Transcript: Analyzing Your Barriers and Strategy Options

AHRQ Quality Indicators™ Toolkit for Hospitals: Interview Series
This is the transcript of an MP3 audio file, Analyzing Your Barriers and Strategy Options, one of a series of interviews will orient users to the AHRQ Quality Improvement Toolkit for Hospitals. The topics provide an overview of the toolkit and information on how to use the tools and engage stakeholders and staff in quality improvement efforts.

Speaker: Maureen Disbot, Vice President of Quality Operations and Patient Safety, Methodist Hospital Health System, Houston, Texas
Interviewer: Lise Rybowski
Date: May 2012
Audio format: Analyzing Your Barriers and Strategy Options (MP3 audio file; 11 min., 38 sec.)

Interviewer: On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to a series of interviews designed to orient and educate users of the AHRQ Quality Indicators Toolkit for hospitals. This toolkit was designed to support hospitals seeking to improve their performance on the AHRQ Inpatient Quality Indicators (IQIs) and the Patient Safety Indicators (PSIs).

Subject: Today's topic is the process of determining what to do once you've analyzed your data and identified your hospital's priorities to figure out how to bridge the gap between your hospital's current practices and best practices. The toolkit includes a Gap Analysis tool to help you with this effort. You can find it on the AHRQ Web site at To get to this tool, open the roadmap and select the tool labeled D5, Gap Analysis.

I'll be speaking today with Maureen Disbot, who is vice president of quality operations and patient safety at the Methodist Hospital Health System in Houston, Texas. Maureen is a nurse with an extensive background in performance improvement, patient safety, and clinical analytics. Thanks, Maureen, for joining me today.

Maureen: Thanks for having me, Lise.

Interviewer: I'd like to start by asking you, when you were considering the AHRQ PSIs, what approach was most helpful to your hospital team for identifying performance issues?

Maureen: Well, there could be a lot of answers to that question depending on the organization, but here at the Methodist Hospital, we're very data and outcomes driven. So when AHRQ released the Patient Safety Indicators, which I'll refer to as PSIs, this was pretty new reporting terrain for us and I'm sure for many other hospitals. I think we all had our own safety measures, but we didn't have good comparative metrics and the specifications that would allow us to benchmark ourselves at a national level.

The question that AHRQ raised for us was whether or not the discharge-coded data that we all currently use could be analyzed as a measure for patient safety in our organizations. Quite honestly, we had really not considered that data for our patient safety metrics. So we pursued the gap analysis.

The original specifications that AHRQ provided us included 18 Patient Safety Indicators. Some of those indicators include things like low-severity DRGs that result in a patient's death, catheter-related bloodstream infections, iatrogenic pneumothorax, and postoperative sepsis. Really studying the AHRQ specifications and using the gap analysis, we pursued our own internal analytics here to see if we could use those measures as useful screens as to whether or not we had more systemic safety issues in our organization.

The ability to benchmark was really meaningful for us and I think it has been a real great asset to our national efforts for patient safety, which I think is well demonstrated in the fact that this is now one of our publicly reported measures. We were quick to adopt and to study and to figure out how we could use the data that AHRQ specifies for this and, of course, use the gap analysis to see whether or not those system issues exist here at Methodist. Obviously, we were interested because in many cases things like those mentioned previously—iatrogenic pneumo, postop sepsis—might be issues that are preventable for our patients.

Once we completed our gap analysis, we looked for the PSIs that had high volume and high risk. But we also considered low-volume PSIs where we didn't have as many but potentially the risk was great for our patients. We also recognize that when these events do happen, whether preventable or not, they result in other metrics that are important to our quality, like length of stay, readmissions, and, of course, cost.

Interviewer: As I had mentioned earlier, one of the resources in the toolkit is a Gap Analysis tool that allows you to set up your own assessment of barriers and best practices. Can you tell me about how you used that tool?

Maureen: Sure. The gap analysis tool provided us with a nice framework to better understand where we might have patient safety issues and what the best practices are so that we can do something about it. It reminded us of what we need to include in our analysis, like policies and procedures, triggers for the measures, evidence-based guidelines, and, of course, measures of success. Some of these are going to be customized based on your own organization's resources, particularly related to more mature IT systems and the ability to capture data in real time and act on it.

Our gap analysis at Methodist brought the most attention to the importance of deploying meaningful information technologies that provided bedside-relevant data and the educational needs of staff and our physicians—both of which, if not done well, can create barriers to an organization's PSI improvement strategies.

I'd also like to mention that a lot of the ability to make improvements is set up by clear accountability. It's critical for the data to be accurate and timely. Before I could get the organization's attention on improvement, I had to be sure to demonstrate there was truly a problem. Our gap analysis revealed some deficiencies in the attribution of our PSIs, which is really an immediate show stopper when trying to promote change and establish accountability. So we ended up providing data weekly by physician and by service line so we could have a current memory of the patient and meaningful responses, which has made the biggest difference in our improvements. The gap analysis tool should be reviewed semiannually so that we can determine whether or not we are making progress or whether there's a need for revision.

Interviewer: Can you talk a little bit about who is involved in performing the gap analysis?
Maureen: Of course, in the performance improvement world, we are very much attached to our multidisciplinary teams. These typically include our content experts, our process improvement specialists, our operational leaders, and an analytic team that tackles the datasets. So with the AHRQ PSIs, we, for example, focused on the postoperative sepsis after completing the analysis and looked for the specific criteria that we would be sure we were modeling against the specification that AHRQ gave us. We had to be absolutely sure that the people who handled the data and the software that AHRQ provided were very facile with manipulating those datasets.

I think that was when we started to get the most attention in the organization, when we were able to put those measures of patient safety in front of our staff and our physicians and the actions were fairly easy to accomplish at that point.

Interviewer: What do you recommend that hospitals do once they have the results of the gap analysis to formulate their own improvement strategies?

Maureen: I think the analysis needs to be sure to direct the caregivers to what areas of improvement will give them the best impact for their patient population. It's really important to consider the patient volume within a specific PSI. In our hospital, as I mentioned before, we recognized that sepsis was a major problem for our patients. So we devoted a whole of time studying the causes and what can be done differently. Based on that work, we decided to go forward on automating our screening procedures for sepsis and we've employed our nurse practitioners to be our second-level screeners as well as the initiators of the sepsis protocol. I'm really happy to report that as a result of these efforts, we've realized a reduction in hospital mortality from sepsis from 36 percent to 13.4 percent since 2009.

Even though we've had great success, we still have more work to do in regards to this PSI, but it was really the attention to this PSI that helped us see the benefits of the screening process, the ability to implement the protocol timely and to save lives. Year to date, at our close of 2011, we have accrued a total of 465 lives saved over the last 3 years.

The gap analysis is not a dormant document; as I mentioned before, you have to keep referring back to it. You'll also see in the benchmark that many other organizations are doing well like us. So that benchmark keeps moving.

We had to think strategically about how to deploy a strategy without doing everything at once. Often in the performance improvement and quality and patient safety efforts, it's very easy to make projects so big that they become unwieldy. We implemented portions of our solutions to improving our sepsis and thus our overall mortality so that we could be sure which of the interventions were the highest benefit. We continue to focus on the pieces that we still want to improve and, of course, refine those that are already implemented. For sepsis we recognize, for example, that broader screening efforts for saving lives, so we're expanding our screening to the transfer patients and other surgical floors in the hospital as well as continuing to screen all patients in the ED and the ICUs.

Finally, the PSIs have become a well-known indicator of potential avoidable complications in our hospital. They are very widely published in our quality and service line meetings. Several years after our first gap analysis of the PSIs, we've made tremendous improvement in our performance and our ranking. But that really doesn't satisfy us or the patient who might leave us with a decubitus ulcer or with a pneumothorax. We work tirelessly to keep practice and policy top of mind for the safety of all of our patients.

Interviewer: Thank you so much, Maureen, for sharing your experience with us. It sounds like the gap analysis was an important step for you between identifying the performance problems and implementing these solutions that clearly have been very effective for you.

As I mentioned earlier, you can download the Gap Analysis tool from the AHRQ Quality Indicators Toolkit by going to Click on the link for the roadmap, and select the tool labeled D5, Gap Analysis. The roadmap is a great way to orient yourself to all of the tools in the toolkit.

I also suggest checking out a video recording that you can use to introduce the toolkit to quality improvement teams and other staff. You can find the video and other materials from a Webinar about the toolkit by clicking a link at the bottom of the toolkit page or by going directly to Again, this is one in a series of audio interviews about the use of specific tools in the quality improvement process, so please check the toolkit pages for additional interviews and watch for announcements from AHRQ. Thank you for listening.

Page last reviewed October 2014
Internet Citation: Transcript: Analyzing Your Barriers and Strategy Options. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.