measure

					        Crayons or Laptop dreaming?

   Is measurement important in improving
     practice?




Don Campbell
Clinical Epidemiology & Health Service Evaluation Unit
Melbourne Health
                Improvements

• the will to make the change
• the ideas to make the change
• the execution of the ideas

Commitment to measurement and reporting
Do you need baseline data before you start?
    Fundamental Questions for
         Improvement

• What is the aim?
• What will be measured to know the aim has
  been achieved?
• What are the changes?
                 Measures
• The key measures should operationalize the
  aim
  – LOS for admitted, discharge, and fast track
  – Clinical improvements
  – Patient satisfaction scores
• Collect data on sub-components of the
  system judiciously
     - ie, only if it is necessary (parsimony)
  Some Things to Consider When
     Making Improvements
• Multiple PDSA Cycles (and time) are
  usually needed to adapt a change
• Pay attention to detail
• Measurement - “useful not perfect”
• Promote the project
• Overcoming barriers to achieving
  success
• Hold the gains
Model for Improvement
  What is the aim?
  What will be measured to know the
  aim has been achieved?
  What are the changes?




            Act      Plan


           Study      Do
Model for Improvement
  What are we trying to accomplish?
  How will we know that a change is
  improvement?
  What change can we make that will
  result in improvement?




            Act       Plan


           Study      Do
                       Use of Data
                                                             Changes That
                                                               Result in
                                          A P                Improvement
                           1d
                                          S D
                      1c

                 1b
                                                       Median LOS for Admitted Patients
           A P                                  320
    1a                                          300      1       2       3
           S D                  LOS (minutes)   280
                                                260
                                                240
                                                220
Theories                                                      Goal
                                                200
 Ideas                                          180
                                                160
                                                                      Week
                                                      1. “quick-look” x-rays   3. Bed ahead
                                                      2. Work-up done on floor
          Useful Measurement

• Data directly related to aims
• Data collected in cycles to determine
  the effect of a particular change
• Qualitative data to assist in refining a
  change
“Have a narrow bandwidth & stay on the
  money”
              Collecting Data

• Use purposive sampling to conserve
  resources
  – Sample data daily for Fast Track, Main ED,
    Admitted
  – Summarize data weekly using median to
    lessen effect of outliers
• Integrate measurement into the daily
  routine
     Operationalising Data Collection -
                  Examples
• Time to analgesia
  – pen/paper stuck on narcotics safe
  – pain scale at triage
• Fast track
  – identify on computer (or manually on assigned
    cubicle)
• Ottawa ankle rules
  – aide memoire at triage and/or in cubicles
Length of Stay for Main ED Discharged
       Patients (n=1 per week)
                 300
                                       Avg=180, SD=50
                 250
    LOS (Min.)




                                                              Avg=135, SD=35
                 200

                 150

                 100

                  50
                       1   3   5   7   9 11 13 15 17 19 21 23 25 27 29
                                               Week
Median Length of Stay for Main ED
Discharged Patients (n=14 per week)
               200

               180
  LOS (Min.)




               160

               140

               120

               100
                     1   3   5   7   9   11 13 15 17 19 21 23 25 27 29
                                              Week
Median Length of Stay for Main ED
Discharged Patients (n=28 per week)
               200

               180
  LOS (Min.)




               160

               140

               120

               100
                     1   3   5   7   9   11 13 15 17 19 21 23 25 27 29
                                              Week
Median Length of Stay for Main ED
Discharged Patients (n=300 per week)
                200

                180
   LOS (Min.)




                160

                140

                120

                100
                      1   3   5   7   9 11 13 15 17 19 21 23 25 27 29
                                             Week
                  A cautionary note
• New performance management structure may support
  abstract managerial values at the expense of other
  cultures of performance evaluation, and foster fear
  rather than QI
• Performance measurement implies a mode of
  management
   – Guidedog or guard dog?
• Risk that this approach will displace existing formal or
  informal internal or professional modes of QA
• What are clinicians already doing that constitutes good
  practice, can we build on this to make it better?
            A cautionary note

• Successful change: “honour the culture and
  respect the past”
• Competition
   – clinical culture naturally competitive
   – can we manage this for improvement?
   – not “competition for competition’s sake”
• Benchmarking
   – opportunity rather than threat
   – driver to improvement
                      Conclusion

• Measurement is important
  – identifying a problem (helps convince others too)
  – demonstrating that change can lead to improvement (data
    will convince sceptics)
  – holding the gains
• If you aren’t committed to measurement
  – how will you know you made a difference?
  – your activity is diversionary therapy
• If this was easy we wouldn’t be sitting here

				
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posted:12/17/2011
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