Everyone talks about benchmarking, but few know what it means
True benchmarks are always data- and outcome-specific
Benchmarking: It’s a hot buzzword in the industry, but few wound care providers really know what it means. David R. Thomas, MD, professor of geriatrics at St. Louis University School of Medicine and member of the National Pressure Ulcer Advisory Panel (NPUAP), says benchmarks are not goals, protocols, decision trees, or best practices — though all of these can be created using benchmarks.
"If you want to develop your own protocol in your own facility to treat a particular illness, then you’re not doing anything but setting up some good medical standards," Thomas says. "You would not call that a benchmark, because you’re not comparing your protocol to an external standard. In wound care, what we want is to compare one facility to another for cost, incidence of illness, prevalence, etc. That’s where you get into problems, because if you are going to compare two populations, they have to be similar in ways that don’t bias the comparison. If I compare my nursing home to your nursing home, it is meaningless to say that I have fewer pressure ulcers than you unless I have the same population."
Benchmarking: Comparing individuals to appropriate data
A true benchmark is always data- and quantitative outcome-specific. Benchmarking, then, is monitoring outcomes by comparing individuals to an appropriate set of data, Thomas says. "Here’s a benchmark: The mortality rate for cardiovascular surgery in this country is less than 4%. Choosing a physician based on comparing his or her rate to 4% is using that benchmark," Thomas explains.
In order to establish benchmarks that would help nursing home personnel choose their best practices, benchmarkers must make adjustments for case-mix severity. Thomas notes that this kind of statistical adjustment is being done in all the Veterans Affairs (VA) long-term care facilities in the country, but it would be very difficult to do in nursing homes, which don’t have the standardized database available to the VA. "Right now, if a clinic is curing 90% of venous stasis ulcers, you don’t know whether this is good or bad, because you do not know what the national cure rate might be," Thomas says.
George T. Rodeheaver, PhD, professor and director of plastic surgery research at the University of Virginia Medical School at Charlottesville, says while externally agreed-upon benchmarks are still largely absent in the wound care industry, clinicians tend to develop their own "internal benchmarks" based on their own experience and their expectations of wound healing. Though the initial "experience base" is probably that of one’s mentors, every case provides more data from which the wound caregiver learns what a good or bad outcome is. "However, the only way we can have a reality check is for me to see what somebody else’s benchmark is," Rodeheaver says. "That gives me a reference point to see if my personal benchmarks are acceptable, below standard, or above standard."
Rodeheaver says there must be agreement within the wound care industry regarding what should be measured. "In wound healing, benchmark outcomes normally stop at closure, but other outcomes, such as removal of odor and reduction of pain, are important in improving the status of the wound. It may not be that our total goal is to get wound closure, but that we get improvement in the status of the wound for the patient," Rodeheaver says.
Even agreeing on when a wound is healed is not as simple as it might sound. Rodeheaver points to the ongoing dialogue between members of the Wound Healing Society (WHS) and officials at the Food and Drug Administration (FDA) about defining when a wound is healed during trials for new products requiring FDA clearance. FDA policy is that every randomized trial must take wounds to closure. Rodeheaver doesn’t necessarily agree.
"There are primary outcomes and secondary outcomes," he says. "The FDA is not particularly interested in improvements, rates of improvements, or partial healings — they want complete closure as the outcome." In clinical reality, chronic wounds take a long time to get complete closure, often more than 20 weeks. Rodeheaver says it is possible to use a wound healing trajectory that illustrates the rate of wound healing with the experimental agent compared to the standard of care, do the study for 10 weeks, and show the slope of the curve.
Wound scale tools — the benchmarker’s best friend
One helpful item available to wound caregivers who want to measure healing outcomes is the Pressure Ulcer Scale for Healing (PUSH) tool, devised at the request of NPUAP. The key criteria in designing the instrument were simplicity of use in clinical settings, validity for measuring whether ulcers are improving, and sensitivity to changes in the ulcer between observations. It also had to be concise so that it could be incorporated into the Minimum Data Set assessment tool now mandated by Health Care Financing Administration for all long-term care facilities.1 (Editor’s note: see the Wound Care Forum in the June 1999 issue of Wound Care for a discussion of minimum data sets.)
"The PUSH tool gives a nice quantitative number for the status of the wound, and you can monitor that rate of change," Rodeheaver says. "Let’s say you and I both have patients with wounds that have a score of 34. We can monitor how quickly we can get that reduced to a score of eight. If it takes me five weeks and it takes you one week, then I’m doing something wrong. Again, we can do it without going to complete healing — it’s a matter of the decrease, of significant improvement in the status of the wound.
You can use your own facility’s past performance as a benchmark. In order to benchmark your own performance, you must begin with accurate, complete data; introduce the new protocol you believe will alleviate the problem you have targeted; and then re-take the exact same data. "If you know what you did in the last six months, you can tell what you’re going to do in the next six months if you make no changes," Thomas says. "When you introduce a new wound care protocol and track it over time, you’ll have the reliable benchmark of your own past performance to use in establishing your best practice."
The ultimate goal of benchmarking is to determine the best practices for your wound care population. Kathi Thimsen Whitaker, RN, CETN, MSN, clinical affairs manager for Coloplast Corp. in Marietta, GA, says when she does a consult at a nursing home, she develops standards of care before taking initial measurements.
It gets down to basic care issues’
At one such facility, Whitaker found residents were experiencing a large number of skin problems. Product inventory and practice analysis showed the facility was spending virtually nothing on skin care products. When more products were bought and used, skin breakdown and related problems were significantly reduced, giving Whitaker and the facility a new benchmark to use in improving care. "If you can have benchmarking for complex disease states such as diabetes, congestive heart failure, [and] fractured hips, you can have it in wound care," Whitaker says. "It gets down to basic care issues: hygiene, nutrition, hydration, management of elimination. There are comorbidity factors you have to process into the equation, but I believe it is achievable."
References
1. Thomas D, Rodeheaver G, Bartolucci A, et al. Pressure ulcer scale for healing: Derivation and validation of the PUSH tool. Adv Wound Care 1997; 10:96-101.
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