Measurement and Quality Improvement

Quality. It’s something we all strive for. It’s the optimum level of care experienced by patients.

‘Measurement and Quality Improvement’ is the second component of Patient Safety and Quality Systems, as outlined by the Australian Government’s National Safety and Quality Health Service Standards (NSQHSS).

Why Do We Have Patient Safety and Quality Systems?

As part of the governance process of a health service patient safety and quality systems are created to advance the safety and the quality of patients’ care (Australian Commission on Safety and Quality in Health Care 2017).

The intent of measurement and quality improvement is to implement effective quality improvement systems that operate across the entire organisation.

The public’s perception of quality in healthcare has assessable consequences. There is growing evidence to indicate that people will avoid using services they deem as lacking in quality (Hanefeld et al. 2017) and that this is ‘a barrier to universal health coverage’, regardless of physical access to care (Berendes 2011).

How Do You Define ‘Quality’?

According to the American Institute of Medicine, quality in a healthcare context is ‘the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ (Institute of Medicine referenced by AHRQ 2018).

Why do we Measure?

Regular measuring of a system is essential to ensuring quality improvements allows a facility to determine the baseline level of current operational performance; establish goals for future performance; and monitor the impact of changes as they are made (Health Quality Ontario 2017). Metrics, when measured properly, can guide every decision made to ultimately improve the end product, in this case, patient care.

What is the First Step to Measuring Quality?

To be able to determine if goals have been met, it is first necessary to define the desired end outcome. Without a clear goal, established from the very start, it is very difficult to measure and recognise if the changes that were made have resulted in improvements – or if they are just changes (Health Quality Ontario 2017).

Create a Measurement Plan

A measurement plan should contain the following (at a minimum):

• A name;
• The measurement type;
• Why it’s needed;
• The method of data collection and sampling;
• And ask these questions:
• How will the data be displayed and communicated?
• Has baseline data been gathered?
• Is there a set goal?

(Health Quality Ontario 2013)

The plan must be reviewed frequently. Rather than displaying data in a standard pre/post-implementation way, plot the data over time (for example, by month) for a clearer picture of how the changes are affecting outcomes. This process should be actively shared with staff to create momentum on an organisation-wide scale (Health Quality Ontario 2017).

Quality Measurement Tools

Quality measurement is a type of evaluation, it requires a tool to carry it out. An effective quality measurement tool must:

• Be reliable (the tool should have the same outcome regardless of who is measuring);
• Be objective;
• Be valid and reliable;
• Be standardised;
• Be evidenced-based;
• Not affect or distort results.

(AHRQ 2018)

Examples of what could be measured for quality improvement within a healthcare facility include:

• The time lapsed between transfer from emergency department (ED) to inpatient bed;
• The presence (or absence) of quality improvement programs;
• The number of nurses to the number of patients.

(AHRQ 2018; Health Quality Ontario 2013)

Measurement Challenges

Six important considerations for designing measurement systems:

• A patient’s experience of quality must be conceptualised as taking place over time, it is not stagnant.
• Responsiveness to the patient is a key aspect of quality.
• Broad factors such as the governance and management of a facility are likely to greatly influence quality.
• Quality can be considered as a construct driven by many different factors.
• Acknowledge that perceptions of the quality of care are an important factor of care utilisation, regardless of whether these perceptions are accurate.
• Approaches should be adapted to manage measurement challenges as they arise.

(Hanefeld 2017)

Measurement and Quality Improvement in an Australian Context

The presence of measurement and quality improvement in the Australian Commission Safety and Quality in Health Care (ASQHC)’s National Safety and Quality Health Service Standards implies its importance and represents a gap present in Australian facilities or services. The NSQHS Standards identify two missions for facilities in terms of measurement and quality improvement

1. The health service organisation should use organisation-wide quality improvement systems that:

• Determine safety and quality measures, and monitor and report performance and outcomes.
• Determine areas for improvement in safety and quality.
• Implement and monitor safety and quality improvement strategies.
• Engage with consumers and the workforce in the review of safety and quality performance and system.

(Australian Commission on Safety and Quality in Health Care 2017)

And:

2. An organisation must ensure that timely reports on safety and quality systems and performance are provided to the following four parties:

1. The governing body;
2. The workforce;
3. Consumers/patients and the local community; and
4. Any other relevant health service organisations.

(Australian Commission on Safety and Quality in Health Care 2017)

Conclusion

To up-scale health interventions, it is necessary for facilities to recognise the multifaceted nature of quality of care. Technical quality must be increased but equally crucial is better acceptability and a shift toward greater patient-centred care (Hanefeld 2017).

The outcomes of care quality improvement should be tailored specifically to the needs of the community the facility exists in.

Additional Resources

• Australian Commission on Safety and Quality in Healthcare 2017, National Safety and Quality Health Service Standards, 2nd Edition: https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

References

• Agency for Healthcare Research and Quality (AHRQ), Understanding Quality Measurement, AHRQ, viewed 22 October 2019, https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html
• Australian Commission on Safety and Quality in Health Care 2017, National Safety and Quality Health Service Standards, 2nd ed, ACSQHC, Sydney (NSW), viewed 16 October 2019, https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf
• Berendes S, Heywood P, Oliver S, Garner P 2011, ‘Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies’, PLoS Med., volume 8(4), https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000433
• Hanefeld J, Powell-Jackson T, Balabanova D 2017, ‘Understanding and Measuring Quality of Care: Dealing with Complexity’, Bulletin of the World Health Organisation, viewed 22 October 2019, https://www.who.int/bulletin/volumes/95/5/16-179309/en/
• Health Quality Ontario 2013, Measurement for Quality Improvement, Health Quality Ontario, viewed 22 October 2019, http://www.hqontario.ca/Portals/0/Documents/qi/qi-measurement-primer-en.pdf