measurement: the why and the what susanne salem-schatz, sc.d project director massachusetts...
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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 [email protected]
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 [email protected] 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.