Effective use of quality indicators in intensive care Maartje L.G. de Vos Effective use of quality indicators in intensive care Maartje L.G. de Vos The research described in this thesis was carried out at the Department of Tranzo, Tilburg University, Tilburg, the Netherlands. The research was financially supported by the National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands. Cover design: Madelief Brandsma Cover photo: Ida Hylkema Printing: CPI Wöhrmann Print Service, Zutphen ISBN: 978-94-6203-163-0 This thesis was printed with financial support of: The National Intensive Care Evaluation (NICE) and Tilburg University. © Maartje de Vos, 2012 All rights reserved. No parts of this publication may be reproduced, stored, or trans- mitted in any way or by any means, without prior permission of the author. Effective use of quality indicators in intensive care PROEFSCHRIFT ter verkrijging van de graad van doctor aan Tilburg University op gezag van de rector magnificus, prof.dr. Ph. Eijlander, in het openbaar te verdedigen ten overstaan van een door het college voor promoties aangewezen commissie in de aula van de Universiteit op vrijdag 7 december 2012 om 14.15 uur door Maartje Louise Gerarda de Vos geboren op 13 december 1977 te Eindhoven Promotiecommissie Promotor: Prof. dr. G.P. Westert Copromotores: Dr. W.C. Graafmans Dr. P.H.J. van der Voort Overige leden: Prof. dr. D.H. de Bakker Prof. dr. D. Delnoij Prof. dr. J.G. van der Hoeven Prof. dr. E. de Jonge Dr. H.C.H. Wollersheim Contents Chapter 1 General introduction and study outline 7 Chapter 2 Quality measurement at intensive care units: which indicators 21 should we use? Chapter 3 Using quality indicators to improve hospital care: a review of the 39 literature Chapter 4 Implementing quality indicators in intensive care units: 61 exploring barriers to and facilitators of behaviour change Chapter 5 Evaluating the effectiveness of a tailored multifaceted perfor- 79 mance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care Chapter 6 Effect of a multifaceted active performance feedback strategy on 103 length of stay compared to benchmark reports alone: a cluster randomized trial in intensive care Chapter 7 Effect of a tailored multifaceted intervention on organizational 125 process indicators in the intensive care: a cluster randomized trial Chapter 8 Process evaluation of a tailored multifaceted feedback program to 143 improve the quality of intensive care by using quality indicators Chapter 9 General Discussion 163 Summary 179 Samenvatting (Summary in Dutch) 185 Dankwoord (Acknowledgement) 191 Curriculum Vitae 195 List of publications 199 6 CHAPTER 1 General introduction and study outline Chapter 1 Background Over the past decade, quality and safety issues have become increasingly important in healthcare. Healthcare suffers from a quality gap, referring to a difference between evidence-based practices and those practices that actually are observed in daily clini- cal practice. 1 To close this gap, health authorities and organizations give high priority to quality improvement (QI), which refers to systematic, data-driven activities for immediate monitoring and improvement of healthcare quality. 2 For healthcare pro- viders it is a challenging task as well as responsibility to respond to growing demands to ensure transparency about healthcare outcomes and reduce variation in clinical practice. 3,4 This development is strengthened by rising healthcare expenditure in many countries. Reforms of healthcare systems are accompanied by questions related to the quality of care and the efficiency of care delivery. It has become more and more important in the western world to demonstrate that healthcare is of high quality as well as efficient. Consequently, measuring and monitoring the quality of healthcare has become a routine business. In order to measure the quality of care, often quality indicators are used, ideally combining measures of structure, process and outcome of care. 5,6 The goals of measuring healthcare quality are to determine the effects of health- care on desired outcomes and to assess the degree to which healthcare adheres to processes based on scientific evidence or agreed to by professional consensus.7,8 Moreover, the rationale for measuring healthcare is the belief that good performance reflects good-quality practice, and that comparing performance among providers and organizations will encourage better performance. 8 However, the impact of monitor- ing quality on the actual performance of healthcare is not completely clear. Looking back to the history of indicators in healthcare, it appears that 10-15 years ago hospital performance assessment was an innovative field. Currently, many indi- cators have been developed worldwide to assess the quality of hospital care. 9 These indicators cover a wide range of dimensions linked to clinical effective- ness, efficiency and safety. The first large national initiative for hospital performance assessment, the Quality Indicator Project (QIP), was launched in the United Stated (USA) in 1984. 10,11 Some years later, the Australian Council on Healthcare Standards (ACHS) launched a hospital indicator project which contained more than 300 indi- cators divided over 22 topics. 12 In Europe, assessing the performance of hospitals appears to be a relatively new area in the field of healthcare delivery science and hospi- tal management, as the majority of projects were launched from 2000 onwards. 13-15 8 Chapter 1 Indicators for quality of care are used in many different settings, for different pur- poses and are developed in different ways. The initiatives differ in the extent to which users, such as healthcare professionals and managers on the one hand and patients on the other hand, were involved in the selection and design of indicators. Differences also exist in obligatory or non-obligatory participation. In addition, quality indicators differ in the underlying philosophy of a policy towards disclosure of the results to the public versus restricted use of data for internal QI. 9,16,17 Governments, patient organi- zations and payers for healthcare use indicators as a tool for external accountability in order to assess and compare the quality of care of healthcare providers. In contrast, healthcare providers mostly use indicators as a tool to monitor and improve their internal care processes. 14 The collection and interpretation of indicator data may not always be simple, and may be subject to gaming with numbers. 18,19 For example when indicator data are used for financial management, it may be profitable to present data in a selective manner. Especially when data are used for different purposes and by different people, there may be a risk of differences in interpretation and presentation of the same indi- cator. Indicators in the Dutch context Also in the Netherlands, assessing the quality of healthcare has become increasingly important. There is a growing political pressure on healthcare professionals and institutions to perform better by developing and implementing quality indicators and performance schemes for external accountability and transparency as well as internal QI. In this thesis we focus on the development and implementation of a set of quality indicators in the Dutch intensive care. Though the use of internal indicators in the intensive care started in 1996, in 2003 the Dutch Health Care Inspectorate (IGZ) developed and implemented the first exter- nal set of hospital performance indicators in the Netherlands, focusing on monitoring and meeting standards for effectiveness and safety. 14 Participation is obligatory for all Dutch hospitals. The results of the data analyses are available to the public by pub- lication of annual reports as well as individual reports on (hospital) websites. Around the same time, the IGZ encouraged several Dutch medical disciplines to develop addi- tional indicators for their own purposes in order to monitor their internal performance without external interference and public disclosure. 9 Chapter 1 Quality indicators as a tool to improve the quality of care Despite worldwide development of hospital performance assessment projects, it remains unclear if the quality of care can be supported effectively by the use of quality indicators. Quality indicators are suggested as useful tools to improve the quality of care. They can be defined as ‘screening tools to identify and signal potential subop- timal clinical care’. 20 Indicators aim to provide insight in the structure and process aspects of care that are related to outcome and can be used as a tool to guide the process of QI in healthcare, 6 Structure indicators are related to the physical aspects of care such as accessibility and availability. Process indicators refer to what is actu- ally done in giving and receiving care such as using protocols and guidelines. Outcome indicators are related to the health status of the patient, e.g. mortality, and improved health status. The primary focus of quality indicators in the context of this thesis is to periodically report and monitor indicator data in order to improve quality of care. Although quality indicators are applied as a tool to guide the process of quality improvement, only few randomized controlled trials (RCTs) showed that the use of indicators significantly improved the quality of hospital care. Carlhed et al. (2006) described the impact of real- time feedback and educational meetings on the adher- ence to acute myocardial infarction (AMI) guidelines. 21 These efforts resulted in sig- nificant improvements in four out of five process indicators. Another study assessed the effects of an educational intervention on management of three common diseases (malaria, pneumonia and diarrhoea), using performance indicators and an audit feed- back approach. 22 The study showed that the aggregated mean scores for all diseases improved significantly. Horbar et al. (2004) showed that a multifaceted intervention including audit and feedback, evidence reviews, QI training and follow-up support changed the behaviour of healthcare professionals and promoted evidence based practice.