How to Use the Hospital Harm Measure for Improvement 

Occurrences of harm are often complex with many contributing factors. Organizations need to: 

1. measure and monitor the types and frequency of these occurrences 
2. use appropriate analytical methods to understand the contributing factors 
3. identify and implement solutions or interventions designed to prevent recurrence and reduce the risk of harm 
4. have mechanisms in place to mitigate consequences of harm when it occurs 

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses or prospective analyses can all be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in the section "Resources for Conducting Incident and/or Prospective Analyses." 

Conducting a chart audit to drive quality improvement 

Chart audits are recommended as a good method to develop a more in-depth understanding of the care delivered to patients identified by the Hospital Harm measure. Chart audits can also help identify quality improvement opportunities. 

Step 1: Prioritize quality improvement opportunities 

Prioritize the clinical groups for review with the help of your multidisciplinary team, and by considering the following factors. 

• Clinical groups with a high volume of patients. 
• Severity of harm including never events, serious reportable adverse events, serious safety events, and critical incidents. 
• Clinical groups that align with: 
• Quality improvement (QI) work already underway or planned in the organization. 
• Provincial/territorial or regional priorities or ministerial directives. 
• Priorities identified through the accreditation or risk assessment process. 
• Priorities from patient safety incident reporting and learning systems, patient safety or quality assurance reviews or patient complaints. 

Step 2: Identify what you want to measure 

Identify specifically what you want to measure through a chart audit. The input of experts is key in this step. Clinical groups are comprised of codes of different but related types of harm. Determine which codes contribute the most harm to the clinical group, what questions you need to answer, and what information you need to collect. The Hospital Harm improvement resource (improvement resource) lists some suggested outcome and process measures for each clinical group. 

For example, C21: patient trauma captures in-hospital injuries such as fractures, dislocations, burns and asphyxiation. If C21 has been identified as a "high volume" clinical group for your facility/organization you will want to determine which codes contribute to the majority of harm (for example fracture, burns, etc.). If fractures are the focus of your audit, you may want to measure the number of fractures due to falls. To understand what contributed to the fall you may need to know where the fall occurred (from bed, wet floor, etc.) and whether the patient had a fall risk assessment, and medication review on admission, etc. 

Step 3: Identify your patient population 

Once your team has identified a clinical group to explore, with the help of the multidisciplinary team you will need to identify the patient population for study. For instance, you may decide to review all cases included in the clinical group or focus on a specific unit or patient population (for example medical, surgical, obstetrical, etc.) 

Step 4: Determine your sample size for the chart audit 

Sample size is at the discretion of your facility/organization. For a chart audit you may arbitrarily choose a sample size; the minimum is usually 10 to 20 charts or 10 percent of the population. For steps on determining a statistically valid sample size see The How’s and Why’s of Chart Audits: http://patientsafetyed.duhs.duke.edu/module_b/steps/step4.html 

A small sample can be effective in QI to help identify themes, understand the patient experience and explore patient care processes. However, findings from a small sample should be used cautiously when considering applicability across an entire population. 

Step 5: Create your audit tools 

Determine the demographic and care processes that you want to capture in your audit. Hospitals may use existing audit tools from external organizations or create their own audit tool. Here are examples of audit tools for medication reconciliation and preventing falls and injury from falls. 

Step 6: Collect your data 

Members of the multidisciplinary QI team can conduct the chart audit of the sample cases, or it can be done by staff familiar with conducting audits (for example health information analysts, clinical educators, risk managers). 

Step 7: Summarize your results 

Summarize the chart audit results and share them with members of your team for additional insights. The input of those who provide the care on a regular basis is also very valuable at this stage. Have them reflect on: "Does this match what you are experiencing in your day-to-day provision of care to our patients? Does it make sense to you or surprise you?" 

Step 8: Use your results to inform and launch a QI initiative 

Pull together a multidisciplinary QI team inclusive of content and process experts and those who provide the care on a regular basis. Analyze the results from the chart audits to identify specific improvement opportunities. Embark on a journey using QI methodology such as the model for improvement or any quality framework used at your organization. 

Use the experiences of others to identify how to make improvements. Find out what high performing organizations are doing, and look at other resources. 

Remember to include ongoing measurement and evaluation to understand if changes have resulted in improvement (see process measures listed for each clinical group in the improvement resource). Identify any other sources of complementary information (for example patient safety incident reporting and learning system data, ongoing quality audits, quality of care reviews). 

If your organization would like further information on how to conduct a chart audit for quality, some helpful references include: 

• The retrospective chart review: important methodological considerations http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853868/ 
• The How's and Why's of Chart Audits http://patientsafetyed.duhs.duke.edu/module_b/chart_audit.html