A Different Way of Measuring Undesired Events Can Better Clinical Performance

A Different Way of Measuring Undesired Events Can Better Clinical Performance 150 150 Kevin Mayhood

Clinical care indexes allow departments to track failures and harm and continually upgrade processes for delivering optimal care.

Three Nationwide Children’s Hospital departments that developed and applied their own clinical index to the care of patients with a certain illness or who underwent specific procedures, substantially improved their clinical performance.

An index allows medical staff to track and total the number of undesirable patient events — preventable harm and failures to provide optimal care — within a timeframe. Staff then use the events to revise care delivery and measure changes in performance.

Working with Quality Improvement Services at Nationwide Children’s, the Section of Nephrology saw a 63 percent improvement in performance using a Chronic Kidney Disease Care Index (CKDCI), the Section of Pulmonology an 89.5 percent improvement using a Lung Transplantation Care Index (LTCI), and the Department of Otolaryngology a 53 percent improvement using a Tracheostomy Care index (TCI).

Researchers published a study of the indexes in The Journal of Pediatrics, to provide other hospitals with a roadmap to their use.

“A clinical care index helps us to define optimal care across a spectrum of diseases in a different way than we have before, including all the things that should happen during the course of treatment and all the things that shouldn’t,” says Wallace Crandall, MD, medical director for Quality at Nationwide Children’s and lead author of the study. “It is a measure of overall program performance.”

Each department tailored their index to their experience and patients’ needs. Department and quality improvement staff used expert opinion, evidence-based protocols and best practices in the medical literature to determine optimal care and harm to avoid.

For example, optimal care for children with chronic kidney disease requires testing for urine protein annually. Development of tracheostomy-related pressure ulcers is preventable harm for every child undergoing the procedure.

The index enables a department to track and measure care failures and harm from month to month, quarter to quarter, or year to year. The staff then uses failures and harm to improve the processes they use to deliver care. Continued use of the index allows a department to measure its changes in performance over time.

“You can improve many processes by standardizing care and delivering it reliably,” says Dr. Crandall, who is also a professor of Clinical Pediatrics at The Ohio State University College of Medicine.  “You measure and adjust until you are delivering optimal care reliably, and the results will follow.”

The researchers believe that the improvement in processes in each department may ultimately improve outcomes for patients, such as slowing the progression of chronic kidney disease. As use of the indexes continues, they hope to determine what indicators may demonstrate improved outcomes.

Dr. Crandall believes that Nationwide Children’s culture of quality improvement, which includes the Zero Hero program focused on eliminating preventable harm, contributed to the success of the departments’ efforts. Quality Improvement Services staff assist each department with process development and data collection and analysis.

The physicians, nurses, fellows and other clinical staff using the indexes report satisfaction with the measures and found them to be an important tool for better care.

Many more departments in the hospital are in various stages of developing and using clinical indexes.

The clinical indexes are spinoffs from Nationwide Children’s Preventable Harm Index (PHI) the hospital introduced in 2010 and the more recent Cancer Care Index. Both reduced preventable harm and improved performance. The PHI, which improved outcomes measurably and was published in 2013, is now being used in other children’s hospitals.

Eventually, “The goal is for each group within the hospital to publish their own clinical index in academic journals within their specialty,” Dr. Crandall says, “so that others can review them and decide how to use them themselves.”



Crandall, W, Davis JT, Dotson J, Elmaraghy C, Fetzer M, Hayes D Jr, Horwitz E, Kogon A, Olshefski R, Patel H, Brilli RJ. Clinical Indices Can Standardize and Monitor Pediatric Care: A Novel Mechanism to Improve Quality and SafetyThe Journal of Pediatrics. 2017 Dec 4. pii: S0022-3476(17)31327-6. [Epub ahead of print]

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