Measurement: the why and
the what
Susanne Salem-Schatz, Sc.D
Project Director
Massachusetts Coalition for the Prevention of Medical Errors
Why measure?
For you
1.
Track progress towards key improvement goals
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“How do we know a change is an improvement?”
What gets measured gets done
For us
2.
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Your experience and progress are a key component
of how we evaluate our efforts (surveys, lessons
shared on monthly reports, measures over time)
For the CDC (our funder)
3.
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National recognition
Continued funding and opportunity to support change
in the community
What to measure
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Limited set of core metrics
Differences by type of facility, when
appropriate
Good enough
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Balance value and effort
Don’t let the perfect be the enemy of the good
Overview of measures: Long term care
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Percent of treated UTIs that meet the
“Protocol criteria” (ABCs)
Rates* over time of:
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new UTI cases
laboratory orders for urine culture
healthcare acquired C. difficile (HA-CDI)
* All rates calculated per 10,000 resident days
Overview of measures: Emergency
Department
1.
2.
3.
4.
Percent of treated UTIs with specific signs
or symptoms of UTI
Percent of treated UTIs with non-specific
signs or symptoms
Percent of treated UTIs with no signs or
symptoms (default)
Rate of urine tests sent to laboratory per ED
visitors > 70 years old
Measuring Progress
Nora McElroy, MPH
General Epidemiologist
Massachusetts Department of Public Health
Bureau of Infectious Disease Prevention, Response and Services,
Epidemiology Program
Measuring Improvement

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Establish baseline UTI rates and chart
attributes
Record which LTC patients have been
treated for UTIs and whether they fit the
protocol definition in long term care facilities
Record the number and attributes of
diagnosed UTIs
Assess certain attributes of ED patients
diagnosed with UTIs through chart review
Provide Feedback

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Caculate and illustrate monthly long term
care UTI rates on an ongoing basis
Communicate how closely patients treated for
UTIs at long term care facilities fit the
protocol criteria
Report the attributes of ED patients
diagnosed with a UTI
Document UTI testing in the ED
Data Collection Tools and Forms

For long term care:
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Chart review form
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Chart review spreadsheet
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An aide for applying the definition of a UTI in LTC
Documentation of monthly chart reviews to be
submitted each month
Measuring facility urinary tract and C difficile
infection rates
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Documentation of events and denominator data
Data Collection Tools and Forms

For Emergency Departments
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Chart review form
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Chart review spreadsheet
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Assists in determining the attributes of patients
diagnosed with UTIs in the ED
Submission of monthly chart review documentation
Measuring urine testing and ED visits
Chart Review Data Collection Form
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Chart reviews will examine the characteristics of
patients that are being treated for UTIs
Include patients >= 70 years of age
In long term care:
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Include only patients with new onset, not recurrent, UTIs
In the Emergency Department:
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Have a diagnosis code for urinary tract infection during the
period under review and
Urine testing was initiated or done by an emergency
department clinician.
Chart Review Data Collection Form for
Long Term Care
Chart Review Data Collection Form for the
Emergency Department
Notes about the chart review
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Review 20 charts a month or five charts a
week
Selecting charts to review:
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If the name of the month starts with A-F review
the first 20 patients with UTIs
If the name of the month starts with J-S review the
last 20 patients with UTIs
Use the chart review form to guide your
completion of the Excel spreadsheet but only
the spreadsheet need to be submitted
Chart Review Spreadsheet
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Document the answers to the questions on
the chart review form and use them to
complete the Data Submission Excel
Spreadsheet
Answer Yes or No to each of the questions
After completing the chart reviews for each
month email the spreadsheet to
nora.mcelroy@state.ma.us
Completing the Chart Review Spreadsheet
for Long Term Care
Completing the Chart Review Spreadsheet
for the Emergency Department
Cases and Figures for Long Term Care
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Track new onset Clostridium difficile and urinary
tract infections monthly for patients >= 70 years
of age in LTC
Determine number of urine cultures performed
each month
Enter the monthly census, or resident days, for
patients >=70 years of age
Submit monthly with the chart review
spreadsheet
Calculating a Rate
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The C difficile and UTI rates are calculated
by:
(UTIs/Resident-days)*10,000

The spreadsheet will automatically
calculate C difficile and UTI rates monthly
Cases and Figures Spreadsheet for Long
Term Care
Cases and Figures for the Emergency
Department
Spreadsheet Demonstration
Summary
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There are three tools to assist the collection of
collaborative data
 Chart Review Data Collection Form
 Chart Review Spreadsheet
 Cases and Figures Spreadsheet
Submit the Chart Review and Cases and Figures
Spreadsheets monthly
Please forward any questions to Nora McElroy and
nora.mcelroy@state.ma.us or (617) 983-6873
Thank you!
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Any Questions?
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Special thanks to all of the collaborators who
provided valuable assistance and advice in
the completion of the tools for this project.