This post is part of a series about how quality standards can be used to support quality improvement together with others who are working on adopting the quality standards. The introductory post can be found here.
From previous research we know that hip fracture is a common injury in older patients with high mortality and morbidity rates (up to 30% one-year mortality and up to 50% unable to return to previous level of function). We also know that there are very well established best practices with respect to various aspects of hip fracture care, like timing of surgery, selection of procedure and osteoporosis management.
A while ago, as a team, we agreed that we wanted to improve hip fracture care and the Quality Standard developed by HQO perfectly aligned with our goals.
Implementing the Hip Fracture Quality Standard represents a true collaborative effort, which is essential in any Quality Improvement project. Our process to use the Hip Fracture Quality Standard included several steps: 1) Performing an audit of hip fracture care at St. Michael’s Hospital, based on metrics derived from each of the Quality Statements; 2) Identifying areas for improvement based on assessment of current performance (target is 90% adherence to each metric); 3) Assembling an interdisciplinary quality improvement team to address each gap until performance in all areas reaches target.
We learned that data collection may be a relatively simple or a very complex matter depending on the statements. For example, data sources may not be easily available or may require a mixed-methods approach. Our data collection process greatly benefited from having reliable electronic data sources (this is really critical), which were supplemented by manual chart reviews for items that cannot easily be extracted from the electronic records.
In using the data, we identify metrics for each of the 15 individual quality statements and for each metric, we determine if 90% or more patients received the appropriate care. If it is less than 90%, this area is identified as a gap. Priorities for the quality improvement team are based on these gaps as well as on the perceived importance and level of difficulty to address the issue.
Our Quality Improvement Team will focus on one area for improvement at a time. We will use the Plan Do Study Act methodology to develop a standardized information package for hip fracture patients and to implement information dissemination to patients, family and caregivers. We will track improvement through the metrics developed and then we will move on to the next gap, using similar methodology.
Our key learnings in the process of using the Hip Fracture Quality Standard are:
- Some statements are more difficult to implement than others
- Sometimes we need a mix of quantitative and qualitative approaches
- It is essential to use electronic data sources as much as possible
- Prioritization is key (addressing all the gaps at once is not feasible)
- Statements that are easier to implement and are more important are the first to focus on
- Assembling a strong Quality Improvement team is critical as well as using PDSA cycles
We would really like to hear about other initiatives supporting the implementation of the Hip Fracture Quality Standard and to learn from others how we can improve our own program!