Indicators to improve clinical quality across an integrated health care system.

PURPOSE To describe key historical and operational elements of change that may assist an organization to develop quality indicators for implementing a strategic plan to improve care, align health care improvement efforts with national directions, and examine the types of medication indicators used to assess these changes. SETTING The Baylor Health Care System (BHCS) is an integrated health care delivery organization in Dallas-Fort Worth, Texas. It includes 11 hospitals with 83 000 admissions per year and 47 primary care and senior centers with more than 500 000 visits annually. INTERVENTION Following a charter by the BHCS Board of Trustees to develop a health care quality improvement strategic plan, BHCS undertook a system-wide effort to improve care supported by the use of clinical quality indicators. RESULTS Consistent with the direction of the US Institute of Medicine, BHCS has implemented a clinical indicator system focused on measures of health care underuse, overuse, and misuse. These indicators demonstrated the accomplishments of specific process of care improvements throughout BHCS. Despite implementing Web-enabled error reporting systems and pilot work with an adverse drug event hospital medical record abstraction tool, BHCS indicators of medication misuse continue to be in a formative stage, much like the national consensus. CONCLUSION Organizational, compensatory, and cultural commitments may be important for successful implementation of clinical indicator initiatives by health care systems. Using clinical indicators to establish baseline performance and to assess the effectiveness of proposed quality improvements provides quantitative and qualitative means to identify and disseminate best care practices. Although indicators to measure underuse of clinically necessary care are well established, there remains a need to achieve consensus regarding practicable medication quality indicators for overuse, misuse, and adverse drug events.