1. Utilizing the Patient Safety Indicators for Improvement Anita Gottlieb, MA, APN, CPHQ St. Joseph’s Mercy Health System Hot Springs, Arkansas

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

3. The process: Beginning Steps  January 2005 began reviewing PSI indicators using an interdisciplinary team  Leadership focused on data: -Quality Committee of the Board, Hospital Board and System Board -Quality Committee of the Board, Hospital Board and System Board  Focused on areas where we exceeded the AHRQ population rate as areas for improvement

4. PSI Data – January 2005 Indicator AHRQ Rate Facility Rate NumeratorCases Denominator Cases PSI-03 Decubitus Ulcer 24.7533.8012355 PSI-11:Post-op Respiratory Failure 4.2943.015147 PSI-13:Postop Sepsis 11.820.83148

5. PSI – 03: Decubitus Ulcer

6.  Reviewed all cases listed in PSI for Decubitius Ulcer and found that present on admissions were not excluded especially for nursing home patients  Even with exclusion of present on admission we still frequently exceeded the AHRQ rate Improvement Plan - Six Sigma Project - Clinical Skin Team

7. “Lowdown on Skin”  Projects purpose: Prevent Nosocomial Decubitus Ulcers  Nosocomial Decubitus Ulcers patients have a longer length of stay than those patients that do not acquire a Decubitus Ulcer while hospitalized  Length of Stay was the common Metric –Medicare’s Geometric Length of Stay for each DRG was the standard that we used to compare both the Ulcer Group and the Non-Ulcer Group

8. X’s causing most of our variation: Daily Performance of Braden Scale Pressure Ulcer Risk Level at Admission X’s causing most of our variation: Daily Performance of Braden Scale Pressure Ulcer Risk Level at Admission Improve Graphical Analysis of X’s Means appear in Red; Medians appear in Blue Low Down on Skin – Six Sigma Project

9. Before & After Pilot Comparison By 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. 29% Improvement in Accuracy of the Braden Scale

10. Improve Improvement strategy

11. What are the Financial Results? There cost reduction after the Six Sigma project and it was directly associated with the length of stay.There cost reduction after the Six Sigma project and it was directly associated with the length of stay. The reductions relates to both direct cost and supplies.The reductions relates to both direct cost and supplies.

12. Prevalence

13. PSI – 11: Post Operative Respiratory Failure

14.  Reviewed all cases listed in PSI for Respiratory Failure  Definition of respiratory varied per physician  Coders were given exclusion PSI criteria and implemented use of documents Review Specialist for querying the physicians  Education provided to physicians regarding definitions of Respiratory Failure

15. PSI-13:Postop Sepsis

16.  Reviewed all cases and diagnosis for sepsis were not meeting the “Surviving Sepsis Campaign” definition and guidelines - Our facilities rate for Sepsis over all was greater than other hospitals in our System -Determined some of “Sepsis” cases were being admitted to the acute units – not ICU Previous Sepsis Six Sigma Project on Sepsis had been focused on Length of Stay

17. Hot Springs Six Sigma Sepsis LOS  Solutions –Standardized processes for referral and evaluation for transfer to SNF/LTAC/Hospice –Implemented providing antibiotics within three hours –Removed barrier to tubing blood cultures and implemented tracking of times  Impact –Reduced LOS by.92 days –Improved time for blood cultures to lab by 126 minutes –Potential financial benefit – X $

18. PSI Data – January2009/ 2005 IndicatorAARQ2009Facility2009Numerator Cases (09/05) Denominator Cases (09/05) PSI-03 Decubitus Ulcer 25.111.87 4 (12) 337 (355) PSI-11:Post-op Respiratory Failure 9.0223.81 1 (5) 42 (147) PSI-13:Postop Sepsis 11.4462.50 1 (1) 16 (48) 16 (48)

19. Lessons Learned  Work on “Present on Admission” prior to October 2008 was impactful  Six Sigma tools have impacted positively on cost savings and quality of care  Must take small steps – it will take time and must continue monitoring to sustain

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