Elsevier

The Lancet

Volume 363, Issue 9414, 27 March 2004, Pages 1061-1067
The Lancet

Series
How can clinicians measure safety and quality in acute care?

https://doi.org/10.1016/S0140-6736(04)15843-1Get rights and content

Summary

The demand for high quality care is increasing and warranted. Evidence suggests that the quality of care in hospitals can be improved. The greatest opportunity to improve outcomes for patients over the next quarter century will probably come not from discovering new treatments but from learning how to deliver existing effective therapies. To improve, caregivers need to know what to do, how they are doing, and be able to improve the processes of care. The ability to monitor performance, though challenging in healthcare, is essential to improving quality of care. We present a practical method to assess and learn from routine practice. Methods to evaluate performance from industrial engineering can be broadly applied to efforts to improve the quality of healthcare. One method that may help to provide caregivers frequent feedback is time series data—ie, results are graphically correlated with time. Broad use of these tools might lead to the necessary improvements in quality of care.

Section snippets

What is quality?

More than 30 years ago, Donabedian23 proposed measurement of the quality of health care through observation of its structure, processes, and outcomes. The Institute of Medicine (IOM) has defined health care quality in the USA as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.24 The IOM's definition and framework thus incorporate two of Donabedian's three elements in a

Efforts to improve safety after assessment of individual patients

The review of incidents or defects in the care of individual patients is common in health care. Examples include peer review, morbidity and mortality conferences, liability claims, and incident reports. In all of these categories, caregivers typically assess single events that are not linked to denominators, thereby restricting the ability to estimate rates. Nevertheless, such methods, when appropriately applied32 help identify what is broken. One of these methods, health care incident

Reporting of health care incidents to improve quality

Incident reporting that identifies broken systems is needed to improve patient safety.33 Unfortunately, its potential has not been understood in healthcare, in which such reporting tends to be punitive and focused on people rather than systems. We need to move from reporting systems that focus on blame to those that assess how we organise our work and include expert analysis and feedback, of which the ICU Safety Reporting System (ICUSRS) project in the USA (http://www.icusrs.org/) is an example

How do we develop measures of quality?

Quality measures can be used for external reporting to regulatory agencies or for internal (within the clinic, hospital, health system) improvement efforts. We and others have previously published methods to develop such measures.26, 28, 29, 37, 38 Here, we focus on how to develop practical quality measures that can be used in routine practice and give feedback to providers.

To develop a measure of quality we need to: (1) prioritise the clinical area to be assessed; (2) select the type of

Types of measures in improvement efforts

During improvement efforts, it is important to distinguish between measures that achieve the goal and those that monitor adherence to the intervention. For example, a goal might be the reduction of errors in medication and an intervention to achieve this target could be completion of a medication reconciliation form at discharge. The goal is to reduce the percentage of patients discharged with the wrong drug or dose. To improve this, we might monitor the percentage of those who completed an

Process versus outcome measures

Measures for achieving the goal of the improvement effort can be either an outcome (such as mortality, morbidity, or length of stay), a process (such as use of β blockers in patients suffering a myocardial infarction), perceptions of care (such as patients' satisfaction, or health-related quality of life as reported by patients or their surrogate).10, 39 Whether to measure processes or outcomes of care is unresolved.29 Measures of process are acceptable to caregivers because they indicate the

Measure specifications

In defining specifications for the measure, the quality to be improved is measured quantitatively. For example, to improve timely delivery of medications, caregivers could focus on delivery of antibiotics, then on the first dose of antibiotics, and finally set the performance standard of delivery of the first dose of antibiotics as being within 30 minutes. Quality measures are often defined too broadly, such as “improve safety”, restricting the ability to develop an empirical measure of

Analysis of performance data

A common feature of well-run quality improvement projects is the correlation of measures related to the aim with time. For example, the X axis can represent time in days, weeks, or months and the Y axis the performance measure. The analyst annotates the graph with the timing of the interventions or other major events; for example, the use of a new drug or the beginning of a new rotation of residents. Though this approach works well for most types of data, it might not be as effective for

SPC as early warning system for patients

The principles of SPC apply not only to groups of patients but also to individuals, helping to identify early changes in patients that signal impending harm and to provide an opportunity to mitigate that harm. Increasingly, evidence shows that the ability to detect early small changes in patients' physiology, such as vital signs, can substantially reduce morbidity and mortality.56, 57 Current physiology monitors generally fail to detect such changes. Rather, alarms on physiology monitors are

How can we use data to improve?

When attempting to improve performance, we should remember the following guiding principles for performance measurement. First, people, not data improve processes and results. Second, the purpose of data is to help us understand, control, and improve the processes and systems within which we work. Third, performance on quality measures should be used to test and learn, not to judge.

Barriers to measuring quality

To provide continuous feedback, several barriers need to be overcome. First, senior executives, managers, and front line staff should want to improve. Second, a team needs to oversee improvement efforts. That team must have a clear direction; the correct people, skills, and resources; a measurement system to collect, analyse, and present data; and a reward system that supports the improvement effort. Third, the team needs to act; they need to set specific goals, have measures for those goals,

Search strategy and selection criteria

We searched MEDLINE from 1995 to 2003 using the following medical subject headings (safety, quality of healthcare). We also used the following text words: patient safety, errors, acute care, intensive care, hospital staff organization. We searched EMBASE, Healthstar (Health Services, Technology, and Research) and HSRPOJ (Health Services Research Projects in Progress) via the Internet Grateful Med.

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