Utilizing the Patient Safety Utilizing the Patient Safety Indicators for ImprovementIndicators for Improvement

Anita Gottlieb, MA, APN, CPHQAnita Gottlieb, MA, APN, CPHQSt. Joseph’s Mercy Health System St. Joseph’s Mercy Health System

Hot Springs, ArkansasHot Springs, Arkansas

““Great things are not done by impulse, Great things are not done by impulse, but by a series of small things brought but by a series of small things brought together”together” Vincent Van Gogh

The process: Beginning StepsThe process: Beginning Steps January 2005 began reviewing PSI January 2005 began reviewing PSI

indicators using an interdisciplinary teamindicators using an interdisciplinary team Leadership focused on data:Leadership focused on data: -Quality Committee of the Board, -Quality Committee of the Board,

Hospital Board and System BoardHospital Board and System Board Focused on areas where we Focused on areas where we exceededexceeded the the

AHRQ population rate as areas for AHRQ population rate as areas for improvementimprovement

PSI Data – January 2005PSI Data – January 2005

IndicatorIndicator AHRQ AHRQ RateRate

Facility Facility RateRate

NumeratorNumeratorCasesCases

Denominator Denominator CasesCases

PSI-03 PSI-03 Decubitus UlcerDecubitus Ulcer

24.7524.75 33.8033.80 1212 355355

PSI-11:Post-op PSI-11:Post-op Respiratory Respiratory FailureFailure

4.294.29 43.0143.01 55 147147

PSI-13:Postop PSI-13:Postop SepsisSepsis

11.811.8 20.8320.83 11 4848

PSI – 03: Decubitus UlcerPSI – 03: Decubitus Ulcer

PSI – 03: Decubitus UlcerPSI – 03: Decubitus Ulcer Reviewed all cases listed in PSI for Decubitius Reviewed all cases listed in PSI for Decubitius

Ulcer and found that present on admissions were Ulcer and found that present on admissions were not excluded especially for nursing home patientsnot excluded especially for nursing home patients

Even with exclusion of present on admission we Even with exclusion of present on admission we still frequently exceeded the AHRQ ratestill frequently exceeded the AHRQ rate

Improvement PlanImprovement Plan- Six Sigma Project - Six Sigma Project - Clinical Skin Team- Clinical Skin Team

““Lowdown on Skin”Lowdown on Skin” Projects purpose: Prevent Nosocomial Projects purpose: Prevent Nosocomial

Decubitus UlcersDecubitus Ulcers Nosocomial Decubitus Ulcers patients Nosocomial Decubitus Ulcers patients

have a longer length of stay than those have a longer length of stay than those patients that do not acquire a Decubitus patients that do not acquire a Decubitus Ulcer while hospitalizedUlcer while hospitalized

Length of Stay was the common MetricLength of Stay was the common Metric– Medicare’s Geometric Length of Stay for each DRG was the Medicare’s Geometric Length of Stay for each DRG was the

standard that we used to compare both the Ulcer Group and the standard that we used to compare both the Ulcer Group and the Non-Ulcer GroupNon-Ulcer Group

X’s causing most of our variation:• Daily Performance of Braden Scale• Pressure Ulcer Risk Level at Admission

Improve

Risk Level Category

Del

ta o

f al

l ca

ses

HighModerateLowNone

30

20

10

0

-10

-20

3.2

10.310.313.8

3.9

12.49.5510.9

Pressure Ulcer Risk Level (Braden Scale Admission Score) - Nosocomial Cases

Worksheet: Nosocomial RevisedBraden Daily? Y or N

Del

ta o

f al

l ca

ses

YESNO

30

20

10

0

-10

-20

5.410.9

7.5811.0

Performance of Daily Braden Scale - Nosocomial Cases

Worksheet: Nosocomial Revised

Graphical Analysis of X’s

Means appear in Red; Medians appear in Blue

Low Down on Skin – Six Sigma ProjectLow Down on Skin – Six Sigma Project

Before & After Pilot ComparisonBefore & After Pilot ComparisonBy using the Braden Scale, we compared the “Gold” Standard auditor’s scores to how the RN’s rated the Patients. We noted a significant improvement with the changes we implemented.

MEASUREMENT SYSTEM94%

65%

Before0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

GROUP

PER

CEN

T C

OR

REC

T

After

29% Improvement

in Accuracy of the Braden

Scale

Improve Improvement Improvement strategystrategy

PROBLEM CAUSE ACTIONX1: Pressure Ulcer Risk Level

● Level of Experience of Nurse ● Developed Skin Care 101 to present to Pilot Unit

● Non Standardized process across continuum of care

● Include statistical findings from "LOS" Six Sigma Project to inform clinical staff

● Fragmented care from team Nursing Process

● In-services scheduled from 10/27 - 10/31

● Randomized Audits on Pilot Unit● Developed Audit Tool - Peer Audit Form

● Instituted Report Outs with teams at beginning and end of shifts

● Develop Scripting for RN to deliver to patients at time of admission explaining importance of skin checks they will be performing

● Created two Risk Categories: 1) High Risk; 2) At Risk

X2: Performance of Skin Assessment Daily

● Relying on previous assessment performed

● Created worksheet to improve communication between Team members

● Charting of Risk Assessment moved to end of shift after review of worksheet

● Not Taking time to review patient because patient is not at risk on admission

● Instituted Report outs with Teams at beginning and end of shifts

● Time of Admission ● Develop Scripting for PCP to alert RN to perform skin check

● Revised Braden Scale Intervention Policy so any decrease of two points for "At Risk" patients would move the patient to the "High Risk" category and protocols would be instituted

What are the Financial Results?What are the Financial Results?

• There cost reduction after the Six Sigma There cost reduction after the Six Sigma project and it was directly associated with project and it was directly associated with the length of stay. the length of stay.

• The reductions relates to both direct cost The reductions relates to both direct cost and supplies.and supplies.

PrevalencePrevalenceYOUR FACILITY

PRESSURE ULCER PREVALENCE

16.6 %

14.4 %15.4 %

13.4 %

10.8 %9.8 %

8.6 %

7.1 % 7.0 %

9.2 %

0 %

2 %

4 %

6 %

8 %

10 %

12 %

14 %

16 %

18 %

PREVALENCE PREVALENCE EXCL STG I

PREVALENCE 16.6 % 14.4 % 15.4 % 13.4 % 10.8 %

PREVALENCE EXCL STG I 9.8 % 8.6 % 7.1 % 7.0 % 9.2 %

2005-03 2006-03 2007-03 2008-03 2009-03

YOUR FACILITYFACILITY ACQUIRED PREVALENCE

9.2 %

3.7 %

5.1 %5.6 %

3.8 %4.3 %

3.2 %

1.9 %1.4 %

2.3 %

0 %

1 %

2 %

3 %

4 %

5 %

6 %

7 %

8 %

9 %

10 %

HOSPITAL ACQ PREVALENCE HOSP ACQ EXCL STG I

HOSPITAL ACQ PREVALENCE 9.2 % 3.7 % 5.1 % 5.6 % 3.8 %

HOSP ACQ EXCL STG I 4.3 % 3.2 % 1.9 % 1.4 % 2.3 %

2005-03 2006-03 2007-03 2008-03 2009-03

PSI – 11: Post Operative Respiratory PSI – 11: Post Operative Respiratory FailureFailure

PSI – 11: Post Operative Respiratory PSI – 11: Post Operative Respiratory FailureFailure

Reviewed all cases listed in PSI for Reviewed all cases listed in PSI for Respiratory Failure Respiratory Failure

Definition of respiratory varied per physicianDefinition of respiratory varied per physician Coders were given exclusion PSI criteria Coders were given exclusion PSI criteria

and implemented use of documents Review and implemented use of documents Review Specialist for querying the physiciansSpecialist for querying the physicians

Education provided to physicians regarding Education provided to physicians regarding definitions of Respiratory Failure definitions of Respiratory Failure

PSI-13:Postop SepsisPSI-13:Postop Sepsis

PSI-13:Postop SepsisPSI-13:Postop Sepsis

Reviewed all cases and diagnosis for sepsis Reviewed all cases and diagnosis for sepsis were not meeting the “Surviving Sepsis were not meeting the “Surviving Sepsis Campaign” definition and guidelines Campaign” definition and guidelines - - Our facilities rate for Sepsis over all was Our facilities rate for Sepsis over all was greater than other hospitals in our Systemgreater than other hospitals in our System-- Determined some of “Sepsis” cases Determined some of “Sepsis” cases were being admitted to the acute units – not were being admitted to the acute units – not ICUICU

Previous Sepsis Six Sigma Project on Sepsis Previous Sepsis Six Sigma Project on Sepsis had been focused on Length of Stayhad been focused on Length of Stay

Hot Springs Six Sigma Sepsis LOS Hot Springs Six Sigma Sepsis LOS

SolutionsSolutions– Standardized processes for referral and Standardized processes for referral and

evaluation for transfer to SNF/LTAC/Hospiceevaluation for transfer to SNF/LTAC/Hospice– Implemented providing antibiotics within three Implemented providing antibiotics within three

hourshours– Removed barrier to tubing blood cultures and Removed barrier to tubing blood cultures and

implemented tracking of timesimplemented tracking of times ImpactImpact

– Reduced LOS by .92 daysReduced LOS by .92 days– Improved time for blood cultures to lab by 126 Improved time for blood cultures to lab by 126

minutesminutes– Potential financial benefit – X $Potential financial benefit – X $

PSI Data – January2009/ 2005PSI Data – January2009/ 2005

IndicatorIndicator AARQAARQ20092009

FacilityFacility20092009

NumeratorNumeratorCases Cases (09/05)(09/05)

Denominator Denominator CasesCases(09/05)(09/05)

PSI-03 PSI-03 Decubitus UlcerDecubitus Ulcer

25.125.1 11.8711.87 4 (12)4 (12) 337337 (355) (355)

PSI-11:Post-op PSI-11:Post-op Respiratory Respiratory FailureFailure

9.029.02 23.8123.81 1 (5)1 (5) 4242 (147) (147)

PSI-13:Postop PSI-13:Postop SepsisSepsis

11.4411.44 62.5062.50 1 (1)1 (1) 1616 (48) (48)

Lessons LearnedLessons Learned Work on “Present on Admission” prior to Work on “Present on Admission” prior to

October 2008 was impactfulOctober 2008 was impactful

Six Sigma tools have impacted positively on Six Sigma tools have impacted positively on cost savings and quality of carecost savings and quality of care

Must take small steps – it will take time and Must take small steps – it will take time and must continue monitoring to sustainmust continue monitoring to sustain

QuestionsQuestions

““One’s destination is never a place but rather One’s destination is never a place but rather a new way of looking at things.”a new way of looking at things.”

Henry MillerHenry Miller