AHRQ Patient Safety Indicators: Constructive Use for Improvement Presented to AHRQ Annual Conference

1. AHRQ Patient Safety Indicators: Constructive Use for ImprovementPresented to AHRQ Annual Conference September 15, 2009 By Cynthia Barnard MBA MSJS CPHQ Director, Quality Strategies 

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

3. Northwestern Memorial HealthCare 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

4. 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

5. Quality and Patient Safety Program Eliminate avoidable adverse events Deliver evidence-based care Enable the best possible outcomes

6. Eliminate Avoidable Severe Adverse Events Avoidable Severe Adverse Events (G,H,I)

7. 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

8. 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

9. Patient Safety Indicators

10. 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

11. Administrative Data for Quality Metrics

12. NMH Patient Safety Indicators

13. Framework for PSI Use

14. 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

15. Case Studies CODING Foreign Body Retained Infection Due to Medical Care DEFINITION Post-op Bleed CLINICAL IMPROVEMENT Pneumothorax Post-op PE / DVT

16. Framework on a Small Sample (2007)

17. Clinical Case StudiesIatrogenic PneumothoraxPost-Operative DVT/PE

18. AHRQ Validation Study:Summary of PPVsPreliminary estimates (2007)

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

20. 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)

21. Procedure Resulting in PTX Our data led us to focus on thoracentesis and central line placement. Later, we found that pacemaker insertion was another procedure associated with more iatrogenic pneumothorax than we had anticipated. Location of procedure (bedside or invasive procedure department or OR) was not a factor. Patient age and other factors were also not associated with this complication. Iatrogenic PTX common causes from the literature: Transthoracic needle aspiration/ biopsy Thoracentesis Closed pleural or transbronchial biopsy Subclavian or jugular vein catheterization Mechanical ventilation, positive pressure Cardiopulmonary resuscitation Nasogastric tube placement Tracheostomy Liver biopsy Source: Dincer HE, Lipchik RJ. The intricacies of pneumothorax: management depends on accurate classification. Postgraduate Medicine, Dec 2005. Our data led us to focus on thoracentesis and central line placement. Later, we found that pacemaker insertion was another procedure associated with more iatrogenic pneumothorax than we had anticipated. Location of procedure (bedside or invasive procedure department or OR) was not a factor. Patient age and other factors were also not associated with this complication. Iatrogenic PTX common causes from the literature: Transthoracic needle aspiration/ biopsy Thoracentesis Closed pleural or transbronchial biopsy Subclavian or jugular vein catheterization Mechanical ventilation, positive pressure Cardiopulmonary resuscitation Nasogastric tube placement Tracheostomy Liver biopsy Source: Dincer HE, Lipchik RJ. The intricacies of pneumothorax: management depends on accurate classification. Postgraduate Medicine, Dec 2005.

22. 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)

23. Interventions to Reduce Complications

24. Post-Operative Venous Thrombosis / PE

25. New VTE Prophylaxis Protocol � Electronic Medical Record Screenshot

26. Hospital DVT/PE Rates

27. Definition Case StudyPost-Operative Hemorrhage / Hematoma

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

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

30. Conclusions / Next Steps

31. Transparency, Accountability

32. Conclusions: The Framework Works Coding Definition Clinical Opportunity Results: Improved quality Reduced harm Reduced cost Improved learning

33. 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