Evidence Based Practice into Clinical Practice

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Chapter 10

The Role of Outcomes and Quality Improvement in Enhancing and Evaluating Practice Changes

Evidence-Based Quality Improvement (EBQI) and Outcomes Management (OM)

EBQI: Systematic and continuous actions that lead to improvement in health services and the health status or health outcomes of targeted patient groups (U.S. Department of Health and Human Services, 2011)
OM: “Technology of patient experience designed to help patients, payers, and providers make rational medical care-related choices based on better insight into the effect of these choices on patient life” (Ellwood, 1988, p. 1549)

Basic Principles Supporting Outcomes Management

Emphasizing practice standards that providers can use to select interventions
Measuring patient functional status, well-being, and disease-specific clinical outcomes
Pooling outcome data on a massive scale
Analyzing and disseminating outcomes, in relation to the interventions used, to appropriate decision makers and stakeholders (Ellwood, 1988)

Health Outcomes Institute’s Outcomes Management Model

First model to provide steps to guide measurement of the impact of new interventions on improving healthcare outcomes

First two phases of the model:

Define clinical problem, including structure/process contributors and descriptive and confounding variables; identify desired outcomes and related measures; build database; measure baseline
Compare appraised evidence with traditional practice; engage stakeholders; negotiate adoption of new practice; develop methods to support new practice; adopt new standard

Health Outcomes Institute’s Outcomes Management Model—(cont.)

Last two phases of the model:

3. Educate all stakeholders; assure that role models and resources are available for troubleshooting processes; monitor reliability and stability of measures and refine as needed; finalize the refined process and measurement methods; begin data collection

4. Close first data collection cycle; analyze results and disseminate to stakeholders; identify opportunities for further improvement (return to phase 2 to begin refinement of improvement)

Question

Is the following statement true or false?

The Health Outcomes Institute’s Outcomes Management Model provides a four-step process for the critical appraisal of evidence.

Answer

False

Rationale: The Health Outcomes Institute’s Outcomes Management Model delineates a process that can be used to guide measurement of the impact of new interventions on improving healthcare outcomes. It does not provide a specific process for critical appraisal of the literature.

Sources of Internal Data for EBQI

Internal Data Resources	Type/Source of Data
Quality management department	Incident reports, patient satisfaction scores, data collected for regulatory or accreditation bodies
Finance department	Charges for tests, medications, equipment, or supplies; patient days; readmission rates; patient demographics; patient diagnosis coding (MS-DRG, ICD-9/10)
Human resources	Staff turnover and education levels; hours by pay/labor category; contract labor use; provider skill mix; staffing ratios

Sources of Internal Data for EBQI—(cont.)

Internal Data Resources	Type/Source of Data
Clinical systems	Will vary with system—at minimum typically diagnostic test results and pharmacy data
Administration	Patient complaints
Electronic health record	Patient-level information captured through documentation of clinical care

Question

Which of the following two sources would be the most likely to house the data needed to measure patient outcomes related to a proposed change in the nursing skills mix at a hospital?

Finance and administration
Human resources and the quality management department
Clinical systems and the electronic health record
Administration and the quality management department

Answer

b. Human resources and the quality management department

Rationale: The human resource department is a key source of data related to nursing skills mix and the quality management department collects data on patient outcomes through incident reports, patient satisfaction scores, and data collected for regulatory or accreditation bodies. Administration data are usually limited to patient complaints, and financial data are related to charges, such as for tests, medications, equipment, or supplies. Finally, clinical systems address lab results and pharmacy orders, while the electronic health record is based on clinical documentation, from which aggregate outcomes are hard to derive.

When Existing Data Sources Are Unavailable

Measurement instruments that are developed must be evaluated as to whether they are valid and reliable

Validity: Is the instrument actually measuring what it is supposed to measure?
Content validity: The minimum demonstration of validity needed; often reflected through a panel of experts reviewing the instrument

When Existing Data Sources Are Unavailable—(cont.)

Reliability: Does the instrument measure the construct consistently every time it is used?

Cronbach’s alpha: A Cronbach’s alpha of .80 or greater usually indicates that an instrument should perform reliably each time that it is used

Levels of Data Measurement

Level of Measurement	Characteristics	Example
Nominal	Data sorted into categories; any numbers assigned to categories used only for labeling	Gender, presence or absence of a quality (e.g., disease)
Ordinal	Data can be ranked in order, but the absolute difference between each level is not equal	Likert scales

Levels of Data Measurement—(cont.)

Level of Measurement	Characteristics	Example
Interval	Numeric data with equal and consistent mathematical values separating each discrete measurement point, however, lacks an absolute zero	Fahrenheit temperature scale
Ratio	Same data characteristics as interval-level data, but also has an absolute zero value	Kelvin temperature scale

Reporting to Key Stakeholders

All parties involved with the process of practice change should have an opportunity to understand the results achieved
Two methods of presenting data in an understandable way are:
Scorecards
Dashboards

Reporting to Key Stakeholders: Scorecards

Reporting to Key Stakeholders: Dashboards

Why Would Quality Projects Need IRB Approval?

HIPAA regulations require IRB approval of all studies involving personal health information (PHI)

If it is possible that knowledge might be shared outside of the specific quality improvement initiative and institution (e.g., publication or presentation of strategies used and resultant outcomes), then IRB approval is required prior to initiation of the project

Question

A rating scale asks patients to rate their nausea by describing it as “no nausea,” “slight nausea,” “significant nausea,” or “severe nausea.” What is the highest level of data measurement that this scale provides?

Nominal
Ordinal
Interval
Ratio

Answer

b. Ordinal

Rationale: In Likert-type scales, data can be ranked in order, but the absolute difference between each level is not equal. It is not possible to calculate a mean or a standard deviation.