Toolkit - Safety And Quality

Measurement for ImprovementToolkit

The views and opinions expressed in this document do not necessarily represent those of the Commonwealthof Australia. Commonwealth of Australia 2006This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may bereproduced by any process without prior written permission from the Commonwealth. Requests and enquiriesconcerning reproduction and rights should be addressed to the Commonwealth Copyright Administration,Attorney General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or postedat http://www.ag.gov.au/ccaDesigned and typeset by Levitate Graphic Design, NSWISBN: 978-0-9803462-0-6

Quick Reference Card to theMeasurement For Improvement ToolkitAim of the ToolkitThe ‘Measurement for improvement toolkit’ (the Toolkit) is a practical resource for health care professionals andorganisations to facilitate measurement in three key areas of patient safety: Organisational capacity. Patient safety incidents. Clinical performance.The collation of tools into a single resource aims to encourage measurement in each of these areas and supportcontinuous safety and quality improvement.The Toolkit is intended for use by a broad range of health care providers within the public and private, acute,subacute, residential care and community health care sectors.Structure of the ToolkitThe ‘Measurement for improvement toolkit’ comprises of three sections. Part A – User’s guide Part B – Background information and resources Part C – Measurement tools and processesPart C1 – Summary of measurement tools and processesPart C2 – One-page description of measurement tools and processesPart A – User’s guideIncluded in this section are instructions for use of the Toolkit, as well as case examples to illustrate when andhow to use the different sections of the Toolkit.Part B – Background information and resourcesThis section provides information about current knowledge regarding the measurement of patient safetyoutcomes, and a comprehensive list of patient safety resources and references.Part C – Measurement tools and processesThe tools are summarised in tables (Part C1) for easy reference and comparison. They are presented accordingto their key area of measurement, that is, organisational capacity; patient safety incidents; and clinicalperformance; and according to the specific component(s) of these key areas that they measure.The attributes of each tool is described in more detail in a single page summary (Part C2) to guide appropriateselection and access.

Contents and links to Toolkit sectionsDisclaimer2Contents4Part A – User’s guide1. Background1.11.21.31.41.51.6 What is the purpose of the Toolkit?Who should use the Toolkit?What does the Toolkit contain?How was the Toolkit developed?How were tools chosen for inclusion in the Toolkit?What are the limitations of the Toolkit11121212121313132. Content and layout of the Toolkit142.12.21516161717Part B – Background information and resourcesPart C – Measurement tools and processesOrganisational capacity measurement tools and processesPatient safety incident measurement tools and processesClinical performance measurement tools and processes3. How to start using the Toolkit183.13.218191920222424The process of measuring patient safetyMeasurement for improvement toolkit stepsStep 1 – Identify the patient safety issueStep 2 – Consult the Toolkit to identify available toolsStep 3 – Decide on an appropriate measurement toolStep 4 – Obtain the chosen tool(s)Step 5 – Understand your chosen measurement tool(s)4. Case example – using the Toolkit264.12626272829Measuring organisational capacity – a case exampleStep 1 – Identify the patient safety issueStep 2 – Consult the Toolkit to identify available toolsStep 3 – Decide on an appropriate measurement toolSteps 4 and 5 – Obtain and understand your chosen s34

Part B – Background information and resources35About this section37Background information38Introduction38Measurement for improvement391. Organisational 14242434343434444454546464646Clinical governance and leadershipWhat is clinical governance and leadership?Measuring clinical governance and leadershipResearch into clinical governance and leadershipSafety cultureWhat is safety culture?Measuring safety cultureResearch into safety cultureCommunication and teamworkCharacteristics of good communicationMeasuring communicationResearch into communication and teamworkConsumer and community involvementWhat is consumer and community involvement?Measuring consumer and community involvementResearch into consumer and community involvementProfessional competence and ongoing educationWhat is professional competence and ongoing education?Measuring professional competence and ongoing educationResearch into professional competence and ongoing educationInformation managementWhat is information management?Research into information managementAccreditation – a process to assess organisational performance2. Patient safety incidents472.1 Risk management and patient safety incidents2.2 Identification of patient safety incidents2.2.1 Medical record review, clinical audits and other surveillance toolsWhat is medical record review?Research into medical record reviewThe pros and cons of medical record reviewRecommendations from the researchOther methods of detecting patient safety incidentsLimited adverse occurrence screeningResearch on limited adverse occurrence screening47484949495050515151

Trigger toolsProspective screening2.2.2 Patient safety incident reportingClinical incident reportingResearch into clinical incident reportingUnderestimates and under-reportingBarriers to clinical incident reportingBenefits of clinical incident reportingSuccessful incident reporting systemsFacilitated incident reportingSentinel event reportingConsumer incident reportingResearch into consumer incident reporting2.2.3 Comparisons of identification methodsUse of multiple methodsSummary2.3 Analysis and investigationWhat is analysis and investigationSystem versus individual approachA general frameworkTypes of analysis and investigationInvestigation and analysis in response to an eventInvestigation and analysis before an eventInvestigation and analysis research2.4 Management – solution development and implementation2.5 Feedback and 59606161613. Clinical performance623.1 What is performance measurement?3.2 How is clinical performance measured?Structural measures for assessing clinical performanceProcess measures for assessing clinical performanceOutcome measures of safety for assessing clinical performanceImplicit measurementExplicit measurement3.3 Characteristics of performance measurement3.4 The pros and cons of measuring clinical performanceThe benefitsThe limitations3.5 Performance measurement strategies and toolsAccreditation – a processBenchmarking – a processClinical auditMedical record reviewElectronically stored informationControl 67676768

Peer review meetings – a processPerformance appraisalPerformance indicatorsChoosing indicatorsThe development and testing of indicators3.6 Research into performance measurementIndividual clinician clinical performance neral patient safety resourcesMedication safety resourcesPatient safety incident resourcesClinical performance measurement resourcesResources for general practitionersConsumer resourcesProfessional bodies71747578818284Part C1 – Summary tables of measurement tools and processes99About this section100List of measurement tools and processes1001. Summary tables: organisational capacity measurement tools1022. Summary tables: patient safety incidents measurement tools and processes1143. Summary tables: clinical performance measurement tools and processes121Part C2 – One-page descriptions of measurement tools and processes125About this section126List of measurement tools and processes1281. Organisational capacity measurement tools and processes130Tool 1: Checklist for reviewing your safety and quality program against the framework elementsTool 2(i)–(iv): A checklist: patient safety management systemsTool 3: Board clinical governance self-evaluationTool 4: Checklist for assessing institutional resilienceTool 5: Clinical governance climate questionnaire (CGCQ)Tool 6(i): Pathways for medication safety: leading a strategic planning effort: Part 1.A3-Strategiesfor leadership; hospital executives and their role in patient safety131132133134135136

Tool 7: Checklist of JCAHO recommended elements of a safety cultureTool 8: Hospital survey on patient safety cultureTool 9: Safety attitudes questionnaireTool 10: Safety climate surveyTool 11: Teamwork and patient safety attitudes questionnaireTool 12: Checklist for assessing health service structures and processes to facilitatecollaboration with consumers in safety and quality improvementTool 13: Consumer feedback standards services improvement toolTool 14: Consumer and community participation self-assessment tool for hospitalsTool 15(i): Academy of Managed Care Pharmacy framework for quality drugtherapy grid/self-assessment toolTool 15(ii): Academy of Managed Care Pharmacy framework for quality drug therapyself-assessment tool for community pharmacy practiceTool 16: Addressing medication errors in hospitals: a practical toolkitTool 16(i): Addressing medication errors in hospitals: an assessment of medication use processesTool 16(ii): Addressing medication errors in hospitals: medication error tracking formTool 16(iii): Addressing medication errors in hospitals: medication error reporting formTool 16(iv): Addressing medication errors in hospitals: a checklist for preparing the organisationTool 17: ISMP medication safety self-assessment for hospitalsTool 6(ii): Pathways for medication safety: leading a strategic planning effort;Part 1.A1 – Survey on perceptions regarding a non-punitive culture in health careTool 6(iii): Part 1.A2 – Survey to solicit information about the culture of reportingTool 6(iv): Part 1.A4–1.A6 – Staff questionnaires about error reportingTool 18: Pathways for medication safety: looking collectively at risk: evaluationtools for health care staff1371381391401412. Patient safety incident measurement tools and processes157Tool 19: Global trigger tool – for measuring adverse eventsTool 20: Limited adverse occurrence screening (LAOS)Tool 21: Medical record review (MRR)Tool 22: Medication reconciliation: transfer/discharge medication toolTool 23: Modular review form (MRF2) for retrospective case record reviewTool 24: Safety briefingsTool 25: Trigger tool for measuring adverse drug eventsProcess 1: Clinical incident reportingProcess 2: Consumer complaintsProcess 3: Consumer satisfaction surveysProcess 4: Sentinel event reportingTool 26: Failure modes and effects analysisTool 27: Probabilistic risk assessmentTool 28: Risk assessment matrix - likelihood and consequence categories tableTool 29: Root cause analysis (RCA)Tool 30: Safety assessment code (SAC) matrixTool 31: Severity assessment code (SAC)Tool 32: Systems analysis of clinical incidents: the London protocol 8159160161162163164165166167168169170171172173174