PubMed Health⌕ Search

Biomedical subjects

P B Batalden

Publications and source records attributed to P B Batalden.

At least 19 recordsLinked to original sources
PubMed1998

Building measurement and data collection into medical practice.

Clinicians can use data to improve daily clinical practice. This paper offers eight principles for using data to support improvement in busy clinical settings: 1) seek usefulness, not perfection, in the measurement; 2) use a balanced set of process, outcome, and cost measures; 3) keep measurement simple (think big, but start small); 4) use qualitative and quantitative data; 5) write down the operational definitions of measures; 6) measure small, representative samples; 7) build measurement into daily work; and 8) develop a measurement team. The following approaches to using data for improvement are recommended. First, begin with curiosity about outcomes or a need to improve results. Second, try to avoid knee-jerk, obstructive criticism of proposed measurements. Instead, propose solutions that are practical, goal-oriented, and good enough to start with. Third, gather baseline data on a small sample and check the findings. Fourth, try to change and improve the delivery process while gathering data. Fifth, plot results over time and analyze them by using a control chart or other graphical method. Sixth, refine your understanding of variation in processes and outcomes by dividing patients into clinically homogeneous subgroups (stratification) and analyzing the results separately for each subgroup. Finally, make further changes while measuring key outcomes over time. Measurement and improvement are intertwined; it is impossible to make improvements without measurement. Measuring and learning from each patient and using the information gleaned to test improvements can become part of daily medical practice in local settings.

Blood Glucose Self-Monitoring↗
PubMed1998

Collaboration in improving care for patients: how can we find out what we haven't been able to figure out yet?

BACKGROUND: Questions, or what the physicist and learning expert Reginald Revans called "insightful inquiry," are essential to learning. People remember and use what they discover themselves. But many habits and activities in front-line workplaces of patient care have not promoted frank discussions of what we haven't figured out yet about improving care for patients. Leaders are no longer defined by having the right answers. Leaders will be the ones who have the right questions and who promote local learning with the right questions. SUGGESTIONS FOR GETTING STARTED IN COLLABORATION. The authors suggest questions to ask to get collaborative inquiry going and cite examples they have collected. The questions and examples are grouped in seven thematic categories: Listening to and appreciating others; Thinking across disciplines and roles; Sharing ideas and linking those shared ideas to execution and deployment of change; Appreciating systems and interdependencies; Using research (including local research) to inform our practices; Using methods, skills, and techniques as facilitators of collaboration; and Working across organizational boundaries.

Communication↗
PubMed1997

Clinical process cost analysis.

BACKGROUND: New systems of reimbursement are exerting enormous pressure on clinicians and hospitals to reduce costs. Using cheaper supplies or reducing the length of stay may be a satisfactory short-term solution, but the best strategy for long-term success is radical reduction of costs by reengineering the processes of care. However, few clinicians or institutions know the actual costs of medical care; nor do they understand, in detail, the activities involved in the delivery of care. Finally, there is no accepted method for linking the two. METHODS: Clinical process cost analysis begins with the construction of a detailed flow diagram incorporating each activity in the process of care. The cost of each activity is then calculated, and the two are linked. This technique was applied to Diagnosis Related Group 75 to analyze the real costs of the operative treatment of lung cancer at one institution. RESULTS: Total costs varied between $6,400 and $7,700. The major driver of costs was personnel time, which accounted for 55% of the total. Forty percent of the total cost was incurred in the operating room. The cost of care decreased progressively during hospitalization. CONCLUSIONS: Clinical process cost analysis provides detailed information about the costs and processes of care. The insights thus obtained may be used to reduce costs by reengineering the process.

Cost Control↗
PubMed1996

Improving health care, Part 1: The clinical value compass.

CLINICAL VALUE COMPASS APPROACH: The clinical Value Compass, named to reflect its similarity in layout to a directional compass, has at its four cardinal points (1) functional status, risk status, and well-being; (2) costs; (3) satisfaction with health care and perceived benefit; and (4) clinical outcomes. To manage and improve the value of health care services, providers will need to measure the value of care for similar patient populations, analyze the internal delivery processes, run tests of changed delivery processes, and determine if these changes lead to better outcomes and lower costs. GETTING STARTED--OUTCOMES AND AIM: In the case example, the team's aim is "to find ways to continually improve the quality and value of care for AMI (acute myocardial infection) patients." VALUE MEASURES--SELECT A SET OF OUTCOME AND COST MEASURES: Four to 12 outcome and cost measures are sufficient to get started. In the case example, the team chose 1 or more measures for each quadrant of the value compass. OPERATIONAL DEFINITION OF MEASURES: An operational definition is a clearly specified method explaining how to measure a variable. Measures in the case example were based on information from the medical record, administrative and financial records, and patient reports and ratings at eight weeks postdischarge. COMMENTS: Measurement systems that quantify the quality of processes and results of care are often add-ons to routine care delivery. However, the process of measurement should be intertwined with the process of care delivery so that front-line providers are involved in both managing the patient and measuring the process and related outcomes and costs.

Cost-Benefit Analysis↗
PubMed1996

Improving health care, Part 2: A clinical improvement worksheet and users' manual.

BACKGROUND: Small tests of change can be conducted in everyday clinical practice, thereby turning the health care delivery team into reflective practitioners who can learn from, and improve on, their work. CLINICAL IMPROVEMENT WORKSHEET AND USERS' MANUAL--CASE STUDY: The worksheet has been designed as a simple tool for applying clinical improvement to the core clinical delivery process. A carpal tunnel surgery (CTS) team was formed to improve outcomes and reduce costs for patients and to promote improvements in quality and value. The team wanted to determine if surgical patients treated with local anesthesia in an ambulatory setting have superior satisfaction with care, comparable clinical and functional outcomes, and lower medical (and social) costs. For the first time, standardized assessments of patient case mix, treatment processes, and health outcomes were designed into the delivery process by gathering data from the patient and from the surgeon presurgery and 4 weeks and 12 weeks postsurgery. Results for the first 49 of 50 to 100 consecutive patients show improved outcomes and reductions in costs, from $937 to $405 per patient. LESSONS LEARNED: Even though CTS was selected to be a quick and noncontroversial opportunity, considerable effort had to be expended to ensure that all clinicians and other affected staff would understand and support "the new way". RECOMMENDATIONS: "Ramp up" improvements as time passes, more and more change trials are conducted and their complexity increases. To ease implementation of changes, teams can diagram core process "components" and attach measures, use flowcharts to plan and monitor implementation and use change management thinking to help sharpen the plan and anticipate problems.

Adult↗
PubMed1996

Improving health care, Part 3: Clinical benchmarking for best patient care.

BACKGROUND: Benchmarking, which shows that a much better way of doing something may be possible, stimulates local interest in changing and in making changes previously thought not possible. A PLANNING WORKSHEET: The Worksheet has five basic steps: Identify measures, determine resources needed to find the "best of the best," design a data collection method and gather data, measure the best against own performance to determine gap, and identify the best practices producing best-in-class results. CASE EXAMPLE--BOWEL SURGERY: The Accelerating Clinical Improvement Bowel Surgery Team at Dartmouth-Hitchcock Medical Center (Lebanon, NH) was formed in November 1994 to improve the care of patients with diagnosis-related group (DRG) 148 or 149. Consulting two large, administrative databases and the medical literature, the team found that a substantial gap existed between the bowel surgery delivery process and the best results, as far as they were known, among comparable organizations. After flowcharting the delivery process, the team identified the high-leverage steps: same-day services, general surgery clinic, and routine care. The team then planned three successive PDCA (plan-do-check-act) cycles: utilization of same-day services for all elective surgery patients, establishment of a standardized preoperative bowel preparation, and utilization of pre- and postoperative routine care orders. These improvement cycles resulted in a reduction in length of stay from 9.66 to 8.29 days. Implementation of a critical pathway resulted in a further reduction to 5.04 days. CONCLUSION: Benchmarking can play an integral role in clinical improvement work and can stimulate wise clinical changes and promote measured improvements in quality and value.

Academic Medical Centers↗
PubMed1996

Improving health care, Part 4: Concepts for improving any clinical process.

BACKGROUND: One promising method for streamlining the generation of "good ideas" is to formulate what are sometimes called change concepts-general notions or approaches to change found useful in developing specific ideas for changes that lead to improvement. For example, in current efforts to reduce health care costs by discounting provider charges, the underlying generic concept is "reducing health care costs," and the specific idea is "discounting provider charges." Short-term gains in health care cost reduction can occur by pursuing discounts. After some time, however, limits to such reduction in costs are experienced. Persevering and continuing to travel down the "discounting provider charges" path is less likely to produce further substantial improvement than returning to the basic concept of "reducing health care costs." THE HIP REPLACEMENT CASE: An interdisciplinary team aiming to reduce costs while improving quality of care for patients in need of hip joint replacement generated ideas for changing "what's done (process) to get better results." After team members wrote down their improvement ideas, they deduced the underlying change concepts and used them to generate even more ideas for improvement. Such change concepts include reordering the sequence of steps (preadmission physical therapy "certification"), eliminating failures at hand-offs between steps (transfer of information from physician's office to hospital), and eliminating a step (epidural pain control). CONCLUSION: Learning about making change, encouraging change, managing the change within and across organizations, and learning from the changes tested will characterize the sustainable, thriving health systems of the future.

Group Processes↗
PubMed1996

The relationship between meeting patients' information needs and their satisfaction with hospital care and general health status outcomes.

OBJECTIVE: The objective of this study was to determine if there is an association between meeting patients' information needs and their overall satisfaction with care and their general health status outcomes. STUDY DESIGN: This non-experimental study used data from hospital medical records as well as patient-completed surveys conducted two and eight weeks post discharge. The setting involved three community hospitals in the southeastern section of the US that provided care to a series of 167 acute myocardial infarction (Acute MI) patients. MEASURES: The independent variable was an index measuring how well patients' information needs were met. The dependent variables were patient satisfaction (ratings of satisfaction with care process, global satisfaction, and health benefit) and general health status outcomes (physical function, psychosocial function and quality of life). Covariates used as control variables to hold patient characteristics constant, included demographics (age, gender) and clinical measures of acute MI severity, comorbidity, angina (at eight weeks), and dyspnea (at eight weeks). ANALYSIS: Univariate analyses were employed to: (1) describe patients' characteristics; (2) determine the relative importance of meeting different types of information needs; and (3) identify information need areas most likely not to be met. Multivariate linear regression and logistic regression was used to evaluate the association between patients' ratings of meeting information needs with satisfaction and health outcomes, respectively, after controlling for covariates. RESULTS: The multivariate regression results show that meeting information needs are positively and significantly associated with both patient satisfaction measures (i.e., Ratings of Care Processes, p < 0.01; Global Satisfaction, p < 0.05, Perceived Health Benefit, p < 0.01) and one general health status measure (i.e. Quality of Life, p < 0.01). CONCLUSION: The results suggest that providers of care should ensure that they meet the information needs of patients with specific conditions because patients' perceptions of both quality of care and quality of life are associated with the clinicians' ability to transfer key information to their patients.

Aged↗
PubMed1995

Report cards or instrument panels: who needs what?

BACKGROUND: The report card movement in health care is a positive response to legitimate customer needs and requirements for comparative information on quality and costs. At the same time, providers have a legitimate concern about potential problems with gathering and using valid data in a prudent manner. Report cards have problems that often detract from their potentially constructive uses. In response to this concern, the authors propose that instrument panels--a newer concept in health care--compared to the static, judgmental image of report cards project an action-oriented, decision-making image. EXAMPLES: Descriptions are given of three types of instrument panels based on work in progress in the Dartmouth-Hitchcock health care system, a regional, integrated delivery system that serves the population of New Hampshire and parts of Vermont and Massachusetts: a 450-physician group practice (The Hitchcock Clinic), which provides more than one million visits per year in more than 25 locations; a tertiary health care facility (Mary Hitchcock Memorial Hospital) with more than 300,000 patient days; and prepaid health plan (Matthew Thornton Health Plan) with approximately 120,000 members. SUMMARY: It would be wise and efficient for providers to design instrument panel data collection systems that can feed directly into report cards, leading to the triple benefit of enhancing accuracy, reducing total costs, and increasing overall utility to both providers and their customers.

Health Services Accessibility↗
PubMed1995

Comparing outcomes and charges for patients with acute myocardial infarction in three community hospitals: an approach for assessing "value".

OBJECTIVE: To assess the value of care (i.e. outcomes in relation to charges) for acute myocardial infarction (Acute MI) patients in three community hospitals after controlling for patient mix differences. DESIGN: An observational study of a cohort of acute MI patients admitted to hospital for care were studied based on medical record review and on patient-completed questionnaires at 8 weeks post-discharge. SETTING: Three community hospitals located in urban areas in the southeastern region of the United States. PATIENTS: A consecutive sample of 133 non-transfer Acute MI patients were entered into the study based on EKG results, enzyme tests and chest pain characteristics. Hospital medical record and charge data were available on all patients and patient-reports on 86% of survivors. MAIN OUTCOME MEASURES: Data were gathered on clinical outcomes (death, angina, dyspnea), functional outcomes (physical and psychosocial), satisfaction, and resource intensity (length of stay, total hospital charges, ancillary charges). Because of patient mix differences across hospitals, outcomes were adjusted for severity of Acute MI, comorbidity and demographics. RESULTS: There were important patient mix differences across hospitals. For example, Hospital C had more comorbidity than Hospital B (57.78% of Hospital C patients vs 15.00% of Hospital B patients were rated moderate or severe using a well tested index, p < 0.0001). After adjusting for patient mix differences, Hospital C scored significantly better on four of six outcome measures (i.e. angina, dyspnea, physical functioning, psychosocial functioning). For example, Hospital C's patients' mean scores on physical functioning at 8 week follow-up averaged 75.19 (on a 0-100 scale), while Hospital A's was 63.03 and Hospital B's was 48.57 (F-ratio = 4.95; p < 0.05). However, Hospital A scored significantly lower on all three resource intensity indicators (length of stay, ancillary charges, and total charges). For example, Hospital A's ancillary charges averaged $10,752 while Hospital B's and C's averaged $11,432 and $16,598 respectively. Between-hospital comparisons on adjusted mortality and satisfaction did not differ significantly. CONCLUSION: The "value" profiles (i.e. outcomes related to charges) produced by these three hospitals were substantially different. Studies that simultaneously measure outcomes, costs, patient mix and processes have potential to: (a) enable clinical teams to improve the measurable value of clinical care; and (b) enable purchasers to better evaluate which providers to select as preferred sources of care.

Acute Disease↗
PubMed1994

Linking outcomes measurement to continual improvement: the serial "V" way of thinking about improving clinical care.

BACKGROUND: Outcomes measurement, process improvement, and continual improvement all have been used to improve quality in health care. However, the mutually complementary approaches have been used primarily in isolation from each other. The "Serial V" ("Vee") concept attempts to integrate these approaches to provide a fuller assessment and practical approach to quality improvement. METHODS: Outcomes measurement is used primarily to identify variations in care and possibly to determine corrective actions that may minimize those variations. Process improvement focuses on breaking down the components of a specific process of health care delivery, identifying or reworking problem areas in the process, then rebuilding the process. Continual improvement involves pinpointing a particular area for improvement, proposing specific changes, testing the instituted changes, and evaluating the success of such changes. The Serial V concept is an integrative strategy that incorporates aspects of all three approaches to create a comprehensive way to evaluate, institute, and reflect on change aimed at improvement. While this way of thinking appears complex at first glance, a practical worksheet that details each step in the process can be used to begin the clinical improvement work. Use of the Serial V approach, which unites measurement of outcomes, analysis of the clinical process, and repeated pilot tests to improve outcomes in real-world clinical settings, will accelerate improvement in health care outcomes and eliminate unnecessary costs.

Clinical Protocols↗
PubMed1993

A framework for the continual improvement of health care: building and applying professional and improvement knowledge to test changes in daily work.

We seem to lack a well-defined, comprehensive, and shared understanding of what is required for the continual improvement of health care--at the organizational and the industry levels. This article presents a framework that defines the new body of knowledge which, when joined with the professional knowledge of health care workers, can make continual improvement possible; and gives requirements for building and applying this knowledge to bring about improvement in health care organizations.

Clinical Competence↗
PubMed1992

The physician and employee judgment system: reliability and validity of a hospital quality measurement method.

Hospitals engaged in quality improvement must measure and assess customer perceptions of hospital services. Hospital customers are either "external"--patients, their families, and payers--or "internal"--physicians and hospital employees. This article describes two measurement systems designed to gather information from internal customers about the quality of hospital services. One system targets physicians, the other hospital employees. This article describes how these systems were developed and pilot-tested, and how the results were analyzed. Analysis of results showed the systems to be reliable, valid, and representative. The article also addresses limitations of the research (focus on general acute-care hospitals), interesting findings and implications (the correlation between physicians' and employees' ratings of hospital quality), and uses of these measures in corporate-level and hospital-level quality improvement (measuring trends and identifying specific opportunities for improvement).

Attitude of Health Personnel↗
PubMed1991

Resolution of otitis media with effusion with the use of a stepped treatment regimen of trimethoprim-sulfamethoxazole and prednisone.

This double blind, placebo-controlled trial was designed to determine whether intervention with a stepped regimen of trimethoprim-sulfamethoxazole (TMP-SMX) and prednisone would prevent high risk children from developing chronic otitis media with effusion (OME) and recurrent acute otitis media. Forty-two children were enrolled, assigned to treatment with active drug or placebo and then examined at 2-week intervals. They received TMP-SMX (or placebo) during the first 2 weeks, TMP-SMX and prednisone (or placebo) during Weeks 3 and 4 for persistent OME and TMP-SMX (or placebo) for Weeks 5 and 6 if OME was still unresolved. After treatment 48% of active drug and 14% of placebo subjects resolved OME bilaterally (P less than 0.05). Active drug subjects also had fewer acute otitis media episodes than placebo subjects while receiving study treatment (P less than 0.01). Although this treatment regimen produced short term OME resolution, long term benefits were not demonstrated.

Child↗