Criteria and Standard

Objectives

• To define performance indicator, criteria and standard

Criterion (definition)

• A systematically developed statement that can be used to assess the appropriateness of specific healthcare decisions, services, and outcomes (Institute of Medicine, 1992)

Definitions of a ‘standard’

• An objective with guidance for its achievement given in the form of criteria sets which specify required resources, activities, and predicted outcomes (Royal College of Nursing, 1990)

• The level of care to be achieved for any particular criterion (Irvine and Irvine, 1991)

• The percentage of events that should comply with the criterion (Baker and Fraser, 1995)

Definition of an indicator

Criteria

• structure (what you need)• process (what you do)• outcome of care (what you expect).

Structure criteria

• Structure criteria refer to the resources required– the numbers of staff and skill mix – organisational arrangements, – the provision of equipment and– physical space

Process criteria

• Process criteria refer to the actions and decisions taken– communication, – assessment, – education, – investigations,– prescribing, – surgical and other therapeutic interventions,– evaluation, and– documentation.

Process criteria

• Process criteria are more sensitive measures of the quality of care, as a poor outcome does not occur every time there is an error or omission in the provision of care.

• the importance of process criteria is determined by the extent to which they influence outcome

Outcome criteria

• Outcome criteria are typically measures of the physical or behavioural response to an intervention and reported health status

• Some audits focus specifically on outcomes and collect data about the outcomes of care. This is a practical possibility when outcomes are easily measurable and occur soon after the delivery of care.

• If the outcomes are also of major importance to users, for example postoperative complications, the direct measurement of outcome is not only appropriate but also expected

Outcome criteria

• When outcomes are used for comparative audit, adjustments may be needed for case mix, a process known as ‘risk adjustment’.

Outcome criteria

Developing valid criteria/ standard

• Based on evidence • Related to important aspects of care• Measurable

METHODS OF DEVELOPING CRITERIA

Using guidelines

• Recommendations from clinical practice guidelines can be used to develop criteria and standards without substantial additional work

Prioritising the evidence method

• This method of developing criteria reviews the evidence in the source guidelines or systematic reviews for each element of care identified as important in determining outcome

• The criteria that have most impact on outcome are then categorised as ‘must do’ or ‘should do’

RAND/UCLA appropriateness method

• The findings of a literature review are submitted to a panel of clinicians, chosen for their clinical expertise and professional influence, who are asked to rate the appropriateness of a set of possible indications for the particular procedure

Examples of criteria

• New benzodiazepine prescriptions must only be issued for short-term relief (no longer than four weeks) of severe anxiety or insomnia

METHODS FOR DEVELOPING STANDARDS

Using levels of performance achieved in trials

• the levels of performance achieved in trials are helpful, but should not be regarded as uniformly achievable in unselected patient populations.

Benchmarking

• An organisation first identifies the areas of practice where the quality of patient care would benefit from comparison and sharing of information about the processes involved in achieving high performance

• Then it compares its performance with that of its most successful ‘competitors’ and considers areas for development in the light of the comparison

Care pathways

• Integrated care pathways define the expected timing and course of events in the care of a patient with a particular condition

• They describe explicitly all the expected processes of care.

• Care pathways are easier to introduce when there is established routine practice and little variation between users

Example for blood transfusion

• Donors should have a health check prior to donation(criterion).

• We would expect 100% compliance, it is mandatory for all donors(standard).