Measures of Performance and Clinical Outcome

Dr. Mohamed Mosaad Hasan

MD, MPH, CPHQ, CPPS

Objectives

• Identify effective methods for using performance measurement

• Discuss the major domains of patient safety measurement

• Identify some approaches to data collection

Institute of Medicine Six Aims

• Safe• Timely• Effective• Efficient• Equitable• Patient-centered

Why Measurement is Important?

• Evaluate current system– Identify high risk areas in health care– Learn what is working and what is

broken• Help set priorities – where should we

start?• Reduce harm and improve outcomes

Definition: Measurement

• The process of applying a standard scale to what you are interested in

• Every measurement includes some error– Some of that error is random

“noise”– Some is systematic “bias”

• Task is to minimize noise and understand bias

Major Domains

• Harm• Mortality• Infections/hospital-acquired conditions• Readmissions• Patient satisfaction• Safety culture

Medical errors

• Institute of Medicine defines medical error as the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.

  Medical errors are:

1- errors of commission (doing the wrong thing);

2- errors of omission (not doing the right thing);

or

3- mistakes in execution (doing the right thing, but doing it incorrectly).

Adverse event (Harm)

• Adverse event can be described as an injury caused by medical management rather than by the underlying disease or condition of the patient.

• Medical error may or may not lead to adverse event.

• Adverse event is preventable (considered as medical error) or non preventable (not a medical error).

Medical error

Preven

table

Non preventable

The Focus on Harm

• Overall patient safety goal is to reduce patient injury or harm

Medical errors are numerous Many have potential to be harmful Numerous reports show that error is often not linked to

injury

• Focus on error tends to focus on individual

• Focus on harm tends to focus on systems Focus on systems more likely to improve care and

outcomes Focus on systems reduces fear of punishment and

encourages cooperation with patient safety efforts

Commission vs. Omission

• Harm measures focus on active care (commission)

• Excludes omission (substandard care)

How do you measure Harm

• Prospective– Direct observation of patient care– Cohort study– Clinical surveillance

• Retrospective– Record review (Chart, Electronic medical record)– Administrative claims analysis– Malpractice claims analysis– Morbidity & mortality conferences/autopsy– Incident reporting systems

Relative Utility of Methods to Measure Errors

Direct Observation

• Good for active errors• Data otherwise

unavailable• Potentially accurate,

precise• Training/expensive• Information overload• Hawthorne effect?• Hindsight bias?• Not good for latent errors

• Potentially accurate and precise for adverse events

• Good to test effectiveness of intervention to decrease specific adverse event

• Can become part of care• Expensive• Not good for detecting

latent errors

Cohort / Clinical Surveillance

Chart Review

• Uses readily available data

• Common• Judgments of adverse

events not reliable• Expensive• Records incomplete,

missing• Hindsight bias

Global Trigger Tool

Triggers: Assessing Harm

• Use of manual chart review to study harm as a result of active medical care

• Use of “trigger” methodology to search for harm

Trigger – event often associated with harm If trigger is present, chart is reviewed further

to determine if harm occurred

Global Trigger Tool• The IHI Global Trigger Tool contains six “modules,” or

groupings of triggers. Four of the groupings are designed to reflect adverse events that commonly occur in a particular unit; the Cares and Medication groupings are designed to reflect adverse events that can occur anywhere in the hospital. The six modules are:

• Cares Intensive Care • Medication Perinatal • Surgical Emergency Department

• All patient records should be reviewed for the triggers in the Cares and Medication modules. The other modules should only be used if applicable.

Outpatient Surgery Example

Conceptual Model for Measuring