Defining and classifying clinical indicators

for quality improvement

Dr.Mohamad Nassereddine
 Very important , here we talk about quality and metrology. Usually I don’t
measure just to have a data and number , the important is what will help me
this number and what Is the outcome of measuring this number.
 Example : weight is 70kg , if only just without purpose so nothing it means. A
person may use weight on 70 to mange his diabetes, cholesterol
,overweight ,bodybuilding, BMI.
 We measure for purpose or action plan or strategy.
 Challenge is :
 We need number , but our culture and society don’t like numbers, so this is
the problem.
 Data collection by hospital may be well done but asking them why u did
collect this data , you will not find the answer. Why we use it. Do the a week
culture to work within the numbers .
 Objective
 to provide a brief review of definitions, characteristics, and
categories of clinical indicators for quality improvement in
health care.
 Introduction
 Assessing the quality of care has become increasingly important to
providers, regulators, and purchasers of care. ( all ppl need quality, ppl who
buy products and services).
 In recent years, providers have begun to be interested in evidence-based
medicine and purchasers have begun to focus on the cost- effectiveness of
health care in producing health outcomes.
 (EBM, any protocol, machine or procedure or service , medication, should
based on a scientific principle, research and recent technology).
 (cost effective: put money in the right place and be efficient and effective in
the use of money).
 If I don’t put issue to measure these so it will stay words so the metrology
invents the indicator usually to measure the outcome.
 Introduction
 Indicators for performance and outcome
measurement allow the quality of care and services to be
measured.
 This assessment can be done by creating quality indicators
that describe the performance that should occur for a
particular type of patient or the related health outcomes,
and then evaluating whether patients’ care is consistent with
the indicators based on evidence-based standards of care.
 Donabedian
 Management theory is based on : PDCA or Donabedian
 It is simple but very deep and important , any service I need to provide is
based on a model made up of 3 issues.

1. Structure: all type of resources

2. Process : activity I use it to convert the input to output

3. Outcome: the end result : safety, quality

This model was done in 1950 and still , last 20 years we are talking about
outcome , but it is a loop so we need to have a good structure and process.

The weight of outcome: is higher then the process and structure .

Donabedian
 Definitions, Terminology
and concepts
 Indicators have been defined in several different ways:
 As measures that assess a particular health care process or outcome .
( number of pt dead).
 As quantitative measures that can be used to monitor and evaluate the
quality of important governance, management, clinical, and support
functions that affect patient outcomes .
 As measurement tools, screens, or tags that are used as guides to monitor,
evaluate, and improve the quality of patient care , clinical support
services, and organizational function that affect patient outcomes.
 ( we are striving for quality improvement ).
 Definitions, concepts and terminology

 Indicators provide a quantitative basis for clinicians, organizations, and

planners aiming to achieve improvement in care and the processes by
which patient care is provided.
 The use of indicators enables professionals and organizations to monitor
and evaluate what happens to patients as a consequence of how well
professionals and organizational systems function to provide for the
needs of patients.
 Indicators are, however, not a direct measure of quality. Because quality
is multidimensional, understanding quality requires many different
measures. ( may need another aspect of metrology like ex: client
satisfaction model.. ACSI).
 Purposes
 document the quality of care
 make comparisons (benchmarking) over time between places
(e.g. hospitals) ( wrt , national and international hosp).
 make judgments and set priorities (e.g. choosing a hospital or
surgery, or organizing medical care);
 support accountability, regulation, and accreditation;
 support quality improvement; and support patient choice of
providers
 Who sets indicators?
 Indicators are based on standards of care.
 Academic literature (literature syntheses, meta-analyses, or randomized
controlled trials).

(if a new issue not have a standard , so the collect literature and see the
surgeon what numbers in the journal they concentrate and consult the expert
and put it )
 When scientific evidence is lacking, indicators are determined by an
expert panel of health professionals in a consensus process based on their
experience.
 Indicators and standards can be described according to the strength of
scientific evidence for their ability to predict outcomes.
Key Characteristics of an ideal indicator

 SMART: Specific , Measurable , Achievable , Realistic , Timeline

 Indicator should have a formula or percentage or A/B or proportion , so

add more scientific criteria

 indicator is based on agreed definitions, and described exhaustively and

exclusively ( obvious not vague, competency of biomedical , very
important too have definition like : the number of request they close,
ex: 90% of competency of maintenance).

 indicator is highly or optimally specific and sensitive, i.e. it detects few

false positives and false negatives;
 Key Characteristics of an ideal
indicator
 indicator is valid ( measure what is really meant to measure ) and
reliable ( I can repeated it and give me same result ).
 indicator discriminates well;
 indicator relates to clearly identifiable events for the user (e.g. if
meant for clinical providers, it is relevant to clinical practice);( based
on data sheet of events to have data and importance , so indicator
should have a meaning , like 20 indicator so these was the important ).
 indicator permits useful comparisons;( benchmarking).
 indicator is evidence-based.
 Indicators validity
 Validity is the degree to which the indicator measures what
it is intended to measure, i.e. the result of a measurement
corresponds to the true state of the phenomenon being
measured.
 A valid indicator discriminates between care otherwise
known to be of good or bad quality and concurs with other
measures that are intended to measure the same dimension
of quality.
 Indicators reliability
 Reliability is the extent to which repeated measurements of
a stable phenomenon by different data collectors, judges, or
instruments, at different times and places, get similar
results.( or same person repeated , or different person work
on same measurements, important because change of staff
both should have the same results).
 Reliability is important when using an indicator to make
comparisons among groups or within groups over time. A
valid indicator must be reproducible and consistent.
 Indicators and evidence
 Indicators should be based on the best available evidence.
 Sackett et al. describe this as ‘the integration of best
research evidence with clinical expertise and patient values’.
 The strength of evidence for an indicator will determine its
scientific soundness or the likelihood that improvement in
the indicator will produce consistent and credible
improvements in the quality of care.
 ( so based on scientific evidence).
Types of indicators
Rate-based versus sentinel
indicators
 A rate-based indicator uses data about events that are expected to
occur with some frequency. ( risk management , frequency and
severity).
 These are not severe, but frequent.
 These can be expressed as proportions or rates (proportions within a
given time period), ratios, or mean values for a sample population.
 To permit comparisons among providers or trends over time,
proportion- or rate-based indicators need both a numerator and a
denominator specifying the population at risk for an event and the
period of time over which the event may take place. ( have SMART).
 Sentinel indicators
 A sentinel indicator identifies individual events or phenomena that
are intrinsically undesirable, and always trigger further analysis
and investigation. ( HIGH SEVERITY , LOW OCCURRENCE).
 Each incident would trigger an investigation.
 Sentinel events represent the extreme of poor performance and
they are generally used for risk management. ( SOME TIME BY
ACCIDENT ,).
 Indicators related to structure, process, and outcomes

 ‘Structure’ denotes the attributes of the settings in which care occurs.

 This includes the attributes of material resources (such as facilities, equipment,
and financing), of human resources (such as the number and qualifications of
personnel), and of organizational structure (such as medical staff, organization,
methods of peer review, and methods of reimbursement).
 Structural indicators describe the type and amount of resources used by a health
system or organization to deliver programs and services, and they relate to the
presence or number of staff, clients, money, beds, supplies, and buildings.
 The assessment of structure is a judgment on whether care is being provided under
conditions that are either conducive or inimical to the provision of good care. ( SEE
IF AM EFFECTIVE IN USE THE RESOURCES).
 ( IF YOU DON’T PAY IN STRUCTURE AND PUT LATEST TECHNOLOGY ,
YOU WILL NOT TAKE THE GOOD OUTCOME, BUT ITS NOT THE ONLY
IMPORTANT ).
 Indicators related to structure, process, and outcomes

 ‘Process’ denotes what is actually done in giving and

receiving care, i.e. the practitioner’s activities in making a
diagnosis, recommending or implementing treatment, or
other inter- action with the patient. Process indicators assess
what the provider did for the patient and how well it was
done.
 Processes are a series of inter-related activities
undertaken to achieve objectives. Process indicators
measure the activities and tasks in patient episodes of care.
 Indicators related to structure, process, and outcomes

 Outcome’ measures attempt to describe the effects of care

on the health status of patients and populations. (HOW
HELATH STATUS CHANGE).
 Improvements in the patient’s knowledge and salutary
changes in the patient’s behavior may be included under a
broad definition of outcome, and so may represent the
degree of the patient’s satisfaction with care.
 An ideal outcome indicator would capture the effect of care
processes on the health and wellbeing of patients and
populations.
 OUT OF 100 HOW MANY PT USE
ADVANCE TECHNOLOGY

INTERMIDEIAT , SEE POT

PROCEDURE .
END RESULT IS POST TRT AND
END.
 5 D’s for outcomes indicators
VERY IMPORTANT
 death: a bad outcome if untimely;
 disease: symptoms, physical signs, and laboratory abnormalities;
 discomfort: symptoms such as pain, nausea, or dyspnea;
 disability: impaired ability connected to usual activities at home, work, or in
recreation;
 dissatisfaction: emotional reactions to disease and its care, such as sadness and
anger.
 VERY IMPORTANT , IF YOUR NOT SURE ABOUT THE TYPE OF
INDICATOR, ASK YOUR SELF IF ITS BELONG TO THE 5Ds so its out
come indicator.
 Generic and disease-specific indicators
medical doctor like this

 Generic indicators measure aspects of care that are relevant to most

patients, while disease-specific indicators are diagnosis-specific and
measure particular aspects of care related to specific diseases. ( generic is
gernalized )
 Both generic and disease-specific indicators can focus on structure, process, or
outcome.
 Generic indicators may be difficult to interpret, especially when making
comparisons among hospitals or providers, because there may be profound
differences in patient mix.( indicator on all and not all are the same , so am not see
some thing specific on them).
 Disease-specific outcome indicators can be used to compare hospitals and plans,
when data are risk- adjusted.
Genaric:
Without
determination
of pt type.
 Indicators related to type of care, function, and
modality

 Indicators classified by type of care may be preventive,

acute, or chronic.
 Function of care can relate to screening, diagnosis,
treatment, and follow-up.
 The modality by which care can be delivered relates to
physical examination of the patient, laboratory or
radiology study, or prescription of medication, for
example
 Conclusion
 Clinical indicators measure the extent to which set targets are achieved.
 In any strategic plan should have indicator , then goal , then action plan with time
line, resources and indicator
 My weight is 100 kg , my strategy is to minimize it by 20%,
 My action plan is : to run , to buy bicycle , do diet.
 My time line: diet on 6 month ,
 Resources: need money to buy bike and gym.
 Indicator: the weigh lost post one month and every month
 They are expressed as numbers, rates, or averages that can provide a basis for clinicians,
organizations, and planners aiming to achieve improvement in care and the processes by
which patient care is provided.
 They can be measures of structure, process, and outcome, either as generic measures
relevant for all diseases, or disease-specific measures that describe the quality of patient
care related to a specific diagnosis.
 conclusion
 In general, indicator data are of interest to patients, purchasers, and providers.
 Outcomes may be of major interest to consumers and payers of care, while providers who
are receiving data for quality improvement purposes need detailed data about the process of
care to make the information credible and possible to act upon.
 Clinical indicators should be valid and sensitive to the events and changes they are
intended to detect.
 Furthermore, clinical indicators should be clearly defined in order to avoid the
measurement of changes in the patient’s status arising from external factors not related to
objectives and targets.
 (The most important is the result of using this indicator).
 A good manger by using the 20 indicator , he is able to mange the hospital to make it right.
 conclusion
 Only evidence-based clinical indicators predict patient outcomes and are true measures
of quality, although indicators based on professional consensus without evidence may
be all that is feasible for certain conditions, treatments or patient populations.
 Patient health outcomes are determined by many other factors besides the quality of
health care.
 Risk adjustment therefore plays an important role in comparison using outcomes data,
in order to adjust for confounding factors.
 The surveillance of health care quality is greatly aided by the use of relevant
quantitative indicators, supplementing other approaches that may include qualitative
analyses of specific events or processes.
 For the healthy population, indicators can also be important with regard to prevention,
quality of life, and satisfaction with health care.