Benchmarking and quality improvement: the Harvard Emergency Department Quality Study

PURPOSE: To determine whether feedback of comparative information was associated with improvement in medical record and patient-based measures of quality in emergency departments. SUBJECTS AND METHODS: During 1-month study periods in 1993 and 1995, all medical records for patients who presented to five Harvard teaching hospital emergency departments with one of six selected chief complaints (abdominal pain, shortness of breath, chest pain, hand laceration, head trauma, or vaginal bleeding) were reviewed for the percent compliance with process-of-care guidelines. Patient-reported problems and patient ratings of satisfaction with emergency department care were collected from eligible patients using patient questionnaires. After reviewing benchmark information, emergency department directors designed quality improvement interventions to improve compliance with the process-of-care guidelines and improve patient-reported quality measures. RESULTS: In the preintervention period, 4,876 medical records were reviewed (99% of those eligible), 2,327 patients completed on-site questionnaires (84% of those eligible), and 1,386 patients completed 10-day follow-up questionnaires (80% of a random sample of eligible participants). In the postintervention period, 6,005 medical records were reviewed (99% of those eligible), 2,899 patients completed on-site questionnaires (84% of those eligible), and 2,326 patients completed 10-day follow-up questionnaires (80% of all baseline participants). In multivariate analyses, adjusting for age, urgency, chief complaint, and site, compliance with process-of-care guidelines increased from 55.9% (preintervention) to 60.4% (postintervention, P = 0.0001). We also found a 4% decrease (from 24% to 20%) in the rate of patient-reported problems with emergency department care (P = 0.0001). There were no significant improvements in patient ratings of satisfaction. CONCLUSION: Feedback of benchmark information and subsequent quality improvement efforts led to small, although significant, improvement in compliance with process-of-care guidelines and patient-reported measures of quality. The measures that relied on patient reports of problems with care, rather than patient ratings of satisfaction with care, seemed to be more responsive to change. These results support the value of benchmarking and collaboration.