Quality Metrics – So much to measure, so little time

Quality Metrics – So much to measure, so little time

By: Koren Way

If you are like many transplant centers, once a year you bring together a group of individuals into a conference room, and that group is charged with a big job.  This committee must come up with a list of quality metrics that will be tracked for the following year.   There are so many important things to measure in every transplant center: how many referrals the center gets each month, what the readmission rate is thirty days following transplant, and is the center 100% compliant with removing the patient from the waiting list within 24 hours of transplant.  With concerns of meeting regulatory requirements, pressure to meet budgetary measures, and desire to improve quality of clinical care, where do you even begin?  We can help with that.   If you just follow these 5 steps, you can put together a comprehensive and useable scorecard.

1.       Identify what monitoring is required. A good place to start is with the “have to’s”.   Check with your hospital quality committee, or maybe your department quality scorecard.  There may be items such as readmission rates or infection rates that you are required to track or report to leadership on a regular basis. If you have contracts with outside vendors, you are required to demonstrate that you monitor these contracts through tracking of related quality metrics. Since these are all examples of metrics you have to follow, this is a nice easy way to start your list.

2.       Identify those areas that you want/need to improve. This can be a difficult discussion.  We all want to look at our scorecard and see lots of green, right?  It makes us feel good.  But the definition of QAPI includes “improvement.”  In order to improve, you have to be willing to tackle the red areas of the scorecard.  If the metric has been at goal or green for more than a year, it may be time to retire that metric.  It is hard to improve on something that has been at 100% for 14 months straight.   Time to move on to those processes or clinical areas that you don’t do as well on.  Contrary to popular belief, there is no penalty for not meeting your goal in every metric.  However, you must demonstrate that you are making improvements.

3.       Identify any new processes or clinical protocols that you want to be sure you are following.  An excellent example here is when UNOS added the requirement in 2016 to document the check-in of the organ to the OR – transplant programs across the country had to implement a new process. It is very important to know if the centers are compliant with the new process.  This is the perfect type of metric to add to your scorecard.   Another example is if you had to implement a corrective action in response to a recent site visit – again, it is very important to know that you are compliant with this process.

4.       Make sure you have a balance of metrics.  You need to be sure that you have metrics in all phases of transplant (pre, transplant event, and post) for both recipients and living donors.  These should be a mix of processes as well as outcome measures.  And there should be a balance of procedural metrics and clinical metrics.  Its OK to track and make sure your activation letters are going out within 10 days, but you also want to know what your delayed graft function rate is.

5.       Now, remove half of the metrics in your list.  I know, that just made your heart stop beating for a second, didn’t it?  No need to panic, you don’t really have to remove half of them.  But you do need to take some of them off.  Remember, less is better here.   Regulatory requirements say you have to demonstrate that you are actively working on those items that you are tracking.  That is hard to do if you have 40 metrics you are following.  And this makes sense, right?  With all that a center has to do just to keep the lights on, it’s impossible to make real improvements in 40 different areas.  Remember, it comes back to that “I” (improvement) in QAPI.   How do you prioritize?   You may have to run through the steps again to remove some.   Another way to weed them out is to be honest about what even can be tracked based on current staffing levels, data systems, and time available.  Also, if you have already fixed the process and it’s working, it’s time to move on to new stuff (which is hard). Also remember, the choice does not need to be set in stone. If you need to add a metric mid-year, that is perfectly acceptable.

There, you have your metrics.  Whew, that was hard, right?   Five steps seems so easy, but it’s not.  This process may take several meetings, and it probably should.  This is important as it will help to direct the priorities of your program for the next year.  Luckily, the I in QAPI doesn’t stand for “me”.  This is a “we” process that will require the work of your team.  But hopefully we made it a little easier with these five steps.  Good luck!


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