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Table 3 Example refinement of prototype measures, data, and display about documenting goals of care conversations for VA providers in long-term care settings

From: Designing clinical practice feedback reports: three steps illustrated in Veterans Health Affairs long-term care facilities and programs

Initial prototype report

Observe user

Understand user

1. Refine measure

2. Refine data

3. Refine display

Key assumption:

Timeliness of goals of care documentation is important because admission to long term care reflects health status changes that may change a patient’s care goals.

Measure:

 Denominator: Veterans newly admitted in quarter

 Numerator: Veterans newly admitted in quarter and having completed documentation within 7 days after admission

Data: Admissions data for long term care facilities

Display: Text and a bar chart showing percentage as a rate with sums for the numerator and denominator over recent quarters (Fig. 3).

Users expressed concern that the numerator’s 7-day window excluded Veterans with appropriate documentation from a prior admission. Users expressed that performance feedback about goals of care documentation at any time for newly admitted Veterans would be valuable.

Users value information about the historical reach of goals of care documentation.Requirement: At least one measure should reflect historical documentation of goals of care.

Include Veterans who have ever had goals of care documentation in the numerator.

Retrieve historical goals of care documentation data from the Corporate Data Warehouse from any prior date, and up to the time of generating the current report.

Revise the bar chart to reflect changes to the measure and data (Fig. 4, top).

Users value timeliness information before and after the 7-day window.

Requirement: At least one measure should show timeliness of documentation before and after admission.

Create a new measure to assess the timeliness of goals of care documentation for newly admitted Veterans. Create three new numerators: 1) Documented between 8 to 30 days following admission, 2) Documented within 7 days following admission, 3) Documented any time prior to admission.

Retrieve historical goals of care documentation data from the Corporate Data Warehouse in three separate time windows, reflecting the new numerators.

Develop a new chart that shows the count data for each numerator during each quarter (Fig. 4, bottom).

Users did not expect that all Veterans admitted to their facilities were required to have a goals of care conversation because many are not seriously ill. Users expressed that separation of measures by short stay and long stay services was an acceptable proxy for serious illness status.

Users perceive priority of goals of care documentation to be high only for Veterans who are seriously ill.

Requirement: Measures should reflect the Veteran populations’ severity of illness.

Divide all measure denominators into two parts, for Veterans who are seriously ill, and those who are not.

Use new data sources: Admitting service categories of short stay and long stay as a proxy for serious illness.

Develop a new chart to show documentation for short stay and long stay admissions (Fig. 5).