Quality Improvement:
Measures and Data Collection
Theresa Scott, MS
TIPQC Data Manager
Peter Grubb, MD
TIPQC Medical Director
Where do measures enter the picture?
AIM statement
MEASURE(S)
What specific measure(s)
will you collect?
•
How will you operationally
define the measure(s)?
•
Types of measures
• Outcome – measure(s) directly related to your AIM.
• Process – measures that assess the points in the sequence (ie,
flow) of the process that lead to an outcome.
• Balancing – measures that look at the entire system from many
viewpoints; can include competing explanations for success or
the unintended consequences/adverse side effects that can
occur when you make changes.
Data to be collected: Monthly Outcome TJC PC-03
• Numerator is the number of patients with antenatal steroid
therapy initiated prior to delivering preterm newborn between
>= 24 weeks and <32 weeks.
• Denominator is the number of patients delivering live preterm
newborns between >=24 weeks and <32 weeks.
• Exclusions (see definitions below) include a reason for not
initiating antenatal steroid therapy that is explicitly
documented in the patient’s chart.
From Toolkit draft 131119
Data to be collected: Monthly TJC PC-03
• Exclusions (see definitions below) include a reason for not
initiating antenatal steroid therapy that is explicitly
documented in the patient’s chart
• Exclusions: generally accepted exclusions would include but
not be limited to:
– precipitous delivery
– maternal infection
– other maternal contraindication to corticosteroid administration.
From Toolkit draft 131119
Data to be collected: Monthly TJC PC-03
• Definitions for Primary Outcome Measure
• Antenatal steroid therapy: dexamethasone 6 mg IM every 12 hours x4
doses or betamethasone 12 mg IM every 24 hours x 2 doses
• Initiation of therapy: completed first dose of dexamethasone 6 mg IM or
betamethasone 12 mg IM
• Gestational age: completed weeks and days based on standard American
Congress of Obstetrics and Gynecology criteria for dating
From Toolkit draft 131119
Data to be collected: Balancing Measures
• Is there evidence to suggest potential unintended consequences of ANS
administration?
• Group discussion: What about “Serious maternal infection”
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–
–
–
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(Need operational definition, including numerator and denominator.)
Could we use CDC NHSN post-operative infection?
Data definitions are standardized between hospitals.
Data is already collected monthly...
Numerators and denominators are readily available
• Any alternatives or additions to propose?
From Toolkit draft 131119
Data to be collected: Process Measures
• Process measures tell us whether we are doing (the PBP) what
we intend to do in a consistent, and highly reliable manner.
• Pragmatic definition: What is really going on at 2 am?
• Hard way: Actually measure and record everything…
• Alternative way: Develop context appropriate, behavior
specific measure that drive improvement, then sample
strategically. (Chart Review, Rounding for Results, Random Clinical Audit, Checklist)
From Toolkit draft 131119
Data to be collected: Process Measures
• Pragmatic definition: What is really going on at 2 am?
• Sometimes useful to map what is happening and compare to map
of what is supposed to happen.
• Many techniques, don’t have time today…
• Plan: collect Outcome and Balancing Measures
•
•
•
•
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Create a baseline 4-6 months
Teams review CPQCC toolkit and their own practice
Develop process measures collectively
Looking for 5 keys to highly reliable implementation of evidence
Deploy 5 measures for monthly auditing & reporting ~7/14
From Toolkit draft 131119
That’s the what, now for the how.
• Once a month
– Outcome: numerator, denominator, exclusions
– Balancing: numerator, denominator
– Note: both of the above are already collected
– Process measures:
– Maximum of 5: numerator, denominator
– You decide frequency and sample size for your
situation
• Total: Enter 15 numbers, once a month
Data Collection Plan
 Collecting data allows you to monitor
variation in a process, to see the effects
of a process change, and to provide an
objective forum for making decisions.
 To maintain consistency and reliability of
data capture, each team will need to
develop a Data Collection Plan.
 Includes:
 purpose (the why) of collecting the
data;
 what data will be collected
 who will collect it;
 AND the storage and editing of data;
and planned analysis.
Data transcribed onto
paper data entry form
Data entered into webbased tool & stored in
database
Quality checks
completed
Report(s), which include
run-charts (ie, plotting
data over time)
Source: http://safercare.net/Training_Modules/Training_Modules.html
Data Entry Tool: REDCap
• REDCap = Research Electronic Data Capture
• Secure, web-based application designed to support traditional case
report form (CRF) data capture for research studies.
• Very intuitive and user friendly.
• Idea for this project: online database will exist where all of the data
for each “record” (from each group) will be entered and
maintained.
• Each record represents a month (& year) of data.
– IMPORTANT: Data to be entered on a monthly basis no
later than the 7th of the following month.
• Will be able to generate real-time reports.
REDCap Demo
• Example: Breastfeeding Promotion Project
• Ongoing for a year
• ANS project is simpler, and requires less data.
• Demo:
• http://tipqc.org/
What does collecting and automating
the data do for us?
Roles of Data
• Baseline – Tells us where you are at the start.
• On-going – Tells us whether and how you are
changing your outcomes and performance.
• Overall – Tells you what impact you (ie, the project
and its initiatives) have on your AIM.
Source: http://safercare.net/Training_Modules/Training_Modules.html
Importance of “Good Data”
• Must ensure that the data you collect are accurate,
complete, and in the required format.
• GIGO: Who are you fooling?
• Good data on measures that matter creates leverageespecially data on solid PBP implementation.
• The data you collect and enter are the ultimate proof
of your success and will be shared broadly (ie, they will
influence care and policy).
Source: http://safercare.net/Training_Modules/Training_Modules.html