Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience

1. Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience John M. Morton, MD, MPH, FACS Associate Professor Director of Surgical Quality

2. �To Err is Human�

3. Administrative Data Financial Clinical Input Goethe � You search where there is light�

4. Administrative Data Consistent Benchmark Prioritize Variance

5. Department of Surgery Quality Plan Preview Imperative from SHC Board Areas of Focus Measurement Goals Communication Education Accountability Leadership

8. PSIs: Quality Diagnostic Tool

10. Top Priority PI Action Plans

11. UHC DVT/PE Measure

12. Incidence of DVT/PE by DRG

13. Concurrent Surgical Audit Concurrent audit started in Feb 08; conducted by Quality Specialist 24 hours after surgery on: Orthopedic surgery General surgery patients �Risk level� of patient is assessed by Quality Specialist & compliance determined based on current order Surgical DVT Prophylaxis must be ordered and 1st drug dose given within 24 hours after surgery If no order or inadequate order, a �fix-it� ticket is placed in medical record so MD can order or revise prophylaxis

14. Radiology DVT/PE Report

15. DVT/PE Risk Assessment in Epic

16. Retrospective Surgical Audit (? radiology test)

17. Retrospective Surgical Audit

18. Action Plan for DVT/PE

19. DVT/PE Rates with SCIP VTE Compliance Comparison by Quarter

20. Incidence of Medical and Surgical Cases

21. UHC Benchmark: IAP

22. CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases Next steps: focus on other causes of IAP: thorascopic lung biopsy, feeding tube placement and EP procedures

23. CVC Insertion Site

24. Action Plan

26. The evidence Early Goal-Directed Therapy Initiation of Appropriate Antimicrobial Therapy Treatment with Hydrocortisone Activated Protein C Glucose Control Lung Protective Strategies

27. Goal of 2008 SHC Quality Initiative on Severe Sepsis and Septic Shock: Reduce hospital mortality by 10% from Jan 08 to Jan 09 May 2008: Initial education of ICU Guidelines for Severe Sepsis & Septic Shock December 2008:Epic order sets revised to reflect changes in guidelines.

35. PPEC: Accountable Outcomes

36. PPEC: Accountable OutcomesSCIP

37. PPEC: Accountable OutcomesPSIs

38. Use of PSI in PPEC: Post-op Hematoma

39. Use of PSI in PPEC: Accidental Puncture or Laceration

40. Persistent Pursuit of Excellence Dedicated Monthly Grand Rounds on Quality NSQIP based Morbidity and Mortality Conference Resident Award for Quality Improvement Novel Quality Improvement/Patient Safety Resident Curriculum Documentation Improvement Program Peer Review Surgery Quality Council Quality Initiatives: DVT, Sepsis, Iatrogenic Pneumothorax,Vent >48 hours, Colo-rectal Wound Infection Rounding Policy OR Checklist Leadership

41. HAWTHORNE EFFECT

42. National PSI RatesMorton 2009

43. Clinical Outcomes Report: Product Line Mortality ComparisonOctober 2006 � September 2007

44. General Surgery

Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience

Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience

Presentation Transcript

Clinical Insights into Implementing the AHRQ Indicators for Hospital Quality Improvement

Patient Safety: You Can Make a Difference

The Culture of Safety in 24 Midwestern Critical Access Hospitals AHRQ Patient Safety and Health IT Conference June 5, 2

NH Patient Safety Culture Survey (AHRQ) Beth Hercher , QI Specialist Patient Safety Team April 2009 Patient Safety Rest

The AHRQ Surveys on Patient Safety Culture Setting the Standard for Patient Safety Culture Around the Globe AHRQ Annual

POSITIVE PREDICTIVE VALUE OF AHRQ PATIENT SAFETY INDICATORS IN A NATIONAL SAMPLE OF HOSPITALS

How Can States and Institutions Work Together to Create a Culture of Safety? Concrete Actions to Improve Patient Safety

Closing the Quality Gap: Revisiting the State of the Science

Partnering with Patients to Improve Safety: The Patient TIPS experience

Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience

Instructions

Patient Safety Indicators

“The right care for every person, every time.”

Analysis of the evolution of quality and management indicators in a Central Hospital

AHRQ Patient Safety & Health IT 2006 Strengthening the Connections Designing a Safe Hospital

Patient Safety Organizations in Their Second Year: The Momentum Builds

Confidentiality, Patient Safety Work Product, and PSOs

AHRQ Quality Indicators 101: Background and Introduction to the AHRQ QIs

National Patient Safety Goals

How Hospital Accreditation facilitates health care quality and patient safety

Day 1: Session I

Armstrong Institute for Patient Safety and Quality

Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience