User Guide - Australian Commission on Safety and Quality in Health
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1. BMJ Qual Saf 2014 23 290 298 Easy Guide to Clinical Practice Improvement A guide for healthcare professionals NSW Department of Health 2002 2 a 22 23 24 25 26 27 28 29 30 32 33 34 35 36 3r 38 39 40 41 42 43 National Quality Use of Medicines Indicators for Australian Hospitals 2014 M Jem n Enhancing Project Spread and Sustainability A Companion to the Easy Guide to Clinical Practice Improvement Clinical Excellence Commission 2008 O Neill C and Robinson M Five steps to practice improvement The easy guide Quorus 2012 World Health Organization Introduction to quality improvement methods WHO 2012 Dartnell J Understanding influencing and evaluating drug use Therapeutic Guidelines Limited 2001 Kaye KI Welch SA Graudins LV et al Pethidine in emergency departments promoting evidence based prescribing Med J Aust 2005 183 3 129 133 Gazarian M and Graudins LV Long term Reduction in Adverse Drug Events An Evidence Based Improvement Model Pediatrics 2012 129 5 e1334 e1342 The Victorian Quality Council A guide to using data for health care quality improvement Rural and Regional Health and Aged Care Services Division Victorian Government Department of Human Services 2008 Perla RJ and Provost LP Judgment sampling a health care improvement perspective Qual Manag Health Care 2012 21 3 169 1752. Clinical engagement Understanding clinical practice toolkit Department of Health Victoria 2013 Mant J Process versus outcome indicators in the assessment of quality of health care Int J Qual Health Care 2001 13 6 475 480 Dixon N and Pearce M Guide to ensuring data quality in clinical audits Healthcare Quality Improvement Partnership 2009 The Good Clinical Documentation Guide National Centre for Classification in Health Commonwealth of Australia 2003 Sentinel events in Australian public hospitals 2004 05 Australian Institute of Health and Welfare and the Australian Commission on Safety and Quality in Health Care 2007 Mackinnon NJ ed Safe and Effective The eight essential elements of an optimal medication use system Canadian Pharmacists Association 2007 Kuzma JW and Bohnenblust SE Basic statistics for the health sciences 5th edn McGraw Hill 2004 Clinical Indicators Australian Council on Healthcare Standards 2013 UHBristol Clinical Audit Team How To Set an Audit Sample amp Plan Your Data Collection Version 3 University Hospitals Bristol NHS Foundation Trust 2009 Ganley H A primer on statistical thinking 2010 unpublished Perla RJ Provost LP and Murray SK The run chart a simple analytical tool for learning from variation in healthcare processes BMJ Qual Saf 2011 20 1 46 51 Thor J Lundberg J Ask J et al Application of statistical process control in healthcare improveme
3. National Quality Use of Medicines Indicators for Australian Hospitals Why use the National QUM Indicators The purpose of measuring indicators using clinical audit analysis and interpretation of data is to inform and guide an ongoing program of local quality improvement activities Results from local quality improvement activities can assist monitoring process performance assessing if interventions to change structures and processes lead to improvements providing feedback to clinicians and helping support practice improvements assessing if improvements are maintained over time The value of using indicators is fully realised with repeated measurement and coordinated action It is recommended that indicator measurement is part of an ongoing multidisciplinary local quality improvement activity e indicator measurement is embedded in routine clinical care feedback is simple to understand and used by clinicians to guide everyday practice e interventions are undertaken in a supportive environment that includes appropriate structures policies systems leadership and organisational culture The National QUM Indicators are designed specifically for data collection as part of local quality improvement activities and can be used in a number of ways e complementing information gained from the use of Medication Safety Self Assessment for Australian Hospitals MSSA tools The MSSA tools assess medication
4. National Quality Use of Medicines Indicators for Australian Hospitals User Guide tag nocere CLINICAL visor EXCELLENCE on SAFETY ano QUALITY in HEALTH CARE lt N Group ne COMMISSION Commonwealth of Australia 2014 and NSW Therapeutic Advisory Group Inc This work is copyright It may be reproduced in whole or in part for Australian quality improvement study or training purposes subject to e the inclusion of an acknowledgement of the source indicators being reproduced without variation from the original Requests and inquiries concerning reproduction and rights for purposes other than those indicated above requires the written permission of either e Australian Commission on Safety and Quality in Health Care GPO Box 5480 Sydney NSW 2001 or mail safetyandquality gov au e NSW Therapeutic Advisory Group Inc PO Box 766 Darlinghurst NSW 2010 or nswtag stvincents com au Suggested citation Australian Commission on Safety and Quality in Health Care and NSW Therapeutic Advisory Group Inc 2014 National Quality Use of Medicines Indicators for Australian Hospitals ACSQHC Sydney This document with associated support materials is available on the Australian Commission on Safety and Quality in Health Care web site at www safetyandquality gov au and the NSW Therapeutic Advisory Group web site at www nswtag org au ISBN 978 1 921983 78 8 Online ISBN 978 1 921983 79 5 Print Er Ss Using the
5. What is it Calculated aaae LIe ELR Td d 0 0 sample Sizg 8293637 A sample size is the number of individuals required to include in the data collection activity so that there is assurance that the results are sufficiently precise See examples in Box 3 Why use it Consider calculating a sample size if you need to infer from the sample to the whole population you need assurance the results are representative of the population itisarequirement of key stakeholders Continuous indicator data collection Not applicable sample sizes are typically not calculated for continuous indicator data collection Considerations An easy to use sample size calculator is available at www openepi com SampleSize SSPropor htm Discuss with stakeholders how precise the results are required to be as this can affect the calculation of results Consider seeking statistical advice See examples in Box 3 6 National Quality Use of Medicines Indicators for Australian Hospitals 2014 Table 3 Sample size considerations continued Judgement sample size 7 12 18 19 28 31 36 What is it Why use it Considerations Intermittent indicator data collection Advice from subject matter experts guides the sample size required by balancing degree of assurance required against resource constraints Exact sample size recommendations cannot be given because they depend on vari
6. ables such as the specific indicator used the size of the hospital and what the expected performance is The final determination will rely on the judgement of the advisory group overseeing the quality improvement activity As above Continuous indicator data collection Consider taking a See Table 2 judgement sample size if e there are resource practical difficulties in calculating a sample size e there is no need to infer from the sample to the whole e stakeholders feel this approach is satisfactory Also see Table 2 A judgement sample size Larger sample sizes generally lead to can be particularly useful greater precision and ability to detect for activities such as the change However there is a point PDSA cycle beyond which increasing sample size gives little improvement in the precision of results Smaller samples can be collected if the test is repeated frequently If a given sample is difficult to collect in one go it can be collected at different times then collated For example a sample of 15 can be collected as three samples of five See examples in Box 3 National Quality Use of Medicines Indicators for Australian Hospitals 2014 7 National Quality Use of Medicines Indicators for Australian Hospitals Box 3 Sample size decisions Examples QUM Indicator 5 8 Percentage of discharge summaries that contain a current accurate and comprehensive list of medicines H
7. ad done a similar data collection and referred to the Society for Hospital Medicine MARQUIS implementation manual http tools hospitalmedicine org resource_rooms imp_guides MARQUIS Marquis_Manual2011 pdf and followed their suggested strategy that recommends using 20 randomly selected patients per month The key stakeholders were happy with this approach Key Decision 3 How to analyse data For both intermittent indicator data collection and continuous indicator data collection a key decision is whether to undertake statistical or descriptive analysis of the collected data Statistical analysis of data allows for calculation of statistical significance and a high level of assurance that the results are true Descriptive analysis of data provides a convenient and quick view of performance and an indication of how performance is trending However with descriptive data it can sometimes be difficult to determine if observed changes are truly due to performance change or are due to chance Key considerations are described in Table 4 below Table 4 Considerations for analysing data What is it Considerations Why use it Statistical Intermittent indicator data collection analysis m as 16 86 36 41 When data have been Consider statistical Statistical advice may be required to collected randomly according analysis if determine the correct statistical tests to a calculated sample size and a valid biostatistical ca
8. alist clinicians relevant to the scope i of specific indicators continuous data collection Key decision 2 Selecting the approach e people with relevant expertise in data collection to sampling data analysis and clinical practice improvement methodology collect data from the whole population or take a sample The advisory group can advise on a number of factors including sample type key stakeholders to consult prior to data random collection particularly clinicians and stakeholders judgement whose practice may be affected TEE SES which indicators to use what type of data collection is appropriate how frequently to measure the indicator calculated sample size judgement sample size Key decision 3 How to analyse data e which population to audit statistical analysis e whether sampling is required or data will be f descriptive analysis collected from the whole population Key decision 4 How to present e i i how many cases records to include in the sample indicatorresulis how to ensure the sample is representative of the population how to determine appropriate local performance targets e appropriate actions to take based on indicator results 2 National Quality Use of Medicines Indicators for Australian Hospitals 2014 Key Decision 1 Selecting the overall approach to data collection There are two types of data collection processes that are commonly under
9. antibiotics that are concordant with drug and therapeutics committee approved criteria Hospital A The advisory group wanted to compile baseline information prior to the introduction of a local antimicrobial stewardship program As part of this program they decided to use QUM Indicator 2 2 Percentage of prescriptions for restricted antibiotics that are concordant with drug and therapeutics committee approved criteria This would provide baseline data but could also be used throughout the program to monitor program progress Because they kept good records that were easily accessible and knew how many people received restricted antibiotics each week the advisory group decided to collect data on all patients prescribed restricted antibiotics over a one week period In this case sample type and size considerations were not required Nevertheless the group needed to discuss whether they would take an intermittent or continuous approach to data collection Discussions regarding audit frequency whether frequent feedback to clinicians was required how analysis would be undertaken and how the future activity would be guided by the results were undertaken prior to data collection Sample type Whether you are collecting a sample for intermittent or continuous data collection a key decision is whether to collect a random probability or judgement non probability sample Both types of sampling are appropriate in different circumstanc
10. e required is feedback to clinicians and key decision makers to influence practice required is demonstration of statistical significance required e Practicalities such as how difficult it is to find cases that are eligible for inclusion in the audit how difficult it is to find the exact information in the medical record or elsewhere required for the audit Time and resources available to conduct data collection analysis feedback reporting Regardless of the approach chosen indicator measurement needs to be ongoing Indicators become meaningful when measurement is repeated regularly and trends can be monitored and acted upon in a timely way Repeated indicator measurement allows an assessment of process stability which is important for understanding influences such as the impact of seasonal or chance variation on interventions The advisory group can advise on how frequently to collect indicator data that is appropriate for the approach chosen for example intermittent data collection or continuous data collection Repeated indicator collection is easier when it is embedded into routine processes of care Note Data collection for many National QUM Indicators relies on good documentation in the medical record In some cases the desired process or procedure will occur without corresponding documentation However clear and complete medical record documentation including discharge sum
11. enous thromboembolism prophylaxis appropriate to their level of risk Hospital l Statistical analysis with biostatistical calculation The hospital had recently implemented a new system of assessing venous thromboembolism VTE risk on admission and wanted to know if this would improve the rates of appropriate VTE prophylaxis The advisory group consulted with the relevant stakeholders and because a high level of assurance was required that results were real and represented the whole population it was decided that a representative sample of high risk patients would be sampled every six months A statistician at a nearby university was consulted to ensure the sample sizes calculated were appropriate and to assist with the required biostatistical calculations Hospital J Statistical analysis using statistical process control charts The advisory group was very interested in using control charts with statistical process control because they wanted to understand if the implementation of a new medication chart that included VTE risk assessment 10 National Quality Use of Medicines Indicators for Australian Hospitals 2014 documentation would result in improvements in rates of VTE assessment and if this could be maintained This was an important project so training options in the use of control charts were investigated Management supported data collection as part of routine work Within a few months this investment had paid off because
12. es and each has strengths and limitations to consider Definitions and factors to consider are outlined in Table 2 Table 2 Sample type considerations What is it Why use it Considerations Random A process of taking Random sampling should be It may be hard to define a fixed sampling a sample so that considered if population from which to take a random 18 31 35 36 each member of the you need to infer from sample given the dynamic nature population has an equal the sample to the whole of health care chance of selection population A small but important patient group This removes bias and could be missed if sampling is left to allows inferences to be e you need assurance the l chance as part of random sampling made from the sample results are representative MH NC HEN IUE choca to the whole population of the population P T iiri e it is a requirement of There are different types of key stakeholders random sampling Consider seeking statistical advice regarding specific sampling needs See examples in Box 2 Judgement A non random process Consider judgement sampling There is a risk of bias when using sampling of taking a sample that when taking a random sample judgement sampling and this needs to also called draws on subject matter is not feasible or when you want be considered when interpreting data purposive expertise to choose the to target a particular area time and may limit the conclusions that can sampling m
13. http app ihi org Workspace tracker See examples in Box 4 Table 4 continued overleaf National Quality Use of Medicines Indicators for Australian Hospitals 2014 9 National Quality Use of Medicines Indicators for Australian Hospitals Table 4 Considerations for analysing data continued What is it Descriptive analysis y Data plotted as a bar chart or as a line graph provides a descriptive display of results These methods are widely used and can help teams in their quality improvement activities Figure 2 is an example of a bar chart used to provide feedback to clinicians Why use it Consider descriptive analysis if there e are resource and practical difficulties in statistical analysis is no need to infer from the sample to the whole population e is areduced need for assurance that results are representative Considerations Intermittent and continuous indicator data collection This approach can be useful for providing feedback to stakeholders during rapid cycle quality improvement activities It can be difficult to determine if any observed differences over time reflect real change It is important to consult with relevant stakeholders from the outset to ensure usefulness and acceptance of this approach See examples in Box 4 Box 4 Analysing data Examples QUM Indicator 1 2 Percentage of hospitalised adult patients that receive v
14. ice Standards Sydney ACSQHC 2012 2 NSW Therapeutic Advisory Group Indicators for the Quality Use of Medicines in Australian Hospitals NSW TAG 2007 3 The National Strategy for Quality Use of Medicines Commonwealth of Australia 2002 4 National Medicines Policy Department of Health and Ageing Commonwealth of Australia 2000 5 Roughhead L Semple S Rosenfeld E Literature Review Medication Safety in Australia Australian Commission on Safety and Quality in Health Care 2013 6 Schaff R Schumock G and Nadzam D Development of the Joint Commission s indicators for monitoring the medication use system Hospital Pharmacy 1991 26 326 329 7 Haaijer Ruskamp FM Hoven J Mol PGM et al Towards a conceptual framework of prescribing quality indicators Br J Clin Pharmacol 2005 59 5 612 8 Hoven JL Haaijer Ruskamp FM and Vander Stichele RH Indicators of prescribing quality in drug utilisation research report of a European meeting DURQUIM 13 15 May 2004 Eur J Clin Pharmacol 2005 60 11 831 834 9 Donabedian A Evaluating the quality of medical care Reprinted from The Milbank Memorial Fund Quarterly vol 44 pg 166 203 1966 Milbank Q 2005 83 4 691 729 10 Medication Safety Self Assessment for Australian Hospitals Institute for Safe Medication Practices USA Adapted for Australian use by the NSW Therapeutic Advisory Group and the Clinical Excellence Commission 2007 11 Medication Safety Self A
15. itals over time and to provide a robust measure for hospitals over a relatively short time period Testing meaningful inter hospital comparison has demonstrated content validity face validity and usefulness of the indicators This is consistent with Where indicators are intended to be used for inter the indicator development method developed by the hospital comparison or comparative reporting issues Joint Commission formerly the Joint Commission Such as consistent availability of data sources and on Accreditation of Healthcare Organizations and is resources for data collection may need to be taken into considered adequate for internal hospital comparison account when determining the approach to sampling over time to inform and monitor local action 9 Risk adjustment on the basis of hospital demographics case mix and or patient characteristics may be Most of the National QUM Indicators are considered necessary Sample size time frames for data collection potentially useful for inter hospital comparisons and the approach to risk adjustment should be agreed However and as for most indicators ongoing validation in advance with the coordinating agency to ensure is recommended to ensure that they are sensitive and uniformity of data collection 12 National Quality Use of Medicines Indicators for Australian Hospitals 2014 References 1 Australian Commission on Safety and Quality in Health Care National Safety and Quality Health Serv
16. lculation performed the results can be generalised from the sample to the whole population you need to infer from This is a useful method to consider the sample to the for overall program evaluation e whole population See examples in Box 4 you need assurance the results are representative of the population itisarequirement of key stakeholders Continuous indicator data collection Statistical process control Considerations as per Effective use of SPC requires training SPC is used to determine intermittent indicator and a commitment to ongoing and if a process is stable or if data collection repeated data collection and feedback an intervention has led to Benenitsinclude To be most helpful in assessing improvement or meaningful processes of care SPC requires change Data are displayed identification of type collection of at least 10 data points graphically using run or of variation present before the results can be analysed control charts and this is common gause or assessed using defined rules special cause variation A control chart template hasa e determination if centre line the mean as well improvements are as upper and lower control statistically significant limits Figure 4 is an example of a control chart Subject matter expertise is required to determine if improvements are clinically significant A resource that may be helpful is the Institute of Healthcare Improvement Improvement Tracker
17. mary documentation is a critical component of patient care Lack of information and documentation are the second most commonly reported contributing factors to sentinel events in Australian hospitals Additionally breakdowns in medication management communication can result in adverse medicine events The National QUM Indicators are therefore calculated using the assumption that if it is not documented it is not done In this way they are intended to promote effective documentation and communication of medication management National Quality Use of Medicines Indicators for Australian Hospitals 2014 3 National Quality Use of Medicines Indicators for Australian Hospitals Key Decision 2 Selecting the approach to sampling Is a sample needed For many indicators testing a sample from a population is recommended rather than testing the whole population because it is a more efficient use of time and resources However for some indicators it is possible to collect data from all cases in the population being studied rather than taking a sample 5 The advisory group can advise on the most appropriate approach as well as other key decisions required regardless of whether a sample is collected or not See the example in Box 1 4 National Quality Use of Medicines Indicators for Australian Hospitals 2014 Box 1 Decisions on the approach to sampling Example QUM Indicator 2 2 Percentage of prescriptions for restricted
18. nt systematic review Qual Saf Health Care 2007 16 5 387 399 Ganley H Demonstration of analysis and reporting for the NSW Therapeutic Advisory Group Bounty Brokers Pty Ltd 2012 Lane S Weeks A Scholefield H et al Monitoring obstetricians performance with statistical process control charts BJOG 2007 114 5 614 618 Lloyd R The Science of Improvement on a Whiteboard Institute of Healthcare Improvement Open School 2014 13 Australian Commission on Safety and Quality in Health Care Level 5 255 Elizabeth St Sydney NSW 2001 GPO Box 5480 Sydney NSW 2001 Phone 02 9126 3600 international 61 2 9126 3600 Fax 02 9126 3613 international 61 2 9126 3613 Email mail safetyandquality gov au www safetyandquality gov au NSW Therapeutic Advisory Group Inc 26 Leichhardt St Darlinghurst NSW 2010 PO Box 766 Darlinghurst NSW 2010 Phone 02 8382 2852 international 61 2 8382 2852 Fax 02 8382 3529 international 61 2 8382 3529 Email nswtag stvincents com au www nswtag org au
19. ol chart not real hospital data Proportion of patients with acute coronary syndrome who are prescribed appropriate medicines on discharge Upper control 1 limit 1 Special cause variation gt P 0 87 87 Lower control limit 0 71 l Intervention X implemented Proportion Month Year pis average proportion The above chart shows that for 22 months an average proportion of 0 48 48 of patients were prescribed the appropriate medicines on discharge November 2015 displayed a positive special cause variation being outside the 3 sigma control limits red horizontal lines This was investigated and found to be due to an isolated intervention X which was subsequently implemented across the hospital in November 2016 This resulted in further special cause variation The chart was therefore split at this point to show the change in process and control limits were recalculated around the new mean As the second part of the chart is now stable we can expect that unless there is another fundamental change to the process future monthly performance will average 8796 and vary between 7196 and 10096 Control chart adapted from chart provided by former Northern Sydney Central Coast Health Clinical Governance Unit Inter hospital comparisons The National QUM Indicators were tested in a reliable enough to measure variation in practice between representative but relatively small number of hosp
20. ospital E Intermittent indicator data collection with calculated sample size The hospital management requested information about discharge medication processes During consultation with the key stakeholders it was clear that assurance was required so that the results would be representative of the whole population A small pilot study suggested that compliance was 60 So a sample size calculation was done using a sample size calculator and a confidence interval of 0 05 giving a precision of 5 The results of this calculation showed that when 234 people were discharged on average each month review of 144 records would be required to be 95 certain that results could be considered representative of the whole population Review of 95 records would be required to be 80 certain The advisory group decides that they are happy to proceed with 80 certainty and audit 95 discharge summaries Repeat data collection is planned in 12 months Hospital F Intermittent indicator data collection with calculated sample size Hospital F averages 500 discharges per month and plans to implement a medication management plan MMP to assist medication reconciliation processes at discharge within the next 12 months They plan to evaluate the impact of the MMP by measuring Indicator 5 8 before and after implementation However the hospital does not know what its performance level with the indicator will be The advisory group considers a recent publication
21. ost appropriate types of day or patient population be drawn TU and numbers of cases This is often a desired approach Although losing the ability to assess ie include Used when as it helps target activity to precision of results using traditional it S rb to PKErCISE those areas it is important statistics judgement sampling improves judgement in selecting to understand the ability to generalise on the basis th Sample fatnier tian Thi of samples selected under a wide leaving this to chance is approach is particularly ae useful for activities such as the range of conditions and over time as PDSA cycle improvements are made See examples in Box 2 For more information about types of random sampling visit www abs gov au ausstats abs nsf Latestproducts A493A524D0C5D1A0CA2571FE007D69E2 0pendocument A simple to use random number generator is available at www random org integers National Quality Use of Medicines Indicators for Australian Hospitals 2014 5 National Quality Use of Medicines Indicators for Australian Hospitals Box 2 Sample type decisions Examples QUM Indicator 5 2 Percentage of patients with systolic heart failure that are prescribed appropriate medicines at discharge Hospital B Intermittent indicator data collection with random sampling The cardiology department wanted to audit the use of ACE inhibitors and beta blockers in systolic heart failure An advisory group was convened to consider which sam
22. pling methodologies would best assure that the results are representative of all patients with systolic heart failure As heart failure admissions vary during the year X patients were randomly selected from all those admitted with systolic heart failure over the whole year A simple random sampling method was chosen and repeated each year Hospital C Continuous indicator data collection with judgement sampling Stakeholders agreed that random sampling was not feasible and a judgement approach was preferred in this situation The first Y patients admitted with systolic heart failure each month over the year were reviewed Sample size Hospital D Intermittent indicator data collection with judgement sampling The advisory group decided to do a snap shot audit including all patients with systolic heart failure over a defined period They decided that one month s worth of data would provide enough information for their needs However they stipulated that data from a winter month must be used because they were aware their greatest numbers of admissions for heart failure were during these months The auditor assessed their workload during these months and decided that collection during August was most feasible For both intermittent and continuous indicator data collection it is important to determine whether a sample size calculation is required or not Key considerations are described in Table 3 Table 3 Sample size considerations
23. rocess control allows clinicians and managers to assess process stability determine the right time to take action and identify real improvements over time 641 Web based learning modules in quality improvement analysis and presentation of results are available at Institute of Healthcare Improvement Open School The Science of Improvement on a Whiteboard Robert Lloyd Feb 201443 www ihi org education IHlOpenSchool resources Pages BobLloydWhiteboard aspx Tools that may assist with analysis and presentation of results include e HI Improvement Tracker http app ihi org Workspace tracker e Data collection tools Clinical Practice Improvement Program Clinical Excellence Commission www cec health nsw gov au programs clinical practice Figure 2 Indicator results presented in a bar graph not real hospital data Proportion of patients with acute coronary syndrome who are prescribed appropriate medicines on discharge Proportion N Month Year The above chart provides a visual representation of trends in prescribing It highlights what appears to be a temporary improvement in November 2012 and an apparently sustained improvement commencing in November 2013 National Quality Use of Medicines Indicators for Australian Hospitals 2014 11 National Quality Use of Medicines Indicators for Australian Hospitals Figure 3 Indicator results presented in a statistical process contr
24. safety structures and systems and systematically identify ways to improve them Periodic measurement of indicators such as annually can help maintain safe medication Systems Using both the National QUM Indicators and MSSA tools assists hospitals to meet National Safety and Quality Health Service Standards and ensure that they have systems and processes in place for improving medication safety and quality use of medicines contributing to quality improvement activities using small scale iterative methods such as the Plan Do Study Act PDSA cycle and using quality improvement models such as Clinical Practice Improvement and Continuous Quality Improvement A useful quality improvement activity is drug use evaluation which is a multidisciplinary methodology for ensuring coordinated action to improve medicines use and which can be used as part of ongoing and coordinated quality improvement programs Use of indicators as part of a drug use evaluation process is a proven way to improve quality use of medicines in hospitals Who should use the National QUM Indicators The National QUM Indicators are designed primarily for use by clinicians involved in hospital medication management especially doctors nurses and pharmacists Ideally clinicians directly responsible for patient care will be involved in the measurement of these indicators interpretation of results and decisions about subsequent action The indicators may pro
25. showing a 60 compliance rate with a similar indicator The hospitals in the study were quite different in size but the advisory group decided to use the published result in their sample size calculation Calculations showed review of 121 records would be required to be 80 certain that results can be considered to be representative of the whole population 8 National Quality Use of Medicines Indicators for Australian Hospitals 2014 Hospital G Continuous audit with judgement sampling size Hospital G is a relatively small hospital and the advisory group wanted to undertake intermittent data collection with a calculated sample size but felt they did not have the resources required to undertake this Instead the group felt taking a smaller sample more frequently was more feasible So the method was changed to continuous indicator data collection and a decision was made to collect data from 10 records a month over the next year as this would provide adequate information Over time the group noticed that missing records occurred frequently so they agreed when that happened they would seek some additional records so they had data from 10 records each month Hospital H Continuous audit with judgement sampling size Hospital H had been considering an intermittent data collection with a calculated sample size but as they were a large hospital the number of records required was too large for the resources available They considered how others h
26. ssessment for Antithrombotic Therapy in Australian Hospitals Institute for Safe Medication Practices USA Adapted for Australian use by the NSW Therapeutic Advisory Group and the Clinical Excellence Commission 2007 12 Bradley EH Herrin J Elbel B et al Hospital quality for acute myocardial infarction Correlation among process measures and relationship with short term mortality JAMA 2006 296 1 72 78 13 Peterson ED Roe MT Mulgund J et al Association between hospital process performance and outcomes among patients with acute coronary syndromes JAMA 2006 295 16 1912 1920 14 National Health Performance Committee NHPC National Health Performance Framework Report Queensland Health 2001 15 Lowinger JS Stark HE Kelly M et al Improving use of medicines with clinician led use of validated clinical indicators Med J Aust 2010 192 4 180 181 16 Benneyan JC Lloyd RC and Plsek PE Statistical process control as a tool for research and healthcare improvement Qual Saf Health Care 20083 12 6 458 464 17 Brock WA Nolan K and Nolan T Pragmatic science accelerating the improvement of critical care New Horizons 1998 6 1 61 68 18 Perla RJ Provost LP and Murray SK Sampling considerations for health care improvement Qual Manag Health Care 2013 22 1 36 47 19 Taylor M McNicholas C Nicolay C et al Systematic review of the application of the plan do study act method to improve quality in healthcare
27. taken for quality improvement and evaluation of interventions 1 Intermittent data collection data is collected relatively infrequently as a cross sectional snapshot or a time series e g every six to twelve months This approach may also be used for global project or program evaluation purposes 6 to determine the overall impact of an intervention 2 Continuous data collection data is collected relatively frequently as a time series e g weekly monthly or quarterly This approach may be used as part of rapid cycle ongoing quality improvement activities using methodology such as the Plan Do Study Act cycles to assess performance of a given process and for data feedback purposes 6 Both intermittent and continuous indicator data collection processes are appropriate scientific approaches when used in the right circumstances They may both be used in a quality improvement program The approach taken to data collection is dependent on the purpose and context for measurement and can be guided by the advisory group The choice of approach depends on a number of factors and should be based on local needs Factors to consider include 1827 31 Purpose of indicator collection such as monitoring processes of care implementation and evaluation of interventions How the results will be used such as isinference from the sample to the whole population required is assurance about how representative the results ar
28. the graphical display was extremely beneficial in helping evaluate the positive impact that had occurred with the introduction of the chart and the ability to monitor whether the improvement was maintained The team is now using control charts for other indicators Hospital K Descriptive analysis using bar graphs The advisory group decided there were no resources to train auditors to use control charts but they were still interested in using a graphical display So they mapped results as a simple time series using a bar graph This would allow them to provide feedback that they thought would be helpful in change management Key Decision 4 How to present indicator results In order to influence practice improvements results of indicator measurement must be able to be interpreted and used by clinicians Unless results are presented in a time frame and format that is meaningful to clinicians they are unlikely to prompt buy in and action Traditional methods of representing results include tables histograms and bar graphs see Figure 2 These are static presentations and represent a snapshot of practice Indicator results can be presented more dynamically using run charts and control charts see Figure 3 In addition to point measurements over time control charts include control limits usually set at plus or minus three standard deviations from the mean The use of control charts using the principles of statistical p
29. vide evidence for accreditation purposes Note The National QUM Indicators are not designed for making comparisons between institutions benchmarking or for accountability purposes When collecting data for these purposes the sampling method needs to be tailored to the audit activity to ensure data collection is appropriate Seek advice from the organisers of the activity before collecting data to ensure that definitions sampling methods and guidelines for audit and reporting are agreed in advance and in consultation with the coordinating agenoy Further information on inter hospital comparisons is provided later in this section National Quality Use of Medicines Indicators for Australian Hospitals 2014 1 National Quality Use of Medicines Indicators for Australian Hospitals Optimising use of the National QUM Indicators Key decisions Getting started Before starting any data collection activity convene a multidisciplinary group of clinicians and other stakeholders to advise on the process An advisory group could include The following pages provide advice for advisory groups and others involved in indicator collection and addresses the following key decisions clinicians of varying disciplines e g medical nursing pharmacy who have relevant expertise and understand the clinical process in question Key decision 1 Selecting the overall approach to data collection intermittent data collection e sub speci
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