Using AHRQ Patient Safety Indicators to

Improve Quality: The Stanford Hospital

Experience

John M. Morton, MD, MPH, FACS

Associate ProfessorDirector of Surgical Quality

“To Err is Human” STANFORDBOARDDIRECTIVE

Administrative Data

• Financial

• Clinical Input

• Goethe

– “ You search where there is light”

Administrative Data

• Consistent

• Benchmark

• Prioritize

• Variance

Department of Surgery Quality Plan Preview

• Imperative from SHC Board

• Areas of Focus

• Measurement

• Goals

• Communication

• Education

• Accountability

• Leadership

DRG Drill Down

BENCHMARK

*

PSIs: Quality Diagnostic Tool

2007 Quality Improvement and Patient Safety ScorecardPatient Safety Indicators - Rate per 1,000

Overall Performance Rankings

SHC UHC SHC SHC UHC SHC SHC UHC SHCPSI Overall Median Rank Overall Median Rank Overall Median RankDeath in Low Mortality DRG 1.70 0.50 119/122 1.60 0.40 125/132 0.60 0.50 57/89Failure to Rescue 134.50 110.60 94/121 141.50 107.60 113/132 127.20 107.20 55/89Decubitus Ulcer 10.90 28.10 12/122 10.90 22.40 9/132 17.40 23.50 26/89Foreign Body 0.10 0.10 65/122 0.30 0.10 103/132 0.10 0.20 21/89Iatrogenic pneumothorax 1.70 0.90 108/122 1.60 0.90 116/132 1.90 1.10 82/89Selected Infection due to Medical Care 4.80 3.80 77/122 4.00 3.60 74/132 4.90 4.10 49/89Post Op Hip Fracture 0.35 0.00 92/120 0.20 0.00 75/132 0.20 0.20 49/89Post Op Hemmorage/Hematoma 3.50 3.10 84/120 4.80 3.90 91/132 5.90 4.70 81/89Post Op Phys/Metabolic 1.70 2.00 54/120 1.80 1.80 68/131 2.60 2.50 79/89Post Op Respiratory Failure 11.20 12.70 47/120 10.10 12.20 47/131 11.40 15.70 24/89Post Op PE or DVT * 18.90 15.60 84/120 17.20 16.70 73/132 18.50 20.10 35/89Post Op Sepsis * 9.90 10.70 56/120 9.10 10.70 52/131 10.30 13.40 36/89Post Op Wound Dehiscence 0.60 2.20 26/118 3.80 2.10 107/131 4.20 2.50 73/89Accidental Puncture or Laceration 7.20 5.00 82/122 8.20 5.00 104/132 8.90 6.30 46/89Transfusion Reaction 0.00 0.00 1/122 0.00 0.00 1/131 0.00 0.00 1/89* Run charts attached

Oct 2006 - Sep 20072005Rate per 1,000Rate per 1,000

2006Rate per 1,000

Comments: The ARHQ indicators are surrogate measures for how well care is delivered based on complication rates. Overall our performance shows tremendous opportunity to improve our standings and requires focused efforts to drill down on the data and look for causal relationships.

Priority PI Initiatives include:SepsisPost Op DVTIatrogenic Pneumothorax

The Clinical Documentation program will establish a consistent baseline for how complications are assigned.

Goals Actions

DVT/PE: Reduce the rate of DVT &

PE by 25% by December 2008.

Increase MonitoringProvide Feedback to PhysiciansImprove Compliance to order sets

Sepsis: Reduce hospital mortality of severe sepsis & septic shock from 50% to 40% by Jan 09

Update Sepsis GuidelinesImplement processes for early identification of sepsis and aggressive treatmentEstablish ICU/ED task force and spread learning

IAP: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08

Promote ultrasound-guided internal jugular (IJ) catheterization as the method of choice for CVCRequire all medical & surgical interns to complete CVC Website Curriculum & Simulation Program during orientationRequire that the first 5 CVCs by a house staff member be supervised by a more senior physician who has successfully inserted & documented the placement of 5 CVCs

Top Priority PI Action Plans

UHC DVT/PE Measure

Incidence of DVT/PE by DRG

Concurrent Surgical Audit• Concurrent audit started in Feb 08; conducted by Quality Specialist 24

hours after surgery on:– Orthopedic surgery

– General surgery patients

• “Risk level” of patient is assessed by Quality Specialist & compliance determined based on current order

• Surgical DVT Prophylaxis must be ordered and 1st drug dose given within 24 hours after surgery

• If no order or inadequate order, a “fix-it” ticket is placed in medical record so MD can order or revise prophylaxis

Radiology DVT/PE Report

DVT/PE Risk Assessment in Epic

Retrospective Surgical Audit ( radiology test)

Accordance of Ordered Drug Agent, Dose & Frequency to Patients Risk Level and SHC Guidelines (N=17)

(Aug-Oct 08)

88% 88% 88%

0%

20%

40%

60%

80%

100%

Drug Agent Drug Dose Drug AdministrationFrequency

%

Retrospective Surgical Audit

Postoperative Drug Prophylaxis Ordered and 1st Drug Dose Administered within 24 Hours of Surgery (N=17)

(Aug-Oct 08)

53%

71%

0%

20%

40%

60%

80%

100%

MD Order w/in 24 hrs of Surgery Receipt of 1st dose w/in 24 hrs ofSurgery

%

Reduce the rate of DVT & PE by 25% by December 2008.Action Agents TimelineMonitor concurrent MD ordering practices of DVT prophylaxis & educate/reinforce Epic order sets.

Quality Specialist to audit 10 charts/wk of General & Ortho Surgery pts & educate MDs.

Begin Feb 1

Review concurrent DVT/PE cases for adherence to DVT prophylaxis guidelines monthly.

Quality Specialist to perform audit based on monthly report of + radiology tests.

Feb 18

Examine & present results from concurrent monitoring & audit & NSQIP data to providers.

P. Pilotin & K. Bashaw to discuss results with Chairs of General & Orthopedic Surgery.

Feb 25

Educate physicians to DVT guidelines and order sets.

P. Pilotin to develop/distribute materials of DVT guidelines & screen shots of Epic DVT order set.

Feb 15

Establish rules & rates for DVT/PE cases for individual MD profiles.

Quality Dept to establish rules & rates in Midas.

March 31

Refine DVT prophylaxis guidelines for medical patients.

K. Posley to review/revise guidelines. Feb 1

REAL-TIME AssessmentDVT/PE Concurrent Review By Action Team

Action Plan for DVT/PE

DVT/PE Rates with SCIP VTE Compliance Comparison by Quarter

Incidence of Medical and Surgical Cases

ANALYSIS: The incidence of hospital-acquired DVT/PE of both medical and surgical cases decreased in Qtr 3 2008.

First quarter 2008 rate 8.37/1000 Second quarter 2008 rate 14.28/1000 Third quarter 2008 rate 8.59/1000

ACTION: Retrospective auditing of cases identified by radiology test is being conducted to assess adherence to guidelines. Process for this is under consideration to move to a concurrent audit to improve patient care and outcomes.

Incidence of DVT/PE by DRG Type(Qtr 1 06 to Qtr 3 08)

14 1410 9 10

21

15

10 11

25

14

43 44

3436 37

4952 53

38

57

35

0

10

20

30

40

50

60

2006-1 2006-2 2006-3 2006-4 2007-1 2007-2 2007-3 2007-4 2008-1 2008-2 2008-3

# o

f C

as

es

0

5

10

15

20

25

Cas

es p

er 1

000

Inp

atie

nt

Dis

char

ges

Medical DRG Cases Surgical DRG Cases Medical Rate Surgical Rate Overall Rate

UHC Benchmark: IAPAHRQ Patient Safety Indicators

Iatrogenic PneumothoraxRate per 1000

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

2003 Q

2

(N=

2969)

2003 Q

4

(N=

4439)

2004 Q

2

(N=

4533)

2004 Q

4

(N=

4474)

2005 Q

2

(N=

4615)

2005 Q

4

(N=

5010)

2006 Q

2

(N=

5139)

2006 Q

4

(N=

5063)

2007 Q

2

(N=

5195)

2007 Q

4*

(N=

5164)

ObservedTargetUHC Median

CVC related Iatrogenic Pneumothorax to all Iatrogenic Pneumothorax cases

• Next steps: focus on other causes of IAP: thorascopic lung biopsy, feeding tube placement and EP procedures

3

76

12

1

2 4

6

9

0

2

4

6

8

10

12

1Q2007 2Q2007 3Q2007 4Q2007 1Q2008

Nu

mb

er

of

Cases

CVC OTHER CAUSES

Start of Education Roll-out

CVC Insertion Site

Insertion Site of CVC-Related Iatrogenic Pneumothoraces in MEDICAL Patients

0

1

2

3

4

5

IJ SC

# of

Cas

es

Insertion Site of CVC-Related Iatrogenic Pneumothoraces in SURGICAL Patients

0

1

2

3

4

5

IJ SC

# of

Cas

es

1Q2007 2Q2007 3Q2007 4Q2007 1Q2008

Action Agent Timeline

Promote ultrasound-guided internal jugular (IJ) catheterization as the method of choice for CVC

Limit use of subclavian approach to:

• access to the neck is limited (e.g., trauma/code resuscitations)• patients with suspected neck injuries• lack of other available sites

• L. Shieh to revise CVC Website Curriculum & Simulation Program to further promote IJ approach

• Drs. Maggio, Williams, Mihm & Lee to educate ED, OR & General Surgery. Drs. Mihm, Riskin and Daniels to educate ICU. Dr. Shieh to educate B2 & D1.

• I. Tokareva to develop & distribute educational materials to reinforce

Start Jan 22 & ongoing

Require all medical & surgical interns to complete CVC Website Curriculum & Simulation Program during orientation (“Bootcamp” for surgical interns)

• Drs. Shieh, Maggio, Williams, Mihm & Lee

• Monitor quarterly IAP rates for impact

June 30

GOAL: Reduce the rate of iatrogenic pneumothorax (IAP) from central venous catheterization (CVC) by 50% by December 08.

Action Plan

• The evidence– Early Goal-Directed Therapy– Initiation of Appropriate Antimicrobial

Therapy– Treatment with Hydrocortisone– Activated Protein C– Glucose Control– Lung Protective Strategies

• Goal of 2008 SHC Quality Initiative on Severe Sepsis and Septic Shock: Reduce hospital mortality by 10% from Jan 08 to Jan 09

• May 2008: Initial education of ICU Guidelines for Severe Sepsis & Septic Shock

• December 2008:Epic order sets revised to reflect changes in guidelines.

ANALYSIS:. 25% of cases received antibiotics within one hour of identification. Appropriate antibiotics were given in nearly all of the cases. In 40% of the cases, antibiotic were given >120 minutes, in 60% antibiotics were given within 64 minutes on average. ACTION: Measure process indicators in context of when SS/SS management guideline algorithm started. Map process to determine areas for improvement.

n = 16

PROCESS INDICATOR 4

Appropriate Antibiotic Administered

(Cases NOT previously receiving antibiotics)N = 16

95

0

20

40

60

80

100

% C

om

plia

nce

PROCESS INDICATOR 3:

Antibiotic Received w/in 1 Hr of Identification

(Cases who were NOT Previously Receiving Antibiotics) N = 12

25

0

20

40

60

80

100

% C

om

pli

ance

PROCESS INDICATOR 5:

Steroids Received w/in 24 hrs for Cases whose MAP < 65 mm despite Adequate

Fluid Resuscitation and Vasopressor Administration

25

0

20

40

60

80

100

% C

om

plia

nc

e

ANALYSIS: Poor compliance in ordering steroids for cases failing therapy. Steroids were given only 25% of the time. Glucose control was reached in 65% of the cases. Of the 35% of cases with BG > 150, mean BG was 176. ACTION: Educate physicians to document rationale for not giving steroids in next quarterly audit. Work with ICU team, nursing groups to determine root causes for elevated BG>150 after 24 hrs.

N =25

PROCESS INDICATOR 6:

Blood Glucose < 150 mg/dl w/in 24 Hrs of ICU Admission

N = 24

65

0

20

40

60

80

100

% C

ompl

ianc

e

PPEC: Accountable Outcomes

PPEC: Accountable OutcomesSCIP

PPEC: Accountable OutcomesPSIs

Use of PSI in PPEC: Post-op Hematoma

Use of PSI in PPEC: Accidental Puncture or Laceration

Persistent Pursuit of Excellence• Dedicated Monthly Grand Rounds on Quality• NSQIP based Morbidity and Mortality Conference• Resident Award for Quality Improvement• Novel Quality Improvement/Patient Safety Resident Curriculum• Documentation Improvement Program• Peer Review• Surgery Quality Council• Quality Initiatives: DVT, Sepsis, Iatrogenic Pneumothorax,Vent

>48 hours, Colo-rectal Wound Infection• Rounding Policy• OR Checklist• Leadership

HAWTHORNE EFFECT

National PSI RatesMorton 2009

High-Frequency Increasing PSIs

10

20

30

40

50

60

70

1998 1999 2000 2001 2002 2003 2004 2005

Year of Discharge

Ris

k-A

dju

ste

d R

ate

per 1

000 D

isch

arg

es

3: Decubitus Ulcer* 11: Postoperative Respiratory Failure** 12: Postoperative PE/DVT*

13: Postoperative Sepsis* *Statistically Significant p<0.005 **Statistically Significant p<0.05

D

DecubitusSepsisPostop RespPE/DVT

Clinical Outcomes Report: Product Line Mortality ComparisonOctober 2006 – September 2007

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

Vascular Surgery Case = 271 Deaths = 6 Rate =2%

Urology Case = 719 Deaths = 2 Rate =0%

Trauma Case = 182 Deaths = 5 Rate =3%

Surgery Oncology Case = 304 Deaths = 5 Rate =2%

Surgery General Case = 2292 Deaths = 54 Rate =2%

Spinal Surgery Case = 1225 Deaths = 0 Rate =0%

Plastic Surgery Case = 176 Deaths = 0 Rate =0%

Otolaryngology Case = 411 Deaths = 4 Rate =1%

Orthopedics Case = 2330 Deaths = 8 Rate =0%

Neurosurgery Case = 903 Deaths = 35 Rate =4%

Lung Transplant Case = 35 Deaths = 1 Rate =3%

Liver Transplant Case = 58 Deaths = 1 Rate =2%

Kidney/Pancreas Transplant Case = 78 Deaths = 0 Rate =0%

Heart Transplant or Implant Case = 58 Deaths = 6 Rate =10%

Gynecology Case = 580 Deaths = 0 Rate =0%

Cardiothoracic Surgery Case = 988 Deaths = 48 Rate =5%

UHC Median

SHC

175 Surgical Deaths, Dept of Surgery 71, 2.1%SF=110, Oakland=140

General Surgery

UHC Mortality Index (Observed/ Expected)

0.97 0.95

0.820.830.79

0.56

0

0.2

0.4

0.6

0.8

1

Year

O/E

Ind

ex

Stanford General Surgery Product Line

  2006 2007 July 2007 to June 2008

General Surgery UHC Ranking

20/92 24/91 1/98

Stanford UHC Ranking 40/90 30/91 26/98