DEFINITIONS

A benchmark in health care refers to an attribute or achievement that serves as a standard for other providers or institutions to emulate.

Benchmarking current process performance against “best in class,” via site visits and data analysis, facilitates knowledge of cutting edge developments, technologies, and best practices–and assists in establishing priorities and target areas for innovation.

Types of benchmarking include:

• Internal Best – in your own organization
• Competitive Best – amongst your competitors
• Functional Best – best-in-class for this type of process
• Out-of-Industry – service classic from another industry

Benchmarks differ from other “standard of care” goals, in that they derive from empiric data—specifically, performance or outcomes data. For example, a statewide survey might produce risk-adjusted 30-day rates for death or other major adverse outcomes. After adjusting for relevant clinical factors, the top 10% of hospitals can be identified in terms of particular outcome measures. These institutions would then provide benchmark data on these outcomes. For instance, one might benchmark “door-to-balloon” time at 90 minutes, based on the observation that the top-performing hospitals all had door-to-balloon times in this range. (Reference)

In the present example regarding infection control, benchmarks would typically be derived from national or regional data on the rates of relevant nosocomial infections. The lowest 10% of these rates might be regarded as benchmarks for other institutions to emulate.

Best Practices or Potentially Better Practices (PBPs), as Vermont Oxford Network terms them, are the culmination of evidence-based practice and provider wisdom, put to the test.  PBPs are a term coined by Paul Plsek to indicate that we will not know if the practices are truly better until we adapt them to our local context, implement them, and measure the results (Pediatrics, Jan 1999; 103: e203).

A bundle is described as a structured way of improving the processes of care and patient outcomes: a set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been demonstrated to improve patient outcomes (Institute for Healthcare Improvement, 2010). It is not simply a list of desirable changes.

• All of the elements are necessary and must be performed together.
• The changes are all based on randomized controlled trials, what we call Level 1 evidence.
• A bundle focuses of how to provide the care, not what care to provide.
• Bundle changes must occur at a specific time and place; every patient, every time, with complete consistency.
• A bundle belongs to a person or team, so there is a strong element of accountability.

(Reference)

In a bundle, the measures are all-or-none (Nolan & Berwick, 2006). All practices must be applied all the time; three out of four practices would not capture the spirit of the concept.

For an example of a bundle, see Central Line Bundle. This is a set of five ideas to help prevent “catheter-related blood stream infections,” deadly bacterial infections that can be introduced through an IV.

A checklist is a list of items to be noted, checked, remembered or done. In healthcare, it is used to prescribe the critical steps needed to execute procedures correctly. A checklist can contain many elements, and have many owners /responsible persons.

Peter Pronovost is credited first with making use of a checklist for line infections, in 2001. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors should: (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. He then worked on pain management and mechanical ventilation checklists, showing tremendous improvement. The checklists helped with memory recall and also made explicit the minimum, expected steps in complex processes. The checklists established a higher standard of baseline performance.

(see Atul Gawande’s “The Checklist” from the Annals of Medicine).

For a specific example, see reality check for checklists, commonly used in safety: Better Understanding Of Use Of Checklists In Healthcare Urged

Clinical Paths include “descriptions of key events that, if performed by caregivers as described, are expected to produce the most desirable outcomes for patients with specific conditions or procedures.”

“Today caregivers are adopting OUTCOMES-BASED PRACTICE methods to achieve desired patient care goals. Outcomes-based practice (sometimes called OUTCOMES MANAGEMENT) involves a combination of teamwork, continuous quality improvement, and process and outcome measurement. These collaborative multidisciplinary efforts build on the pathway development work of the 1990s.”

“Protocols are also an effective strategy for reducing undesirable variation in patient care practices. Unlike clinical paths that cover all aspects of care for a particular group of patients, protocols are designed for specific clinical situations, e.g. administration of heparin, management of postoperative nausea, treatment of pressure sores, etc. Protocols can be used by themselves or in combination with clinical paths.”

An algorithm is a set of prescribed steps, a detailed sequence of actions, or a formula to produce a certain outcome. It contains a set of rules for a certain procedure. As such, it is more akin to protocols than clinical paths.

A checklist is “an algorithmic listing of actions to be performed in a given clinical setting to ensure that, no matter how often performed by a given practitioner, no step will be forgotten. An analogy is often made to flight preparation in aviation.” (Reference. See also: Checklists)

Using flowcharts or flow diagrams can help depict clinical paths, protocols, or algorithms.

Evidence-based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise, for a recommended treatment, diagnostic procedure, or cause of a condition. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach, but implies that the results of medical research weigh over personal opinion. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings.

The practice of EBP includes five fundamental steps:

Step 1: Formulating a well-built question

Step 2: Identifying articles and other evidence-based resources that answer the question

Step 3: Critically appraising the evidence to assess its validity

Step 4: Applying the evidence

Step 5: Re-evaluating the application of evidence and areas for improvement

(Reference: The 5-Step Process: Introduction)

There are a number of systems for evaluating the strength of evidence during the review process. See one example: Oxford Centre for Evidence-based Medicine – Levels of Evidence

Failure Modes and Effects Analysis (FMEA) is an error analysis, which may involve retrospective investigations (as in Root Cause Analysis) or prospective attempts to predict “error modes.”  Different frameworks exist for predicting possible errors.  One commonly used approach is failure mode and effect analysis (FMEA), in which the likelihood of a particular process failure is combined with an estimate of the relative impact of that error to produce a “criticality index.”  By combining the probability of failure with the consequences of failure, this index allows for the prioritization of specific processes as quality improvement targets.  For instance, an FMEA analysis of the medication dispensing process on a general hospital ward might break down all steps from receipt of orders in the central pharmacy to filling automated dispensing machines by pharmacy technicians.  Each step in this process would be assigned a probability of failure and an impact score, so that all steps could be ranked according to the product of these two numbers. Steps ranked at the top (i.e., those with the highest “criticality indices”) would be prioritized for error proofing.

Order sets are collections of pre-formed groups of orders designed to manage a disease state or a procedure. An order set usually seeks to standardize the instructions that initiate or sustain a care plan for a specific clinical situation. Thus an order set may include not only medications, but also orders for laboratory tests, radiographs, diet, activity, rehabilitation, temperature management, patient education…. They are usually designated by the lead persons responsible for that care. They may include clinical paths or protocols/algorithms.

Reliability has to do with “repeatability” or the capability of a process to perform consistently—the right way at the right time under the right conditions.  Healthcare professionals hope to design reliable systems of care in order to prevent failure.  Reliability in health care is often discussed in terms of the percentage of time that a system performs as it is designed to perform.  Performance at less than 80% is considered chaos, according to the Institute for Healthcare Improvement.  High reliability organizations(HROs) refer to organizations or systems that operate under hazardous conditions, but have learned to mitigate the high‐risk, error‐prone nature of the organization’s activities; they do so by studying failure, developing the ability to contain unanticipated events, and by attentive listening to front-line workers for help in identifying threats to reliability (this open dialogue is often referred to as “a culture of safety”).  In a culture of safety, you will see all levels of staff involved in root cause analyses, debriefings of error events, and modeling of procedures and processes.

In TIPQC, we are assembling Toolkits for improvement. Toolkits are all inclusive packages to help facilitate improved clinical outcomes, excellent patient care, and efficient resource allocation. They can be any collection of aids that support quality in health care. These could include bundles, checklists, scorecards, films, educational materials, fact sheets, sample letters, assessment tools, posters, references, and more.

CPQCC Toolkits are examples of ready-to-use quality improvement interventions provided to member hospitals, but also offered to anyone who can help improve the lives of neonates and their families.