A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 17: Quality Improvement
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Table 17-4. Examples of Specific Measures
with Definitions of Responses
Measure
TB screening
(Eligibility: HIVinfected
patients
without a history
of previous TB
treatment or
a history of a
positive PPD)
PCP prophylaxis
Definition of
measure
Was PPD testing
performed (placed
and read within
72 hours) in the
past 12 months?
Did the patient
with 200/
mm 3 during the
last 6 months of
the review period
receive PCP
prophylaxis?
Yes/No
response
Yes: PPD screening
was performed
(placed and read)
No: PPD
screening was not
performed (or it
was placed but
results were not
documented)
Yes: The patient
received PCP
prophylaxis
No: The patient
did not receive
PCP prophylaxis
The data collection plan includes determining the
source of information, such as whether medical records
or an electronic database will be used, how the data
will be recorded, who will record the data, and how a
sample will be selected. A representative sample will
allow inferences to be made about the clinic population
based on observations of the smaller sample. Some
form of random sampling should be used, either from
a random numbers table, or a selection of every nth
record from the list of eligible patients.
A common pitfall at this point is to think of the
measurement sample as a research project. For the
purposes of QI, a sample just needs to be current,
representative, and readily obtained (ie, sample size
calculations and the achievement of statistically
significant results are not necessary).
Should you measure only one indicator at a time?
Definitely not. Several indicators should be measured
simultaneously, whether abstracted from medical
records or analyzed through administrative databases.
Indicators reflecting different aspects of patient
management should be selected, as well as those
involving different populations. Indicators should also
be selected to evaluate different components of the
health care system, such as the different components of
the chronic disease model.
How should you analyze and display data?
Data should be reviewed and distributed to all members
of the team and others involved in the care process
under evaluation. Whenever possible, data should be
displayed in graphic format. Once data from several
time periods have been collected (eg, rates of patients
with viral load performed every 4 months collected
in 2 different time periods), a simple line graph (run
chart) can be constructed with each point representing
a performance rate (percentage) for a given period of
time. This is usually the simplest and most effective
way to show performance data (see Figure 17-1).
Figure 17-1: Sample Run Chart: Percentage
of Patients PPD Tested, by Month
Run Chart: Annual PPD Rate
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Source: Measuring Clinical Performace: A Guide for HIV Health Care
Providers. New York, NY: New York State Department of Health AIDS
Institute. April, 2002.
How does improvement occur?
Once the data have been reviewed by the team and the
process for improvement identified, the next step is to
decide where opportunities for improvement exist. This
process is described as the PDSA (Plan-Do-Study-Act) or
PDCA (Plan-Do-Check-Act) cycle (see Figure 17-2).
The first step is to investigate this care process in
greater detail. Several techniques are often used to
accomplish this goal. The simplest is brainstorming,
in which individuals offer their suggestions for which
processes are the best candidates for change. Another
easy method is flowcharting, in which the group breaks
down the process into its components to identify how
it is coordinated and how its parts fit together. Then,
the areas that would be most likely to benefit from
improvement are selected for change (see Figure 17-3).
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau