Quality Measures - Description Resources

In today's healthcare environment, institutions are striving to streamline processes, reduce costs of healthcare, and establish best practice patterns while maintaining and improving the quality of care provided. Various healthcare delivery models are in use including case management and outcomes management. Various tools or structured-care methodologies (SCMs) are incorporated into these different models to support cost reduction and streamline processes while enhancing quality of care. This article discusses the tools frequently used, such as critical pathways, algorithms, and guidelines, as well as how these tools can be used in combination to support each other. This article also addresses the benefits of SCMs, how these tools are developed, and how the data obtained can be used in quality enhancement programs.

Crisis resource management (CRM) is a team-training program that teaches nontechnical skills such as: collaboration, communication, task management, teamwork, and leadership 1. The purpose of this study was to evaluate improvement in the nontechnical skills of a multidisciplinary team of pediatric residents, anesthesiology residents and pediatric nurses following participation in the CRM educational program. Self-efficacy theory guided the teaching method used in the CRM program. The Collaboration and Satisfaction about Care Decisions instrument 2 and the Anesthetists' Nontechnical Skills System 3 served as outcome measures. Seven multidisciplinary groups were studied with a total of 40 subjects. A significant increase was found in posttest scores for perceived collaboration and satisfaction with care and in numerical ratings of observed team skills following the CRM program. The results suggest multidisciplinary team participation in the CRM program increased perceived team collaboration, satisfaction with care, and observed teamwork skills.

Team performance measurement is a critical and frequently overlooked component of an effective simulation-based training system designed to build teamwork competencies. Quality team performance measurement is essential for systematically diagnosing team performance and subsequently making decisions concerning feedback and remediation. However, the complexities of team performance pose a challenge to effectively measuring team performance. This article synthesizes the scientific literature on this topic and provides a set of best practices for designing and implementing team performance measurement systems in simulation-based training.

Methods to measure patient safety include structure, process and outcome measures, safety attitude and climate surveys, focus groups, storytelling, executive walk rounds, and external review. Ideally, measures of patient safety should be meaningful, science based, psychometrically sound, feasible, and actionable. Accurate and timely data feedback to caregivers is critical to effect required changes. A balanced set of patient safety measures provides valuable data to guide efforts to improve perinatal patient safety.

Medical professionals and educators recognize that Simulation Based Medical Education (SBME) can contribute considerably to improving medical care by boosting medical professionals' performance and enhancing patient safety. A central characteristic of SBME is its unique approach to making (and learning from) mistakes, which is regarded as a powerful educational experience and as an opportunity for professional improvement. The basic assumption underlying SBME is that increased practice in learning from mistakes and in error management in a simulated environment will reduce occurrences of errors in real life and will provide professionals with the correct attitude and skills to cope competently with those mistakes that could not be prevented. The main message of the present paper is that this assumption, which serves as the driving force of SBME, should also serve as a starting point for critical thinking and questioning regarding the multiple aspects and components of SBME. These questions, in turn, should lead to empirical research that will provide feedback concerning changes that may be necessary in order to attain the goal of improving medical professionals' performance. Based on such research, SBME will be held accountable for its outcomes, i.e. whether its educational techniques indeed result in decreased occurrence of errors or not, and whether the ability to cope with the errors that do occur is significantly improved. The first of three issues that were addressed concerns individuals' experience of performing mistakes. It is suggested that in order to benefit fully from the experience of performing mistakes in a simulated context, medical educators should create a balance between the emotional load associated with the experience and the professional lessons that can be learned. Furthermore, research should focus on the long-term effects of the experience in changing professionals' attitudes and behaviour. The second question concerned the contribution of the different components of the educational experience to creating the desired changes in professionals' performance. Analysis of the teaching and learning involved in each stage of the educational event should serve as the basis for research that aims at identifying the unique contribution and efficiency of each element, and defining the essential core activities of a simulated experience. Finally, the need to define a newly emerging profession-SBME educator-was addressed. The professional qualifications are, clearly, multidisciplinary and should be based on the growing experience of medical educators in training students and professionals. Defining the profession is essential in order to create academic environments in which professionals will be trained to develop and implement new programmes, accompanied by research and assessment.

DESCRIPTION: Patients with elective vaginal deliveries or elective cesarean sections at 37 to 39 weeks of gestation completed.
RATIONALE: For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 1996). A survey conducted in 2007 of almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009). According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns (Tita et al., 2009).
TYPE: Process.
IMPROVEMENT: Decrease in the rate.
NUMERATOR: Patients with elective deliveries. Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following: * Medical induction of labor as defined in Appendix A, Table 11.05 * Cesarean section as defined in Appendix A, Table 11.06 Excluded Populations: None. Data Elements: * ICD-9-CM Other Procedure Dates * ICD-9-CM Principal Procedure Code.
DENOMINATOR: Patients delivering newborns with 37 to 39 weeks of gestation completed Included Populations: Not applicable. Excluded Populations: * ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions justifying elective delivery as defined in Appendix A, Table 11.07 * Less than 8 years of age * Greather than or equal to 65 years of age * Length of stay > 120 days * Enrolled in clinical trials * Active Labor * Spontaneous Rupture of Membranes

DESCRIPTION: Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section.
RATIONALE: The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are no data that higher rates improve any outcomes, yet the CS rates continue to rise. This measure seeks to focus attention on the most variable portion of the CS epidemic, the term labor CS in nulliparous women. This population segment accounts for the large majority of the variable portion of the CS rate, and is the area most affected by subjectivity. As compared to other CS measures, what is different about NTSV CS rate (Low-risk Primary CS in first births) is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2006) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen in all populations studied is striking according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and Development [OSHPD], 2007) and physicians within a hospital (Main, 1999) have rates with a 3-5 fold variation.
TYPE: Outcome.
IMPROVEMENT: Decrease in the rate.
NUMERATOR: Patients with cesarean sections Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for cesarean section as defined in Appendix A, Table 11.06 Excluded Populations: None Data Elements: ICD-9-CM Other Procedure Codes ICD-9-CM Principal Procedure Code
DENOMINATOR: Nulliparous patients delivered of a live term singleton newborn in vertex presentation Included Populations: Nulliparous patients with ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table 11.08 and with a delivery of a newborn with 37 weeks or more of gestation completed Excluded Populations: * ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes, for contraindications to vaginal delivery as defined in Appendix A, Table 11.09 Less than 8 years of age Greater than or equal to 65 years of age Length of Stay >120 days Enrolled in clinical trials