New Series on Patient Safety Indicators Debuts Today

The series begins today on Talk Ten Tuesday with ChristianaCare.

The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency under the U.S. Department of Health and Human Services (HHS) with the mission to produce evidence to make healthcare safer, of higher quality, and more accessible, equitable, and affordable.

Some iteration of quality indicators has been in place since 2000. AHRQ has resources and toolkits available to assist organizations in improving the care they offer to their patients.

ICD10monitor and Talk Ten Tuesdays is excited to introduce a new series aimed at assisting institutions in understanding and managing their Patient Safety Indicators (PSIs). PSIs address potentially avoidable safety events related to in-hospital occurrences. Many are related to procedures, including childbirth.

A Talk Ten Tuesdays listener recently approached me and asked if I had advice on PSI 04: Death Rate among Surgical Inpatients with Serious Treatable Complications. I had to confess that I had never really looked into this particular PSI, nor had I had occasion to address it when I was a physician advisor. So, I reached out to my LinkedIn connections, and Dr. Varadarajan (Raj) Subbiah, vice president of Utilization Management and Quality of ChristianaCare, contacted me. His organization had turned its attention to this metric and markedly improved its ranking, and they were willing to share their experience and expertise on PSI 04 – and other PSIs as well.

I am going to remind you all that there are two ways that PSIs (and any quality metrics in general) can be improved. The first is improving clinical care. If your organization has too many wound infections, the answer isn’t to manipulate the denominator of the observed-to-expected ratio; it is to have the providers wash their hands more thoroughly! The numerator (i.e., observed) is dependent on the actual care provided.

The second way PSIs improve is denominator management (i.e., expected), which requires organizations to ensure that all exclusions are being captured, that documentation is optimized, and that attention is focused on the entire population.

In my conversations with the knowledgeable staff at ChristianaCare, I discovered something very interesting regarding the aforementioned PSI 04. The related conditions are shock/cardiac arrest, sepsis, pneumonia, gastrointestinal hemorrhage/acute ulcer, and deep vein thrombosis/pulmonary embolism. Our experts will explain the stratification and how they attacked the denominator population.

My observation was that an issue with PSI 04 can be an unintended consequence of squeezing the balloon. This is an analogy that my friend Dr. Dick Gregg taught me. When you attend to individual metrics in healthcare, it can be like squeezing a balloon. An issue with CDI (clinical documentation integrity) can make the balloon bulge out. If you squeeze the balloon in that area (like with a query), that section may be pressed back into alignment, but on the opposite side, a different region, say, quality can pop out. You push that in, and, voilà, over there, compliance gets knocked out of position.

Institutions that still cling to the definitions of Sepsis-2 and SIRS (systemic inflammatory response syndrome)may overcall sepsis. This may increase their case mix index (CMI), but it may also threaten PSI 04, because sepsis is one of the conditions that jeopardize a surgical patient, triggering PSI 04. Similarly, if a surgical patient has atelectasis, and CDI queries for an uncertain diagnosis of pneumonia, they may find themselves with a major comorbid condition or complication (MCC), and another encounter with PSI 04.

I am looking forward to ChristianaCare sharing with us how their multidisciplinary approach improved their patient safety, which was reflected in their data. They plan to touch on PSIs 03, 04, 11, 12, and 13, and composite measure PSI 90. We hope you will find this series educational and actionable.

Programming note: Listen to live reports on the new PSI series beginning today on Talk Ten Tuesdays and continuing Nov. 1, 15, and 22.


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