Measurement is an important part of the improvement process, allowing teams to quantify changes and determine whether or not a specific change actually leads to an improvement. It should provide answers to specific questions. For example, did instituting a protocol reduce the incidence of pain? Did establishing a set of advance care planning progress notes and procedures increase the percentage of patients who had discussed what they wished with their physician? Did the provision of written information and reminders prevent families from making unnecessary ER visits?
Improvement efforts require one or two key indicators documented over time. How much information will you need? Just enough to convince a benevolent skeptic. The data have to be credible, and on target, but not extensive. Avoid spending time building a large dataset; you really only need to know two or three things about each of a dozen patients. If you want to learn more about whether patient preferences are made part of treatment planning, you don't really need to collect reams of demographic and psychological profile data, only data focused on whether wishes were sought, documented, and respected.
The most convincing indicators are often those documented in a time series - percent of clinic patients each month who have had an advance care planning discussion, or the average response time for pain relief on the oncology unit each week. Data plotted over time show the temporal relationship between changes made and the results, making a more convincing case that specific changes lead to improvement. Sometimes it is enough to measure "before" and "after," but that strategy won't let you evaluate whether it was the interventions or something else that had an effect.
Don't know where to start? Measures can have a positive or negative spin, depending on what a group wishes to show. Here are three sample "positive" measures:
Other indicators may reflect poorly on what an organization is doing - but can demonstrate the need for change. Negative indicators might include the following:
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].