6/30/2015. Lunch and Learn. Objectives. Who owns Quality and Patient Safety? We all do It s a Balance of Responsibility

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1 Lunch and Learn Patient Safety Indicators June 11, 2014 Objectives List at least 3 entities that drive patient quality and safety initiatives Define AHRQ Patient Safety Indicators Describe the 10 diagnoses and procedures that make up the AHRQ Composite Measure Explain why documentation and coding accuracy impacts quality and safety initiatives Who owns Quality and Patient Safety? We all do It s a Balance of Responsibility Direct Patient Care Indirect Patient Care 1

2 What Drives Quality & Patient Safety Regulations: CMS/Joint Commission Required Reporting: CMS Core Measures, POA, IPPS, OPPS, PQRI Patient Safety: NPSG/IHI/AHRQ Patient Safety Indicators Quality Metrics standard setters : National Quality Forum Scorecards: US News and World Reports/Payors Metrics Metrics Metrics Data: If you can t measure it, you can t manage it. Edward Deming AHRQ and Quality Indicators Quality Indicators (QI) are designed on Evidenced Based Guidelines QIs identify quality topics for monitoring and performance improvement Use hospital administrative data Highlight potential quality concerns Identify areas that need further study and investigating Track changes over time 2

3 Why are the AHRQ QIs Important? Some QIs are publicly reported on CMS s Hospital Compare website CMS and other payors have tied reimbursement to many QIs Other organizations are using QIs to rate hospitals and physicians practices Four Quality Indicator Modules Pediatric QIs reflect quality of care inside the hospital and identify potentially avoidable hospitalizations among children Prevention QIs - identify hospital admission that evidence suggests could have been avoided, at least in part, through high quality outpatient care Inpatient QIs reflect quality of care inside the hospital including inpatient mortality for medical and surgical procedures Patient Safety Indicators (PSIs) reflect quality care inside hospitals but focus on potentially avoidable complications and iatrogenic events What are the Patient Safety Indicators? The PSIs are a set of indicators for adverse events that patients may experience as a result of exposure to the health care system A composite measure is also available These events are likely amenable to prevention by changes at the system or patient care provider level PSIs are measured using hospital administrative data 3

4 How are the QIs structured? Definitions based on: ICD-9-CM diagnosis and procedure codes Often along with other measures (DRG, MDC sex, age, procedure dates, admission type) Numerator number of cases with the outcome interest (e.g. cases with pressure ulcers) Denominator = population at risk Observed rate = numerator/denominator Some QIs measured as volume counts A PSI Example: Pressure Ulcer Numerator: Discharges with ICD-9-CM code of a pressure ulcer in any secondary diagnosis field among cases meeting inclusion and exclusion rules for the denominator Denominator: All medical and surgical discharges age 18 years and older defined by specific Medicare Severity-DRGs AHRQ PSI Composite Measure Pressure Ulcer Rate Iatrogenic Pneumothorax Rate Central Venous Catheter-Related Blood Stream Infection Rate Postoperative Hip Fracture Rate Postoperative Hemorrhage or Hematoma Rate Postoperative Physiologic and Metabolic Derangement Rate 4

5 AHRQ PSI Composite Measure Postoperative Respiratory Failure Rate (not in VBP) Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate Postoperative Sepsis rate Postoperative Wound Dehiscence Rate Accidental Puncture or Laceration Rate Pressure Ulcer - Inclusion Stage III, Stage IV, and Unstageble Not present on admission Reported based on rate per 1,000 discharges All medical and surgical patients age 18 years and older Pressure Ulcer - Exclusions LOS < 5 days Present on Admission Any listed ICD-9-CM Code for Hemiplegia, paraplegia, quadriplegia Spina bifida Anoxic brain damage Debridement or Pedicle Graft before or on day of admission/only listed surgical procedure Transfer from a hospital, SNF, ICF or other health care facility MDC 9 and 14 5

6 Post operative Metabolic Derangement Identifies patients who suffered uncontrolled blood sugar or harm to their kidneys requiring dialysis following a wide range of elective surgeries Postoperative diabetic or kidney complications can be life-threatening A lower rate may indicate that a hospital provides a higher level of patient care. Postoperative Metabolic Derangement - Inclusions Elective surgery and age 18 years or older Diabetic complications (ketoacidosis, hyperosmolarity, hypoglycemic coma) Or acute kidney failure/injury requiring dialysis Reported based on rate per 1,000 surgeries Surgical patients age 18 years and older Post operative Metabolic Derangement - Exclusions Present on Admission Diabetes Acute Renal Failure/Injury Acute Myocardial Infarction, Cardiac arrhythmia, Cardiac Arrest Shock Hemorrhage Chronic Renal Failure (all stages and ESRD) MDC 14 Dialysis on or before the same day as the first OR procedure (Acute Renal Failure must be POA 6

7 Postoperative Sepsis - Inclusions Based on elective surgeries Ages 18 years and older Postoperative Sepsis - Exclusions Sepsis Present on Admission Principal Diagnosis of Infection with Sepsis secondary Any code for immunocompromised state or cancer LOS < 4 days MDC 14 (Pregnancy, Childbirth and Puerperium) Immunocompromised State Diagnosis HIV Severe Malnutrition Selective IGA immunodeficiencies Immunity Deficiency NOS Graft vs. Host Disease Chemo, other drug induced & other pancytopenia Neutropenia Leukocytopenia NOS CKD V & ESRD V code for transplant status V code for renal dialysis & dialysis encounter Procedures Infusion of Immunosuppressive Antibody Monoclonal Polyclonal Bone Marrow Transplant Solid Organ Transplant Heart, Lung, Liver, Pancreas, Kidney 7

8 Summary Analysis of Rates Evaluation of Individual Cases Patient risk factors, process of care Assess preventability of adverse events Identify contributing factors Report rates and trends Analysis Results Age distribution, common dx procedures and DRGs, what unit, what service Outcome of Analysis Opportunities to improve care and medical record documentation and coding Being average is contagious. If you demand more of yourself you get more. There is always room to improve. You ve never really arrived. Nick Sabin Alabama Head Coach Questions 8

9 References 0/ Default.aspx ules/psi_overview.aspx /guidelines/ahrq.jsp 9