Utilizing the Patient Safety Indicators for Improvement (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 19, 2009, Anita Gottlieb made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (450 KB) (Plugin Software Help).

Slide 1

Slide 1. Utilizing the Patient Safety Indicators for Improvement

Utilizing the Patient Safety Indicators for Improvement

Anita Gottlieb, MA, APN, CPHQ

St. Joseph's Mercy Health System

Hot Springs, Arkansas

Slide 2

Slide 2. A quote from Vincent Van Gogh is displayed along with one of his paintings.

"Great things are not done by impulse, but by a series of small things brought together"

- Vincent Van Gogh


Slide 3

Slide 3. The process: Beginning Steps

The process: Beginning Steps

  • January 2005 began reviewing PSI indicators using an interdisciplinary team
  • Leadership focused on data:
    • Quality Committee of the Board, Hospital Board and System Board
  • Focused on areas where we exceeded the AHRQ population rate as areas for improvement


Slide 4

Slide 4. PSI Data - January 2005

PSI Data - January 2005

IndicatorAHRQ RateFacility RateNumerator CasesDenominator Cases
PSI-03: Decubitus Ulcer25.7533.8012355
PSI-11: Post-op Respiratory Failure4.2943.015147
PSI-13: Postop Sepsis11.820.83148


Slide 5

Slide 5. PSI - 03: Decubitus Ulcer

PSI - 03: Decubitus Ulcer


Slide 6

Slide 6. PSI - 03: Decubitus Ulcer

PSI - 03: Decubitus Ulcer

  • Reviewed all cases listed in PSI for Decubitius Ulcer and found that present on admissions were not excluded especially for nursing home patients
  • Even with exclusion of present on admission we still frequently exceeded the AHRQ rate

Improvement Plan

  • Six Sigma Project
  • Clinical Skin Team


Slide 7

Slide 7. Lowdown on Skin

"Lowdown on Skin"

  • Projects purpose: Prevent Nosocomial Decubitus Ulcers
  • Nosocomial Decubitus Ulcers patients have a longer length of stay than those patients that do not acquire a Decubitus Ulcer while hospitalized
  • Length of Stay was the common Metric
    • Medicare's Geometric Length of Stay for each DRG was the standard that we used to compare both the Ulcer Group and the Non-Ulcer Group


Slide 8

Slide 8. Low Down on Skin - Six Sigma Project

This information from the Six Sigma project demonstrates in the first graph the risk for pressure ulcer in the patients. The second graph represents whether the daily assessment was done on those identified at risk. DMAIC (Define, Measure, Assess, Improve and Control)  was utilized for the project and the I – improve phase is where we have really placed emphasis.


Slide 9

Slide 9. Before and After Pilot Comparison

Before & After Pilot Comparison

By using the Braden Scale, we compared the "Gold" Standard auditor's scores to how the RN's rated the Patients. We noted a significant improvement with the changes we implemented.

29% Improvement in Accuracy of the Braden Scale


Slide 10

Slide 10. Improvement strategy

Improvement strategy

The template presents in detail the action steps to support the reduction in pressure ulcers bases on the me . It is very specific and measurable. These have been implemented and the project has gone house wide.

Slide 11

Slide 11. What are the Financial Results?

What are the Financial Results?

  • There cost reduction after the Six Sigma project and it was directly associated with the length of stay.
  • The reductions relates to both direct cost and supplies.


Slide 12

Slide 12. Prevalence


To further exemplify our improvement in this area the data for our 2009 Prevalence study conducted by KCI is included. This slide list our facilities prevalence from 2005 until 2009 and demonstrates a reduction in facility acquired pressure ulcers. hospital. All  patients were assessed on day one and 3 day three of the study.

Slide 13

Slide 13. PSI - 11: Post Operative Respiratory Failure

PSI - 11: Post Operative Respiratory Failure


Slide 14

Slide 14. PSI - 11: Post Operative Respiratory Failure

PSI - 11: Post Operative Respiratory Failure

  • Reviewed all cases listed in PSI for Respiratory Failure
  • Definition of respiratory varied per physician
  • Coders were given exclusion PSI criteria and implemented use of documents Review Specialist for querying the physicians
  • Education provided to physicians regarding definitions of Respiratory Failure


Slide 15

Slide 15. PSI-13: Postop Sepsis

PSI-13: Postop Sepsis


Slide 16

Slide 16. PSI-13: Postop Sepsis

PSI-13: Postop Sepsis

  • Reviewed all cases and diagnosis for sepsis were not meeting the "Surviving Sepsis Campaign" definition and guidelines
    • Our facilities rate for Sepsis over all was greater than other hospitals in our System
    • Determined some of "Sepsis" cases were being admitted to the acute units - not ICU

Previous Sepsis Six Sigma Project on Sepsis had been focused on Length of Stay


Slide 17

Slide 17. Hot Springs Six Sigma Sepsis LOS

Hot Springs Six Sigma Sepsis LOS

  • Solutions
    • Standardized processes for referral and evaluation for transfer to SNF/LTAC/Hospice
    • Implemented providing antibiotics within three hours
    • Removed barrier to tubing blood cultures and implemented tracking of times
  • Impact
    • Reduced LOS by .92 days
    • Improved time for blood cultures to lab by 126 minutes
    • Potential financial benefit - X $


Slide 18

Slide 18. PSI Data - January2009/ 2005

PSI Data - January2009/ 2005

IndicatorAARQ 2009Facility 2009Numerator Cases (09/05)Denominator Cases (09/05)
PSI-03: Decubitus Ulcer25.111.874 (12)337 (355)
PSI-11: Post-op Respiratory Failure9.0223.811 (5)42 (147)
PSI-13: Postop Sepsis11.4462.501 (1) 16 (48)


Slide 19

Slide 19. Lessons Learned

Lessons Learned

  • Work on "Present on Admission" prior to October 2008 was impactful
  • Six Sigma tools have impacted positively on cost savings and quality of care
  • Must take small steps - it will take time and must continue monitoring to sustain


Slide 20

Slide 20. Questions


"One's destination is never a place but rather a new way of looking at things."

- Henry Miller

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