Ahrq patient safety indicators constructive use for improvement presented to ahrq annual conference
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AHRQ Patient Safety Indicators: Constructive Use for Improvement Presented to AHRQ Annual Conference. September 15, 2009 By Cynthia Barnard MBA MSJS CPHQ Director, Quality Strategies. Northwestern Memorial. HealthCare. Agenda. Framework for PSI analysis within the hospital

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Ahrq patient safety indicators constructive use for improvement presented to ahrq annual conference

AHRQ Patient Safety Indicators: Constructive Use for ImprovementPresented to AHRQ Annual Conference

September 15, 2009

By

Cynthia Barnard MBA MSJS CPHQ

Director, Quality Strategies

Northwestern Memorial

HealthCare


Agenda
Agenda

  • Framework for PSI analysis within the hospital

    • Making Sense To Clinicians

  • Case Studies

  • Conclusions and Recommendations


Northwestern memorial healthcare
Northwestern Memorial HealthCare

  • 873-bed Nationally Recognized Academic Medical Center

  • Primary Teaching Hospital for Northwestern University since 1925

  • Nationally Ranked for Quality

  • New World-Class Facilities in 1999 and 2007

  • Aa/AA Category Bond Rating for Over 25 Years

Feinberg and Galter Pavilions

May 1, 1999

New Prentice Women’s Hospital October 20, 2007


Nmh recognized for quality and excellence
NMH Recognized for Quality and Excellence

  • Magnet Certification since 2006

  • 11 Specialties in 2009 U.S. News & World Report of Best Hospitals

  • 2005 National Quality Health Care Award

  • “Most Preferred Hospital” for 14 Years (NRC)

  • Leapfrog Group’s “Top Hospitals List” twice

  • Named to “100 Best Companies for Working Women” for 9 Years

  • “Most Wired” for 9 years

  • Among University Healthsystem Consortium Top 15 in Quality and Accountability


Quality and patient safety program
Quality and Patient Safety Program

  • Eliminate avoidable adverse events

  • Deliver evidence-based care

  • Enable the best possible outcomes


Eliminate avoidable severe adverse events avoidable severe adverse events g h i

50

2200

2000

45

1800

40

1600

35

1400

30

1200

25

1000

20

800

15

600

10

400

5

200

0

0

FY04Q2

FY04Q3

FY04Q4

FY05Q1

FY05Q2

FY05Q3

FY05Q4

FY05Q4

FY06Q1

FY06Q2

FY06Q3

FY06Q4

FY07Q1

FY07Q2

FY07Q3

FY07Q4

FY08Q1

FY08Q2

FY08Q3

FY08Q4

FY09Q1

FY09Q2

FY09Q3

Eliminate Avoidable Severe Adverse EventsAvoidable Severe Adverse Events (G,H,I)

# of Incidents Reported

Total Incidents Reported

# of Severe Harm Events

Severe Harm


Agency for healthcare research and quality ahrq
Agency for Healthcare Research and Quality (AHRQ)

  • AHRQ Quality and Patient Safety Indicators (QIs/PSIs) are measures of health care quality that make use of readily available hospital inpatient administrative data.

  • To improve the quality of healthcare, accessible and reliable indicators are needed to:

    • Flag potential problems or successes

    • Follow trends over time

    • Identify disparities across regions, communities and providers

    • Address multiple dimensions of care


Ahrq quality indicators
AHRQ – Quality Indicators

  • Inpatient Quality Indicators, 2002

    • Reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures.

  • Patient Safety Indicators (PSI), 2003

    • Reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events

    • Screen for adverse events that patients experience as a result of exposure to the health care systems

    • Target events that are likely amenable to prevention by changes at the system provider level

    • Includes 20 indicators



Example of psi specification
Example of PSI Specification

  • Iatrogenic Pneumothorax, (PSI 6)

  • Provider Level Definition (only secondary diagnosis)

  • Definition: Cases of iatrogenic pneumothorax per 1,000 discharges.

  • Numerator: Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field.

  • Denominator: All medical and surgical discharges age 18 years and older defined by specific DRGs.

  • Exclude cases: • with ICD-9-CM code of 512.1 in the principal diagnosis fiel • MDC 14 (pregnancy, childbirth, and puerperium) • with an ICD-9-CM diagnosis code of chest trauma or pleural effusion • with an ICD-9-CM procedure code of diaphragmatic surgery repair • with any code indicating thoracic surgery or lung or pleural biopsy or assigned to cardiac surgery DRGs

  • Empirical Perf: Population Rate (2003): 0.562 per 1,000 population at risk

  • Risk Adjustment: Age, sex, DRG, comorbidity categories



Nmh patient safety indicators

200.00%

Complications Of Anesthesia

Death In Low Mortality DRG

150.00%

Decubitus Ulcer

Failure To Rescue

100.00%

Foreign Body Retained

Iatrogenic Pneumothorax

50.00%

Decub

Infection Due To Medical Care

0.00%

Postoperative Hip Fracture

OB

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

Postop Hemorrhage Or Hematoma

FTR

Variance to AHRQ Empiric Value

-50.00%

Postop Physio Metabol Derangmnt

Postop Respiratory Failure

-100.00%

Postoperative Pe Or Dvt

Postoperative Sepsis

-150.00%

Postoperative Wound Dehiscence

APL

OB

PE/DVT

Accidental puncture/laceration

-200.00%

Transfusion Reaction

Birth Trauma

-250.00%

OB Trauma - Vaginal W Instrument

-300.00%

Pneumothorax

OB Trauma - Vaginal Wo Instrument

Size of bubble represents number of cases

OB Trauma - C-Section

-350.00%

NMH Patient Safety Indicators



Framework
Framework

  • Coded accurately?

  • Definition omits important clinical factors?

  • Actual clinical process problem?

    Similar approaches:

    Houchens, Elixhauser, Romano. How Often are Potential Patient Safety Events Present on Admission? Joint Commission Journal on Quality and Patient Safety, March 2008

    Henderson, et al. Clinical Validation of the AHRQ Postoperative Venous Thromboembolism Patient Safety Indicator. Joint Commission Journal on Quality and Patient Safety, July 2009


Case studies
Case Studies

CODING

  • Foreign Body Retained

  • Infection Due to Medical Care

    DEFINITION

  • Post-op Bleed

    CLINICAL IMPROVEMENT

  • Pneumothorax

  • Post-op PE / DVT



Clinical case studies iatrogenic pneumothorax post operative dvt pe
Clinical Case StudiesIatrogenic PneumothoraxPost-Operative DVT/PE


Ahrq validation study summary of ppvs preliminary estimates 2007
AHRQ Validation Study:Summary of PPVsPreliminary estimates (2007)


Ahrq validation study iatrogenic pneumothorax and outcomes n 154
AHRQ Validation Study:Iatrogenic Pneumothorax and Outcomes (N=154)*

*Check all that apply


Nmh assessment of clinical practice iatrogenic pneumothorax
NMH Assessment of Clinical Practice Iatrogenic Pneumothorax

  • Question: Was the condition preventable?

  • Variables Reviewed for Trends:

  • Procedure resulting in pneumothorax (PTX)

    • Type

    • Location

    • Physician/Service (no identifiable trend)

    • Day of the week (no identifiable trend)

    • Time of day (no identifiable trend)

  • Patient factors

    • Reason for admission

    • Age (no identifiable trend)

    • Pulmonary comorbidity (no identifiable trend)


Procedure resulting in ptx

Insufficient documentation

24%

Thoracentesis

21%

Lung surgery

15%

Central line placement

9%

Chest tube removal

9%

Back surgery

3%

Biliary drain placement

3%

Bronchoscopy/biopsy

3%

Diaphragm resection

3%

Expected pleural laceration

3%

Lung biopsy

3%

Pacemaker insertion

3%

0

1

2

3

4

5

6

7

8

Procedure Resulting in PTX

Type and Frequency of Procedure Resulting in PTX, N=33

Dincer HE, Lipchik RJ. The intricacies of pneumothorax: management depends on accurate classification.

Postgraduate Medicine, Dec 2005.


Pneumothorax interventions
Pneumothorax Interventions

  • Focus on potentially preventable PTX in thoracentesis, pacemaker, and central line procedures

  • Weekly case review by patient safety professional, MD

  • Focus: Central Line and Pacemaker placement (clinical)

    • Refreshers, simulation training (central lines), supervision

  • Focus: Correctly capturing exclusions (coding)

  • Outcome:

  • Rate has fallen from 1/week (3-4x expected) to 1-2/month (~expected)



Post operative venous thrombosis pe

Venous Thrombosis/ Pulmonary Embolism

Frequency of DVT/PE; 2007-2008(Q1-Q3)

20.0

17.4

17.3

18.0

16.0

14.3

13.9

13.7

14.0

11.9

11.9

11.5

12.0

10.6

Frequency (rate per 1000 discharges*)

10.2

9.8

10.0

8.0

6.0

4.0

2.0

0.0

NMH

Rush

UCLA

U of C

Mayo

UCSF

Loyola

Hopkins

Stanford

Brigham

Mass Gen

Post-Operative Venous Thrombosis / PE

In 2007 and 2008(Q1-Q3), approximately 17.3 patients per 1000 discharges*experienced a DVT or PE complication at NMH.

Source: UHC Clinical Database

*excludes OB Product line



Hospital dvt pe rates

NMH DVT/PE and Bleed Events (excluding OB, Peds, and Psych) Screenshot

30.0

25.0

20.0

15.0

10.0

5.0

0.0

Jan-

Feb-

Mar-

Apr-

May-

Jun-

Jul-

Aug-

Sep-

Oct-

Nov-

Dec-

Jan-

Feb-

Mar-

Apr-

May-

Jun-

Jul-

08

08

08

08

08

08

08

08

08

08

08

08

09

09

09

09

09

09

09

DVT/PE Rate per thousand

Goal

Bleed Rate per thousand

Hospital DVT/PE Rates

Protocol Implemented

Source: EPSI Coded Diagnosis Data

Excludes patients with DVT/PE Present on Admission

Bleeding Data represents patients that had a bleeding complication due to an anticoagulant


Definition case study post operative hemorrhage hematoma
Definition Case Study ScreenshotPost-Operative Hemorrhage / Hematoma


Observed and expected post op bleed rates with and without transplant calendar 2008
Observed and Expected Post-Op Bleed Rates Screenshotwith and without Transplant - Calendar 2008


Observed post op bleed rates with and without transplant calendar 2008
Observed Post-Op Bleed Rates Screenshotwith and without Transplant - Calendar 2008

  • In organizations that performed more then 300 Transplants 60% of the Organizations were in the worst 3rd for Observed Rates

    • When we exclude transplant from the Post Operative Hemorrhage and Hematoma metric, all but 2 organizations saw a rate improvement ranging from 0.19 to 4.28



Transparency accountability
Transparency, ScreenshotAccountability


Conclusions the framework works
Conclusions: The Framework Works Screenshot

  • Coding

  • Definition

  • Clinical Opportunity

  • Results:

    • Improved quality

    • Reduced harm

    • Reduced cost

    • Improved learning


Cynthia Barnard ScreenshotDirector, Quality Strategies

Northwestern Memorial Hospital

Research Assistant Professor

Institute for Healthcare Studies

Northwestern University Feinberg School of Medicine

676 St Clair #700

Chicago IL 60611

voice 312.926.4822

fax 312.926.8734

[email protected]


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