AHRQ Toolkit The Harborview Experience

1. AHRQ ToolkitThe Harborview Experience Ellen F. Robinson, PT ATC Clinical Quality Specialist Seattle, WA

2. The Harborview Experience WAMI REGION 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 Improvement

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

4. Quality Improvement InitiativeTwo Goals 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 Improvement

5. Section AReadiness for Change • 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 Improvement

6. Section B: Applying the Indicators to your hospital data • 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 How do we get PSI data in “real time”? Three months to implement software Confidential: Quality Improvement

7. Data Challenges • 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 Improvement

8. Other Data Challenges • 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 Improvement

9. Section C: Identifying Priorities for Quality Improvement • HMC Project Originally utilized UHC as source • UHC runs the SAS version software on each hospitals administrative data set Confidential: Quality Improvement

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

11. Take it on the road! • 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 Improvement

12. Section D: Implementation Tools • Team Charter and Goals • Gap Analysis • Implementation Plan • Effective PSI improvement strategies • Evidence-based best practices for select PSIs Confidential: Quality Improvement

13. PSI Improvement Opportunities • Understanding of Metrics • Validation of Metrics Make Friends with your Coders Confidential: Quality Improvement

14. Evidence-based best practices for select PSIs • 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 Improvement

15. HMC Implementation • 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 Improvement

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

17. HMC Analysis and Tracking Confidential: Quality Improvement

18. Section E: Monitoring Progress *Web based tool for Quality Metrics reporting Confidential: Quality Improvement

19. HMC Outcomes – AHRQ ToolkitPSI 12 Selected as focus area • 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 Improvement

20. QI Confidential

21. Implementation Measurement • 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? QI Confidential

22. Clinical Opportunities • 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 Improvement

23. Clinical Opportunities • 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 Improvement

24. PSI 12 Monitoring Progress Task Force currently meeting with each clinical team individually to review guidelines and formalize each “standard of care” Confidential: Quality Improvement

25. Section F: Return on Investment • 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 Improvement

26. Section G: Existing QI Resources • Reviewed by our Research Librarian • Incorporated into University of Washington Health Sciences LibGuidesweb 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 Improvement

27. PSI as a Quality Measure • 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 Improvement

28. PSI Review Findings • 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 At HMC ~ 1/3rd are not “real” events Confidential: Quality Improvement

29. VTE events from CES PSI 12 • 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 QI Confidential

30. HMC PSI Project Lessons Learned • 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 Validate, validate, validate……….. Confidential: Quality Improvement

31. Technical “bumps” • 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 Improvement

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

33. PSIs and Public Reporting • 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 Improvement

34. The “Future” of PSI • 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 Improvement

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