A Guide To Using Data For Health Care Quality Improvement
A guide to using datafor health carequality improvementJune 2008
Published by the Rural and Regional Health and Aged Care Services Division,Victorian Government Department of Human Services, Melbourne, Victoria.June 2008This booklet is available in pdf format and may be downloaded from the VQCwebsite at www.health.vic.gov.au/qualitycouncil Copyright State of Victoria, Department of Human Services, 2008This publication is copyright. No part may be reproduced by any process exceptin accordance with the provisions of the Copyright Act 1968Authorised by the Victorian Government, 50 Lonsdale St., Melbourne 3000.Printed by Big Print, 50 Lonsdale St, Melbourne VIC 3000.rcc 080507Victorian Quality Council SecretariatPhone 1300 135 427Email vqc@dhs.vic.gov.auWebsite www.health.vic.gov.au/qualitycouncil
AcknowledgementsA GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTThis resource has been developed for the Victorian Quality Council by:Project HealthFiona Landgren, authorJessie Murray, research and documentationIts development has been overseen by a reference group comprising:Victorian Quality Council membersAssociate Professor Caroline Brand, Chair(Clinical Epidemiology and Health Service Evaluation Unit, Melbourne Health)(Centre for Research Excellence in Patient Safety)Ms Kerry Bradley(Mary MacKillop Aged Care)Dr Peter McDougall(Royal Children’s Hospital)Associate Professor Les Reti(The Royal Women’s Hospital)External expertsDr Chris Bain(The Western and Central Melbourne Integrated Cancer Service)Ms Anna Donne(Department of Human Services)Ms Mary Draper(The Royal Women’s Hospital)Ms Pollyanna Hardy(Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute)Dr Joseph Ibrahim(Coronial Liaison Services, Victorian Institute of Forensic Medicine)Mr Steven McConchie(Department of Human Services)Project support was provided by the Victorian Quality Council Management GroupMr Oliver FurnessMs Jo HeardMs Anna LairdThe contributions of those who reviewed the draft resource are gratefully acknowledged.1
ContentsA GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENT1. INTRODUCTION41.1 Data and quality improvement51.2 Purpose and scope of the guide51.3 About the Victorian Quality Council52. MEASURING AND IMPROVING QUALITY IN HEALTH CARE62.1 What is quality?62.2 What is the role of data in quality improvement?72.3 Using data to help define your quality improvement project112.5 Using data to formulate and prioritise interventions122.6 Using data to measure impact132.7 Using data to guide sustained improvement133. GETTING STARTED – PLANNING YOUR DATA-RELATED ACTIVITIES143.1 Taking a systematic approach153.2 Getting the right advice153.3 Staying on track174. COLLECTING AND STORING DATA184.1 Where can you access the data you need?194.1.1 Existing internal data194.1.2 Existing external data194.2 Data collection techniques and tools204.2.1 Process mapping204.2.2 Brainstorming20How to brainstorm23How to create an affinity diagram234.2.3 Cause and effect techniques292.4 Using data to evaluate existing processes and identify opportunities for improvement23How to create a cause and affect diagram23How to use the ‘five why technique’234.2.4 Audit (including clinical record reviews and observations)254.2.5 Surveys and questionnaires254.2.6 Focus groups and key informant interviews36How to use key informant interviews26How to use focus groups264.3 ‘Good’ data – what is it and how to get it274.3.1 Attributes of good data collection tools274.3.2 Sampling294.3.3 Data entry, checking and cleaning294.4 Storing and managing your data30
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENT5. ANALYSING AND PRESENTING DATA315.1 Analysing numerical (quantitative) data325.1.1 Counts and sums325.1.2 Ratios, rates and percentages32Using ratios, rates and percentages to make comparisons5.1.3 Measures of centre3234Mean or average34Median34Mode345.1.4 Measures of variability and spread36Range36Interquartile range36Standard deviation365.1.5 Using statistics to make comparisons37How to use and interpret confidence intervals37How to use and interpret p values385.1.6 Other measures of causationHow to use correlation coefficients5.2 Presenting data3939405.2.1 Tabulating data405.2.2 Graphing and charting data42How to use pie charts43How to use bar graphs43How to use bar charts to make comparisons45How to use box plots46How to use histograms and histographs47How to use a scatter diagram48How to use line graphs and time charts495.3 Analysing qualitative data506. INTERPRETING AND USING THE DATA517. APPENDICES53Appendix 1. Data planning template54Appendix 2. National/state databases and registries55Appendix 3. Useful resources57Appendix 4. Glossary59Appendix 5. References631.1 Data and quality improvementQuality improvement is now a driving force in health care and3
01Section 01Introduction4Collecting and analysing data are central to the function of qualityimprovement in any health service.
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTIntroduction1.1 Data and quality improvementQuality improvement is now a driving force in healthcare and is an essential aspect of service delivery at alllevels. Put simply, quality is everyone’s business.But, unless we measure, it’s difficult to know exactlywhat to improve and whether we have in factachieved improvement, so efforts to improve systemsor processes must be driven by reliable data. Data notonly enables us to accurately identify problems, it alsoassists to prioritise quality improvement initiatives andenables objective assessment of whether change andimprovement have indeed occurred. Collecting andanalysing data are therefore central to the functionof quality improvement in any health service.The good news is that you don’t have to be astatistician to be successful in quality improvement.As this guide demonstrates, the fundamentals of dataare accessible and understandable concepts that allhealth professionals can and should apply to theirroutine practice.1.2 Purpose and scopeof the guideThe purpose of this guide is to assist all membersof the health care team to understand the role of datain quality improvement and how to apply some basictechniques for using data to support their qualityimprovement efforts.The guide describes the fundamental conceptsassociated with data collection, analysis, interpretationand reporting, and how these relate to the variousstages of the quality improvement cycle. It alsodescribes how data informs and integrates with theother key aspects of quality improvement, includingcommunication, people and systems. It assumesa basic understanding of quality improvementprinciples and provides links for detailed informationfor those who wish to explore the topic in more detail.Underpinning the content of this guide is therecognition that careful planning and effectiveteamwork are also essential elements of any qualityimprovement initiative.The focus of the guide is on using data in qualityimprovement rather than research; however, thedata management principles are also largelyapplicable to research.The Victorian Quality Council (VQC) was establishedin 2001 as an expert strategic advisory group to leadthe safety and quality agenda for Victorian health careservices. The council is responsible for fostering betterquality health services in Victoria by working withstakeholders to develop useful tools and strategiesto improve health service safety and quality.This project stems from the VQC objectiveto ‘Promote access to and use of meaningful,targeted information, relevant to clinicians andpatients, to improve practice’, and further,to ‘assist health services to measure and monitorsafety and quality’.More information:See the VQC website at:www.health.vic.gov.au/qualitycouncilData is the raw material from which information is constructed via processing or interpretation.This information in turn provides knowledge on which decisions and actions are based.InformationThe more effortyou put intounderstanding andutilising data, themore you will berewarded in termsof solving theright problem in theright way.1.3 About the VictorianQuality CouncilFigure 1.1 From data to actionDataDATATIP:KnowledgeDecisionAction5
02Section 02Measuring and improvingquality in health care6This section of the guide aims to equip readers to:recognise the key phases in the quality improvement cycleunderstand how data supports each stage of the qualityimprovement cycleunderstand the role of people and systems in data management.
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTMeasuring and improving quality in health care2.1 What is quality?Quality in the health care setting may be definedas the ‘extent to which a health care serviceor product produces a desired outcome’.1Quality improvement is a system by which betterhealth outcomes are achieved through analysing andimproving service delivery processes.With this in mind, it is useful to consider quality andquality improvement as spanning a number of keydomains. These provide a practical framework forquality measurement and improvementThe National Health Performance Committee2 identifiednine domains of health system usSafeCapableEfficientSustainableResponsive2.2 What is the role of datain quality improvement?Health service organisations are complex adaptivesystems. Making changes to improve quality of carecan therefore be a complex business. Fundamentallyit requires us to understand what is happeningin the delivery of our health services, what factorsaffect delivery and how we can influence themto achieve improvement. In such a complex system,solid evidence is what we need to support decisionmaking, rather than information based on isolatedoccurrences, assumptions, emotion or politics.With this in mind it is useful to consider that qualityimprovement can be both reactive and proactive.For example, most health services collect and analysedata routinely across various quality domains, thusproblems are often clear and self-evident andthe health service reacts to introduce appropriateimprovements. Examples include adverse events,infection rates and a range of other clinical indicators.In addition, health services are likely to proactivelylook for opportunities for improvement. Theseopportunities become evident when the processesand outcomes are examined more closely.Data therefore helps to ‘push’ improvementby identifying problems, and to ‘pull’ improvementby identifying opportunities. Data helpsus to understand and improve our service by givingus the tools to describe what’s going on andto compare our performance, either against knownstandards or against previous performance.To understand the role of data in quality improvementmore clearly it is useful to consider the five phasesof the quality improvement cycle. These phases aredescribed briefly overleaf and are best viewedas a continuous cycle of activity as illustratedin Figure 2.3. As this figure shows, the phasestake place within, and rely upon, an overallorganisational context.Data plays an important role in each of these phases,and therefore helps us to:tackle the right problem (phases 1 and 2)implement the right strategies/solutions (phase 3)demonstrate the required outcome and monitor forcontinued improvement (phases 4 and 5).Figure 2.2 The ‘push’ and ‘pull’ of quality improvement7
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTThe following sections describe in more detail how data can be used at each of the phases of the qualityimprovement cycle.The phases of the quality improvement cycle1.Project definition phase – What is the question or problem?This involves identifying the ‘area of interest’ or potential problem area.2.Diagnosis phase – What can we improve?This involves evaluating existing processes within that area of interest to diagnose potential qualityproblems and/or opportunities for improvement.3.Intervention phase – How can we achieve improvement?This involves:determining potential interventions for the processes that require improvementdefining performance measuresimplementing interventionsmonitoring the progress of improvement.4.Impact measurement phase – Have we achieved improvement?This involves evaluating the impact of interventions on the predetermined performance measures.5.Sustainability phase – Have we sustained improvement?This involves monitoring and refining interventions as well as providing feedback in order to sustainthe improvement process and ensure the improved processes are integrated into health care deliveryas appropriate.Figure 2.3 The quality improvement cycle8Source: NSW Health 2001, The clinician’s toolkit for improving patient careNote: P Plan, D Do, S Study, A ActSource: NSW Health 2001,The clinician’s toolkit forimproving patient careNote: P Plan, D Do,S Study, A Act
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTFigure 2.4 The Plan-Do-Study-Act cycleSource: Langley G, Nolan K, Nolan T, Norman C, Provost L 1996, The improvement guide: a practical approachto enhancing organisational performance, Jossey Bass Publishers, San Francisco.2.3 What is the problemor question? Using datato help define your qualityimprovement projectWith (good) data you can:assess current performance and identifyperformance gapsunderstand the needs and opinionsof stakeholdersprioritise problems and improvement projectsestablish overall aims and targetsfor improvementestablish a clear case for the needfor improvement.All quality improvement activities start with a problemor a question, for example:How can we improve the use of bloodproducts within theatre in line with currentclinical practice guidelines?Why is the post-surgery infection rate higherin our hospital/department than other comparablehospitals/departments?Are clients satisfied with current waiting timesat our clinic?Is the use of sedatives on discharge appropriateat our hospital and how can it be improved?As mentioned earlier, data helps to ‘push’improvement by identifying problems, and to ‘pull’improvement by identifying opportunities. Withoutdata we can only guess what issues we shouldaddress to benefit patients/clients/residents, thehealth service and other stakeholders.The domains of quality provide a framework forconsidering what problems might exist in your healthservice. Table 2.1 provides some examples, includingexamples of the types of data that may guide decisionmaking. These can be applied at both a clinical teamlevel as well as an organisational level. Organising yourquality issues and the relevant supporting data will helpdirect the focus of your quality improvement initiatives.9
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTTable 2.1 Identifying areas of concern for quality improvement(based on the domains of quality - National Quality Committee2)Quality domain/criteriaWhat data/types of measures might help youidentify and prioritise quality improvement projects?EffectiveClinical indicatorsCare, intervention or action achieves desired outcome.Benchmarking against other services/departmentsMorbidity and mortality meetings/reportsAppropriateClinical indicatorsCare/intervention/action provided is relevant to theclient’s needs and is based on established standards.Audits against international standards/evidencebased guidelinesBenchmarking against other services/departmentsService utilisation dataSafeAdverse events and incidentsThe avoidance or reduction to acceptable limits ofactual or potential harm from health care managementor the environment in which health care is delivered.Sentinel eventsClinical indicatorsBenchmarking against other services/departmentsMorbidity and mortality meetings/reportsAccreditation reportsEfficientService utilisation dataAchieving desired results with the most cost-effectiveuse of resources.Expenditure dataAudits of equipment/resource usageCustomer complaintsWaiting timesFailure-to-attend rates10ResponsiveService utilisation dataService provides respect for all and is client orientated.It includes respect for dignity, confidentiality,participation in choices, promptness, qualityof amenities, access to social support networks andchoice of provider.Customer complaintsAccessibleService utilisationAbility of people to obtain health care at the right placeand right time irrespective of income, physical locationand cultural background.Customer complaintsContinuousService mappingAbility to provide uninterrupted, coordinated careor service across programs, practitioners, organisationsand levels over time.Clinician feedbackCapableWaiting timesAn individual’s or service’s capacity to provide a healthservice based on skills and knowledge.Adverse eventsWaiting timesFailure-to-attend ratesAccreditation reportsWaiting timesFailure-to-attend ratesAdverse eventsAccreditation reportsSustainableAccreditation reportsSystem or organisation’s capacity to provideinfrastructure such as workforce, facilities andequipment, and be innovative and respond to emergingneeds (research, monitoring).Organisational score boardsIntegration with data systemsBusiness plans/resource allocation
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENTSo how do you actually decide what qualityinitiative should be addressed next?A formal exercise called quality impact analysis canbe useful. Best conducted as a group, quality impactanalysis is a brainstorming-type activity that enablesa structured consideration of the potential problemsand opportunities for improvement within your healthservice. Based on the list of problems or potentialquality initiatives and supporting data, the group maybe asked to identify:five things that are done frequentlyfive things that involve riskfive things that are of concern to staff or clients.Participants are then asked to score each item basedon the frequency, risk level and general levelof concern. Scoring may be, for example, from1 to 3, where 1 is low frequency, risk or concernand 3 is high frequency of risk or concern. The highestscoring topics should indicate the priority of topicsfor attention. The activity may also be adaptedto address a range of other criteria such as costor clinical effectiveness.2.4 What can we improve?Using data to evaluate existingprocesses and identifyopportunities for improvementWith (good) data you can:define the processes and people involvedin the processesidentify problem steps in the processidentify and prioritise opportunitiesfor improvementestablish clear objectives for improvementof process stepsidentify barriers and enablers to change.Once you have identified your area of concern, andyou have agreement that the problem is worthyof attention, the next step is to analyse the issue andassociated processes in sufficient detail to meet theneeds of your project.As with all brainstorming activities, it is importantthat you involve all relevant stakeholders in this activityto avoid bias. See section 4.2.2 for more information.This diagnosis phase will enable you to establishthe precise nature and cause of the problem andto identify where in the process improvements mightneed to be made.DATA TIP: Setting targets for improvementTools likely to be useful in gaining a betterunderstanding of your processes and improvementopportunities include:Use data to help set clear and measurable targetsfor your improvement initiative.Make sure your targets are linked to your aimsand objectives.Be realistic in your expectations – you won’tbe able to eliminate all adverse events or allinappropriate admissions.Express the target as a value, not as a percentageimprovement. For example, if baseline throughputin a clinic is five patients per hour and you wantto improve by 10%, then state your target as 5.5patients per hour.Reassess targets throughout the project andbe prepared to modify them in light of experienceand in consultation with stakeholders.brainstorming: members of the improvement teampresent and record
Measuring and improving quality in health care Figure 2.2 The ‘push’ and ‘pull’ of quality improvement Accessible Continuous Capable Sustainable. A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENT 8 The following sections describe in more detail how data can be u
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