The document discusses methods for measuring performance and clinical outcomes in healthcare. It describes the major domains of patient safety measurement as harm, mortality, infections, readmissions, patient satisfaction, and safety culture. It then focuses on defining medical errors and adverse events, and explaining why measurement is important for evaluating current systems and improving outcomes. Different methods of data collection are outlined, including direct observation, cohort studies, record review, and incident reporting systems. The Global Trigger Tool for assessing harm using chart review is also summarized.

1. Measures of Performance and
Clinical Outcome
Dr. Mohamed Mosaad Hasan
MD, MPH, CPHQ, CPPS

2. Objectives
• Identify effective methods for using
performance measurement
• Discuss the major domains of patient
safety measurement
• Identify some approaches to data
collection

3. Institute of Medicine Six Aims
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

4. Why Measurement is Important?
• Evaluate current system
– Identify high risk areas in health care
– Learn what is working and what is
broken
• Help set priorities – where should we
start?
• Reduce harm and improve outcomes

5. Definition: Measurement
• The process of applying a
standard scale to what you
are interested in
• Every measurement
includes some error
– Some of that error is random
“noise”
– Some is systematic “bias”
• Task is to minimize noise
and understand bias

6. Major Domains
• Harm
• Mortality
• Infections/hospital-acquired conditions
• Readmissions
• Patient satisfaction
• Safety culture

7. Medical errors
• Institute of Medicine defines medical error as
the failure to complete a planned action as
intended or the use of a wrong plan to achieve
an aim.
Medical errors are:
1- errors of commission (doing the wrong thing);
2- errors of omission (not doing the right thing);
or
3- mistakes in execution (doing the right thing, but
doing it incorrectly).

8. Adverse event (Harm)
• Adverse event can be described as an
injury caused by medical management
rather than by the underlying disease or
condition of the patient.
• Medical error may or may not lead to
adverse event.
• Adverse event is preventable (considered
as medical error) or non preventable (not a
medical error).

9. Medical
error
Preventable
Non
preventable

10. The Focus on Harm
• Overall patient safety goal is to reduce
patient injury or harm
 Medical errors are numerous
 Many have potential to be harmful
 Numerous reports show that error is often not linked
to injury
• Focus on error tends to focus on individual
• Focus on harm tends to focus on systems
 Focus on systems more likely to improve care and
outcomes
 Focus on systems reduces fear of punishment and
encourages cooperation with patient safety efforts

11. Commission vs. Omission
• Harm measures focus on active care
(commission)
• Excludes omission (substandard care)

12. How do you measure Harm
• Prospective
– Direct observation of patient care
– Cohort study
– Clinical surveillance
• Retrospective
– Record review (Chart, Electronic medical record)
– Administrative claims analysis
– Malpractice claims analysis
– Morbidity & mortality conferences/autopsy
– Incident reporting systems

13. Relative Utility of Methods to
Measure Errors

14. Direct Observation
• Good for active errors
• Data otherwise
unavailable
• Potentially accurate,
precise
• Training/expensive
• Information overload
• Hawthorne effect?
• Hindsight bias?
• Not good for latent
errors

15. • Potentially accurate and
precise for adverse
events
• Good to test
effectiveness of
intervention to decrease
specific adverse event
• Can become part of care
• Expensive
• Not good for detecting
latent errors
Cohort / Clinical Surveillance

16. Chart Review
• Uses readily available
data
• Common
• Judgments of adverse
events not reliable
• Expensive
• Records incomplete,
missing
• Hindsight bias

17. Global Trigger Tool

18. Triggers: Assessing Harm
• Use of manual chart review to study
harm as a result of active medical care
• Use of “trigger” methodology to search
for harm
Trigger – event often associated with harm
 If trigger is present, chart is reviewed further
to determine if harm occurred

19. Global Trigger Tool
• The IHI Global Trigger Tool contains six “modules,” or
groupings of triggers. Four of the groupings are designed
to reflect adverse events that commonly occur in a
particular unit; the Cares and Medication groupings are
designed to reflect adverse events that can occur
anywhere in the hospital. The six modules are:
• Cares Intensive Care
• Medication Perinatal
• Surgical Emergency Department
• All patient records should be reviewed for the triggers in
the Cares and Medication modules. The other modules
should only be used if applicable.

20. Outpatient Surgery Example

21. Conceptual Model for
Measuring