meaningful quality rating system
By David H Levien
Apply for or renew ACHT Fellowship The first thing one needs to do to have a meaningful quality rating system is to pick the proper dependent variable. One must also pick the appropriate stakeholder to know the proper dependent variable. In medicine and critical care we call this picking the proper therapeutic endpoint. For instance, we have known for decades now that blood pressure is not the appropriate therapeutic endpoint in an intensive care unit. It is more reasonable to use the relationship between oxygen delivery and oxygen demand and one way of measuring this might be the mixed venous oxygen saturation or even the lactic acid level. I have been seeking a noninvasive way to measure the oxygen saturation in the coronary sinus.
Getting back to hospital quality measures morbidity and mortality are two dependent variables that are meaningful for most people and which are appropriately emphasized in applications such as the former CareScience, now known as Premier. Patient satisfaction Is measured by Press Ganey scores. The Net Promoter score is quite valuable in this domain. There are various quality of life (QOL) measures and if we pick those it's important that they be validated but are very useful in when measuring outcomes for people who receive treatments at various institutions for Crohn's disease or ulcerative colitis or faecal incontinence. There are also various validated measures to assess quality of life after total joint or spine procedures. The reason CMS measures correlate poorly with other scores is it they are often measures of process which may or may not measure outcome. CMS picks a measure such as the percentage of people receiving prophylactic antibiotics within a 1/2 hour window prior to a given procedure but they often have very little evidence that this metric is meaningful. They then published this metric to the general public as if it truly measured the quality of that institution. To do the process correctly, one needs to choose dependent variables meaningful to the end user. If the end user is a consumer this might be mortality, morbidity, patient experience, and functional ability one and five years out. In terms of measuring the independent variables it is important to use multiple linear regression analysis and only measure the independent variables that have independent significant. I believe there are some variables that haven't been sufficiently used such as anergy and relative anergy and other measures of immune competence such as total lymphocyte count. The ACHT will be offering the opportunity to earn blue, brown, and black belts in quality and safety and credits earned thru our activities and courses will enable leaders to earn the designations of Fellow with Special Merit and Fellow with Distinction.
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