Section 2.2 Utilize – Effective Use
Quality Measurement Reporting and
Improvement
Use National Quality Forum (NQF) endorsed measures for your quality reporting activities, as they
may be associated with various incentive programs, such as the Physician Quality Reporting
Initiative (PQRI) and the HITECH meaningful use of electronic health record (EHR) technology
incentives. Approach quality reporting from both a measurement and an improvement perspective.
Reporting alone may not necessarily tie to improvement. For instance, one measure that may be
required for HITECH incentive reporting is “Adoption of Medication e-Prescribing.” or “Medical
Home System Survey. While an important technology, its adoption does not demonstrate movement
from baseline to better performance. Even when a measure is as specific as “Comprehensive
Diabetes Care: HbA1c control (<8.0),” it does not measure improvement.
This tool helps you to consider how to best measure quality in your organization and how to effect
improvements beyond mere reporting of measures.
Evaluating and Using Clinical Interventions
Your hospital should evaluate the measures required to be reported under the incentive programs it
intends to participate in. Consider adding other improvement goals that may be suitable for your
hospital.
1. Understand the process or processes impacted by the measures. It might be diabetes management
for the HITECH incentive or other formal incentive programs. Other elements of a hospital visit
might also be impacted, such as the need to improve the accuracy and efficiency of patient intake
documentation in order to improve productivity of providers and patient satisfaction.
2. Identify the intervention you intend to apply in order to improve, such as pneumococcal
vaccinations. Look for the ability to do proactive follow up with your patients—using the EHR’s
registry functionality, and the ability to be prompted during a patient visit to measure if patients
were screened and if the immunization was given. In the case of improved patient intake
documentation, you will look for context-sensitive templates to be included in your EHR.
3. Cite the purpose of the measurement, reporting, and improvement. In some cases, this may be
driven by an external body; in other cases, it may be an internal goal. Share this rationale with
hospital representatives who wonder why certain data collection is being performed and
monitored.
4. Identify the desired goal, which may be set for you by an external organization. For instance,
NQF currently sets the HbA1c control as <8.0. However, a state reporting program may set the
bar higher. For example, in Minnesota, the 2009 goal is described as D5, meaning the percentage
of diabetes patients, ages 18-75, who met all five diabetes goals:
1)
2)
3)
4)
5)
Maintain blood pressure less than 130/80
Lower LDL or “bad” cholesterol to less than 100 mg/dl
Control blood sugar so that A1c level is less than 7%
Don’t smoke
Take an aspirin daily, for those ages 40 and older
5. Identify the metrics you will use to collect the data on the measure and report it, as applicable. In
the case of external reporting requirements, the metrics will generally be supplied. For diabetes
Section 2.2 Utilize – Effective Use – Quality Measurement Reporting and Improvement - 1
management, the value of the patient’s A1c is a key metric. For the patient intake documentation
example, the number of entries missed on an audit and the number of procedures having to be
repeated—identified on processing mapping—may be the metrics.
6. Monitor and record improvement with the intervention you are using. Determine the timeframe
in which you will measure for improvement and document results. If you are meeting your target
goals, celebrate success and monitor to ensure you sustain the desired level or to get even better.
If you are not meeting your target goals, you may need to consider other interventions. Most
interventions are not solely based in health information technology. People, policy, and other
process issues factor in as well.
Processes
Impacted
Intervention
Diabetes
management
Proactive F/U
EHR prompts
Patient intake
and
documentation of
vitals, chief
complaint
Contextspecific
templatebased charting
Purpose
Metrics
Goals
Achieved
HITECH
A1c
Q1
< 8.0 (NQF) < 7.8
State-based
provider
report cards
D5*
<7.0 (MN)
Improve
accuracy to
reduce
repetitive
interviewing
to improve
provider
productivity
# missed
entries on
audit
every 5
patients
Patient
satisfaction
through fewer
repetitive
questions &
procedures
# procedures
repeated via
process
mapping (PM)
No
unjustified
repeats on
quarterly
PM
Yes
No
% satisfaction
on survey
98% score
97%
99%
Q2
<7.5
...
Copyright © 2009, Margret\A Consulting, LLC. Used with permission of author.
For support using the toolkit
Stratis Health  Health Information Technology Services
952-854-3306  info@stratishealth.org
www.stratishealth.org
Section 2.2 Utilize – Effective Use – Quality Measurement Reporting and Improvement - 2
<2
Yes