28/10/2022

Lecture 3:

Quality
Improvement
Measurements

Adopted by Dr. Haitham Khatatbeh

Jerash University- Faculty Of Nursing

Aims
• Define quality improvement measurements;

• List characteristics of quality improvement measurements;

• Mention and understand the types of quality improvement measurements,

& give examples on each type of quality improvement measurements;

• Recognize the pros and cons of each type of quality improvement

measurements;

• Understand the key principles of quality improvement.

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Definition of QI measurement

• Measurement is a critical part of testing and implementing changes;

measures tell a team whether the changes they are making actually lead to
improvement.

Characteristics of QI measures

WELL OBJECTIVE MEASURABLE COMPARATIVE GRAPHICALLY

DEFINED (RELIABLE AND DISPLAYED
VALID)

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Types of measures

1. Structural Measures: Structural measures

give consumers a sense of a health care
provider’s capacity, systems, and
processes to provide high-quality care.

Examples on structural measures

➢ For medication systems: Whether the health care organization uses
electronic medical records or medication order entry systems;

➢ The number or proportion of board-certified physicians.

➢ The ratio of healthcare providers to patients.

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The Pros and Cons of Structural Measures

✓The benefit of structural measures is that they provide an indication of a
healthcare organization’s or clinician’s capacity to provide a high quality
care.

✓Without the resources, policies, and procedures to provide services

patients need, quality likely suffers.

✓Since infrastructure is relatively stable, structural measures are relatively

easy to develop and report.

• The limitation of structural measures is that they do not measure the

quality of care received or indicate whether a patient’s health was
improved as a result of that care.

2. Process Measures..
• Process measures indicate what a provider does to
maintain or improve health, either for healthy people
or for those diagnosed with a health care condition.
These measures typically reflect generally accepted
recommendations for clinical practice.
• Process measures can inform consumers about
medical care they may expect to receive for a given
condition or disease, and can contribute toward
improving health outcomes.
• The majority of health care quality measures used for
public reporting are process measures.

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Examples on process measures:

➢ For diabetes: Percentage of patients whose hbA1c level was measured

twice in the past year;

➢ For access: Average daily clinician hours available for appointments;

➢ For critical care: Percent of patients with regular checks completed on

schedule (hourly or twice hourly).

The Pros and Cons of Process Measures

• The advantage of process measures is that data can be collected
relatively quickly;

• Process measures frequently do not require large sample sizes and

therefore allow for a quicker feedback process;

• This allows for reduced costs, manpower, and thus allows for quicker
feedback and system change.

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3. Outcome Measures..
• Outcome measures reflect the impact of the
health care service or intervention on the
health status of patients.

• Outcome measures may seem to represent the

“gold standard” in measuring quality, but an
outcome is the result of numerous factors,
many beyond providers’ control.

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Examples on Outcome Measures:

➢ For diabetes: Average hbA1c level for a group of patients with DM;
➢ For access: Number of days to next available appointment;
➢ For critical care: Intensive Care Unit (ICU) percent mortality rate;
➢ For medication systems: medication errors per 1,000 doses.
➢ The percentage of patients who died as a result of surgery (surgical
mortality rates).
➢ The rate of surgical complications or hospital-acquired infections.

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The Pros and Cons of Outcome Measures

• Outcome measures can be rare or difficult to track, this can make the
data collection process difficult.
• Also a larger sample size may be necessary to capture the outcome
measure.
• Outcome measures do have value but can be difficult to interpret in
the critical care setting due to the heterogeneity of patients,
• Multiple disciplines involved in care and measures can be subjective.
• For example, several factors could have contributed to the result such
as mortality.

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4. Balancing Measures:
Balancing Measures: Are changes designed to
improve one part of the system causing new
problems in other parts of the system?
• Examples:
➢ For reducing time patients spend on a
ventilator after surgery: Make sure
reintubation rates are not increasing;
➢ For reducing patients' length of stay in
the hospital: Make sure readmission
rates are not increasing.

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HOW TO SELECT RELEVANT MEASURES OF

QUALITY
• Quality measures are determined by the
nature of the problem and the desired goal
for improvement.

• The project should focus on at least one of

the six domains of quality: safety, timeless,
equity, efficiency, effectiveness, and
patient-centered care (STEEP).

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Considerations for selection and application of

measures for quality improvement projects

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Data Sources for Health Care

Quality Measures

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• In the course of providing healthcare services,

organizations generate administrative data on
the characteristics of the population they serve
as well as their use of services and charges for
those services, often at the level of individual
users.
1. Administrative
Data
• The data is gathered from claims, encounter,
enrollment, and providers systems. Common
data elements include type of service, number
of units (e.g., days of service), diagnosis and
procedure codes for clinical services, location of
service, and amount billed and amount
reimbursed.

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Advantages and challenges

• Advantages of Administrative Data
• Available electronically.
• Less expensive than obtaining medical record data.
• Available for an entire population of patients and across payers.
• Fairly uniform (and improving) coding systems and practices.

• Challenges of Administrative Data

• Limited clinical information.
• Questionable accuracy for public reporting because the primary purpose is
billing.

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• A medical record is documentation of a

patient's medical history and care. The
advent of electronic medical records has
increased the accessibility of patients’
2. Patient Medical files.
Records
• Wider use of electronic medical record
systems is expected to improve the ease
and cost of using this information for
quality measurement and reporting.

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Advantages and challenges

• Advantages of Medical Records
• Rich in clinical detail.
• Viewed by providers as credible.

• Challenges of Medical Records

• The cost, complexity, and time required to compile data when patients
receive services across different sites, particularly if a different record format
is used.
• Current use of paper for most records, which means that trained staff must
manually abstract information.

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• Survey instruments capture self-

reported information from patients
about their health care experiences.
Aspects covered include reports on the
3. Patient Surveys care, service, or treatment received and
perceptions of the outcomes of care.

• Surveys are typically administered to a

sample of patients by mail, by
telephone, or via the Internet.

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Advantages and challenges

• Advantages of Patient Surveys
• Captures types of information for which patients are the best source.
• Well-established methods for survey studies’ design and administration.
• Easy to understand and relate to survey results.

• Challenges of Patient Surveys

• Cost of survey administration.
• Possibility of misleading results if questions are worded poorly, survey
administration procedures are not standardized, the population sampled is
not representative of the population as a whole (sampling bias), or the
population is not represented in the responses (response bias).

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• Comments from individual patients,

often referred to as anecdotal
information, include any type of
information on health care quality that is
gathered informally rather than by
4. Comments carefully designed research efforts.
from Individual
Patients
• Anecdotal information is becoming
increasingly more common as private
Web sites make it possible for health
care consumers to share their personal
experiences with health plans, hospitals,
and, most prominently, physicians.

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Advantages and challenges

• Advantages of Patient Comments
• Compelling to consumers to read about other people’s experiences.
• Efficient means for conveying information and influencing people’s decisions
and behaviour.
• Challenges of Patient Comments
• Not an fair assessment of health care quality because comments are not
collected systematically.
• Not representative of the patient population. For example, many Internet sites
that present patient ratings of doctors often contain just a few reviews per
doctor. Even if a doctor has many reviews, the reviews are still likely to
represent only a fraction of his or her entire patient population—and not
necessarily a balanced fraction.

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• Certain kinds of facilities, such as nursing

homes and home health agencies, are
required to report detailed information
about the status of each patient at set
time intervals.
5. Standardized
Clinical Data • The Minimum Data Set (MDS), the
required information for nursing homes,
and the Outcome and Assessment
Information Set (OASIS), the data
required by Medicare for certified home
health agencies, store the data used in
quality measures for these provider
types.

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Advantages and challenges

• Advantages of Standardized Clinical Data
• Uses existing data sets.
• Characterizes facility performance in multiple domains of care.

• Challenges of Standardized Clinical Data

• May not address all topics of interest.

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References

• Joint Commission International. International Library of Measures.

https://www.jointcommissioninternational.org
• Agency for Health Research and Quality. Resources for health care quality
measurement. https://www.ahrq.gov
• https://www.definitivehc.com/blog/history-of-quality-improvement-in-healthcare
• http://squire-statement.org/
• https://www.who.int
• https://www.cdc.gov
• https://www.ihi.org
• https://www.ahrq.gov/

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