School of Nursing, Purdue University, West Lafayette, Indiana, USA
Nursing Facility Rates and Policy Division, Minnesota Department of Human Services, Saint Paul, Minnesota, USA.
BMJ Qual Saf. 2023 Jun;32(6):319-329. doi: 10.1136/bmjqs-2021-014384. Epub 2022 Oct 3.
Healthcare quality measurement systems, which use aggregated patient-level quality measures to assess organisational performance, have been introduced widely. Yet, their usefulness in practice has received scant attention. Using Minnesota nursing home quality indicators (QIs) as a case example, we demonstrate an approach for systematically evaluating QIs in practice based on: (a) parsimony and relevance, (b) usability in discriminating between facilities, (c) actionability and (d) construct validity.
We analysed 19 risk-adjusted, facility-level QIs over the 2012-2019 period. Parsimony and relevance of QIs were evaluated using scatter plots, Pearson correlations, literature review and expert opinions. Discrimination between facilities was assessed by examining facility QI distributions and the impact of the distributions on scoring. Actionability of QIs was assessed through QI trends over time. Construct validity was assessed through exploratory factor analysis of domain structure for grouping the QIs.
Correlation analysis and qualitative assessment led to redefining one QI, adding one improvement-focused QI, and combining two highly correlated QIs to improve parsimony and clinical relevance. Ten of the QIs displayed normal distributions which discriminated well between the best and worst performers. The other nine QIs displayed poor discrimination; they had skewed distributions with ceiling or floor effects. We recommended scoring approaches tailored to these distributions. One QI displaying substantial improvement over time was recommended for retirement (physical restraint use). Based on factor analysis, we grouped the 18 final QIs into four domains: incontinence (4 QIs), physical functioning (4 QIs), psychosocial care (4 QIs) and care for specific conditions (6 QIs).
We demonstrated a systematic approach for evaluating QIs in practice by arriving at parsimonious and relevant QIs, tailored scoring to different QI distributions and a meaningful domain structure. This approach could be applied in evaluating quality measures in other health or long-term care settings.
医疗保健质量衡量系统广泛采用汇总的患者层面质量衡量标准来评估组织绩效。然而，其在实践中的有效性却很少受到关注。我们以明尼苏达州养老院质量指标（QI）为例，展示了一种基于以下几个方面在实践中系统评估 QI 的方法：（a）简约性和相关性，（b）在区分设施方面的可用性，（c）可操作性和（d）结构有效性。
我们分析了 2012 年至 2019 年期间 19 个风险调整后的设施层面 QI。使用散点图、皮尔逊相关分析、文献回顾和专家意见评估 QI 的简约性和相关性。通过检查设施 QI 分布以及分布对评分的影响来评估设施之间的区分度。通过随时间推移的 QI 趋势评估 QI 的可操作性。通过探索性因子分析对 QI 进行分组，以评估其结构有效性。
相关分析和定性评估导致重新定义了一个 QI，增加了一个以改善为重点的 QI，并结合了两个高度相关的 QI，以提高简约性和临床相关性。十个 QI 显示出正态分布，可很好地区分表现最好和最差的机构。另外九个 QI 显示出较差的区分度；它们的分布呈偏态，存在上限或下限效应。我们建议针对这些分布采用定制的评分方法。一个随着时间推移显示出显著改善的 QI 建议退休（使用身体约束）。基于因子分析，我们将 18 个最终 QI 分为四个领域：失禁（4 个 QI）、身体机能（4 个 QI）、心理社会护理（4 个 QI）和特定疾病护理（6 个 QI）。
我们通过制定简约而相关的 QI、针对不同 QI 分布定制评分方法以及具有有意义的领域结构，展示了一种在实践中评估 QI 的系统方法。该方法可应用于评估其他医疗或长期护理环境中的质量衡量标准。
