Use Of Quality Indicators Research Articles

Use of Quality Indicators in Patient Care

Dr A is a senior primary care physician who recently moved from a small private practice to a larger group-model practice. He believes he was able to provide higher-quality and more individualized care for his patients in his small practice. As Dr A has discovered, quality measurement and improvement activities in primary care have evolved from a focus on an individual patient in an examination room to a systems approach that incorporates population management. Although many frustrations remain with physicians' ability to measure and influence the quality of care received by populations of patients, quality measures and monitoring have improved and should continue to improve. However, the perspective of patients and experienced physicians like Dr A also should be incorporated into quality measurement and management systems. Dr A clearly has the welfare of his patients at heart, and his experience and perspective could help improve his organization's systems of care and identify resources to deliver the best care.

Use of Quality Indicators in Physical Therapist Practice: An Observational Study

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 contain provisions specific to health care quality that apply to physical therapists. Published evidence examining gaps in the quality of physical therapy services is limited. The primary purpose of this study was to determine the use of quality indicators in physical therapist practice. This was an observational study. All members of the Orthopaedic and Private Practice sections of the American Physical Therapy Association were invited to participate by completing an electronic survey. The survey included 22 brief patient descriptions, each followed by questions regarding the use of examinations and interventions based on the 2009 list of Medicare-approved quality measures. Separate multivariate logistic regression models were used to determine the odds ratios related to the performance of each examination and intervention on more than 90% of patients, given perceptions of its importance to care, the burden of performing it, and the level of evidence supporting its use. Participants (n=2,544) reported a relatively low frequency of performing examinations and interventions supporting primary and secondary prevention (3.6%-51.3%) and use of standardized measures (5.5%-35.8%). Perceptions of high importance and low burden were associated with greater odds of performing an examination or intervention. Importance and burden were more influential factors than the perceived availability of evidence to support use of identified techniques. The survey was not assessed for test-retest reliability. A low response rate was a source of potential bias. The study findings suggest that physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome.

Role of Intervention on Laboratory Performance: Evaluation of Quality Indicators in a Tertiary Care Hospital

Quality in laboratory has huge impact on diagnosis and patient management as 80-90% of all diagnosis is made on the basis of laboratory tests. Monitoring of quality indicators covering the critical areas of pre-analytical, analytical and post-analytical phases like sample misidentification, sample rejection, random and systemic errors, critical value reporting and TATs have a significant impact on performance of laboratory. This study was conducted in diagnostic laboratories receiving approximately 42,562 samples for clinical chemistry, hematology and serology. The list of quality indicators was developed for the steps of total testing process for which errors are frequent and improvements are possible. The trend was observed for all the QI before and after sensitisation of the staff over the period of 12months. Incomplete test requisition form received in the lab was the most poor quality indicator observed (7.89%), followed by sample rejection rate (4.91%). Most significant improvement was found in pre- and post-analytical phase after sensitisation of staff but did not have much impact on analytical phase. Use of quality indicators to assess and monitor the quality system of the clinical laboratory services is extremely valuable tool in keeping the total testing process under control in a systematic and transparent way.

Cluster-randomized trial to evaluate the effects of a quality improvement program on management of non–ST-elevation acute coronary syndromes: The European Quality Improvement Programme for Acute Coronary Syndromes (EQUIP-ACS)

Registries have shown that quality of care for acute coronary syndromes (ACS) often falls below the standards recommended in professional guidelines. Quality improvement (QI) is a strategy to improve standards of clinical care for patients, but the efficacy of QI for ACS has not been tested in randomized trials. We undertook a prospective, cluster-randomized, multicenter, multinational study to evaluate the efficacy of a QI program for ACS. Participating centers collected data on consecutive admissions for non-ST-elevation ACS for 4 months before the QI intervention and 3 months after. Thirty-eight hospitals in France, Italy, Poland, Spain, and the United Kingdom were randomized to receive the QI program or not, 19 in each group. We measured 8 in-hospital quality indicators (risk stratification, coronary angiography, anticoagulation, β-blockers, statins, angiotensin-converting enzyme inhibitors, and clopidogrel loading and maintenance) before and after the intervention and compared composite changes between the QI and non-QI groups. A total of 2604 patients were enrolled. The absolute overall change in use of quality indicators in the QI group was 8.5% compared with 0.8% in the non-QI group (odds ratio for achieving a quality indicator in QI versus non-QI 1.66, 95% CI 1.43-1.94; P < .001). The main changes were observed in the use of risk stratification and clopidogrel loading dose. The QI strategy resulted in a significant improvement in the quality indicators measured. This type of QI intervention can lead to useful changes in health care practice for ACS in a wide range of settings.

Quality Indicators in Pediatric Orthopaedic Surgery: A Systematic Review

The ability to measure health system quality has become a priority for governments, the private sector, and the public. Quality indicators (QIs) refer to clear, measurable items related to outcomes. The use of QIs can initiate local quality improvement and track changes in quality over time as interventions are implemented. We identified existing evidence-based indicators of quality pediatric orthopaedic care and evaluated published QIs that may be applicable to pediatric orthopaedic care. Using five standard search engines we searched the literature using terms such as "quality indicators," "orthopaedic surgery," and "pediatric." Study selection was performed in a stepwise manner, first by title, then abstract, and then full-text review. Of the 604 citations identified, 13 articles were selected for inclusion. Eight papers included only pediatric patients. The most commonly reported indicator was mortality followed by postoperative complications. Reoperation and readmission rates were also reported along with patient-centered QIs, although with less frequency. Although mortality and postoperative complications were the most frequently reported QIs, concern for their applicability was raised because of their relative infrequency in pediatrics. Patient-centered QIs appear to be the most useful tools reported, although their use is somewhat limited in the published literature. Although there are benefits and drawbacks to all reported QIs, patient-centered and surgeon-defined outcomes along with cost-effectiveness have important roles in evaluating the quality of pediatric orthopaedic care.

A utilidade dos indicadores da qualidade no gerenciamento de laboratórios clínicos

O uso dos indicadores da qualidade vem sendo valorizado na gestão dos laboratórios clínicos para otimizar a qualificação e a quantificação das falhas nos diferentes processos laboratoriais, bem como para auxiliar a implantação de medidas corretivas e preventivas e apontar a eficácia das ações tomadas. O objetivo deste trabalho é discorrer sobre a evolução da qualidade na área da saúde, com ênfase na área laboratorial. Alguns indicadores laboratoriais citados na literatura nas fases pré-analítica, analítica e pós-analítica também são apresentados e discutidos neste artigo. Por fim, destaca-se a experiência brasileira do Programa de Indicadores Laboratoriais desenvolvido pela Sociedade Brasileira de Patologia Clínica/Medicina Laboratorial (SBPC/ML) em parceria com a Control-Lab e o projeto Model of Quality Indicator, em fase de desenvolvimento pela International Federation of Clinical Chemistry and Laboratory Medicine (IFCC).

Development and use of quality indicators for clinical laboratories

To provide an effective approach to select, develop, interpret and apply well-designed quality indicators. Then to promote the continual improvement of laboratory quality and to assure patient safety. We focused on the quality cycle of selecting, development, implementation and processing for quality indicators. And some examples for essential activities in the development and use of quality indicators were shown. Through the presentation of process and examples, we put forward an organized approach that provides the laboratory with a plan to structure its development of quality indicators to gather useful information. Quality indicators are important. However, they should be integrated with internal review plan, External Quality Assessment (EQA) and the process of activities in plan. Only then can we really promote the continual improvement of quality. Key words: Laboratory; Quality management; Indicators; Continual improvement

Improving the Quality of Clinical Pharmacy Services: A Process to Identify and Capture High-Value “Quality Actions”

Patients are harmed and resources wasted because of underuse, overuse, and misuse of medications and treatments. To improve health services, governments and other key organizations use quality indicators. These indicators improve quality through 2 main mechanisms. First, the process of developing quality indicators allows standards, targets, and priorities to be set. Second, quality indicators are used to retrospectively measure and report various aspects of care, providing a framework that increases accountability, allows benchmarking, and identifies areas for improvement. Despite the widespread use of quality indicators to improve health services, the pharmacy profession has not widely adopted this concept for quality improvement in the clinical realm. We propose that this concept can be used to redesign the delivery of care. As pharmacists, we need to redefine what we need to be doing, find out whether we are doing it, and then use this information to find areas to improve. Pharmacists cannot identify and manage all of the drugrelated problems that patients experience or are at risk of experiencing. Rather, the goal should be to maximize patient benefit with available resources. Pharmacists need to identify those drug-related problems for which management or prevention would result in the greatest benefit for as many patients as possible. In other words, they need to prioritize. In this article, we define a new concept that we call “quality actions” and describe a process to identify high-value quality actions for specific patient populations. Measurement consists of documenting whether or not a quality action has been considered or performed. This system will allow pharmacists to identify, measure, and report what they should be doing, which is fundamental to achieving improvement. BACKGROUND ON QUALITY INDICATORS AND QUALITY IMPROVEMENT

Quality Indicators in Laboratory Medicine: from theory to practice

The adoption of Quality Indicators (QIs) has prompted the development of tools to measure and evaluate the quality and effectiveness of laboratory testing, first in the hospital setting and subsequently in ambulatory and other care settings. While Laboratory Medicine has an important role in the delivery of high-quality care, no consensus exists as yet on the use of QIs focussing on all steps of the laboratory total testing process (TTP), and further research in this area is required. In order to reduce errors in laboratory testing, the IFCC Working Group on "Laboratory Errors and Patient Safety" (WG-LEPS) developed a series of Quality Indicators, specifically designed for clinical laboratories. In the first phase of the project, specific QIs for key processes of the TTP were identified, including all the pre-, intra- and post-analytic steps. The overall aim of the project is to create a common reporting system for clinical laboratories based on standardized data collection, and to define state-of-the-art and Quality Specifications (QSs) for each QI independent of: a) the size of organization and type of activities; b) the complexity of processes undertaken; and c) different degree of knowledge and ability of the staff. The aim of the present paper is to report the results collected from participating laboratories from February 2008 to December 2009 and to identify preliminary QSs. The results demonstrate that a Model of Quality Indicators managed as an External Quality Assurance Program can serve as a tool to monitor and control the pre-, intra- and post-analytical activities. It might also allow clinical laboratories to identify risks that lead to errors resulting in patient harm: identification and design of practices that eliminate medical errors; the sharing of information and education of clinical and laboratory teams on practices that reduce or prevent errors; the monitoring and evaluation of improvement activities.

KBV entwickelt Starter-Set ambulanter Qualitätsindikatoren – AQUIK®-Set

Development of a starter set of quality indicators for application by general practitioners and specialists in the outpatient care sector. The results of a systematic search for national and international quality indicators relevant to the outpatient care sector in Germany provided the basis for the indicator selection process. Outpatient care doctors rated the relevance and feasibility of the indicators according to the RAND/UCLA method. In a further step the indicators were tested in medical practices, focussing on data availability and accessibility. As a result, we established a set of 48 reliable, structurally developed and patient-oriented quality indicators which can be used for quality improvement in the outpatient care setting, both by specialists and general practitioners. The project provides important information with regard to the future development and use of quality indicators. Depending on the potential fields of application, the development of new indicators as well as a corresponding IT infrastructure is of high priority. Possible unintended effects of indicators will have to be considered.

Die Darstellung der hausärztlichen Versorgungsqualität durch Qualitätsindikatoren

The publication of two German systems of quality indicators for ambulatory care (AQUIK and QISA) in 2009 stimulated a discussion in German general practice about how to appropriately measure the quality of care in general practice / family medicine. The basic properties and requirements of quality indicators (QIs) in the international literature are discussed in terms of their ability to measure the specific processes of care in general practice. In the second part of the article the QISA system is presented as an example of a methodologically sound development of QIs for ambulatory care for use in both small practices and practice networks. In addition, the context of application and usage of QIs in primary care and the quality control they may provide are discussed. We conclude that important methodological problems have yet to be solved, particularly with measuring 'horizontal' dimensions of quality in primary care (such as comprehensiveness, co-ordination and person-centredness), but that the use of QIs may increase the visibility of general practice in Germany.

Implementing quality indicators in intensive care units: exploring barriers to and facilitators of behaviour change.

BackgroundQuality indicators are increasingly used in healthcare but there are various barriers hindering their routine use. To promote the use of quality indicators, an exploration of the barriers to and facilitating factors for their implementation among healthcare professionals and managers of intensive care units (ICUs) is advocated.MethodsAll intensivists, ICU nurses, and managers (n = 142) working at 54 Dutch ICUs who participated in training sessions to support future implementation of quality indicators completed a questionnaire on perceived barriers and facilitators. Three types of barriers related to knowledge, attitude, and behaviour were assessed using a five-point Likert scale (1 = strongly disagree to 5 = strongly agree).ResultsBehaviour-related barriers such as time constraints were most prominent (Mean Score, MS = 3.21), followed by barriers related to knowledge and attitude (MS = 3.62; MS = 4.12, respectively). Type of profession, age, and type of hospital were related to knowledge and behaviour. The facilitating factor perceived as most important by intensivists was administrative support (MS = 4.3; p = 0.02); for nurses, it was education (MS = 4.0; p = 0.01), and for managers, it was receiving feedback (MS = 4.5; p = 0.001).ConclusionsOur results demonstrate that healthcare professionals and managers are familiar with using quality indicators to improve care, and that they have positive attitudes towards the implementation of quality indicators. Despite these facts, it is necessary to lower the barriers related to behavioural factors. In addition, as the barriers and facilitating factors differ among professions, age groups, and settings, tailored strategies are needed to implement quality indicators in daily practice.

Implementing the quality accounts agenda in tissue viability

This article attempts to summarise and interpret recent quality initiatives from the Department of Health to improve tissue viability nursing services across England. It is directed towards nurses responsible for the planning and delivery of tissue viability services, and to nursing management at trust level. Quality initiatives are aimed at encouraging trust board members and service providers to assess, and make public, the quality and standards of care that they provide in the form of quality accounts. All healthcare service providers will have to produce a quality account in 2010. This article offers guidance on the use of quality indicators or nursing metrics to measure quality, and prepare quality accounts in tissue viability.

Quality assurance in psychiatry: quality indicators and guideline implementation

In many occasions, routine mental health care does not correspond to the standards that the medical profession itself puts forward. Hope exists to improve the outcome of severe mental illness by improving the quality of mental health care and by implementing evidence-based consensus guidelines. Adherence to guideline recommendations should reduce costly complications and unnecessary procedures. To measure the quality of mental health care and disease outcome reliably and validly, quality indicators have to be available. These indicators of process and outcome quality should be easily measurable with routine data, should have a strong evidence base, and should be able to describe quality aspects across all sectors over the whole disease course. Measurement-based quality improvement will not be successful when it results in overwhelming documentation reducing the time for clinicians for active treatment interventions. To overcome difficulties in the implementation guidelines and to reduce guideline non-adherence, guideline implementation and quality assurance should be embedded in a complex programme consisting of multifaceted interventions using specific psychological methods for implementation, consultation by experts, and reimbursement of documentation efforts. There are a number of challenges to select appropriate quality indicators in order to allow a fair comparison across different approaches of care. Carefully used, the use of quality indicators and improved guideline adherence can address suboptimal clinical outcomes, reduce practice variations, and narrow the gap between optimal and routine care.

The IFCC Working Group on laboratory errors and patient safety

The increasing attention paid to patient safety, and the awareness that the information provided by clinical laboratories impacts directly on the treatment received by patients, has made it a priority for clinical laboratories to reduce their error rates and promote an excellent level of quality. The capacity for reporting, analysing and learning from experience is still seriously hampered by a lack of methodological uniformity in identification and measurement, inadequate reporting schemes for error events, the fear of professional liability, and weak information systems. In previous years, the use of quality indicators to assess and monitor the quality systems of clinical laboratories considerably benefited quality management. Yet currently there are no guidelines available for identifying and correcting development of quality indicators in laboratory medicine, although the International Standard ISO 15189:2007 for Accreditation of Medical Laboratory requires them to be implemented. The aim of this work was therefore to report on the project, nominated “Model of Quality Indicator”, undertaken by the Working Group, “Laboratory Errors and Patient Safety (WG-LEPS)” instituted by the division of Education and Management (EMD) of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). The mission of the WG-LEPS is to promote and encourage investigations into errors in laboratory medicine, collect data available on this issue and recommend strategies and procedures for improving patient safety.

Canadian quality indicators for percutaneous coronary interventions

Quantifying adherence to quality indicators can serve as a direct measure of quality of care and provide the foundation for quality improvement. However, quality indicators for percutaneous coronary intervention (PCI) have not been developed in Canada. To develop a set of quality and outcome indicators for PCI that can be used across Canada. A 12-member national expert panel was selected to represent practice in different regions of Canada. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, and follow-up discussions to obtain consensus. A total of 26 indicators including six structure indicators, nine process indicators, and 11 outcomes indicators were identified by the national expert panel to be representative of high quality of care for PCI. Pharmacological indicators included prescription of acetylsalicylic acid, clopidogrel and statin therapy as adjunctive therapy for PCI. Nonpharmacological process indicators included minimal procedure volumes, door-to-balloon time in primary PCI, prevention of contrast-induced nephropathy and selected patient education counselling instructions. Outcome indicators included death, myocardial infarction, target vessel revascularization and vascular access complications after PCI. A new set of PCI quality indicators for use in the Canadian health care system was developed. The widespread adoption and implementation of PCI quality indicators in clinical practice will facilitate the identification of practice gaps to enable quality improvement efforts and to optimize the outcomes of patients undergoing PCI throughout Canada.

Association Between Hospital and Surgeon Radical Prostatectomy Volume and Patient Outcomes: A Systematic Review

We examined the association between hospital and surgeon volume, and patient outcomes after radical prostatectomy. Databases were searched from 1980 to November 2007 to identify controlled studies published in English. Information on study design, hospital and surgeon annual radical prostatectomy volume, hospital status and patient outcome rates were abstracted using a standardized protocol. Data were pooled with random effects models. A total of 17 original investigations reported patient outcomes in categories of hospital and/or surgeon annual number of radical prostatectomies, and met inclusion criteria. Hospitals with volumes above the mean (43 radical prostatectomies per year) had lower surgery related mortality (rate of difference 0.62, 95% CI 0.47-0.81) and morbidity (rate difference -9.7%, 95% CI -15.8, -3.6). Teaching hospitals had an 18% (95% CI -26, -9) lower rate of surgery related complications. Surgeon volume was not significantly associated with surgery related mortality or positive surgical margins. However, the rate of late urinary complications was 2.4% lower (95% CI -5, -0.1) and the rate of long-term incontinence was 1.2% lower (95% CI -2.5, -0.1) for each 10 additional radical prostatectomies performed by the surgeon annually. Length of stay was lower, corresponding to surgeon volume. Higher provider volumes are associated with better outcomes after radical prostatectomy. Greater understanding of factors leading to this volume-outcome relationship, and the potential benefits and harms of increased regionalization is needed.

The Incidence of Unplanned Returns to the Operating Room After Peripheral Arterial Bypass Surgery and Its Value as Indicator of Quality of Care

In recent years, a growing need has arisen to define possible indicators of quality of care. To examine whether unplanned return to the operating room within 30 days after the initial procedure could serve as an indicator to assess quality of care in peripheral arterial bypass surgery, all bypass procedures performed between January 1996 and January 2004 were evaluated. Data were obtained from a prospectively kept hospital registration system. A total of 607 consecutive procedures were performed in 468 patients. The overall unexpected return to the operating room rate was 11.2%. Patients requiring peripheral arterial bypass surgery for critical ischemia with gangrene were significantly more at risk for an unplanned reoperation (20.2%) than patients with disabling claudication (2.1%) (P < .0001). Patients requiring femorocrural bypass surgery (24.2%) were also more at risk than patients with a suprageniculate bypass procedure (5.2%) (P < .0001). Unplanned return to the operating room within 30 days after the initial operation can be a useful indicator of quality of care after peripheral arterial bypass surgery. However, a prospective, well-defined registration system to collect all data is essential. Furthermore, the severity of peripheral arterial disease and the type of procedure performed should be taken into account.

A survey of quality indicator use in the clinical laboratory.

A survey of clinical laboratories was conducted to capture information about quality indicators in use within the state of Arizona. This information was then used to determine which quality indicators are applicable across the spectrum of clinical laboratories making them suitable for benchmarking laboratory performance. The objectives of this study were also to heighten awareness of benchmarking practices for clinical laboratory managers and laboratory quality assurance personnel, to develop objective methods of quality monitoring for performance improvement, and to encourage collaboration between laboratories and accreditation agencies. A review of the current literature was conducted to assess the status of benchmarking within the clinical laboratory. Data were also obtained from the Centers for Medicare & Medicaid Services (CMS) about all licensed clinical laboratories in Arizona. A mail survey was then created and conducted to investigate the use of clinical laboratory quality indicators in Arizona. A paper survey was mailed to a representative sample of clinical laboratory managers included in the CMS licensed laboratories listing for the state of Arizona. The selected sample was surveyed by mail and validation testing of the survey was conducted using the t-test. The compiled survey data is also presented in the form of histograms. Applying the t-test to the sample vs. population data proved that the sample was not a very good representation of the population and a better selection method should be used in future studies. Of the 319 of 3198 clinical laboratories randomly selected to receive the survey, 21 (6.58% of the sample or 0.66% of the population) responded with completed surveys. The information received from the respondents revealed a relationship between test volume and the number of indicators being monitored by clinical laboratories, the preference of indicators being monitored by those laboratories, the size of the laboratories where the majority of benchmarking is occurring, and a link between accrediting agencies and benchmarking activities. The survey proved that quality indicators are used for quality improvement purposes within the clinical laboratory; although it also showed that the industry still does not have a standardized approach to the use of quality indicators for benchmarking performance against other laboratories.

Evaluating Nursing Home Performance Indicators: An Illustration Exploring the Impact of Facilities on ADL Change

Performance measurement systems for nursing homes assume that facility performance contributes heavily to individual outcomes. This research illustrates how that assumption can be assessed using the change in residents' activities of daily living (ADLs). The data used in these analyses were all from residents with both an admission and a quarterly assessment in a sample of all admissions to a randomly chosen 10% of Medicare- or Medicaid-certified nursing homes operating during 2002. Models including both facility and individual variables explained up to 20% of the variation in ADL change after admission. Facility identity in isolation explained between 8% and 14% of the variation in ADL change. The results suggest that quality indicators based on change in ADLs may be problematic when used in nursing home performance measurement systems. More generally, the results recommend that the level of variation in performance measures attributable to facility identity or performance become a much more central consideration when researchers evaluate quality indicators for use in nursing home performance measurement systems.