One of the fundamental elements behind demonstrating change is the ability to evaluate progress by regularly tracking and monitoring project measures. Data shows whether or not a change is an improvement. If your data are housed in an electronic medical record or in paper charts, your team must establish baseline data to prioritize areas for improvement and to gauge success and continued challenges as the clinic tests new processes. Monthly tracking facilitates efficient assessment of small tests of change and supports data driven decision-making.
Determining the Data Collection Plan relates directly with two other change elements: Element 1: Defining the Population and Element 6: Process Improvement Meetings with the Clinic Project Team. Regularly reported and evaluated measures together with commitment throughout the clinic and organization result in improvement for services to serve the target population.
Steps for Implementation
- Working with the clinic leadership and the project team, identify project outcome measures and benchmarks specific to breast health service delivery.
- Establish baseline data for each measure through chart review, electronic medical record reports, or billing database.
- Compute the exact monthly referral and screening goals using the number of active patients defined as the target population. (See Element 1: Define the Population)
- Use the Initiative’s one-page tracking report (see sidebar) or develop your own breast health tracking tool to report outcome measures on a monthly basis.
- Review monthly outcome measures with the Project Team to evaluate process improvement activities and identify priority areas for improvement.
- Share monthly measures among partner breast health providers to facilitate and strengthen relationships by demonstrating successes and challenges along the continuum of care.
Establishing Baseline Referral and Screening Rates Using Paper Charts:
Community Health Care Network, Fairfax County, Virginia
Community Health Care Network (CHCN) was in the process of transitioning from paper to electronic medical records during baseline data collection. The number of active patients could be pulled electronically; however, referral and screening rates had to be determined by looking for documentation in paper charts. Instead of reviewing each chart for all 1,340 women 40 and over seen over the past year, the team pulled a sample of 134 charts (10%) to gather and record data from referral reports and mammogram results into the chart review template (see sidebar). The team analyzed the data using Excel spreadsheets. In smaller clinics, the team will have to determine how many charts will constitute a representative sample.
Monthly Report Tool and Goals: Mercy Health Center, Montgomery County, Maryland
Through the Initiative, Mercy Health Center (MHC) established the following AIM and objectives using baseline data. Then, over the first year, the clinic tracked and reported the following measures using the monthly report template (see sidebar).
AIM: To provide efficient and evidence-based breast cancer screening services to 45 women per month. (2011 HEDIS Medicaid breast cancer screening benchmark 65%)
Objective 1: Refer 90% (743 annually / 61 monthly) of eligible women for mammography screening.
Objective 2: Screen 65% (536 annually / 45 monthly) of eligible women for mammography screening.
Frequently Asked Questions
Q1. How do we prioritize which measures are most important to track?
A1. Various breast health measures are tracked and reported nationally, some of which are required by national certification boards and/or registries. Your facility may already be tracking and reporting some measures, which could be a good starting point. In order to gain support for process improvement, engage your providers and clinic in the decision-making process to capture what is important to them. In the end, you want meaningful measures that will track monthly performance in the delivery of breast health to steer process evaluation as well as quarterly and yearly measures to evaluate overall patient outcomes.
Q2. What measures can we establish that are within the Triple AIM framework?
A1. The Institute for Healthcare Improvement (IHI) asserts that health care system design can and must be developed to simultaneously accomplish three critical objectives, called the “Triple Aim”. The objectives are to 1) improve the health of the population, 2) enhance the patient experience of care (including quality, access, and reliability, and 3) reduce, or at least control, the per capita cost of care.