Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience

1. Using AHRQ Patient Safety Indicators to Improve Quality: The Stanford Hospital Experience John M. Morton, MD, MPH, FACS Associate Professor Director of Surgical Quality

2. “To Err is Human” STANFORD BOARD DIRECTIVE

3. Administrative Data • Financial • Clinical Input • Goethe • “ You search where there is light”

4. Administrative Data • Consistent • Benchmark • Prioritize • Variance

5. Department of Surgery Quality Plan Preview • Imperative from SHC Board • Areas of Focus • Measurement • Goals • Communication • Education • Accountability • Leadership

7. DRG Drill Down * BENCHMARK

8. PSIs: Quality Diagnostic Tool

10. Top Priority PI Action Plans

11. UHC DVT/PE Measure

12. Incidence of DVT/PE by DRG

13. Concurrent Surgical Audit • Concurrent audit started in Feb 08; conducted by Quality Specialist 24 hours after surgery on: • Orthopedic surgery • General surgery patients • “Risk level” of patient is assessed by Quality Specialist & compliance determined based on current order • Surgical DVT Prophylaxis must be ordered and 1st drug dose given within 24 hours after surgery • If no order or inadequate order, a “fix-it” ticket is placed in medical record so MD can order or revise prophylaxis

14. Radiology DVT/PE Report

15. DVT/PE Risk Assessment in Epic

16. Retrospective Surgical Audit( radiology test)

17. Retrospective Surgical Audit

18. Action Plan for DVT/PE Reduce the rate of DVT & PE by 25% by December 2008. REAL-TIME Assessment DVT/PE Concurrent Review By Action Team

19. DVT/PE Rates with SCIP VTE Compliance Comparison by Quarter

20. Incidence of Medical and Surgical Cases

21. UHC Benchmark: IAP

22. CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases • Next steps: focus on other causes of IAP: thorascopic lung biopsy, feeding tube placement and EP procedures

23. CVC Insertion Site

24. Action Plan GOAL: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08.

26. The evidence • Early Goal-Directed Therapy • Initiation of Appropriate Antimicrobial Therapy • Treatment with Hydrocortisone • Activated Protein C • Glucose Control • Lung Protective Strategies

27. Goal of 2008 SHC Quality Initiative on Severe Sepsis and Septic Shock: Reduce hospital mortality by 10%from Jan 08 to Jan 09 • May 2008: Initial education of ICU Guidelines for Severe Sepsis & Septic Shock • December 2008:Epic order sets revised to reflect changes in guidelines.

30. n = 16

31. N =25

35. PPEC: Accountable Outcomes

36. PPEC: Accountable OutcomesSCIP

37. PPEC: Accountable OutcomesPSIs

38. Use of PSI in PPEC: Post-op Hematoma

39. Use of PSI in PPEC: Accidental Puncture or Laceration

40. Persistent Pursuit of Excellence • Dedicated Monthly Grand Rounds on Quality • NSQIP based Morbidity and Mortality Conference • Resident Award for Quality Improvement • Novel Quality Improvement/Patient Safety Resident Curriculum • Documentation Improvement Program • Peer Review • Surgery Quality Council • Quality Initiatives: DVT, Sepsis, Iatrogenic Pneumothorax,Vent >48 hours, Colo-rectal Wound Infection • Rounding Policy • OR Checklist • Leadership

41. HAWTHORNE EFFECT

42. National PSI RatesMorton 2009 D Decubitus Sepsis Postop Resp PE/DVT

43. Clinical Outcomes Report: Product Line Mortality ComparisonOctober 2006 – September 2007 175 Surgical Deaths, Dept of Surgery 71, 2.1% SF=110, Oakland=140

44. General Surgery