Transcript No Slide Title

Adapting AHRQ
Patient Safety
Indicators to QIO
Data
Jocelyn Andrel, MSPH
Charles P. Schade, MD, MPH
Patricia Ruddick, RN, MSN
Outline of Presentation
What are AHRQ Patient Safety Indicators?
How can you use QIO data to get them?
What are their characteristics in one state?
How can you share them with hospitals?
What do one state’s hospitals think of
them?
How do they relate to other evidence about
safety in a state’s hospitals?
AHRQ Patient Safety
Indicators
What they are
How to compute them
AHRQ Patient Safety Indicators:
Background
Early 1990s
Developed by the Agency for Healthcare
Research and Quality (AHRQ) to measure
the safety of hospital care using
administrative inpatient discharge data.
The Indicators screen for problems that
patients experience as a result of exposure
to the healthcare system.
Concept of PSIs
Based on conditions that clearly reflect
medical error (foreign body left in)
Based on conditions that could reflect
medical error (PE or DVT)
Not based on underlying comorbidities
Steps to determine PSIs
1. Define the concepts and the evaluation
framework
2. Search the literature to identify potential PSIs
3. Develop a candidate list of PSIs
4. Review the PSIs
5. Evaluate the PSIs using empirical analysis
Limitations
Some events don’t show up in discharge data
– Adverse drug reactions
– Medical events
– Psychiatric events.
Administrative data may not address finer detail
Patient Safety Indicators should be used to prompt
investigation into areas where the hospital could
potentially improve quality of care
PSIs
Accidental puncture or laceration
Complications of Anesthesia
Death in low mortality DRGs
Decubitus Ulcer
Failure to Rescue
Foreign body left in during procedure
Iatrogenic pneumothorax
Postoperative hemorrhage or hematoma
Postoperative hip fracture
PSIs continued
Postoperative physiologic and metabolic derangement
Postoperative pulmonary embolism or DVT
Postoperative respiratory failure
Postoperative sepsis
Postoperative wound dehiscence
Selected infections due to medical care
Transfusion reaction
 Plus 4 Obstetric measures not addressed here
Converting ISAT data
General Instructions from AHRQ
– 1. The data must be in SAS
– 2. You may have to recode specific data elements to
match what is used in the software.
Fortunately, conversion of the ISAT file to
comport with the AHRQ input requirements is
fairly simple
Conversion Elements
Creating/Formatting Variables
– Age
– Length of Stay
– Create variables for the number of diagnoses and the
number of procedures
– Set payor to the code for Medicare
– Format Hospital codes, Race, Sex, Key, Hospital ID,
DRG, Admission Source, Admission Type
– Rename Diagnosis and Procedure codes
Major Diagnostic Codes from the HSE Claims
Lookup Table
And then…
The ISAT file is ready to be input into the
AHRQ Patient Safety Indicator programs
AHRQ Patient Safety
Indicators:
Results in a Single
State
Methods
Adapted standard output (psp3 table at
hospital level) to a graphic display and
comparative report
Generated histograms of hospital
performance on each indicator for 20002002
Generalized code to run with any state’s
data as input
Results: Distribution of Hospitals
Some indicators appeared normally
distributed
Some were highly skewed, with outliers
Some appeared bimodal
AHRQ Risk Adjusted PSI Rate
Failure to Rescue
WV Hospitals, 2002
Definition
15
Death rate in discharges
with potential complications
of care, e.g., pneumonia,
DVT/PE, sepsis, acute renal
failure, shock/cardiac arrest,
GI hemorrhage/acute ulcer.
10
Ra te per 1,000 ca ses
475.0 or more
425.0 to 475.0
375.0 to 425.0
325.0 to 375.0
275.0 to 325.0
225.0 to 275.0
175.0 to 225.0
125.0 to 175.0
75.0 to 125.0
0
25.0 to 75.0
5
0.0 to 25.0
Number of Hospitals
20
AHRQ Risk Adjusted PSI Rate
Selected Infections Due To Medical Care
WV Hospitals, 2002
Definition
15
Discharges with ICD-9-CM
code of 999.3 or 996.62 in any
secondary diagnosis field
excluding immunocompromised and cancer
10
Ra te per 1,000 ca ses
9.5 or more
8.5 to 9.5
7.5 to 8.5
6.5 to 7.5
5.5 to 6.5
4.5 to 5.5
3.5 to 4.5
2.5 to 3.5
1.5 to 2.5
0
.5 to 1.5
5
0.0 to .5
Number of Hospitals
20
AHRQ Risk Adjusted PSI Rate
Post-Operative Sepsis
WV Hospitals, 2002
Definition
15
Elective surgical discharges
with ICD-9-CM code for
sepsis in any secondary
diagnosis field excluding
immunocompromised and
cancer
10
Ra te per 1,000 ca ses
47.5 or more
42.5 to 47.5
37.5 to 42.5
32.5 to 37.5
27.5 to 32.5
22.5 to 27.5
17.5 to 22.5
12.5 to 17.5
7.5 to 12.5
0
2.5 to 7.5
5
0.0 to 2.5
Number of Hospitals
20
Results: Statewide Values Over 3
Years
We also used the following format for the
tabular report to individual hospitals
Most indicators based on small numerators
statewide and appeared to show statistical
fluctuation from year to year
Failure to rescue declining?
Postop sepsis and DVT/PE increasing?
AHRQ Risk-Adjusted Patient Safety Indicator Rates--WV, 2000
Statewide
Indicator
Complications of Anesthesia
Death in Low Mortality DRGs
Decubitus Ulcer
Failure to Rescue
Foreign Body Left in During Proc
Iatrogenic Pneumothorax
Infection Due to Medical Care
Postoperative Hip Fracture
Postop Hemor or Hemat-No Prday
Postop Physio Metabol Derangmnt
Postop Respiratory Failure
Postop PE or DVT-No Prday
Postoperative Sepsis
Postoperative Wound Dehiscence
Accidental Puncture/Laceration
*Rates per 1,000 eligible cases
Number
DenomNuminator
erator
29,053
11
13,278
52
57,736
1,670
4,656
741
131,145
6
119,616
124
110,892
230
21,083
52
29,028
62
12,576
21
9,278
62
28,870
330
4,946
47
5,399
20
131,049
290
Hospital Percentiles*
Rate*
Crude
Adjusted
10th
50th
90th
0.4
3.9
28.9
159.1
0.046
1.0
2.1
2.5
2.1
1.7
6.7
11.4
9.5
3.7
2.2
0.3
1.9
25.0
176.2
0.063
0.9
1.7
1.8
1.9
1.1
2.6
8.7
7.9
2.4
3.3
0
0
4.3
54.6
0.013
0
0
0
0
0
0
0
0
0
1.7
0
0.099
24.2
168.5
0.027
0.448
0.897
0.724
0.570
0.397
1.3
4.2
5.0
0
2.6
1.1
5.2
49.0
240.7
0.222
2.1
2.8
10.0
4.3
6.0
9.3
14.9
21.5
8.5
3.9
AHRQ Risk-Adjusted Patient Safety Indicator Rates--WV, 2001
Statewide
Indicator
Complications of Anesthesia
Death in Low Mortality DRGs
Decubitus Ulcer
Failure to Rescue
Foreign Body Left in During Proc
Iatrogenic Pneumothorax
Infection Due to Medical Care
Postoperative Hip Fracture
Postop Hemor or Hemat-No Prday
Postop Physio Metabol Derangmnt
Postop Respiratory Failure
Postop PE or DVT-No Prday
Postoperative Sepsis
Postoperative Wound Dehiscence
Accidental Puncture/Laceration
*Rates per 1,000 eligible cases
Number
DenomNuminator
erator
28,926
7
13,657
47
56,299
1,552
5,209
692
129,442
5
117,966
119
109,233
271
20,674
42
28,876
60
12,971
15
9,542
82
28,689
360
4,990
48
5,367
22
129,303
272
Hospital Percentiles*
Rate*
Crude
Adjusted
10th
50th
90th
0.242
3.4
27.6
132.8
0.039
1.0
2.5
2.0
2.1
1.2
8.6
12.5
9.6
4.1
2.1
0.185
1.6
24.0
151.7
0.056
0.9
2.1
1.3
1.9
0.6
4.2
10.1
7.8
2.9
3.2
0
0
9.7
76.5
0.008
0.044
0.308
0
0
0
0
0
0
0
1.5
0
0
22.0
160.1
0.026
0.281
1.4
0.670
0.855
0.138
0
8.8
6.6
0
2.8
0.185
5.5
42.8
232.2
0.131
1.5
3.2
7.0
5.3
1.3
13.2
17.8
23.3
9.0
4.0
AHRQ Risk-Adjusted Patient Safety Indicator Rates--WV, 2002
Statewide
Indicator
Complications of Anesthesia
Death in Low Mortality DRGs
Decubitus Ulcer
Failure to Rescue
Foreign Body Left in During Proc
Iatrogenic Pneumothorax
Infection Due to Medical Care
Postoperative Hip Fracture
Postop Hemor or Hemat-No Prday
Postop Physio Metabol Derangmnt
Postop Respiratory Failure
Postop PE or DVT-No Prday
Postoperative Sepsis
Postoperative Wound Dehiscence
Accidental Puncture/Laceration
*Rates per 1,000 eligible cases
Number
DenomNuminator
erator
26,188
11
13,174
59
53,879
1,604
5,031
679
124,902
4
114,155
100
105,239
241
17,965
51
26,155
64
11,993
29
9,564
82
25,961
381
4,689
57
5,091
17
124,798
219
Hospital Percentiles*
Rate*
Crude
Adjusted
10th
50th
90th
0.420
4.5
29.8
135.0
0.032
0.9
2.3
2.8
2.4
2.4
8.6
14.7
12.2
3.3
1.8
0.347
2.6
26.1
148.4
0.050
0.8
1.9
2.1
2.2
1.8
4.4
11.4
10.3
2.3
3.0
0
0
4.3
72.5
0.008
0
0.021
0
0
0
0
0
0
0
1.5
0
1.4
25.9
159.0
0.026
0.639
1.2
0
0.610
0.147
1.5
8.7
5.7
0
2.6
0.347
8.5
36.5
225.1
0.050
1.4
3.2
6.9
3.8
3.1
27.3
21.4
36.0
14.4
3.7
Report to Hospitals
Calendar year 2002, with offer of other
years’ results
Tabular (see previous) and graphical format
Explanatory letter, definitions of indicators
Mailed to hospital patient safety contact or
HCQIP contact
Asked for feedback on report contents and
utility
AHRQ Patient Safety Indicators--WV, 2002 (Risk Adjusted)
Hospital A
Medicare Fee For Service Patients
Accidental Puncture/Laceration
(2.1)
Postoperative Wound Dehiscence
(0)
Postoperative Sepsis
(16.4)
Postop PE or DVT-No Prday
(10.0)
Postop Respiratory Failure
(17.4)
Postop Physio Metabol Derangmnt
(1.1)
Postop Hemor or Hemat-No Prday
(2.3)
Postoperative Hip Fracture
(3.8)
Infection Due to Medical Care
(1.5)
Iatrogenic Pneumothorax
(0.859)
Foreign Body Left in During Proc
(0.018)
Failure to Rescue
(160.6)
Decubitus Ulcer
(25.7)
Death in Low Mortality DRGs
(2.7)
Complications of Anesthesia
State Range (10th-90th Percentile)
State Median (50th Percentile)
Hospital Risk Adjusted Value
(0.544)
0.001
0.01
0.1
1
10
Indicator Rate (Per Thousand Cases)
100
1000
Patient Safety
Indicators:
Implications for
WVMI’s Patient Safety
Project
Specific Goals of the WV Patient
Safety Project
Establish a system of confidential reporting
for medical errors and near misses
Stimulate reporting of such events by
developing a non-punitive response system
Provide feedback of surveillance data at
appropriate levels of aggregation
Educate consumers of healthcare about
patient safety guidelines
Comparing PSI Data to the Patient
Safety Data
Purpose:
1. Ascertain the usefulness of the PSI
data in hospitals in West Virginia
2. Compare the data received from the
PSI data to the data received from
the Patient Safety Project
3. Explore further opportunities for
quality improvement projects
PSI/Patient Safety Data Study
CEOs and Quality Improvement staff from 41
acute care West Virginia hospitals received:
1. Information letter
2. Patient Safety Indicator definitions
3. Table which showed the actual number of specific
incidences of each PSI (2002), crude and adjusted
rates, and comparative percentiles of all hospitals in
the state combined
4. Graphical representation of the data presented in the
table
5. Brief questionnaire on the usefulness of the graph
and tables
Patient Safety Questionnaire
Feedback on the Patient Safety Indicator Reports
Please take a minute or two to tell us your reaction to the
enclosed reports. Your responses will be kept confidential
and used only for evaluating this project.
1. Please check the box that most closely describes your role in
the hospital
o Quality improvement staff
o Patient safety staff
o Medical staff
o Clinical nursing staff
o Administration
o Other ________________
Patient Safety Questionnaire, cont.
2. Please circle the number indicating the extent to which you
agree or disagree with each statement, where:
5 = strongly agree
4 = agree
3 = indifferent
2 = disagree
1 = strongly disagree
If a question is not applicable to your situation, please leave
it blank.
Strongly agree...strongly disagree
a. The patient safety indicator reports were easy to understand
5
4
3
2
1
b. The graphic report was easier to use than the tabular report
5
4
3
2
1
Patient Safety Questionnaire, cont.
c. The tabular report provided more information than the graphic
report
5
4
3
2
1
d. My hospital’s indicator results, compared with the state’s rates,
are about what I would have expected
5
4
3
2
1
e. I want to share the report with colleagues in my hospital
5
4
3
2
1
f. I need additional information about one or more of the
indicators
5
4
3
2
1
Patient Safety Questionnaire, cont.
3. Please tell us anything you liked about the reports:
4. Please let us know of anything you did not like about
the reports:
5. Finally, please let us know any questions you’d like
answered about the reports:
Results
(14/41 questionnaires returned)
5
4
a. The PSI reports were easy to understand
28%
42%
b. The graphic report was easier to use than the
tabular report
35%
28%
c. The tabular report provided more information
than the graphic report
21%
d. My hospital’s indicator results, compared with
the state’s rates, are about what I expected
3
2
1
14%
14%
14%
14%
7%
28%
35%
7%
14%
25%
25%
33%
e. I want to share the report with colleagues in my
hospital
35%
28%
21%
7%
7%
f. I need additional information about one or more
of the indicators
50%
7%
14%
21%
7%
17%
Likes/dislikes about the PSI Reports
Likes:
 Good overview of our results
 Serves as a step for further analysis
 Great idea-shared this with Department of
Medicine
 Graphs were self-explanatory
Dislikes:
 Leaves many questions unanswered
 Need more current information
 Would like to set up and run on their own
Examples
Patient Safety Indicator
Patient Safety Event
Complications of anesthesia
Adverse Clinical Event
-sedation management
-complication/monitoring
Decubitus ulcers
Adverse Clinical Event
-skin integrity
-decubitus
Foreign body left in during
procedure
Adverse Clinical Event
-operative/invasive procedure
-instrument/needle/sponge count
Infection due to medical care
Adverse Clinical Event
-infection
May have to search
several fields to find
coordinating PSI
Conclusions
 Data captured from PSIs may best be used to investigate
potential patient safety problems when hospitals compare
PSIs to the coordinating medical error on the incident
reporting tool since:
 Some events don’t show up in discharge data that are
captured in the incident reporting tool, e.g.
– Adverse drug reactions
– Administrative events
– Fall events
– Employee events
– Visitor events
 PSI data is more general and may have to use several
fields in the incident reporting tool to capture complete
PSI data
WVMI plans to:
Compare 2003 PSI data with data from Web-based
incident reporting tool for hospitals that are part of
the WV Patient Safety Project
– Unable to compare 2002 PSI data with patient safety data
since the hospitals participating in the Patient Safety Project
did not start until middle of 2002; and indicators do not
correspond exactly.
– Provide this information to each participating hospital in
order that they will be able to compare their reporting rates
to PSI data
Source
 AHRQ patient safety indicator programs
http://www.qualityindicators.ahrq.gov
 Conversion routines and hospital output
code:
– [email protected]
– [email protected]
WVMI’s Patient Safety Project
– [email protected]