Module 4
QI measurement doesn't have to be complicated. The examples below highlight practical ways different audiences can collect and use data to support improvement.
- Electronic Medical Record (EMR): Run reports or track fields tied to screenings, consults, or referrals.
- Manual logs or checklists: Often used when EMR customization isn't available — especially in schools, EMS, or smaller clinics.
- Spreadsheets (HIPAA Compliant Platforms): Useful for pilot projects or early tracking. Simple, accessible, and easy to update.
- Surveys and interviews: Collect qualitative data from families or staff. Brief (3–5 question) pulse surveys work well for ongoing feedback.
- Direct observation: Structured observation (e.g., watching the triage workflow) can reveal gaps not visible in chart data.
Audience-Specific Data Collection Examples
| Audience | Scenario / Application | Key Takeaway |
|---|---|---|
Emergency Physician |
Tracks suicide risk screening compliance using a weekly EMR report filtered by age group and presenting complaint. Cross-references against triage documentation to identify which shifts and providers have lower compliance rates. Adds a monthly qualitative component: brief conversations with 3 triage nurses about barriers. |
Combines quantitative EMR data with qualitative staff insight for a complete picture. |
EMS Team / EMS Medical Director |
Uses a paper run report field to document whether a pediatric behavioral health protocol was activated. Data is entered into a monthly aggregate tracker (Excel spreadsheet maintained by the QI lead). Supplemented by post-call debrief notes. |
Simple field-level data that doesn’t require system changes. Practical for pre-hospital settings. |
PECC |
Runs a monthly audit of 10 randomly selected charts of pediatric behavioral health ED visits, reviewing screening completion, documentation quality, safety plan presence, and follow-up appointment scheduling. Presents findings at monthly department meeting. |
Focus study approach that provides quick, actionable insights without requiring large-scale data infrastructure. |
School Clinician |
Uses a shared Google Sheet to track each student referred for behavioral health services — including referral date, agency name, follow-up contact date, and whether the appointment was attended. Updated weekly. |
Low-tech solution that works across school and community settings. Creates accountability through visibility. |
Primary Care Team |
Sends a 3-question post-visit survey to families of children referred for behavioral health services, asking about ease of referral, time to appointment, and satisfaction with the process. Results reviewed monthly. |
Captures qualitative data on the family experience. Helps the team understand whether process changes are felt by patients. |
Behavioral Health Staff |
Tracks safety plan completion rates using a monthly audit of 10 randomly selected behavioral health discharge records, reviewing whether a safety plan was documented, printed, and given to the family. Supplements with brief exit interviews — asking 3 questions of families before discharge: Did you receive a safety plan? Do you know who to call if symptoms worsen? Do you have your follow-up appointment information? Results reviewed at weekly behavioral health team huddle. |
Combines chart audit with real-time family feedback. The exit interview catches gaps that documentation review alone might miss — a family may have received a form they didn’t understand. |
Hospital Leadership / CMO |
Reviews a monthly executive dashboard tracking four behavioral health quality metrics: ED boarding time, suicide screening compliance, safety plan completion rate, and 72-hour return visit rate. Each metric is displayed as a run chart with 12 months of data and a target line. The CMO presents this dashboard at quarterly Board quality meetings and uses it to set improvement priorities for the multidisciplinary behavioral health task force. |
A leadership-level dashboard consolidates key metrics into a single view that drives organizational accountability. Run charts allow leadership to see trends over time, not just point-in-time snapshots. |