Thursday, September 22, 2011

Structure, Process, Outcomes and CKM

Over 40 years ago, Donabedian described a model of assessing quality within a system.  The model had three components: structure, process and outcomes. AHRQ has a detail description of Donabedian’s Model. In short, it states that a system’s outcomes are based on its processes and its processes are bound by its structure. In order to have a long lasting effect on outcomes of interest you need to make changes to the system’s structure and processes.  

An understanding of this system is essential to clinical knowledge management because each component of the model represents a different knowledge type and often a different knowledge source. Knowledge about all three is needed to reach the threshold for actionable knowledge when solving system-based quality problems. If the threshold of actionable knowledge is not met, you will be guessing at which parts of the system to change. In my opinion, the guessing of which parts of the healthcare system to change explains the limited success there has been with improving quality in healthcare.

A stepwise process should be used to create actionable knowledge for system-based quality questions.

Step 1. Define, measure and benchmark the outcome of interest.

Step 2. Determine if the outcome of interest is at goal levels of performance. If not, go to step 3. Otherwise, spend you energy on a different issue.

Step 3. Define, measure and benchmark the processes driving the outcome of interest.

Step 4. Determine which process or processes are preventing the outcome from reaching goal levels.

Step 5. Define the structure of the processes identified in Step 4.

Step 6. Combine the knowledge developed in the previous steps to make actionable knowledge.

Step 7. Now that you have completed the first step of the AURI cycle (analysis), complete the AURI cycle to develop appropriate system changes and track their effect.

This process was used to reduce sepsis mortality at my previous hospital. It was first determined that sepsis mortality was above goal. Two main processes were identified as driving the mortality: the identification of the presence of sepsis and the time it took to deliver antibiotics. The structure around the diagnosis process was that physicians and nurses did not receive standard education on recognizing sepsis and there were no job aids to help them identify patients. With regards to the delivery of antibiotics, one of the most popular antibiotics ordered for these patients had to be mixed in a sterile hood by a pharmacist and thus administration was delayed. 

The structural changes made to improve the outcome were the standard education of nurses and physicians as well as the creation of posters that were posted in the emergency department on how to identify patients with sepsis. Additionally, a formulary change allowed an alternative antibiotic to be immediately available in the emergency department. These structural changes resulted in improved processes for identifying patients and delivering antibiotics more rapidly. The effect on the outcome has been a sustained 37% reduction in mortality for patients presenting to the emergency department with sepsis.