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Utilizing the Patient Safety Indicators for Improvement

Utilizing the Patient Safety Indicators for Improvement. Anita Gottlieb, MA, APN, CPHQ St. Joseph’s Mercy Health System Hot Springs, Arkansas. “ Great things are not done by impulse, but by a series of small things brought together”. Vincent Van Gogh. The process: Beginning Steps.

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Utilizing the Patient Safety Indicators for Improvement

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  1. Utilizing the Patient Safety Indicators for Improvement Anita Gottlieb, MA, APN, CPHQ St. Joseph’s Mercy Health System Hot Springs, Arkansas

  2. “Great things are not done by impulse, but by a series of small things brought together” Vincent Van Gogh

  3. The process: Beginning Steps • January 2005 began reviewing PSI indicators using an interdisciplinary team • Leadership focused on data: -Quality Committee of the Board, Hospital Board and System Board • Focused on areas where we exceeded the AHRQ population rate as areas for improvement

  4. PSI Data – January 2005

  5. PSI – 03: Decubitus Ulcer

  6. PSI – 03: Decubitus Ulcer • Reviewed all cases listed in PSI for Decubitius Ulcer and found that present on admissions were not excluded especially for nursing home patients • Even with exclusion of present on admission we still frequently exceeded the AHRQ rate Improvement Plan - Six Sigma Project - Clinical Skin Team

  7. “Lowdown on Skin” • Projects purpose: Prevent Nosocomial Decubitus Ulcers • Nosocomial Decubitus Ulcers patients have a longer length of stay than those patients that do not acquire a Decubitus Ulcer while hospitalized • Length of Stay was the common Metric • Medicare’s Geometric Length of Stay for each DRG was the standard that we used to compare both the Ulcer Group and the Non-Ulcer Group

  8. Low Down on Skin – Six Sigma Project Improve • X’s causing most of our variation: • Daily Performance of Braden Scale • Pressure Ulcer Risk Level at Admission Graphical Analysis of X’s Means appear in Red; Medians appear in Blue

  9. Before & After Pilot Comparison By using the Braden Scale, we compared the “Gold” Standard auditor’s scores to how the RN’s rated the Patients. We noted a significant improvement with the changes we implemented. 29% Improvement in Accuracy of the Braden Scale

  10. Improve Improvement strategy

  11. What are the Financial Results? • There cost reduction after the Six Sigma project and it was directly associated with the length of stay. • The reductions relates to both direct cost and supplies.

  12. Prevalence

  13. PSI – 11: Post Operative Respiratory Failure

  14. PSI – 11: Post Operative Respiratory Failure • Reviewed all cases listed in PSI for Respiratory Failure • Definition of respiratory varied per physician • Coders were given exclusion PSI criteria and implemented use of documents Review Specialist for querying the physicians • Education provided to physicians regarding definitions of Respiratory Failure

  15. PSI-13:Postop Sepsis

  16. PSI-13:Postop Sepsis • Reviewed all cases and diagnosis for sepsis were not meeting the “Surviving Sepsis Campaign” definition and guidelines - Our facilities rate for Sepsis over all was greater than other hospitals in our System - Determined some of “Sepsis” cases were being admitted to the acute units – not ICU Previous Sepsis Six Sigma Project on Sepsis had been focused on Length of Stay

  17. Hot Springs Six Sigma Sepsis LOS • Solutions • Standardized processes for referral and evaluation for transfer to SNF/LTAC/Hospice • Implemented providing antibiotics within three hours • Removed barrier to tubing blood cultures and implemented tracking of times • Impact • Reduced LOS by .92 days • Improved time for blood cultures to lab by 126 minutes • Potential financial benefit – X $

  18. PSI Data – January2009/ 2005

  19. Lessons Learned • Work on “Present on Admission” prior to October 2008 was impactful • Six Sigma tools have impacted positively on cost savings and quality of care • Must take small steps – it will take time and must continue monitoring to sustain

  20. Questions “One’s destination is never a place but rather a new way of looking at things.” Henry Miller

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