Clinical Performance Measurement in a Large Academic Medical Center

Author: Benjamin C. Kays

Primary Advisor: Irmgard Willcockcon, PhD (co-author)

Committee Members: Craig W. Johnson, PhD (co-author)

Masters thesis, The University of Texas School of Health Information Sciences at Houston.


Purpose:  To describe and measure the utility of a web based Quality Management Information System (QMIS) pilot that will ensure compliance to Joint Commission outcomes measurement guidelines and also facilitate performance improvement (PI) efforts.

Methods: Data included in the QMIS was collected from the Institutional Information Warehouse. Statistical Process Control (SPC) methodology was used by the QMIS in the display of these data. To measure user satisfaction with the QMIS, a small survey was developed using a 5 part Likert Scale and completed by 5 PI users of the application (Cronbach Alpha .925).

Results: Of the 5 participates surveyed, 100% either agreed or strongly agreed that the web based display showed a meaningful result in the test metric, Average Length of Stay (ALOS). Regarding the ‘drill down’ feature of the application, 100% of those surveyed either agreed or strongly agreed that this feature provided appropriate scope to measure entity performance. 80% of those surveyed were satisfied with the speed of the application. Finally, to measure QMIS utility in a PI scenario, 80% of those surveyed were confident they could use the QMIS in response to the scenario goal.

Conclusion: Based on the initial results from the satisfaction survey, the QMIS system could facilitate performance improvement efforts when reviewing Joint Commission quality measures such as Average Length of Stay.