Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford

Slide Presentation from the AHRQ 2009 Annual Conferenc

Slide presentation from the AHRQ 2009 conference.

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

GoalsActions
DVT/PE: Reduce the rate of DVT & PE by 25% by December 2008.
  • Increase Monitoring
  • Provide Feedback to Physicians
  • Improve Compliance to order sets
Sepsis: Reduce hospital mortality of severe sepsis & septic shock from 50% to 40% by Jan 09
  • Update Sepsis Guidelines
  • Implement processes for early identification of sepsis and aggressive treatment
  • Establish ICU/ED task force and spread learning
IAP: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08
  • Promote ultrasound-guided internal jugular (IJ) catheterization as the method of choice for CVC
  • Require all medical & surgical interns to complete CVC Website Curriculum & Simulation Program during orientation
  • Require that the first 5 CVCs by a house staff member be supervised by a more senior physician who has successfully inserted & documented the placement of 5 CVCs

 

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

ActionAgentsTimeline
Monitor concurrent MD ordering practices of DVT prophylaxis & educate/reinforce Epic order sets.Quality Specialist to audit 10 charts/wk of General & Ortho Surgery pts & educate MDs.Begin Feb 1
Review concurrent DVT/PE cases for adherence to DVT prophylaxis guidelines monthly.Quality Specialist to perform audit based on monthly report of + radiology tests.Feb 18
Examine & present results from concurrent monitoring & audit & NSQIP data to providers.P. Pilotin & K. Bashaw to discuss results with Chairs of General & Orthopedic Surgery.Feb 25
Educate physicians to DVT guidelines and order sets.P. Pilotin to develop/distribute materials of DVT guidelines & screen shots of Epic DVT order set. Feb 15
Establish rules & rates for DVT/PE cases for individual MD profiles.Quality Dept to establish rules & rates in Midas.March 31
Refine DVT prophylaxis guidelines for medical patients.K. Posley to review/revise guidelines.Feb 1

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.

ActionAgentTimeline

Promote ultrasound-guided internal jugular (IJ) catheterization as the method of choice for CVC

Limit use of subclavian approach to:

  • Access to the neck is limited (e.g., trauma/code resuscitations)
  • Patients with suspected neck injuries
  • Lack of other available sites
  • L. Shieh to revise CVC Website Curriculum & Simulation Program to further promote IJ approach
  • Drs. Maggio, Williams, Mihm & Lee to educate ED, OR & General Surgery. Drs. Mihm, Riskin and Daniels to educate ICU. Dr. Shieh to educate B2 & D1.
  • I. Tokareva to develop & distribute educational materials to reinforce
Start Jan 22 & ongoing
Require all medical & surgical interns to complete CVC Website Curriculum & Simulation Program during orientation (“Bootcamp” for surgical interns)
  • Drs. Shieh, Maggio, Williams, Mihm & Lee
  • Monitor quarterly IAP rates for impact
June 30

 

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

Product Line20062007July 2007 to June 2008
General Surgery Product Line0.830.790.56
Stanford0.970.950.82

 

Slide 45

An image of a building is shown. 

Current as of December 2009
Internet Citation: Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford : Slide Presentation from the AHRQ 2009 Annual Conferenc. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/morton/index.html