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Overview of the AHRQ QI Toolkit for Hospitals

Slide presentation of the webinar held on November 7, 2014
The Agency for Healthcare Research and Quality (AHRQ) developed a toolkit to help hospitals understand the Quality Indicators (QIs). To update users on the expanded version of the QI toolkit, The Leapfrog Group held a Web seminar on November 7, 2014.

Alternate Formats

Overview of the AHRQ QI Toolkit for Hospitals: Slide Presentation (PowerPoint; 3.1 MB)

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The AHRQ Quality Indicators (QI) Toolkit is available at: www.ahrq.gov/professionals/systems/hospital/qitoolkit/index.html

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Panelists

Images: Photos of the 3 panelists along with their names and titles. Peter Hussey, PhD, Senior Policy Researcher, RAND Corporation; Courtney Gidengil, MD, MPH, Physician Scientist, RAND Corporation; and Ellen Robinson, PT, Manager, Clinical Quality Specialist, Harborview Medical Center, Seattle, Washington.

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AHRQ Quality Indicators Toolkit Presentation Overview

  1. QI Toolkit Overview
    • Development, field testing, and expansion of the QI Toolkit
    • How hospitals can use it to improve performance on AHRQ PSIs and other QIs
      • Peter Hussey, RAND
      • Courtney Gidengil, RAND (clarifying questions)
  2. A hospital’s experience using the AHRQ PSIs and QI Toolkit for quality improvement
    • Ellen Robinson, Harborview Medical Center in Seattle, WA
  3. Discussion with audience

Are you using the AHRQ QI Toolkit? If so, we’d like to hear about your experience! Please contact us at: QIsupport@ahrq.hhs.gov.

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Overview of the AHRQ QI Toolkit for Hospitals

Courtney Gidengil, MD MPH
Peter Hussey, PhD
RAND Corporation

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  • What is the toolkit?
  • How was the toolkit developed?
  • What tools are in the toolkit? How can they be used for quality improvement at my hospital?

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What Is the Toolkit?

  • Set of tools that hospitals can use to help improve performance in quality and patient safety
  • The AHRQ Quality Indicators (QIs):
    • Inpatient Quality Indicators (IQIs)
    • Patient Safety Indicators (PSIs)
  • Targeted to wide range of hospitals
    • Independent or system-affiliated
    • Varying quality improvement experience

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Toolkit Development

  • Developed through the AHRQ ACTION program
  • RAND partnered with UHC to develop and test the toolkit

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How Hospitals Can Use the Toolkit

  • Applicable for hospitals with differing knowledge, skills, and needs
  • Serves as a “resource inventory” from which hospitals can select tools
  • Different audiences for each tool (e.g., quality officer, finance officer, programmer)

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What Are the Quality Indicators?

  • Inpatient Quality Indicators - 28 indicators of quality in four sets:
    • Utilization, rates (7)
    • Mortality for procedures, rates (8)
    • Mortality for conditions, rates (7)
    • Volume, counts (6)
  • Patient Safety Indicators:
    • 17 indicators and a composite indicator
    • Screen for adverse events for inpatients
    • Expressed as rates

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The Development Process

  • Toolkit version 1 – released in 2011:
    • Developed “alpha” toolkit
    • Field tested and evaluated
    • Revised and published the toolkit
  • Toolkit version 2 – released in 2014:
    • Added best practice forms for additional indicators
    • Brought all tools up to date

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Tool Development Steps

  • Established principles to guide toolkit development
  • Reviewed literature to guide design
  • Developed outline of toolkit based on steps of a quality improvement process
  • Identified and developed specific tools for each step

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Technical Advisory Panel

  • Various skills and perspectives:
    • Hospital experience
    • Quality improvement
    • Relevant research skills
  • Providing guidance throughout toolkit development:
    • Toolkit design principles
    • Content of the tools

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Principles Guiding Toolkit Development

  • Parsimony in tool choice and design
  • Target the most important factors for implementation
  • Provide tools that offer most value for a range of hospitals
  • Readily accessible content
  • Enable hospitals to assess effectiveness of their actions

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Field Test Feedback

  • The tools were judged by the hospitals to be usable and useful
  • Hospitals varied widely in how many and which tools they chose to apply
  • Toolkit was useful for achieving staff consensus on the extent of quality gaps and on evidence-based practices

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Three Key Learnings

  • Hospitals need to trust their data
  • Priority-setting is challenging
  • Keep the tools short and simple

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Revised Toolkit to Address These Issues

  • Added a documentation and coding tool to improve PSI validity
  • Made prioritization matrix tools flexible so a hospital can tailor it with factors it considers in priority-setting
  • Simplified tools and instructions to increase usability

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Next Steps

  • Developing a pediatric toolkit:
    • Following similar development process, with field test and evaluation
  • Release planned in spring 2016

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Structure of the Toolkit

Introduction and Roadmap

  1. Readiness to Change
  2. Applying QIs to the Hospital Data
  3. Identifying Priorities for Quality Improvement
  4. Implementation Methods
  5. Monitoring Progress and Sustainability of Improvements
  6. Return-on-Investment Analysis
  7. Existing Quality Improvement Resources

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The Roadmap

  • A navigational guide through the toolkit
  • For each tool, it summarizes:
    • Action step being taken
    • Brief description of the tool
    • Key audience(s) to use the tool
    • Position with lead role responsibility

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A. Readiness to Change

  • Tools A.1a and A.1b. Fact Sheets on Inpatient Quality Indicators (IQI) and Patient Safety Indicators (PSI):
    • Introduces the IQIs and PSIs
    • Provide 2011 national rates where available for each indicator (based on HCUP data)
    • Indicates National Quality Forum endorsement status for each indicator

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A. Readiness to Change

  • Tool A.2. Board/Staff PowerPoint® Presentation on the Quality Indicators:
    • Helps Board members and relevant staff understand the importance and financial and clinical implications of the AHRQ Quality Indicators
    • The "notes" view in PowerPoint® has additional instructions for using this tool

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Tool A.2 Board/Staff PowerPoint® Presentation

Leadership is key to improvement

  • Hospital boards are increasingly turning to the QIs as a tool for monitoring performance, particularly on patient safety
  • To be successful, improvement efforts within hospitals need to have attention and active support from boards and senior hospital leadership
  • Your active support will demonstrate that the hospital has made it a priority to improve quality and patient safety
  • This support will help to motivate our staff to engage fully in improvement activities

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A. Readiness to Change

  • Tool A.3. Getting Ready for Change Self-Assessment:
    • Provides a checklist to assess for capabilities that should be in place before implementing improvement efforts:
      • Infrastructure for change management
      • Readiness to work on the AHRQ QIs
    • Senior executives review this tool independently (e.g. CMO, chief quality officer, nursing leadership, and members of hospital’s quality committee), then meet to discuss

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Tool A.3. Getting Ready for Change Self-Assessment

Image: Screen shot of the top of a self-assessment survey form for hospitals.

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B. Applying QIs to Hospital Data

  • Tool B.1. Applying the AHRQ Quality Indicators to Hospital Data:
    • Overview of the AHRQ QIs, data requirements, and issues involved in using them
    • Descriptions of the rates calculated for the QIs and how to work with them
    • Example of how to interpret a hospital’s QI rates
    • Guidance for assessing performance on the QIs (trends and benchmarking)

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B. Applying QIs to Hospital Data

  • Tools B.2a and B.2b. IQI and PSI Rates Generated by the AHRQ SAS Programs (a) and Windows QI Software (b):
    • Outline of the steps and programs used to calculate rates for the IQIs and PSIs
    • Notes for analysts and programmers on issues to manage in working with the SAS programs/Windows software
    • Example of the output from the SAS programs/Windows software for one hospital

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B. Applying QIs to Hospital Data

  • Tool B.3a. Excel® Worksheets for Charts on Data, Trends, and Rates To Populate the PowerPoint® Presentation:
    • Takes the rates for your hospital’s performance on the AHRQ Quality Indicators (QIs) and displays them graphically
  • Tool B.3b. PowerPoint® Presentation: The AHRQ Quality Indicators, Results, and Discussion of Data Analysis:
    • Provides a PowerPoint template for presenting the results of your analysis

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Tool B3b: Comparing Hospital’s Performance to National Performance Over Time

Image: Line chart titled: "Comparing Risk-Adjusted Rates of Iatrogenic Pneumothorax (PSI 6) to Benchmark Rates". Three different risk-adjusted rates are compared from 2009-2012. They all start up high in 2009, go down in 2010, slightly elevating in 2011, and go back up above 2009 rates in 2012.

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B. Applying QIs to Hospital Data

  • Tool B.4. Documentation and Coding for Patient Safety Indicators:
    • Designed to facilitate improvements to documentation and coding processes to ensure that PSI rates are accurate:
      • Describes procedures to address problems with documentation and coding practices
      • Illustrates issues that can arise when documenting and coding each PSI

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B. Applying QIs to Hospital Data

  • Tool B.5. Assessing Indicator Rates Using Trends and Benchmarks:
    • Supports the development of trend and benchmark information for comparing your hospital’s current performance on the QI rates:
      • To performance in previous years (trends)
      • To similar hospitals (benchmarks)
    • Can help identify which QIs the hospital may need to address for quality improvement

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C. Identifying Priorities for Quality Improvement

  • Tool C.1. Prioritization Matrix
  • Tool C.2. Prioritization Matrix Example

Image: Screen shot of an AHRQ Quality Indicators Prioritization Matrix.

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D. Implementation Methods

  • Tool D.1. Improvement Methods Overview:
    • Provides framework to evaluate current systems in place, and promote development of new systems and processes of care
  • Tool D.2. Project Charter Template
    • Charter template to describe the performance improvement rationale, goals, barriers, and anticipated resources which the team will commit

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D. Implementation Methods

  • Tool D.4. Best Practices and Suggestions for Improvement:
    • Tool D.4 is an introduction to the best practices tool
    • Tools D4.a through D4.n outline best practices for 14 PSIs and a more general  mortality review relating to mortality-based IQIs

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Best Practices Tool

  • Covers the following PSIs:
    • PSI 03 Pressure Ulcer Rate
    • PSI 05 Retained Surgical Item or Unretrieved Device Fragment Count
    • PSI 06 Iatrogenic Pneumothorax Rate
    • PSI 07 Central Venous Catheter-Related Blood Stream Infection Rate
    • PSI 08 Postoperative Hip Fracture Rate
    • PSI 09 Perioperative Hemorrhage or Hematoma Rate
    • PSI 10 Postoperative Physiologic and Metabolic Derangement Rate

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Best Practices Tool

  • Covers the following PSIs (cont’d):
    • PSI 11 Postoperative Respiratory Failure Rate
    • PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
    • PSI 13 Postoperative Sepsis Rate
    • PSI 14 Postoperative Wound Dehiscence Rate
    • PSI 15 Accidental Puncture or Laceration Rate
    • PSIs 18 and 19 – Obstetric Trauma Rate – Vaginal Delivery With/Without Instrument
  • Does not include PSI 4 (Death Rate Among Surgical Inpatients With Serious Treatable Conditions)

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Best Practices From Components

  • “Why Focus on….”
  • High-level summary of best practices
  • Recommended practices:
    • Staff required
    • Equipment
    • Communication
    • Authority/Accountability
  • References

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Sample Best Practices Form: PSI 06

Image: Screen shots of a sample best practices form for QI PSI 06 (Iatrogenic Pneumothorax).

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D. Implementation Methods

  • Tool D.5. Gap Analysis:
    • Understand the extent to which current practices align with best practices
  • Tool D.6. Implementation Plan:
    • Assign team responsibilities and set timeline

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D. Implementation Methods

  • Tool D.7. Implementation Measurement:
    • Measure progress in improving work and clinical care processes
  • Tool D.8. Project Evaluation and Debriefing
    • Understand what worked in the implementation process and what needs improvement

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E. Monitoring Progress and Sustainability of Improvements

  • Tool E.1. Monitoring Progress for Sustainable Improvement:
    • What is involved in ongoing monitoring?
    • Establish a schedule for regular reporting
    • Develop report formats to communicate clearly
    • Establish procedures for acting on problems identified
    • Assess sustainability on a periodic basis

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F. Return-on-Investment Analysis

  • Tool F.1. Return on Investment Estimation:
    • Step-by-step guide to calculating ROI
    • Worksheets for calculating net costs and returns
    • Case study for ROI calculation
    • Additional guidance for effective ROI calculation
    • Resources and information sources

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G. Existing Quality Improvement Resources

  • Tool G.1. Available Comprehensive Quality Improvement Guides:
    • Obtain further guidance for conducting effective quality improvements
  • Tool G.2. Specific Tools To Support Change:
    • Identify specific analytic or action tools to use in improvement processes
  • Tool G.3. Case Study of PSI Improvement Implementation

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Summary

  • The QI Toolkit supports hospitals that want to improve performance
  • Addresses all stages of improvement, from self-assessment to ongoing monitoring
  • The tools are practical, easy to use, and designed to meet a variety of needs

QI Toolkit available at:  http://archive.ahrq.gov/professionals/systems/hospital/qitoolkit/index.html

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AHRQ Toolkit: The Harborview Experience

Ellen F. Robinson, PT
Manager, Clinical Quality Specialist
Seattle, WA

Image at top right of slide for UW Medicine, Harborview Medical Center.

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Objectives

  • Discuss utilization of the AHRQ Patient Safety Indicator (PSI) data to develop a high level enterprise measure of hospital quality
  • Provide examples of how to utilize the AHRQ Toolkit to operationalize PSI review
  • Discuss how to utilize PSI information to identify opportunities to improve patient care

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The Harborview Experience

Mission and Priority of Care

  • Persons incarcerated in the King County Jail
  • Mentally ill patients, particularly those treated involuntarily
  • Persons with sexually transmitted diseases
  • Substance abusers
  • Indigents without third-party coverage
  • Non-English speaking poor
  • Trauma
  • Burn treatment
  • Specialized emergency care
  • Victims of domestic violence
  • Victims of sexual assault

Images: On top left is an image of the Harborview Medical Center. The top right image is a map of the United States with the WAMI Region shown with lines around it. The region includes Washington State, Oregon, Idaho, Montana, and Wyoming, Alaska, and a part of northern California, Nevada and Utah. The bottom right image is a photo of a Medevac helicopter.

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The Steps

Image of a timeline that also shows a cartoon image of a person working to achieve a goal.

July 2008: What is a PSI? Cartoon image of a person sitting down with a big question mark next to his head.

July 2009: Oh I wish I had a "toolkit". Cartoon image of a person smiling and holding a big magnifying glass.

July 2010: AHRQ Toolkit Project. Cartoon image of a person climbing up a ladder.

July 2011: PSI Project Full Integration. Cartoon image of a person on top of a mountain holding a red flag and celebrating.

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Where Are We Now?

2012 to 2014

  • Integrated a PSI Metric as a marker of Patient Safety
  • Spans the UW Medicine Enterprise: 2 Academic Medical Centers & 2 Community Hospitals
  • Consistently reviewed at Board and Leadership Meetings

Images: Logos of the components of the University of Washington Medical Enterprise, six of them in all.

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Quality Improvement Initiative: Two Goals

External Reporting and Internal Case Identification.

Medical QI Committee (MQIC)

  • Departmental M&M review/report
  • Standard identification of potentially preventable harm events for clinical review
  • Tracking of outcomes of reviews for trending of possible opportunities

Image: Screen shot of the Harborview Medical Center 2010 Quality and Performance Scorecard.

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Section A: Readiness for Change

  • IQI/PSI Fact Sheets
  • AHRQ Specification Guidelines
  • Readiness to Change (Self Assessment):
    • Medical Director  - previous director of QI Dept
    • Leadership Support and directive for project
    • The Board was “on board”
    • Challenges identified: information dissemination about quality and patient safety to staff at all levels of the organization

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Section B: Applying the Indicators to your hospital data

  • Utilizing UHC database to track rates for PSI
  • UHC Quarterly Summaries ~ 3 months behind
  • Individual Case review ~ 6 weeks behind
  • Too late to make an impact

How do we get PSI data in “real time”?

Can we use our internal data and the AHRQ software and get the same results?

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Data Challenges - Input

  • Internal Source System for data points (3M)
  • 3M Report output= 2 pages, multiple Rows
  • PERL Script to transform into usable input file

AHRQ Software is free and easy to download, but each hospitals’ source system may be slightly different. IT Resources may be required for mapping.

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Data Challenges - Output

  • Validate Numerator and Denominator against publically reported values
  • Quality Improvement Projects:
    • Track each PSI cases individually for possible opportunities to improve care

**Version changes and updates

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Section C: Identifying Priorities for Quality Improvement

  • HMC Project Originally utilized UHC as source
  • UHC runs the SAS version software on each hospitals administrative data set

Image: Screen shot of the Harborview Medical Center Quality and Safety Management Report for July-Sept. 2008 (Q3).

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Prioritization Matrix

HMC Highest Prioritization scores:  PSI 3 PSI 7 PSI 12. Have since focused on PSI 11 PSI 13 and PSI 15.

Image: Screen shot of the Prioritization Matrix for Q3 2009 to Q2 2010.

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Prioritization: Take it on the road!

  • Presented to Surgical Council, Medical Executive Board, Critical Care Council, Hospital Board, Clinical Documentation Specialists, Coding:
    • What are the PSIs?
    • Why do we care?
    • Current performance/UHC ranking
    • How are we going to review/expectations from teams
    • Possible opportunities for improvement:
      • Clinical areas
      • Documentation -Coding

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Section D: Implementing Improvement

  • Examples of effective PSI improvement strategies
  • Evidence-based best practices for selected PSIs
  • Improvement Methods Overview
  • Implementation Team Charter and Goals*
  • Selected Best Practices
  • Gap Analysis*
  • Implementation Plan*
  • Implementation Measurement

Image on bottom right of slide: Text box with the words "Performance Improvement Model" and four arrows encircling the box. Surrounding the image are the steps for the performance improvement model.

Step 1: Diagnose the Problem

  • Describe Improvement Initiative - Project Charter (Tool D.2).
  • Review and Select Best Practices (Tools D.3, D.4).
  • Conduct Gap Analysis (Tool D.5).
  • Select Best Practices on Gap Analysis

Step 2: Plan and Implement Best Practices

  • Develop Implementation Plan (Tool D.6)

Step 3: Measure Results and Analyze

  • Implementation Measurement (Tool D.7):
    • Collect data on key process measures related to each best practice
    • Review data to determine effectiveness

Step 4: Evaluate Effectiveness of Actions Taken

  • Results satisfactory:
    • Continue implementation, data measurement, and analysis
    • Integrate and standardize best practices throughout facility
  • Results not satisfactory:
    • Identify issues blocking success
    • Report results to facility leadership

Step 5: Evaluate, Standardize, and Communicate

  • Project Evaluation (Tool D.8):
    • Focus on lessons learned
    • Future planning
    • Standardization of best practices

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Evidence-based best practices for PSIs

  • Forming Implementation Teams (“Task Forces”) - Who are the “experts” in these areas?
    • PSI 03: Clinical Nurse Specialists wound care
    • PSI 07: Infection Control
    • PSI 12: Anticoagulation Task force: Trauma Surgeon, Hospitalist, Pharmacy, Nursing
    • PSI 11: Spine Surgeon, Anesthesia, Respiratory
    • PSI 13: Sepsis Team: MD, CNS, Patient Safety
    • PSI 15: Surgeons, Clinical Document, Coding

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PSI Improvement Opportunities

  • Understand PSI Definitions
  • Consider how coding and documentation impact PSI rates
  • Validation of Event Cases
  • Consider specific populations

Image below text: Screen shot of the top of a chart documenting problems by PSI type.

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Section E: Monitoring Progress and Improvement Sustainability

  • Run Input file through AHRQ Software 10 days after previous month for case identification
  • Upload PSI internal database to track outcomes
  • Providers report up through M&M conferences and Medical Quality Improvement Committee

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HMI PSI Case Review

Image: Flowchart showing steps in PSI Case Review. It starts with a Monthly Data Feed which is sent to AHRQ. AHRQ then conducts a QI Analysis. If there is No Event, then there is No Coding Issue. If there is a coding or documentation issue, then it is sent for Documentation Code Review. If it is agreed that there is a problem with wrong code or exclusion criteria code missing, then the coding is updated. It is then determined if it is a real event, and if it is then it goes through Service Review. The Service Review determines if there are QI Concerns.

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HMC Analysis and Tracking

Image: Screen shot of HMC analysis and tracking online input system.

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Monitoring Progress

Image: Graph showing progress in decreasing patient safety events for PSI-90. Below the chart is a table with the following data:

  FY 2013 Rate FY 2013 Events FY 2013 Eligible Cases FY 2014 Rate FY 2014 Events FY 2014 Eligible Cases FY 2015 Rate FY 2015 Events FY 2015 Eligible Cases
HMC 3.31 220 66491 2.42 157 64749 2.23 38 17007
  • High rate of PSI events = quality issue at a hospital?
  • Are all PSI events “preventable”?

* Web based tool for Quality Metrics reporting

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Finding Improvement Opportunities

  • Review PSI 12 events – standard of care met?
    • Compliance with UW Medicine guidelines for:
      • Prophylaxis Type?
      • Prophylaxis Timing?
      • Dose intensity?
      • Mechanical when Chemical contraindicated?

Image: Bar chart titled: "HMC - Hospital Acquired Venous Thromboembolism Events: Pulmonary Embolism and Deep Vein Thrombosis FY 2014. The chart shows the number of Guideline Directed Therapy and Possible Opportunities for the various departments in the medical center. To the left of the chart is the text:

  • Categorize Opportunities
  • Refer for further review as needed

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Section F: Return on Investment

How can you measure the impact of PSI reduction?

  • UW Medicine Finance
  • Annual Process Review
  • Simple comparison to measure the impact of safety projects across the 4 hospital systems
  • Raw count differential X $$ = cost savings
  • Greatly valued by executive team

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Section G: Existing QI Resources

  • Reviewed by our Research Librarian
  • Incorporated into University of Washington Health Sciences LibGuides web page
    • Healthcare Quality News
    • Pub Med Searches (preselected QI topics)
    • eJournals related to quality and safety
    • PubMed Notifications for specific topics
    • Measures – links to TJC, NQF, CMS, UHC, IHI, WSHA,
    • Publishing/RefWorks/EndNote

http://libguides.hsl.washington.edu/qualitysafety

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HMC PSI Project Lessons Learned

  • Validate, validate, validate…………
  • Leadership backing for project importance and accountability from providers
  • Presentations to clinical providers should focus on actual clinical events and outcomes
  • Coding department project lead/liaison with clinical documentation specialists involvement
  • Customize task forces to address specific PSI categories and determine “preventability”

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Thank You

Harborview Medical Center

  • Dr. J. Richard Goss
  • Dr. Anneliese Schleyer
  • Dr. Joseph Cuschieri
  • Ronald Pergamit, QI/IT
  • Derk Adams, QI/IT
  • Patty Calver QI
  •  
  •  
  •  
  •  
  •  
  •  
  •  

Ellen F. Robinson
(206) 744-9550
lnrobin@u.washington.edu

Image: To the right of the text is a screen shot of the 2014 Quality and Accountability Performance Scorecard.

Page last reviewed August 2015

 

The information on this page is archived and provided for reference purposes only.

 

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