Putting the Tools to Use: One Hospital's Experiences

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Slide 1

Putting the Tools to Use: One Hospital's Experiences

Donna Farley, PhD—RAND
Ellen Robinson, PT ATC—Harborview Medical Center

Slide 2

Format for This Discussion

• Goals of the discussion:
  • Highlight how groups of tools apply at different steps of an improvement process.
  • Offer opportunity for audience questions as each group of tools is discussed.
• Three groups of tools to be addressed:
  • Work with data for the Patient Safety Indicators (PSIs) and IQIs.
  • Diagnose issues and develop strategies.
  • Implement improvement plans.

Slide 3

Structure of the Toolkit

Introduction and Roadmap:

A. Readiness to Change.
B. Applying QIs to the Hospital Data.
C. Identifying Priorities for Quality Improvement.
D. Implementation Methods.
E. Monitoring Progress and Sustainability of Improvements.
F.  Return-on-Investment Analysis.
G. Existing Quality Improvement Resources.

Slide 4

Working with PSIs and IQIs

Introduction and Roadmap:

A. Readiness to Change.
B. Applying QIs to the Hospital Data.
C. Identifying Priorities for Quality Improvement.
D. Implementation Methods.
E. Monitoring Progress and Sustainability of Improvements.
F.  Return-on-Investment Analysis.
G. Existing Quality Improvement Resources.

Slide 5

Tools for Working With the PSIs and IQIs

A.1. Fact sheets on the PSIs and IQIs.
A.2. Template Powerpoint presentations on the Quality Indicators for Board or staff.
B.1. Applying PSIs and IQIs to hospital data.
B.2. Examples of AHRQ software outputs.
B.3. Spreadsheets and presentations of hospital rates for PSIs and IQIs.
B.4. Documentation and coding guidance.
B.5. Assessing hospital rates using trends and benchmarks.

Slide 6

Harborview's Project Goals

• Internal Reporting:
  • Utilize the AHRQ software to identify cases of possible preventable harm.
  • Standardize case referral across all teams in the hospital.
• External Reporting:
  • Understand and validate publicly reported rates of hospital performance.

Slide 7

Readiness for Change

• Medical Director—previous director of QI Dept.
• Leadership support and directive for project.
• The Board was "on board".
• Challenges identified: information dissemination about quality and patient safety to staff at all levels of the organization.

Slide 8

Applying your Data

• Input data challenges
  • Format billing system export into a file format that can run through the AHRQ software.
• Output data challenges
  • Validate rates against external source to ensure capture of all cases.
  • Software versions (currently 4.3) and format (SAS vs. Windows).

AHRQ Software is free and easy to download, but each hospitals' source system may be slightly different.

Slide 9

Sharing your Data

• Surgical Council, Medical Executive Board, Critical Care Council, Hospital Board, Clinical Documentation Specialists, Health Information Management:
  • What are the PSIs? Why do we care?
  • Current performance/UHC ranking.
  • How are we going to review cases and expectations from the medical teams.
  • Possible opportunities for improvement.

Slide 10

Documentation and Coding

• Specifications for each PSI and common challenges for "false positives".
• Recognize limitations of administrative data, but also recognize the potential.
• Partnerships with clinical documentation programs and coding department are critical to success of the project.

Slide 11

Questions?

Slide 12

Diagnose Issues and Develop Strategies

Introduction and Roadmap:

A. Readiness to Change.
B. Applying QIs to the Hospital Data.
C. Identifying Priorities for Quality Improvement.
D. Implementation Methods.
E. Monitoring Progress and Sustainability of Improvements.
F.  Return-on-Investment Analysis.
G. Existing Quality Improvement Resources.

Slide 13

Tools to Assess Readiness, Priorities, Strategies

A.3 Getting ready for change self-assessment
     – Readiness for quality improvement.
     – Readiness to work with the QIs.
C.1 Prioritization matrix.
C.2 Example of completed matrix.
D.1 Improvement methods overview.
D.2 Project charter.
D.3 Examples of effective PSI improvements.
D.4 Best practices for PSI improvements.
D.5 Gap Analysis.
F.1 Return-on-investment analysis.

Slide 14

Tools to Assess Readiness, Priorities, Strategies

A.3 Getting ready for change self-assessment
      – Readiness for quality improvement.
      – Readiness to work with the QIs.
C.1 Prioritization matrix.
C.2 Example of completed matrix.
D.1 Improvement methods overview.
D.2 Project charter.
D.3 Examples of effective PSI improvements.
D.4 Best practices for PSI improvements.
D.5 Gap Analysis.
F.1 Return-on-investment analysis.

Slide 15

Factors Addressed in the Prioritization Matrix

• An important decision-support tool.
• Considers factors that influence choice of improvement priorities
  • Benchmarks
  • Costs
  • Strategic alignment.
  • Regulation
  • Barriers to implementation.

Slide 16

Role of a Return-on-Investment Analysis (ROI)

• A useful tool for assessments:
  • Planning phase—estimate potential effects on hospital finances.
  • Post-implementation—estimate actual effects on hospital finances.
• The tool provides instructions for performing an ROI and an example.

Slide 17

Prioritization Matrix

Tool allows you to compare to a like group for benchmarking, identify areas that are highest impact, assess barriers.

Image: Sample matrix is shown with list of PSIs/IQIs, annual rate per 100, NQF rate per 1,000, AHRQ target rate per 1,000, UHC median rate per 1,000, volume of cases at risk, cost of single event, total cost, and ratings related to cost and ease of implementation.

Slide 18

Return on Investment

• Currently partnering with our Decision Support/Finance teams to identify a meaningful reporting metric.
• "Costs" of PSI events vary in the literature so makes it difficult to have a "target".

Slide 19

Questions?

Slide 20

Implement Improvement Plans

Introduction and Roadmap:

A. Readiness to Change.
B. Applying QIs to the Hospital Data.
C. Identifying Priorities for Quality Improvement.
D. Implementation Methods.
E. Monitoring Progress and Sustainability of Improvements.
F. Return-on-Investment Analysis.
G. Existing Quality Improvement Resources.

Slide 21

Tools to Help Make Improvements Happen

D.6 Implementation planning.
D.7 Implementation measurement.
D.8 Project evaluation and debriefing.
E.1 Monitoring progress for sustainable improvement.
F.1 Return-on-investment analysis.

Slide 22

Tools to Help Make Improvements Happen

D.6 Implementation planning.
D.7 Implementation measurement.
D.8 Project evaluation and debriefing.
E.1 Monitoring progress for sustainable improvement.
F.1 Return-on-investment analysis.

Slide 23

Monitoring for Sustainable Improvement

• For use after completion of an improvement initiative.
• Focus on sustainability.
• Guidance for monitoring system:
  • A limited set of effective measures.
  • Schedule for regular reporting.
  • Report formats to communicate clearly.
  • Procedures to act on problems found.
  • Periodic assessment of sustainability.

Slide 24

A Project Management "Toolkit"

• Useful tools for clinicians who may not have as much experience with project management.
• Selected Best Practices.
• Assisted with development of "task forces" in our selected PSI areas.
• Kept teams focused and on track during early stages of the implementation.

Slide 25

Monthly PSI Case Review

Image: Flowchart shows monthly data feed to AHRQ, leading to QI analysis, which leads to two options: No event, no coding issue or coding or documentation issue. Coding or documentation issue leads to documentation coding review. That leads to Agree? (Wrong code or exclusion criteria code missing), which leads to Update coding. Agree? Box also leads to another box, Real Event?, which leads to Service Review. Service Review has two possible outcomes, QI concerns or no QI concerns.

Slide 26

Monitoring and Sustainability

Image: Screenshot of a database page showing various fields used for case analysis and tracking of outcomes: first name, last name, admit date, discharge date, event information such as source, description (e.g., PSI number), event date, finding; and referral information such as contact ID, sent date, reason for sending, response date, type (e.g., case review), and response description.

Slide 27

Ongoing Reporting

Image: Bar chart showing example of Web-based reporting on Harborview Intranet. Chart shows number of AHRQ patient safety events and harm event categories for fiscal years 2009 through 2012. Categories include DVT/PE (deep vein thrombosis or pulmonary embolism), accidental puncture, ARF (elective), post op hematoma, CLABSI (central-line associated blood stream infections), iatrogenic pneumothorax, and pressure ulcer. For example, pressure ulcers go from 26 in fiscal year 2009 to 1 in fiscal year 2012.

Slide 28

Lessons Learned

• Validate, Validate, Validate.
• Understand details of the specifications and be able to apply to your population.
• Leadership backing for project importance.
• Presentations to clinical staff should begin with real case examples.
• Coding lead liaison is critical.

Slide 29

Harborview MC Outcomes

• Standardized Case Review—2011.
• PSI 3,6,7,9,11,12,15:
  • 45% no quality concerns.
  • 18% teams identified possible QI system opportunities.
  • 25% related to documentation/coding.
  • 12% "flawed metric".
• PSI 11 flagged in a planned two stage surgery.
• PSI 9 flag related to intra-operative bleeding.

Slide 30

Hospital Challenges

• AHRQ Software is one tool to assist with identification of improvement opportunities.
• As Health Care IT becomes more sophisticated, hospitals have more data.
• Challenge ourselves to be creative and identify clinical systems to provide additional sources for events.
• How do we find the "false negatives?"

Slide 31

VTE Events from Exams vs. PSI 12

• Jan to Dec 2011: HAC—VTE Events.
• 70% also identified by AHRQ PSI 12.
• 30% flagged by diagnostic systems:
  • Not identified in administrative data (not coded, not in top 24 diagnosis, or "POA" = Y).
  • Did not have an operative procedure, so not included in the denominator for PSI 12.

Without our internal clinical event search tool, these cases would be missed QI opportunities.

Slide 32

AHRQ QI Toolkit

• Allowed our hospital to translate from rate-based tracking to one that provides an opportunity for real changes for patients.
• Hospitals can use the QIs to analyze "gaps" in current clinical care.
• Toolkit can assist with "what to do" about areas of opportunity you identify.

Download the toolkit at: http://www.ahrq.gov/qual/qitoolkit.

Slide 33

Questions?

Slide 34

Getting More Information

• Where can I find the Toolkit?
  http://www.ahrq.gov/qual/qitoolkit
• Can other people hear this presentation later?
  Yes, a video of this Webinar will be available on the Toolkit page.
• Will I be able to learn more about the Toolkit?
  Yes, audio interviews about specific tools will be added to the Toolkit page.