1. Ellen F. Robinson, PT ATC Clinical Quality Specialist Seattle, WA

2. 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 Confidential: Quality Improvement2 WAMI REGION

3. Confidential: Quality Improvement3 July 2008 WHAT IS A PSI? July 2009 Oh I wish I had a “toolkit” July 2010 AHRQ Toolkit Project July 2011 PSI Project Full Integration

4. External Reporting Internal Case Identification Medical QI Committee (MQIC) Departmental M & M review reporting Standardization of identification of potentially preventable harm events for clinical review Confidential: Quality Improvement4

5.  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 Confidential: Quality Improvement5

6.  Utilizing UHC database to track rates for PSI  UHC Quarterly Summaries ~ 3 months behind  Individual Case review from UHC ~ 6 weeks  Too late to make an impact Confidential: Quality Improvement6 How do we get PSI data in “real time”? Three months to implement software

7.  Internal Source System for data points (3M)  3M Report output= 2 pages, multiple Rows  PERL Script to transform into usable input file  Windows Version 3.2  Validate Numerator and Denominator against UHC output  Take the data from AHRQ software and be able to track the QI process for each case Confidential: Quality Improvement7

8.  Phase II AHRQ Validation Project Participation  Changed to Beta Version 4.0  Provided feedback to AHRQ technical staff on issues with new version  Challenges – Version discrepancies, running different versions concurrently on two machines to validate cases Confidential: Quality Improvement8

9.  HMC Project Originally utilized UHC as source  UHC runs the SAS version software on each hospitals administrative data set Confidential: Quality Improvement9

10. HMC Highest Prioritization scores: PSI 3 PSI 7 PSI 12 Confidential: Quality Improvement10

11.  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 Confidential: Quality Improvement11

12. Team Charter and Goals Gap Analysis Implementation Plan  Effective PSI improvement strategies  Evidence-based best practices for select PSIs Confidential: Quality Improvement12

13.  Understanding of Metrics  Validation of Metrics Confidential: Quality Improvement13 Make Friends with your Coders

14.  Clinical Teams Reviewed  PSI 03: Clinical Nurse Specialists wound care  PSI 07: Infection Control  PSI 12: Anticoagulation Task force: Trauma Surgeon, Hospitalist, Pharmacy, Nursing Confidential: Quality Improvement14

15.  Monthly Case Review by QI  10 days after end of previous month  Upload to internal database to track outcomes of each PSI  Providers report back through M&M conferences and MQIC Confidential: Quality Improvement15

16. Confidential: Quality Improvement16 HMC PSI Case Review HMC PSI Case Review Monthly Data Feed AHRQ QI Analysis Coding or Documentation issue? Documentation Coding Review Update coding Agree? ( Wrong code or exclusion criteria code missing) Real Event? Service Review No Event No Coding Issue No QI Concerns QI Concerns

17. Confidential: Quality Improvement17 HMC Analysis and Tracking

18. *Web based tool for Quality Metrics reporting Confidential: Quality Improvement18

19.  Clinical Event Search (CES) Tool ◦ VTE case finding from internal diagnostic systems for vascular and radiology events  VTE prophylaxis data points from EMR  Anticoagulation task force review all events to determine quality concerns on a case Confidential: Quality Improvement19

20. 20QI Confidential

21. For all VTE events, was standard of care met? Compliance with UW Medicine guidelines? Type? Timing? Dose intensity? If guidelines do not specify, what is the standard? What are the opportunities for improvement? 21QI Confidential

22.  Transitions of care - OR Procedures  Missed/held doses for OR ◦ Changed Dalteparin dosing to 2100  Education for Residents ◦ Noted doses “held for surgery” ◦ Attending physicians were not aware doses held ◦ Guideline directed therapy algorithm with increased web links through EMR and “clinical toolkit” Confidential: Quality Improvement22

23.  Transitions in care – Communication ◦ Clinical team pharmacists, ARNPs, Hospitalists receive daily list of all patients who did not receive chemical prophylaxis in the last 24 hours ◦ Both “not ordered” and “pt refusal  Nursing Education ◦ Doses held for “patient ambulatory” Confidential: Quality Improvement23

24. Task Force currently meeting with each clinical team individually to review guidelines and formalize each “standard of care” Confidential: Quality Improvement24

25.  Currently under review with our Decision Support and Finance groups  Task force on “Efficiency”  Utilizing the Cost Data from Prioritization Matrix as a quarterly tracking tool Confidential: Quality Improvement25

26.  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 ◦ Keep Current with Pub Med notifications ◦ Measures – links to TJC, NQF, CMS, UHC, IHI, WSHA, ◦ Publishing/RefWorks/EndNote http://libguides.hsl.washington.edu/qualitysafety Confidential: Quality Improvement26

27.  Systematic review of all PSI events  Is a high rate of events a true indicator of a quality issue at a hospital?  Are all PSI events “preventable”?  What about “missed” clinical events or “false negatives”? How do we identify those? Confidential: Quality Improvement27

28.  Standardized Case Review ◦ Jan to June 2011 ◦ PSI 3,6,7,9,11,12,15 ◦ 132 Events  58 occurred – no quality concerns  30 occurred – possible opportunities  33 events related to documentation or coding error  11 events “flawed metric”  PSI 11 flagged related to a planned two stage surgery  PSI 9 flag related to intra-operative bleeding Confidential: Quality Improvement28 PSI Cases Reviewed N = 132 No QI concerns44% Possible Opportunity 23% Documentation25% Flawed Metric8% At HMC ~ 1/3 rd are not “real” events

29.  January to June 2011 (67 VTE Events)  42 AHRQ PSI 12  25 additional VTE events (false negative) ◦ 16 cases not identified in administrative data ◦ 9 cases no operative procedure Without out internal clinical event search tool these cases would be missed QI opportunities * There were also 10 Cases of PSI 12 that were not real clinical events 29QI Confidential

30.  Presentations to clinical providers should focus on actual patient harm events  Coding department project lead/liaison  Leadership backing to encourage provider accountability and sustain project importance Confidential: Quality Improvement30 Validate, validate, validate………..

31.  Technical Issues to implement the AHRQ software may be challenging for hospitals  Version changes, input file specifications ◦ Continue to provide support via website/help line ◦ Consider asking hospitals what else they need? Confidential: Quality Improvement31

32.  Suggestions  Technical roadmap  Webinars for front end users  Reporting options  Information regarding risk adjustment coefficients and “targets” for each PSI Confidential: Quality Improvement32

33.  AHRQ QI rates are increasingly being used by external sources as a measure of quality  Version used and data source may result in disparate rates for the same institution  Information regarding version used should be clearly published on reporting sites  Transparency regarding methods for “PSI composite” calculations Confidential: Quality Improvement33

34.  Transition from a rate based tracking tool to one that provides hospitals opportunity for real changes for patients? ◦ How can hospitals use the indicators to analyze “gaps” in current clinical care? ◦ What to do about the gaps? Ongoing development of the evidence based “best practice” documents ◦ Should hospitals do enhanced chart audit of PSIs for additional data points regarding “preventablity”? Confidential: Quality Improvement34

35. Confidential: Quality Improvement35 Thank You AHRQ/RAND/UHC  Robin Weinick  Donna Farley  Rachel Burns  Lindsay Mayer Harborview Medical Center  Dr. J. Richard Goss  Dr. Anneliese Schleyer  Dr. Joseph Cuschieri  Ken Jarman, PharmD  Ronald Pergamit, QI/IT  Derk Adams, QI/IT  Patty Calver QI Ellen F. Robinson (206) 744 9550 lnrobin@u.washington.edu