS to both staff and customers.

Cooperative Cardiovascular Project (CCP) quality improvement in Maine, New Hampshire, and Vermont.

The Cooperative Cardiovascular Project (CCP) is a nationwide quality improvement project (quality indicator measurement, feedback, remeasurement) in Medicare acute myocardial infarction (AMI) patients sponsored by the Health Care Financing Administration (HCFA). In Maine, New Hampshire, and Vermont, 3,472 baseline records were abstracted from 76 hospitals from January 1994 to February 1995. After feedback, 2,270 remeasurements were collected from October 1996 to May 1997. At remeasurement, performance improved significantly for "ideal" candidates (defined by the CCP) on five quality indicators--aspirin during hospitalization 88% to 93% (p < .001), thrombolytic timing 60% to 69% (p < .01), discharge aspirin 83% to 90% (p < .001), discharge beta-blockers 69% to 82% (p < .01), and calcium channel blocker avoidance 83% to 93% (p < .05). Reperfusion, angiotensin converting enzyme inhibitors, and smoking cessation advice did not improve significantly. This study demonstrates that evidence-based indicators, nationally designed data collection, and locally based interventions can significantly improve AMI care.

A clinical path for adult diabetes.

The use of clinical paths for patient care management was explored by this development team as a mechanism to provide consistent, high-quality care to hospitalized patients in high-volume, high-risk diagnostic categories. Reviewing the historical aspects and importance of clinical paths helped expand the team's perspective to incorporate pre- and posthospitalization phases of patient care into the clinical path being developed. A multidisciplinary team of physicians, nurses, health educators, and dietitians from both inpatient and outpatient departments of Kaiser-Santa Teresa Medical Center in San Jose, California, devised and implemented an Adult Diabetes Mellitus care path. Staff education preceded the implementation of the care paths. Measurements of quality indicators showed improvements in patient satisfaction, patient education, patient knowledge, and nutrition assessments.