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September 15, 2009 By Cynthia Barnard MBA MSJS CPHQ Director, Quality Strategies

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. Agenda. Framework for PSI analysis within the hospital

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September 15, 2009 By Cynthia Barnard MBA MSJS CPHQ Director, Quality Strategies

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  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 Northwestern Memorial HealthCare

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

  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. 50 2200 2000 45 1800 40 1600 35 1400 30 1200 25 1000 20 800 15 600 10 400 5 200 0 0 FY04Q2 FY04Q3 FY04Q4 FY05Q1 FY05Q2 FY05Q3 FY05Q4 FY05Q4 FY06Q1 FY06Q2 FY06Q3 FY06Q4 FY07Q1 FY07Q2 FY07Q3 FY07Q4 FY08Q1 FY08Q2 FY08Q3 FY08Q4 FY09Q1 FY09Q2 FY09Q3 Eliminate Avoidable Severe Adverse EventsAvoidable Severe Adverse Events (G,H,I) # of Incidents Reported Total Incidents Reported # of Severe Harm Events Severe Harm

  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. 200.00% Complications Of Anesthesia Death In Low Mortality DRG 150.00% Decubitus Ulcer Failure To Rescue 100.00% Foreign Body Retained Iatrogenic Pneumothorax 50.00% Decub Infection Due To Medical Care 0.00% Postoperative Hip Fracture OB 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Postop Hemorrhage Or Hematoma FTR Variance to AHRQ Empiric Value -50.00% Postop Physio Metabol Derangmnt Postop Respiratory Failure -100.00% Postoperative Pe Or Dvt Postoperative Sepsis -150.00% Postoperative Wound Dehiscence APL OB PE/DVT Accidental puncture/laceration -200.00% Transfusion Reaction Birth Trauma -250.00% OB Trauma - Vaginal W Instrument -300.00% Pneumothorax OB Trauma - Vaginal Wo Instrument Size of bubble represents number of cases OB Trauma - C-Section -350.00% 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)* *Check all that apply

  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. 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% 0 1 2 3 4 5 6 7 8 Procedure Resulting in PTX 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.

  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. Venous Thrombosis/ Pulmonary Embolism Frequency of DVT/PE; 2007-2008(Q1-Q3) 20.0 17.4 17.3 18.0 16.0 14.3 13.9 13.7 14.0 11.9 11.9 11.5 12.0 10.6 Frequency (rate per 1000 discharges*) 10.2 9.8 10.0 8.0 6.0 4.0 2.0 0.0 NMH Rush UCLA U of C Mayo UCSF Loyola Hopkins Stanford Brigham Mass Gen 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. Source: UHC Clinical Database *excludes OB Product line

  25. New VTE Prophylaxis Protocol – Electronic Medical Record Screenshot

  26. NMH DVT/PE and Bleed Events (excluding OB, Peds, and Psych) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- 08 08 08 08 08 08 08 08 08 08 08 08 09 09 09 09 09 09 09 DVT/PE Rate per thousand Goal Bleed Rate per thousand Hospital DVT/PE Rates Protocol Implemented 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

  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 • 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

  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 BarnardDirector, 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

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