# Presentation: 528812

## Going Public

**Ben Yandell**, PhD, CQE
- Clinical Information Analysis
- Norton Healthcare, Louisville, KY
- ben.yandell@nortonhealthcare.org

## Norton HealthcareQuality Report

**We don’t have to do this, but ...**
-    In a spirit of openness and accountability, we will show the public our performance on nationally endorsed _**lists**_ of quality indicators and practices.
- Not: invent or choose indicators that make us look **good**
- Not: hide or redefine indicators that make us look **bad**

**Notes:**
Not PR.  Not homegrown.  Not cherry-picked indicators.  Brutally honest.

## >270 indicators + safe practices

- National Quality Forum (NQF)
- Hospital care
- Adult cardiac surgery
- Nursing-sensitive indicators
- Safe practices
- Shell in place for ambulatory indicators
- JCAHO
- JCAHO/CMS adult core measures
- National patient safety goals
**AHRQ**
**Patient safety indicators (PSIs)**
**Inpatient quality indicators (IQIs)**
- Others (e.g., pediatric ORYX, NICU mortality)
- Also:  financials, patient satisfaction

## Surgery

| brief description | desired | AUD | NH | SW | SUB | KCH | KY | U.S. |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| % select surg. patients given preop. antibiotic on time | high | 80 | 80 |   | 96 |   |  63 | 69 |
| % select surg. patients given recom. preop. antibiotic | high |   |   |   |   |   |   |   |
| % select surg. pats. w/antibiotic discontinued on time | high | 58 | 80 |   | 81 |   |  68 | 64 |
| % gall bladder surgery done laparoscopically | high | 87 | 84 |   | 79 | 77 | 91 | 75 |
| % incidental appendectomy in those over 64 years old | low | 0 | 1.5 |   | 0.2 |   | 2.6 | 2.4 |
| % inpatients with a reported complication of anesthesia | low | 0.07 | 0.13 |   | 0.05 | 0.06 | 0.07 | 0.08 |
| % surgeries where foreign body was unintentionally left | low | 0 | 0.01 |   | 0 | 0.02 | 0.00 | 0.01 |
| % select surgeries encountering technical difficulties | low | 0.10 | 0.81 |   | 0.23 | 0.41 | 0.34 | 0.35 |

- September 14, 2005 posting

**Red or green if outside 99% C.I. based on U.S.**

**Notes:**
Note mix of AHRQ and other indicators on same page.
Consistent use of %, rather than per 1,000.
Pediatric (KCH) AHRQ indicators in unshaded italics, due to no national comparison.

## How we use PSIs and IQIs 

- Publicly report rolling 12 months
- Risk-adjusted (not smoothed) rates straight from AHRQ software.  Period.
- Use KY hospital discharge database, despite limited # of diagnosis codes
- Create service line report cards (only that patient population; no U.S.)

## Surgery

| brief description | desired | AUD | NH | SW | SUB | KCH | KY | U.S. |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| % surgeries w/ postoperative bleeding | low | 0.15 | 0.23 |   | 0.30 | 0.19 | 0.22 | 0.22 |
| % abdominal surgeries w/ postop wound dehiscence | low | 0.00 | 0.20 |   | 0.22 | 0.24 | 0.16 | 0.20 |
| % w/ pneumothorax resulting from medical care | low | 0.09 | 0.08 |   | 0.05 | 0.07 | 0.07 | 0.08 |
| % surgeries w/ postoperative physiologic derangement | low | 0.05 | 0.09 |   | 0.05 | 0.03 | 0.09 | 0.11 |
| % surgeries w/ postoperative respiratory failure | low | 0.6 | 1.6 |   | 0.6 | 0.9 | 0.8 | 0.4 |
| % surgeries w/ postoperative PE or DVT | low | 1.1 | 1.5 |   | 0.8 | 0.8 | 0.9 | 0.9 |
| % surgeries w/ postoperative sepsis | low | 5.2 | 3.1 |   | 1.8 | 0 | 1.9 | 1.2 |
| % craniotomy patients who die (AHRQ risk-adjusted) | low | 6.5 | 6.8 |   | 6.6 |   | 7.4 | 7.4 |

- September 14, 2005 posting

**Red or green if outside 99% C.I. based on U.S.**

## Chart review vs. administrative data

- Our data validation process
- Secondary review of measure failures
- Interrater reliability reviews on data from retrospective medical records
- Rarely find a coding error
- Initial physician reaction:Then I just won’t write that down.

## PSI 13.  Postop. sepsis

-  **Include**
- Elective surgery inpatients with a stay of 4+ days
-  **Exclude**
- Principal dx of sepsis or certain infections
- Any dx of immunocompromised state or cancer
-  **Adjust for**
- Patient age, sex
- DRG
- comorbid secondary dx

**Although they were **_**correctly coded**_**, ****as many as ****50%**** of these patients did not have postop sepsis.**

## PSI 1 – complications of anesthesiaNurse reviewer uncomfortable that any true post-admission complication found in 4 of the 5 cases (1 hx-only from previous admission; 2 PONV)
PSI 7 – infection due to medical care (IV lines)Comments on 23% of 97 reviews.  POA; redness only w/ no or negative cultures
PSI 8 – postop hip fractureIn 3 of 5 cases the hip fx was pre-admission.
PSI 10 – postop physiologic derangement2/5 present on admission
PSI 11 – postop respiratory failureComments on 49% of 84 reviews.  POA or missed risk factor.
PSI 15 – accidental puncture or laceration in surgeryMostly accurate, but many unavoidable or trivial.
PSI 19/28 – vaginal deliveries with “3rd- & 4th-degree lacerations”Many not 3rd/4th.  Near vs. injury to...

**PSI 7 – infection due to medical care (IV lines)**Comments on 23% of 97 reviews.  POA; redness only w/ no or negative cultures
**PSI 8 – postop hip fracture**In 3 of 5 cases the hip fx was pre-admission.
**PSI 10 – postop physiologic derangement**2/5 present on admission
**PSI 11 – postop respiratory failure**Comments on 49% of 84 reviews.  POA or missed risk factor.
**PSI 15 – accidental puncture or laceration in surgery**Mostly accurate, but many unavoidable or trivial.
**PSI 19/28 – vaginal deliveries with “3****rd****- & 4****th****-degree lacerations”**Many not 3rd/4th.  Near vs. injury to...

## Results

- New pressures and attention on physician documentation and medical records coding.  Financial still first, but clinical now relevant.
- Physicians generally accepting so far
**Go Green**
- KHA has patient safety committee (AHRQ)
- Kentucky govt. may publish PSIs/IQIs
- More scrutiny of indicator definitions

## Some requests

- Imitate AHRQ in documenting inclusions, exclusions, risk adjustment, etc.
- Need more comparative data.  Remove restrictions on use of aggregate data
- Guidance on analysis and display
- Fix obvious data gaps:  present on admission, DNR
- Better documentation of rationale  E.g., why not use the relevant 99 code?
- Name indicators operationally – not by their presumed cause (“failure to rescue”)
- Recognize that the public is not the only audience in public reporting

## Final thoughts

- Data do not become valid until used.
- The number is what the number is.
- Even lousy indicators improve care.