Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford

Slide Presentation from the AHRQ 2009 Annual Conferenc

On September 14, 2009, John M. Morton made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (5.92 MB) (Plugin Software Help).

Slide 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

Slide 2

"To Err is Human"

STANFORD
BOARD
DIRECTIVE

A number of images are shown.

• Measuring Patient Safety cover
• The Joint Commission logo,
• AHRQ - Agency for Healthcare Research and Quality logo
• U.s. Department of Health and Human Services logo

Slide 3

Administrative Data

• Financial
• Clinical Input
• Goethe
  • " You search where there is light"

Slide 4

Administrative Data

• Consistent
• Benchmark
• Prioritize
• Variance

Slide 5

Department of Surgery Quality Plan Preview

• Imperative from SHC Board
• Areas of Focus
• Measurement
• Goals
• Communication
• Education
• Accountability
• Leadership

Slide 6

Clinicians in Quality Improvement - A New Career Pathway in Academic Medicine

A table of the types of Health Care Quality Activities and Their Potential Academic Merit is shown.

Slide 7

Screen Shot of Stanford Hospital and Clinics

Slide 8

PSIs: Quality Diagnostic Tool

Slide 9

2007 Quality Improvement and Patient Safety Scorecard

Slide 10

Top Priority PI Action Plans

Slide 11

UHC DVT/PE Measure

A graph of the Post Operative DVT or PE is shown.

Slide 12

Incidence of DVT/PE by DRG

A graph of the Incidence of DVT/PE by DRG is shown

Slide 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

Slide 14

Radiology DVT/PE Report

An image of the Radiology DVT/PE Report is shown.

Slide 15

DVT/PE Risk Assessment in Epic

A screen shot of the DVT/PE Risk Assessment in Epic is shown.

Slide 16

Retrospective Surgical Audit (? radiology test)

Accordance of Ordered Drug Agent, Dose & Frequency to Patients Risk Level and SHC Guidelines (N=17) (Aug-Oct 08)

• Drug Agent: 0.88
• Drug Dose: 0.88
• Drug Administration Frequency: 0.88

Slide 17

Retrospective Surgical Audit

MD Order for Postoperative Drug Prophylaxis and Receipt of 1st Drug Dose within 24 Hours of Surgery (N=17)

• MD Order w/in 24 hrs of Surgery 0.71
• Receipt of 1st dose w/in 24 hrs of Surgery 0.53

Slide 18

Action Plan for DVT/PE

REAL-TIME Assessment
DVT/PE Concurrent Review By Action Team

Slide 19

DVT/PE Rates with SCIP VTE Compliance Comparison by Quarter

Slide 20

Incidence of Medical and Surgical Cases

A graph of the Incidence of Medical and Surgical Cases is shown.

ANALYSIS: The incidence of hospital-acquired DVT/PE of both medical and surgical cases decreased in Qtr 3 2008.

• First quarter 2008 rate 8.37/1000
• Second quarter 2008 rate 14.28/1000
• Third quarter 2008 rate 8.59/1000

ACTION: Retrospective auditing of cases identified by? radiology test is being conducted to assess adherence to guidelines. Process for this is under consideration to move to a concurrent audit to improve patient care and outcomes.

Slide 21

UHC Benchmark: IAP

A graph of the UHC Benchmark: IAP is shown.

Slide 22

CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases

A graph of the CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases is shown.

• Next steps: focus on other causes of IAP: thorascopic lung biopsy, feeding tube placement and EP procedures

Slide 23

CVC Insertion Site

Two graphs are shown.

• Insertion Site of CVC-Related latrogenic Pneumothoraces in Medical Patients
• Insertion Site of CVC-Related latrogenic Pneumothoraces in Surgical Patients

Slide 24

Action Plan

GOAL: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08.

Slide 25

Two publications are shown.

• Prevention of latrogenic Pheumothorax from Central Line Insertion
• Documenting the CVC Procedure Note is Required

Slide 26

PSI: Surviving Sepsis Guidelines

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

Slide 27

Performance Improvement Initiative: Severe Sepsis and Septic Shock

• 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.

Slide 28

Two publications are shown.

• SHC Critical Care Management Guidlines for Severe Sepsis and Septic Shock
• Critical Care Management Guidlines for Severe Sepsis and Septic Shock

Slide 29

Screen shot - Order Set

Slide 30

Audit of Process Indicators

ANALYSIS: .25% of cases received antibiotics within one hour of identification. Appropriate antibiotics were given in nearly all of the cases. In 40% of the cases, antibiotic were given >120 minutes, in 60% antibiotics were given within 64 minutes on average.

ACTION: Measure process indicators in context of when SS/SS management guideline algorithm started. Map process to determine areas for improvement.

Slide 31

Audit of Process Measures

ANALYSIS: Poor compliance in ordering steroids for cases failing therapy. Steroids were given only 25% of the time. Glucose control was reached in 65% of the cases. Of the 35% of cases with BG > 150, mean BG was 176

ACTION: Educate physicians to document rationale for not giving steroids in next quarterly audit. Work with ICU team, nursing groups to determine root causes for elevated BG>150 after 24 hrs.

Slide 32

Two photos are show. One of a building and the other is 5 Doctors in an operating room.

Slide 33

An image of a chart labeled "Departmental Quality Structure" is shown

Slide 34

An image of "Specific Responsibilities the PPEC is designated to" is shown.

Slide 35

PPEC: Accountable Outcomes

An image of "PPEC: Accountable Outcomes" is shown.

Slide 36

PPEC: Accountable Outcomes SCIP

An image of "PPEC: Accountable Outcomes SCIP" is shown.

Slide 37

PPEC: Accountable Outcomes PSIs

An image of "PPEC: Accountable Outcomes PSIs" is shown.

Slide 38

Use of PSI in PPEC: Post-op Hematoma

An image of "Use of PSI in PPEC: Post-op Hematoma" is shown.

Slide 39

Use of PSI in PPEC: Accidental Puncture or Laceration

An image of "Use of PSI in PPEC: Accidental Puncture or Laceration" is shown.

Slide 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

Slide 41

HAWTHORNE EFFECT

An image of a character with text saying "He's Watching you" is shown.

Slide 42

National PSI Rates Morton 2009

A graph Decubitus, Sepsis, Postop Resp, PE/DVT

Slide 43

Clinical Outcomes Report: Product Line Mortality Comparison October 2006 - September 2007

175 Surgical Deaths, Dept of Surgery 71, 2.1%
SF=110, Oakland=140

An image of the "Clinical Outcomes Report" is shown.

Slide 44

General Surgery

Slide 45

An image of a building is shown.