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PATIENT SAFETY AND DOCUMENTATION: Connecting the Dots
Eleftherios Xenos, MD Associate Chief Medical Officer Assistant Medical Director Clinical Documentation Integrity Amanda Green, DNP, RN Director, Quality Monitoring & Reporting Tracy Nassida, BSN, RN Clinical Quality Specialist
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Faculty Disclosure Neither presenter has any relevant financial relationships to disclose.
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Educational Need/Practice Gap
Patient Safety Indicators are based upon physician documentation and ICD 10 coding. These indicators impact patient safety performance and performance in multiple quality scorecards.
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Objectives Upon completion of this educational activity, you will be able to: Explain the definition, including exclusions and inclusions, for Patient Safety Indicators. Identify the most common documentation opportunities regarding Patient Safety Indicators.
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What are Patient Safety Indicators (PSI’s)?
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PSI’s Set of measures defined by AHRQ
Provide information on potential complications and adverse events following hospitalization and procedures Based on ICD 10 codes
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PSI 03 – Pressure Ulcer Inclusions Exclusions
Documentation of Stage III, Stage IV or Unstageable (including DTI’s) pressure injuries not POA Surgical or medical patients Exclusions Transfer from another hospital, SNF or intermediate care facility Hemiplegia, paraplegia, quadriplegia, spina bifida, anoxic brain injury
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PSI 06 – Iatrogenic Pneumothorax
Inclusions Documentation of iatrogenic pneumothorax or post procedural pneumothorax Exclusions Chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic surgical repair, cardiac procedures
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PSI 07 – Central Venous Catheter Related Blood Stream Infection
Inclusions Documentation of infection complicating central venous catheter Medical and surgical discharges Exclusions POA, Diagnosis of cancer or immunocompromised
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PSI 08 – In Hospital Fall with Hip Fracture
Inclusions Documentation of hip fracture not POA Medical and surgical discharges Exclusions Principle diagnosis that is susceptible to falls (seizure disorder, syncope, stroke, occlusion of arteries, coma, trauma, delirium, psychoses, metastatic cancer, lymphoid or bone malignancy) or self-inflicted injury
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PSI 09 – Perioperative Hemorrhage or Hematoma
Inclusions Documented hemorrhage or hematoma (not POA) in surgical patients involving a procedure to treat the hemorrhage or hematoma Exclusions Documented coagulation disorder or postoperative coagulopathy secondary to medication
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PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis
Inclusions Documented postoperative kidney failure in elective surgery patients resulting in dialysis Exclusions Acute kidney failure POA Patients with cardiac arrest, shock, urinary tract obstruction or chronic kidney failure
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PSI 11 – Postoperative Respiratory Failure
Inclusions Elective surgery with documented Postoperative respiratory failure Prolonged mechanical ventilation Reintubation Exclusions Principle diagnosis for acute respiratory failure Documented neuromuscular disorders, laryngeal/pharyngeal/craniofacial surgery, esophageal resection, lung cancer, lung transplant
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PSI 12 – Perioperative PE or DVT
Inclusions Documented PE or DVT not POA Exclusions Upper extremity clots Documentation of IVC filter
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PSI 13 – Postoperative Sepsis
Inclusions Elective surgery with documented postoperative sepsis Exclusions Principle diagnosis for infection
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PSI 14 – Postoperative Wound Dehiscence
Inclusions Abdomen or pelvic surgeries with wound dehiscence documented postoperatively and return to OR for wound reclosure Exclusions POA wound dehiscence Principle diagnosis of immunocompromised state
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PSI 15 – Unrecognized Abdominopelvic Accidental Puncture or Laceration
Inclusions Documented accidental puncture or laceration during a procedure of the abdomen or pelvic that requires a second abdominopelvic procedure one or more days after the index procedure Exclusions POA
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What is PSI 90? Composite score of PSI’s
Also referred to as Harm Score
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How Do I Document to Accurately Reflect PSI’s?
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Terms and Examples Implies Adverse Event Implies NO Adverse Event
Inadvertent Complication Complicated by Accidental Accidentally Unintended Unintentionally Iatrogenic Implies NO Adverse Event To facilitate Necessary Required Intentional Intended Inherent Integral Routinely expected
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Most Frequent Queries PSI 11 PSI 12 PSI 13 PSI 15
Complication of surgery/related to other conditions or comorbidities PSI 12 POA status PSI 13 Diagnosis ruled out PSI 15 Inherent to procedure
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How Does UK HealthCare Decide Which Cases are PSI’s?
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ICD 10 Codes for discharged patients are run through AHRQ software
PSI Review Process ICD 10 Codes for discharged patients are run through AHRQ software Patients identified with PSI’s are entered into SharePoint and reviewed by Coding Physician Reviewers Clinical Quality Specialist PSI charts are reviewed at biweekly PSI Review Meeting True PSI cases are communicated with appropriate teams Queries sent to clarify cases as needed
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How Does UK HealthCare Perform on PSI’s?
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Where are PSI’s Reported?
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CMS Quality Reporting Programs
Hospital Acquired Condition Reduction Program PSI 90 = 15% of score Hospitals performing in the bottom quartile have hospital payments reduced by 1% Value Based Purchasing Program PSI 90 Included in Safety Domain with is 25% of score Up to 2% of hospital payments based on score
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Vizient Quality and Accountability Study
Safety Domain is 26.25% of score Includes PSI 03 – Pressure Ulcer PSI 06 – Iatrogenic Pneumothorax PSI 09 – Postoperative Hemorrhage or Hematoma PSI 11 – Postoperative Respiratory Failure PSI 13 – Postoperative Sepsis
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Questions?
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