Measurement: the why and the what

Susanne Salem-Schatz, Sc.DProject DirectorMassachusetts Coalition for the Prevention of Medical Errors

Why measure?1. For you

Track progress towards key improvement goals “How do we know a change is an improvement?”

What gets measured gets done

2. For us Your experience and progress are a key component

of how we evaluate our efforts (surveys, lessons shared on monthly reports, measures over time)

3. For the CDC (our funder) National recognition Continued funding and opportunity to support change

in the community

What to measure

Limited set of core metrics Differences by type of facility, when

appropriate Good enough

Balance value and effort Don’t let the perfect be the enemy of the good

Overview of measures: Long term care Percent of treated UTIs that meet the

“Protocol criteria” (ABCs) Rates* over time of:

new UTI cases laboratory orders for urine culture healthcare acquired C. difficile (HA-CDI)

* All rates calculated per 10,000 resident days

Overview of measures: Emergency Department1. Percent of treated UTIs with specific signs

or symptoms of UTI

2. Percent of treated UTIs with non-specific signs or symptoms

3. Percent of treated UTIs with no signs or symptoms (default)

4. Rate of urine tests sent to laboratory per ED visitors > 70 years old

Measuring Progress

Nora McElroy, MPHGeneral EpidemiologistMassachusetts Department of Public HealthBureau of Infectious Disease Prevention, Response and Services, Epidemiology Program

Measuring Improvement Establish baseline UTI rates and chart

attributes Record which LTC patients have been

treated for UTIs and whether they fit the protocol definition in long term care facilities

Record the number and attributes of diagnosed UTIs

Assess certain attributes of ED patients diagnosed with UTIs through chart review

Provide Feedback

Caculate and illustrate monthly long term care UTI rates on an ongoing basis

Communicate how closely patients treated for UTIs at long term care facilities fit the protocol criteria

Report the attributes of ED patients diagnosed with a UTI

Document UTI testing in the ED

Data Collection Tools and Forms For long term care:

Chart review form An aide for applying the definition of a UTI in LTC

Chart review spreadsheet Documentation of monthly chart reviews to be

submitted each month Measuring facility urinary tract and C difficile

infection rates Documentation of events and denominator data

Data Collection Tools and Forms For Emergency Departments

Chart review form Assists in determining the attributes of patients

diagnosed with UTIs in the ED Chart review spreadsheet

Submission of monthly chart review documentation Measuring urine testing and ED visits

Chart Review Data Collection Form Chart reviews will examine the characteristics of

patients that are being treated for UTIs Include patients >= 70 years of age In long term care:

Include only patients with new onset, not recurrent, UTIs In the Emergency Department:

Have a diagnosis code for urinary tract infection during the period under review and

Urine testing was initiated or done by an emergency department clinician.

Chart Review Data Collection Form for Long Term Care

Chart Review Data Collection Form for the Emergency Department

Notes about the chart review Review 20 charts a month or five charts a

week Selecting charts to review:

If the name of the month starts with A-F review the first 20 patients with UTIs

If the name of the month starts with J-S review the last 20 patients with UTIs

Use the chart review form to guide your completion of the Excel spreadsheet but only the spreadsheet need to be submitted

Chart Review Spreadsheet

Document the answers to the questions on the chart review form and use them to complete the Data Submission Excel Spreadsheet

Answer Yes or No to each of the questions After completing the chart reviews for each

month email the spreadsheet to nora.mcelroy@state.ma.us

Completing the Chart Review Spreadsheet for Long Term Care

Completing the Chart Review Spreadsheet for the Emergency Department

Cases and Figures for Long Term Care Track new onset Clostridium difficile and urinary

tract infections monthly for patients >= 70 years of age in LTC

Determine number of urine cultures performed each month

Enter the monthly census, or resident days, for patients >=70 years of age

Submit monthly with the chart review spreadsheet

Calculating a Rate

The C difficile and UTI rates are calculated by:

(UTIs/Resident-days)*10,000

The spreadsheet will automatically calculate C difficile and UTI rates monthly

Cases and Figures Spreadsheet for Long Term Care

Cases and Figures for the Emergency Department

Spreadsheet Demonstration

Summary There are three tools to assist the collection of

collaborative data Chart Review Data Collection Form Chart Review Spreadsheet Cases and Figures Spreadsheet

Submit the Chart Review and Cases and Figures Spreadsheets monthly

Please forward any questions to Nora McElroy and nora.mcelroy@state.ma.us or (617) 983-6873

Thank you!

Any Questions?

Special thanks to all of the collaborators who provided valuable assistance and advice in the completion of the tools for this project.