Using clinical indicators in a quality improvement programme targeting cardiac care

The Brisbane Cardiac Consortium, a quality improvement collaboration of clinicians from three hospitals and five divisions of general practice, developed and reported clinical indicators as measures of the quality of care received by patients with acute coronary syndromes or congestive heart failure.

An expert panel derived indicators that measured gaps between evidence and practice. Data collected from hospital records and general practice heart-check forms were used to calculate process and outcome indicators for each condition. Our indicators were reliable (kappa scores 0.7-1.0) and widely accepted by clinicians as having face validity. Independent review of indicator-failed, in-hospital cases revealed that, for 27 of 28 process indicators, clinically legitimate reasons for withholding specific interventions were found in <5% of cases.

Indicators were reported every 6 months in hospitals and every 10 months in general practice. To stimulate practice change, we fed back indicators in conjunction with an education programme, and provided, when requested, customized analyses to different user groups. Significant improvement was seen in 17 of 40 process indicators over the course of the project.

Lessons learnt included the need to: (i) ensure brevity and clarity of feedback formats; (ii) liberalize patient eligibility criteria for interventions in order to maximize sample size; (iii) limit the number of data items; (iv) balance effort of indicator validation with need for timely feedback; (v) utilize more economical methods of data collection and entry such as scannable forms; and (vi) minimize the burden of data verification and changes to indicator definitions. Indicator measurement is being continued and expanded to other public hospitals in the state, while divisions of general practice are exploring lower-cost methods of ongoing clinical audit.

Use of clinical indicators succeeded in supporting clinicians to monitor practice standards and to realize change in systems of care and clinician behaviour.