AHRQ Patient Safety Indicators: Constructive Use for Improvement (Text Version)

On September 15, 2009, Cynthia Barnard made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (3.41 MB).

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AHRQ Patient Safety Indicators: Constructive Use for Improvement

Presented to
AHRQ Annual Conference

September 15, 2009

By
Cynthia Barnard MBA MSJS CPHQ
Director, Quality Strategies

Northwestern Memorial HealthCare 

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Agenda

• Framework for PSI analysis within the hospital
  • Making Sense To Clinicians
• Case Studies
• Conclusions and Recommendations 

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Northwestern Memorial HealthCare

Feinberg and Galter Pavilions
May 1, 1999
New Prentice Women's Hospital October 20, 2007 

• 873-bed Nationally Recognized Academic Medical Center
• Primary Teaching Hospital for Northwestern University since 1925
• Nationally Ranked for Quality
• New World-Class Facilities in 1999 and 2007
• Aa/AA Category Bond Rating for Over 25 Years 

Images of the Feinberg and Galter Pavilions and New Prentice Women's Hospital are shown on the left.

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NMH Recognized for Quality and Excellence

• Magnet Certification since 2006
• 11 Specialties in 2009 U.S. News & World Report of Best Hospitals
• 2005 National Quality Health Care Award
• "Most Preferred Hospital" for 14 Years (NRC)
• Leapfrog Group's "Top Hospitals List" twice
• Named to "100 Best Companies for Working Women" for 9 Years
• "Most Wired" for 9 years
• Among University Healthsystem Consortium Top 15 in Quality and Accountability 

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Quality and Patient Safety Program

• Eliminate avoidable adverse events (circled)
• Deliver evidence-based care
• Enable the best possible outcomes

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Eliminate Avoidable Severe Adverse Events

Avoidable Severe Adverse Events (G,H,I)

Image of a line graph showing a timeline of the # of incidents reported and the amount of severe harm.

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Agency for Healthcare Research and Quality (AHRQ)

• AHRQ Quality and Patient Safety Indicators (QIs/PSIs) are measures of health care quality that make use of readily available hospital inpatient administrative data.
• To improve the quality of healthcare, accessible and reliable indicators are needed to:
  • Flag potential problems or successes
  • Follow trends over time
  • Identify disparities across regions, communities and providers
  • Address multiple dimensions of care

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AHRQ - Quality Indicators

• Inpatient Quality Indicators, 2002
  • Reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures.
• Patient Safety Indicators (PSI), 2003
  • Reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events
  • Screen for adverse events that patients experience as a result of exposure to the health care systems
  • Target events that are likely amenable to prevention by changes at the system provider level
  • Includes 20 indicators

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Patient Safety Indicators

Patient Safety Indicators	PSI Number
Complications of Anesthesia	1
Death in Low-Mortality DRGs	2
Decubitus Ulcer	3
Failure to Rescue	4
Foreign Body Left During Procedure	5
Iatrogenic Pneumothorax	6
Selected Infections Due to Medical Care	7
Postoperative Hip Fracture	8
Postoperative Hemorrhage or Hematoma	9
Postoperative Physiologic and Metabolic Derangements	10
Postoperative Respiratory Failure	11
Postoperative Pulmonary Embolism or Deep Vein Thrombosis	12
Postoperative Sepsis	13
Postoperative Wound Dehiscence	14
Accidental Puncture or Laceration	15
Transfusion Reaction	16
Birth Trauma – Injury to Neonate	17
Obstetric Trauma – Vaginal with Instrument	18
Obstetric Trauma – Vaginal without Instrument	19
Obstetric Trauma – Cesarean Delivery	20

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Example of PSI Specification

• Iatrogenic Pneumothorax, (PSI 6)
• Provider Level Definition (only secondary diagnosis)
• Definition: Cases of iatrogenic pneumothorax per 1,000 discharges.
• Numerator: Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field.
• Denominator: All medical and surgical discharges age 18 years and older defined by specific DRGs.
• Exclude cases: . with ICD-9-CM code of 512.1 in the principal diagnosis fiel . MDC 14 (pregnancy, childbirth, and puerperium) . with an ICD-9-CM diagnosis code of chest trauma or pleural effusion . with an ICD-9-CM procedure code of diaphragmatic surgery repair . with any code indicating thoracic surgery or lung or pleural biopsy or assigned to cardiac surgery DRGs
• Empirical Perf: Population Rate (2003): 0.562 per 1,000 population at risk
• Risk Adjustment: Age, sex, DRG, comorbidity categories 

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Administrative Data for Quality Metrics

Advantages	Disadvantages
Convenient and inexpensive	Incomplete
Standardized rules	Depends on non-standardized charting, vague clinician usage, and ability to find evidence in chart
Audited (for billing purposes)	Audit focus is not on clinical completeness but on DRGs
Includes diagnoses, procedures, age, gender, admission source and discharge status	Excludes important clinically influential data: DNR/palliative, clinical context, degree of severity

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NMH Patient Safety Indicators
 

Image of a chart showing the number of cases of different patient safety indicators.

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Framework for PSI Use

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Framework

• Coded accurately?
• Definition omits important clinical factors?
• Actual clinical process problem?

Similar approaches:
Houchens, Elixhauser, Romano. How Often are Potential Patient Safety Events Present on Admission? Joint Commission Journal on Quality and Patient Safety, March 2008
Henderson, et al. Clinical Validation of the AHRQ Postoperative Venous Thromboembolism Patient Safety Indicator. Joint Commission Journal on Quality and Patient Safety, July 2009

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Case Studies

Coding

• Foreign Body Retained
• Infection Due to Medical Care

Definition

• Post-op Bleed

Clinical Improvement

• Pneumothorax
• Post-op PE / DVT

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Framework on a Small Sample (2007)

 

AHRQ PSI	Coding	Definition	Potential Clinical Issue
Pneumothorax	5 (12%)	0 (%)	38 (88%)
Post-op Bleed	3 (8%)	10 (26%)	26 (67%)
Post-op PE / DVT	12 (30%)	0 (0%)	28 (70%)

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Clinical Case Studies

Iatrogenic Pneumothorax Post-Operative DVT/PE

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AHRQ Validation Study: Summary of PPVs
Preliminary estimates (2007)

PSI	%PPV
Accidental puncture or laceration	90%
Iatrogenic pneumothorax	75%
Postoperative DVT/PE	72%
Postoperative sepsis	42%
Selected infections due to medical care	61%

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AHRQ Validation Study: Iatrogenic Pneumothorax and Outcomes (N=154)*

Patient Outcomes	%
Treated with chest tube	44.8
Discharge delay	11.7
Readmitted within 30 days of discharge (generally for reasons unrelated to pneumothorax according to the abstractor)	9.1
Moved to a higher level of care	7.1
Tension pneumothorax	6.5
None or Unable to Determine	29.9

*Check all that apply.

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NMH Assessment of Clinical Practice
Iatrogenic Pneumothorax

Question: Was the condition preventable?
Variables Reviewed for Trends:

• Procedure resulting in pneumothorax (PTX)
  • Type
  • Location
  • Physician/Service (no identifiable trend)
  • Day of the week (no identifiable trend)
  • Time of day (no identifiable trend)
• Patient factors
  • Reason for admission
  • Age (no identifiable trend)
  • Pulmonary comorbidity (no identifiable trend)

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Procedure Resulting in PTX

Image of a bar chart showing the following data:

Insufficient documentation: 24%
Thoracentesis: 21%
Lung surgery: 15%
Central line placement: 9%
Chest tube removal: 9%
Back surgery: 3%
Biliary drain placement: 3%
Bronchoscopy/biopsy: 3%
Diaphragm resection: 3%
Expected pleural laceration: 3%
Lung biopsy: 3%
Pacemaker insertion: 3%

Type and Frequency of Procedure Resulting in PTX, N=33
Dincer HE, Lipchik RJ. The intricacies of pneumothorax: management depends on accurate classification.
Postgraduate Medicine, Dec 2005.

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Pneumothorax Interventions

• Focus on potentially preventable PTX in thoracentesis, pacemaker, and central line procedures
• Weekly case review by patient safety professional, MD
• Focus: Central Line and Pacemaker placement (clinical)
  • Refreshers, simulation training (central lines), supervision
• Focus: Correctly capturing exclusions (coding)
• Outcome: Rate has fallen from 1/week (3-4x expected) to 1-2/month (~expected)

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Interventions to Reduce Complications

Image of the top of a medical article titled "Use of Simulation-Based Education to Reduce Catheter-Related Bloodstream Infections".

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Post-Operative Venous Thrombosis / PE

In 2007 and 2008(Q1-Q3), approximately 17.3 patients per 1000 discharges*.experienced a DVT or PE complication at NMH.
*excludes OB Product line
Source: UHC Clinical Database

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New VTE Prophylaxis Protocol - Electronic Medical Record Screenshot
 

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Hospital DVT/PE Rates

Image of a line graph.

Source: EPSI Coded Diagnosis Data
Excludes patients with DVT/PE Present on Admission
Bleeding Data represents patients that had a bleeding complication due to an anticoagulant
Protocol Implemented

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Definition Case Study

Post-Operative Hemorrhage / Hematoma

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Observed and Expected Post-Op Bleed Rates with and without Transplant - Calendar 2008

Stratification	Numerator	Denominator	Observed Rate/1000	Expected Rate/1000	O/E Ratio	Percentile
All eligible cases (includes Transplant)	62	12158	5.1	2.86	1.78	Between the bottom 25th and 10th Percentile
Liver/kidney/pancreas transplant	22	360	61.11	4.84	12.62	Bottom 10th Percentile
Liver transplant	11	104	105.77	5.47	19.34	Bottom 10th Percentile
MS-DRG 5: Liver transplant w MCC or intestinal transplant	7	66	106.06	5.98	17.73	Bottom 10th Percentile
MS-DRG 6: Liver transplant w/o MCC	4	38	105.26	4.58	23.01	Bottom 10th Percentile
Kidney/pancreas transplant	11	256	42.97	4.59	9.37	Bottom 10th Percentile
MS-DRG 8: Simultaneous pancreas/kidney transplant	5	15	333.33	3.65	91.32	Bottom 10th Percentile
MS-DRG 10: Pancreas transplant	1	16	62.5	3.25	19.2	Bottom 10th Percentile
MS-DRG 652: Kidney transplant	5	225	22.22	4.74	4.69	Bottom 10th Percentile
All other MS-DRGs (Excludes above Transplant MS-DRGS)	40	11798	3.39	2.8	1.21	Just Below Top 25th Percentile

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Observed Post-Op Bleed Rates with and without Transplant - Calendar 2008

• In organizations that performed more then 300 Transplants 60% of the Organizations were in the worst 3rd for Observed Rates
• When we exclude transplant from the Post Operative Hemorrhage and Hematoma metric, all but 2 organizations saw a rate improvement ranging from 0.19 to 4.28

Image of a bar chart.

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Conclusions / Next Steps

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Transparency, Accountability

Screenshot images of a quality report card for Northwestern Memorial Hospital.

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Conclusions: The Framework Works

• Coding
• Definition
• Clinical Opportunity
• Results:
  • Improved quality
  • Reduced harm
  • Reduced cost
  • Improved learning

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Cynthia Barnard Director, Quality Strategies
Northwestern Memorial Hospital
Research Assistant Professor
Institute for Healthcare Studies
Northwestern University Feinberg School of Medicine
676 St Clair #700
Chicago IL 60611
voice 312.926.4822
fax 312.926.8734

cbarnard@nmh.org