AHRQ Patient Safety Indicators: Constructive Use for Improvement (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Cynthia Barnard made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (3.41 MB) (Plugin Software Help).


Slide 1

 Slide 1. AHRQ Patient Safety Indicators: Constructive Use for Improvement

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 

Slide 2

 Slide 2. Agenda

Agenda

  • Framework for PSI analysis within the hospital
    • Making Sense To Clinicians
  • Case Studies
  • Conclusions and Recommendations 

Slide 3

 Slide 3. Northwestern Memorial HealthCare

Northwestern Memorial HealthCare

Feinberg and Galter Pavilions
May 1, 1999
New Prentice Women's Hospital October 20, 2007 

  • 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 

Images of the Feinberg and Galter Pavilions and New Prentice Women's Hospital are shown on the left.

Slide 4

 Slide 4. 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 

Slide 5

 Slide 5. Quality and Patient Safety Program

Quality and Patient Safety Program

  • Eliminate avoidable adverse events (circled)
  • Deliver evidence-based care
  • Enable the best possible outcomes

Slide 6

Slide 6. Eliminate Avoidable Severe Adverse Events Avoidable Severe Adverse Events

Eliminate Avoidable Severe Adverse Events

Avoidable Severe Adverse Events (G,H,I)

Image of a line graph showing a timeline of the # of incidents reported and the amount of severe harm.

Slide 7

 Slide 7. 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

Slide 8

Slide 8. 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

Slide 9

Slide 9. Patient Safety Indicators

Patient Safety Indicators

Patient Safety IndicatorsPSI Number
Complications of Anesthesia1
Death in Low-Mortality DRGs2
Decubitus Ulcer3
Failure to Rescue4
Foreign Body Left During Procedure5
Iatrogenic Pneumothorax6
Selected Infections Due to Medical Care7
Postoperative Hip Fracture8
Postoperative Hemorrhage or Hematoma9
Postoperative Physiologic and Metabolic Derangements10
Postoperative Respiratory Failure11
Postoperative Pulmonary Embolism or Deep Vein Thrombosis12
Postoperative Sepsis13
Postoperative Wound Dehiscence14
Accidental Puncture or Laceration15
Transfusion Reaction16
Birth Trauma – Injury to Neonate17
Obstetric Trauma – Vaginal with Instrument18
Obstetric Trauma – Vaginal without Instrument19
Obstetric Trauma – Cesarean Delivery20

Slide 10

Slide 10. 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 

Slide 11

 Slide 11. Administrative Data for Quality Metrics

Administrative Data for Quality Metrics

AdvantagesDisadvantages
Convenient and inexpensiveIncomplete
Standardized rulesDepends on non-standardized charting, vague clinician usage, and ability to find evidence in chart
Audited (for billing purposes)Audit focus is not on clinical completeness but on DRGs
Includes diagnoses, procedures, age, gender, admission source and discharge statusExcludes important clinically influential data: DNR/palliative, clinical context, degree of severity

 Slide 12

Slide 12. NMH Patient Safety Indicators  

NMH Patient Safety Indicators
 

Image of a chart showing the number of cases of different patient safety indicators.

Slide 13

 Slide 13. Framework for PSI Use

Framework for PSI Use

Slide 14

 Slide 14. 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

Slide 15

 Slide 15. Case Studies

Case Studies

Coding

  • Foreign Body Retained
  • Infection Due to Medical Care

Definition

  • Post-op Bleed

Clinical Improvement

  • Pneumothorax
  • Post-op PE / DVT

Slide 16

 Slide 16. Framework on a Small Sample (2007)

Framework on a Small Sample (2007)

 

AHRQ PSI Coding Definition Potential Clinical Issue 
Pneumothorax5 (12%)0 (%)38 (88%)
Post-op Bleed3 (8%)10 (26%)26 (67%)
Post-op PE / DVT 12 (30%)0 (0%)28 (70%)

Slide 17

 Slide 17. Clinical Case Studies Iatrogenic Pneumothorax Post-Operative DVT/PE

Clinical Case Studies

Iatrogenic Pneumothorax Post-Operative DVT/PE

Slide 18

 Slide 18. AHRQ Validation Study: Summary of PPVs Preliminary estimates (2007)

AHRQ Validation Study: Summary of PPVs
Preliminary estimates (2007)

PSI %PPV
Accidental puncture or laceration90%
Iatrogenic pneumothorax75%
Postoperative DVT/PE72%
Postoperative sepsis42%
Selected infections due to medical care61%

Slide 19

 Slide 19. AHRQ Validation Study: Iatrogenic Pneumothorax and Outcomes (N=154)*

AHRQ Validation Study: Iatrogenic Pneumothorax and Outcomes (N=154)*

Patient Outcomes 
Treated with chest tube44.8
Discharge delay11.7
Readmitted within 30 days of discharge (generally for reasons unrelated to pneumothorax according to the abstractor)9.1
Moved to a higher level of care7.1
Tension pneumothorax6.5
None or Unable to Determine29.9

*Check all that apply.

Slide 20

Slide 20. 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)

Slide 21

 Slide 21. Procedure Resulting in PTX

Procedure Resulting in PTX

Image of a bar chart showing the following data:

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%

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.

Slide 22

 Slide 22. 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)

Slide 23

Slide 23. Interventions to Reduce Complications  

Interventions to Reduce Complications

Image of the top of a medical article titled "Use of Simulation-Based Education to Reduce Catheter-Related Bloodstream Infections".

Slide 24

 Slide 24. Post-Operative Venous Thrombosis / PE

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.
*excludes OB Product line
Source: UHC Clinical Database

Slide 25

Slide 25. New VTE Prophylaxis Protocol - Electronic Medical Record Screenshot

New VTE Prophylaxis Protocol - Electronic Medical Record Screenshot
 

Slide 26

Slide 26. Hospital DVT/PE Rates

Hospital DVT/PE Rates

Image of a line graph.

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
Protocol Implemented

Slide 27

Slide 27. Definition Case Study: Post-Operative Hemorrhage / Hematoma

Definition Case Study

Post-Operative Hemorrhage / Hematoma

Slide 28

Slide 28. Observed and Expected Post-Op Bleed Rates with and without Transplant - Calendar 2008

Observed and Expected Post-Op Bleed Rates with and without Transplant - Calendar 2008

Stratification Numerator Denominator Observed Rate/1000 Expected Rate/1000 O/E Ratio Percentile 
All eligible cases (includes Transplant)62121585.12.861.78Between the bottom 25th and 10th Percentile
Liver/kidney/pancreas transplant2236061.114.8412.62Bottom 10th Percentile
Liver transplant11104105.775.4719.34Bottom 10th Percentile
MS-DRG 5: Liver transplant w MCC or intestinal transplant766106.065.9817.73Bottom 10th Percentile
MS-DRG 6: Liver transplant w/o MCC438105.264.5823.01Bottom 10th Percentile
Kidney/pancreas transplant1125642.974.599.37Bottom 10th Percentile
MS-DRG 8: Simultaneous pancreas/kidney transplant515333.333.6591.32Bottom 10th Percentile
MS-DRG 10: Pancreas transplant11662.53.2519.2Bottom 10th Percentile
MS-DRG 652: Kidney transplant522522.224.744.69Bottom 10th Percentile
All other MS-DRGs (Excludes above Transplant MS-DRGS)40117983.392.81.21Just Below Top 25th Percentile

Slide 29

Slide 29. Observed Post-Op Bleed Rates with and without Transplant - Calendar 2008

Observed Post-Op Bleed Rates with 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

Image of a bar chart.

Slide 30

Slide 30. Conclusions / Next Steps

Conclusions / Next Steps

Slide 31

Slide 31. Transparency, Accountability

Transparency, Accountability

Screenshot images of a quality report card for Northwestern Memorial Hospital.

Slide 32

Slide 32. Conclusions: The Framework Works

Conclusions: The Framework Works

  • Coding
  • Definition
  • Clinical Opportunity
  • Results:
    • Improved quality
    • Reduced harm
    • Reduced cost
    • Improved learning

Slide 33

Slide 33. Contact  Slide

Cynthia Barnard Director, 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

cbarnard@nmh.org

Current as of December 2009
Internet Citation: AHRQ Patient Safety Indicators: Constructive Use for Improvement (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/barnard/index.html