Tools for PM in HC - title page before jpg.qxp
4/3/2008
12:23 PM
Page 1
Tools for
Performance Measurement
in Health Care:
A Quick Reference Guide
Second Edition
Includes
CD-ROM
Senior Editor: Ilese J. Chatman
Project Manager: Bridget Lillie
Manager, Publications: Paul Reis
Editorial Associate Director: Diane Bell
Production Associate Director: Johanna Harris
Executive Director: Catherine Chopp-Hinckley, Ph.D.
Vice President, Learning: Charles Macfarlane, F.A.C.H.E.
Joint Commission/Joint Commission Resources Reviewers: Stephen Anderson, Nancy Kupta, Nancy Lawler, Paul Reis,
Laurel Shing, Frank Zibert
Joint Commission Resources Mission
The mission of Joint Commission Resources is to continuously improve the safety and quality of care in the United States and
in the international community through the provision of education and consultation services and international accreditation.
Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities
of the Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission
Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation
process.
The inclusion of an organization name, product, or service in a Joint Commission publication should not be construed as an
endorsement of such organization, product, or services, nor is failure to include an organization name, a product, or a service to
be construed as disapproval.
© 2008 by the Joint Commission on Accreditation of Healthcare Organizations
Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of the Joint Commission on Accreditation of Healthcare
Organizations (Joint Commission), has been designated by the Joint Commission to publish publications and multimedia
products. JCR reproduces and distributes these materials under license from the Joint Commission.
All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission
from the publisher.
Printed in the U.S.A. 5 4 3 2 1
Requests for permission to make copies of any part of this work should be mailed to
Permissions Editor
Department of Publications
Joint Commission Resources
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
[email protected]
ISBN: 978-1-59940-191-1
Library of Congress Control Number: 2008925569
For more information about Joint Commission Resources, please visit http://www.jcrinc.com.
Table of Contents
Introduction.............................................................................................................................................v
Using This Book ......................................................................................................................................................v
The Accompanying CD............................................................................................................................................vi
Acknowledgments...................................................................................................................................................vi
Chapter 1: Benefits of Performance Measurement Assessment.......................................................1
Using Performance Measurement in Performance Improvement .......................................................................... 1
Using Performance Measurement to Promote Improvement Initiatives................................................................ 12
The Joint Commission..................................................................................................................................... 12
National Quality Forum.................................................................................................................................... 14
Hospital Quality Alliance (HQA): Improving Care Through Information.......................................................... 14
Hospital CAHPS (HCAHPS)............................................................................................................................ 15
Home Health Compare.................................................................................................................................... 15
Nursing Home Compare.................................................................................................................................. 16
Center for Mental Health Services (CMHS).................................................................................................... 16
The Leapfrog Group........................................................................................................................................ 17
Institute for Healthcare Improvement (IHI)...................................................................................................... 17
National Committee for Quality Assurance (NCQA)........................................................................................ 18
Using Performance Measurement to Be Proactive............................................................................................... 18
The Next Step....................................................................................................................................................... 19
Chapter 2: Navigating the World of Performance Measurement.....................................................21
Deciding What to Measure.................................................................................................................................... 21
High-Risk, High-Volume, Problem-Prone Areas.............................................................................................. 21
Other Measurable Processes.......................................................................................................................... 23
Prioritizing Projects................................................................................................................................................ 25
Establishing Goals........................................................................................................................................... 28
Setting Up an Effective Team................................................................................................................................ 28
Composition and Responsibilities of the Team............................................................................................... 28
Team Training.................................................................................................................................................. 29
Choosing Measures.............................................................................................................................................. 30
Existing Measures from Outside Sources............................................................................................................. 30
Understanding Data Needs................................................................................................................................... 30
Data Availability............................................................................................................................................... 31
Data Accuracy and Completeness.................................................................................................................. 35
iii
Tools for Performance Measurement in Health Care: A Quick Reference Guide, Second Edition
Time Frame for Data Collection...................................................................................................................... 36
Using Reliable Tools.............................................................................................................................................. 36
Using Comparative Data to Set Performance Goals............................................................................................. 38
Internal Benchmarking.................................................................................................................................... 38
External Benchmarking................................................................................................................................... 38
Setting Your Goals.......................................................................................................................................... 40
Chapter 3: Measuring Up with the Right Tools..................................................................................57
Tools for Team Planning ....................................................................................................................................... 57
Brainstorming.................................................................................................................................................. 57
Flowchart......................................................................................................................................................... 60
Cause-and-Effect Diagram.............................................................................................................................. 63
Tools for Data Collection....................................................................................................................................... 65
Checklist.......................................................................................................................................................... 65
Check Sheet.................................................................................................................................................... 66
Survey............................................................................................................................................................. 70
Tools for Data Analysis and Presentation.............................................................................................................. 73
Boxplot............................................................................................................................................................ 73
Data Distribution.............................................................................................................................................. 73
Measures of Central Tendency....................................................................................................................... 73
Variation and Standard Deviation.................................................................................................................... 74
Comparison Chart........................................................................................................................................... 76
Risk Adjustment.............................................................................................................................................. 76
Variation Across Units..................................................................................................................................... 78
Control Chart................................................................................................................................................... 79
The Types of Control Charts........................................................................................................................... 82
Histogram........................................................................................................................................................ 87
Line Graph....................................................................................................................................................... 89
Pareto Chart.................................................................................................................................................... 92
Run Chart........................................................................................................................................................ 94
Stratum Chart.................................................................................................................................................. 96
Balanced Scorecard/Dashboard Display......................................................................................................... 99
Radar Chart................................................................................................................................................... 100
Performance Matrix....................................................................................................................................... 103
Stratified/Multivariable Display...................................................................................................................... 104
Chapter 4: Understanding Standardized Performance Measures and Future Goals ................. 109
ORYX© and Accreditation ................................................................................................................................... 109
Core Measure Sets..............................................................................................................................................112
Requirements for Organizations.....................................................................................................................116
Quality Check®.....................................................................................................................................................117
The Future............................................................................................................................................................118
Glossary..............................................................................................................................................127
Index....................................................................................................................................................133
iv
Introduction
There is an adage that says numbers don’t lie, although in
the case of preventable health care errors in the United
States, many people wish they did. When the Institute of
Medicine released its 2000 report on preventable medical
errors and the need for a more comprehensive approach
to patient safety, it estimated that 98,000 Americans may
die each year due to such errors.1 Data from other sources
have not been encouraging. The Institute for Healthcare
Improvement estimates that nearly 15 million instances of
medical harm occur in the United States each year—a rate
of more than 40,000 per day.2 Perhaps most disturbing of
all are the recently published results from a study sponsored
by the Commonwealth Fund and conducted by researchers
from the London School of Hygiene and Tropical Medicine.
Data from 19 countries, including the United States, Japan,
Australia, New Zealand, Canada, and western European
countries, were compiled and analyzed—first between
1997 and 1998 and then again between 2002 and 2003—to
determine the number of deaths in subjects under 75 years
of age that could have been prevented by timely and effective
medical care. In the first part of the study, the United
States finished 15th, with a mortality rate of 114.7 deaths
per 100,000 people; by the second part of the study, the
United States had fallen to last place, with a rate of 109.7
per 100,000. The U.S. decline in preventable deaths was only
4%, whereas the other countries in the study experienced an
approximately 16% decline (first place: France’s rate was only
64.8 per 100,000). The researchers estimated that anywhere
from 75,000 to 101,000 lives could have been saved in 2002
alone if the United States had achieved either the average
rate of all the other countries or the average of the top three
performing countries (France, Japan, and Australia).3
The quality of care delivered by health care organizations
has long been a subject of debate among facilities, clinicians,
insurers, and patients. However, the 1990s saw this topic
rise to national prominence due to a wide variety of factors,
including the following:
• Skyrocketing health care costs
• The merging, acquisition, reorganization, and restructuring
of all types of health systems and facilities
• Highly publicized reports of medical errors such as
wrong-site surgery and medication overdoses
• Increasing demands from third-party payers and
employers for increased efficiency, waste reduction, and
reduced costs
• An increased emphasis on patient involvement in
responsibility for care
• A public that was better educated than ever before
thanks to the growing availability of health care–related
information via the Internet and other sources
Government agencies, accrediting bodies, health care
systems, professional associations, and private organizations
all struggle with how to define high-quality care and how tp
achieve it effectively and affordably.
The interest in how well health care organizations provide
clinical and support services has led to calls for greater
transparency and better reporting of performance levels.
Many government and private entities are working to facilitate
the sharing of performance data and to establish standards of
care to educate the field and the public.
Using This Book
Health care professionals are in the habit of collecting and
interpreting medical data, such as red blood cell count or
milligrams of a medication to use for patients, but when it
comes to data related to processes and performance, vision
v
Tools for Performance Measurement in Health Care: A Quick Reference Guide, Second Edition
can be blurred. What is performance measurement? When
is it used? How do you know what to measure? What good
will measurement do? How do you go about setting up a
measurement process? How does measurement relate to
performance improvement? What are the best ways to collect
and analyze data?
This book will lead you through the sometimes confusing
process of gathering and interpreting data, showing you
the many tools and techniques available for each step in
the process and providing guidelines as to which tools are
appropriate at different stages. It will also help you see how
performance measurement can be integrated into—in fact,
is probably already a part of—your organization’s existing
improvement and quality activities.
Chapter 1 introduces you to performance measurement
and how it forms the basis of both internal and external
performance improvement initiatives. The proactive use of
measurement and the importance of involving leaders and
clinicians in measurement and improvement activities are also
illustrated.
Chapter 2 examines the practical aspects of preparing for
performance measurement, including identifying what should
be measured in a process, setting goals, putting together a
project team, and determining how to manage data.
Chapter 3 is the heart of the book. Examples of tools for
planning, data collection, and data analysis and presentation
are presented, with details of how to use them, when to use
them, and their benefits and drawbacks.
Chapter 4 discusses The Joint Commission’s current and
future goals for performance measurement, including the
ORYX® core measure sets for hospitals, measures for diseasespecific care certification, and how Quality Check® uses
performance data in its reports on accredited organizations.
Case studies showing how actual health care organizations use
various tools as part of their measurement and improvement
activities are scattered throughout the book.
The Accompanying CD
Many of the tools in this book are also available on the
accompanying CD. The
Check the CD symbol in the
book indicates that the particular topic and tool can be found
on the CD and can be printed or adapted for your own use.
vi
When you use the CD, you will also
See the Text symbol
which indicates that the topic is covered in more detail in
the book. Refer to the appropriate chapter for additional
information on how to use or re-create a specific tool.
Acknowledgments
Joint Commission Resources sends our thanks to Karen
Steib for writing this book. We also thank Joint Commission
reviewers Stephen Anderson (Joint Commission Resources
consultant), Nancy Kupta, Nancy Lawler, Paul Reis, Laurel
Shine, and Frank Zibrat for their indispensable knowledge
and insight on this topic.
A special thank you from Joint Commission Resources is
extended to the following health care organizations that
allowed us to feature their examples and tools in this book:
Brattleboro Memorial Hospital
17 Belmont Avenue
Brattleboro, VT 05301
Diversified Clinical Services
4500 Salisbury Road, Suite 490
Jacksonville, FL 32216
Pekin Memorial Hospital
600 South 13th Street
Pekin, IL 61554
Riverside Methodist Hospital
3535 Olentangy River Road
Columbus, OH 43214
References
1. Committee on the Quality of Health Care in America,
Institute of Medicine. To Err Is Human: Building a Safer
Health System. Washington, D.C.: National Academy Press,
2000.
2. Institute for Healthcare Improvement: Overview of the
5 Million Lives Campaign. http://www.ihi.org/IHI/
Programs/Campaign/Campaign.htm?TabId=1 (accessed
Jan. 5, 2008).
3. Nolte E., McKee C. M.: Measuring the health of nations:
Updating an earlier analysis. Health Affairs 27(1):58–71,
Jan./Feb. 2008.