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Providing actionable healthcare analytics at scale: Understanding improvement measures
This document discusses measurement for quality improvement. It explains that measurement in improvement aims to provide a basis for action to improve processes and outcomes, rather than just estimating parameters. Improvement measures should be simple, specific, and available in real-time. Statistical process control methods are important to separate normal variation from changes resulting from interventions. Examples are provided of run charts measuring improvements in recording BMI for mental health patients and compliance with care bundles. The document advocates making the theories behind improvement efforts more explicit.
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Providing actionable healthcare analytics at scale: Understanding improvement measures
- 1. Providing actionable healthcareanalytics at scale: Understanding improvement measures Thomas Woodcock, Improvement Science Fellow, Imperial College London
- 2. NIHR CLAHRC Northwest London Collaborationfor Leadership in Applied Health Research and Care Northwest London The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with North West London Understanding Improvement Measures Dr Tom Woodcock Programme Lead Information Intelligence Health Foundation Improvement Science Fellow
- 3. NIHR CLAHRC Northwest London Toachieve this: Develop a comprehensive systematic approach to improvement which is transferable and generalizable across the NHS 3 Primary aims Translate research into practice Improve health outcomes and patient experience Deliver value locally and to the wider NHS Working in collaboration with: Patients, communities, health and care services, healthcare professionals, academics, universities, third sector, industry…
- 4. NIHR CLAHRC Northwest London Collaborationfor Leadership in Applied Health Research and Care Northwest London The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with North West London Measurement for Improvement
- 5. NIHR CLAHRC Northwest London Solberget al 1997 Three reasons for measurement
- 6. NIHR CLAHRC Northwest London Measurementfor Improvement A few simple and specific measures, linked to your objectives and aims, and available in real time to demonstrate whether changes are making improvements. NHS Institute for Innovation and Improvement
- 7. NIHR CLAHRC Northwest London Measurementin, and of, Improvement • Are changes happening in the way health care is delivered? • Are these associated with improvements for patients, carers & the public? • Are these changes causally linked? • How can we reproduce this improvement elsewhere?
- 8. NIHR CLAHRC Northwest London Themeasurement cycle 1 Decide aim 2 Choose measures 3 Confirm collection 6 Take appropriate action 5 Analyse & present 8 Repeat steps 4-6 4 Collect data 7 Review measures 5 Analyse & present Adapted from a slide by Mike Davidge
- 9. NIHR CLAHRC Northwest London Whatto measure? Aim Concept Measure Operational Definitions Data Collection Plan Data Collection Analysis Action R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators.
- 10. NIHR CLAHRC Northwest London Aims Measures Ideas (NOTSolutions) How do we change? Ideas -> Solutions The Model for Improvement
- 11. NIHR CLAHRC Northwest London Enumerativevs Analytic Study On Probability As a Basis For Action, W E Deming, The American Statistician, Vol. 29 No. 4 1975, pp. 146-152 (and previously in ‘42 and ‘50) “An enumerative study has for its aim an estimate of the number of units of a frame that belong to a specified class. An analytic study has for its aim a basis for action on the cause-system or the process, in order to improve product of the future”
- 12. NIHR CLAHRC Northwest London Enumerativevs Analytic Study Analytical studies: a framework for quality improvement design and analysis, Lloyd P Provost BMJ Qual Saf 2011; 20 (Suppl. 1) doi:10.1136/bmjqs.2011.051557 “Because of the temporal nature of improvement, the theory and methods for analytical studies are a critical component of the science of improvement.” Analogy: pond vs river
- 13. NIHR CLAHRC Northwest London SPC:Origins • Dr. Walter Shewhart: physicist & engineer, Western Electric and Bell Laboratories, 1920s. Quality in manufacturing. • Dr. W. Edwards Deming extended Shewhart’s work, developing and explaining applications (U.S. Then Japan after WWII, worldwide in the 80s and 90s). • Increasingly seen in healthcare – but applied with varying degrees of rigor and success.
- 14. NIHR CLAHRC Northwest London Understandingvariation Everything we can measure will vary Statistical Process Control separates out Special Cause from Common cause (routine variation) – Common: inherent to the process, none dominant – Special: due to a specific reason, dominant Distinguishing between the two is crucial for good decision making SPC provides tools to make this distinction – run and control charts
- 15. NIHR CLAHRC Northwest London Collaborationfor Leadership in Applied Health Research and Care Northwest London The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with North West London An Example QI Initiative
- 16. NIHR CLAHRC Northwest London AnExample QI Initiative
- 17. NIHR CLAHRC Northwest London Physicalhealth and severe and enduring mental illness “Adults with serious mental illness represent the greatest and least recognized health disparity... reflected in a 13- to 30-year reduced life expectancy. The primary cause... is cardiovascular disease associated with disproportionately high rates of obesity and tobacco use... the greatest current challenge to providing appropriate mental health services is not a knowledge gap, but an implementation gap.” Bartels, Am J Psych, 2015
- 18. NIHR CLAHRC Northwest London Don’tjust screen- intervene
- 19. NIHR CLAHRC Northwest London Linkingproject aims and activities…
- 20. NIHR CLAHRC Northwest London Untanglingsystems and processes…
- 21. NIHR CLAHRC Northwest London 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% RunChart - Percentage of Admissions with BMI Recorded A MENTAL HEALTH WARD IN NORTHWEST LONDON Percentage with BMI recorded Baseline Median (21%) Baseline Median - Extended New process median (61%) Baseline audit (247 admissions) Intervention period (311 admissions)
- 22. NIHR CLAHRC Northwest London Collaborationfor Leadership in Applied Health Research and Care Northwest London The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with North West London Additional Examples
- 23. NIHR CLAHRC Northwest London 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 02-Jan02-Feb 02-Mar 02-Apr 02-May 02-Jun 02-Jul 02-Aug 02-Sep 02-Oct 02-Nov 02-Dec COPD Care Bundle - Hospital X Overall Compliance Percentage Compliance Average Lower Control Limit
- 24. NIHR CLAHRC Northwest London 0% 5% 10% 15% 20% 25% 30% PercentageED attendances admitted Seasonalised Average Seasonalised Lower Process Limit Seasonalised Upper Process Limit Monthly % ED Attendances Admitted; England 2011-2014 0 0.1 0.2 0.3 0.4 0.5 0.9 0.92 0.94 0.96 0.98 1 1.02 1.04 1.06 1 2 3 4 5 6 7 8 9 101112 RangeChart AverageChart Month Average and Range Chart for Monthly Seasonal Factors Average Grand Average Lower Average Limit Upper Average Limit
- 25. NIHR CLAHRC Northwest London Collaborationfor Leadership in Applied Health Research and Care Northwest London The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with North West London What next?
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- 27. NIHR CLAHRC Northwest London Weconclude that although informal theory is always at work in improvement, practitioners are often not aware of it or do not make it explicit. The germane issue for improvement practitioners, therefore, is not whether they use theory but whether they make explicit the particular theory or theories, informal and formal, they actually use.
- 28. NIHR CLAHRC Northwest London SaferClinical Systems Evaluation findings (http://www.health.org.uk/publication/safer-clinical-systems- evaluation-findings)
- 29. NIHR CLAHRC Northwest London Collaborationfor Leadership in Applied Health Research and Care Northwest London The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with North West London Plan Explore Design Test and Scale Up Spread MeasurementPlanning SupportTool Measurementfor ImprovementSupportTool SPCPublication Standards WISH MeasureDefinition Process MeasurementTraining (inc.QI4U) Technicalsupport
- 30. NIHR CLAHRC Northwest London Measurementfor Improvement - Summary • Goal is improvement – analytic study • Methodology required is different – SPC • Not an excuse to sacrifice rigour! • QI methods support good practice – if used correctly • Further research required – how to reliably achieve good measurement • More support and guidance is needed for QI teams