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How to Assess Quality of Care at Hospitals: Patient Safety Indicators

How to Assess Quality of Care at Hospitals: Patient Safety Indicators

 

The Agency for Healthcare Research and Quality (AHRQ) developed Patient Safety Indicators (PSI) to judge the quality of care at Hospitals.  The data can be used:

  • By patients to choose where they go for care
  • Third party payers to select facilities to contract for services
  • Assist QA departments identify potential problem areas
  • Help leadership assess. monitor, track, and improve patient safety
  • Determine financial gain or loss (CMS PSI 90, contract bonuses for quality)

ICD-10 CM/PCS Coders provide the data used to measure hospital performance against these standards.  It behooves Coders to understand these measures and how they are affected by coding.

AHRQ is a part of the U. S. Department of Health and Human Services.  A brief history would include Congress creating the Agency for Healthcare Policy and Research (AHPR) in 1989 with a ten year mission to “support research designed to improve quality, safety, efficiency and effectiveness of healthcare for all Americans.”  After ten years, the AHPR agency was reauthorized, and its name changed to Agency for Healthcare Research and Quality (AHRQ). More details can be found at: https://www.allgov.com/.

The AHRQ conducts an annual review of the PSIs to identify global healthcare problems and insure relevancy to current quality assurance trends. The Patient Safety Indicators (PSIs) were developed by AHRQ to provide information on safety-related events occurring in hospitals, Healthcare facilities and physician practices. We also provide a detailed overview of the 2020 Proposed Rule for the Inpatient Prospective Payment System (IPPS) CMS-1716-P in a previous article here: https://yes-himconsulting.com/inpatient-prospective-payment-system-ipps-2020-proposed-rule-a-detailed-overview/. This past summer, the AHRQ retired PSI – 16 Transfusion Reaction Count, which explains gaps in current PSI numbering.  Below is a brief description of the 17 active PSIs applicable to hospitals for 2019 (source: https://www.qualityindicators.ahrq.gov/):

PSI 02 – Death Rate in Low-Mortality Diagnostic Related Groups (DRGs)

In-hospital deaths per 1,000 discharges for low mortality DRGs (patients 18 years and older or obstetric patients).  Excludes cases with trauma, cancer, an immunocompromised state, and transfers to an acute care facility.

PSI 03 – Pressure Ulcer Rate

Stage III or IV pressure ulcers or unstageable (secondary diagnosis) per 1,000 discharges (surgical or medical patients 18 years and older).  Excludes stays less than 3 days; cases with a principal or secondary diagnosis of stage III or IV pressure ulcer or unstageable that is present on admission; obstetric cases; severe burns; exfoliative skin disorders.

Assess Quality of Care at HospitalsPSI 04 – Death Rate among Surgical Inpatients with Serious Treatable Complications

Inpatient deaths per 1,000 surgical discharges (patients 18 through 89 years or obstetric patients) with serious treatable complications (deep vein thrombosis/pulmonary embolism, pneumonia, sepsis, shock/cardiac arrest, or gastrointestinal hemorrhage/acute ulcer).  Excludes cases transferred to an acute care facility and cases in hospice care at admission.

PSI 05 – Retained Surgical Item or Unretrieved Device Fragment Count

The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) (surgical and medical patients 18 years and older or obstetric patients).  Excludes cases with principal or secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

*** 1Q 2014 Coding Clinic page 21 – Foreign body intentionally left during surgery where risk of removal exceeds risk of retention is not coded as a complication***

PSI 06 – Iatrogenic Pneumothorax Rate

Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical (medical discharges for patients 18 years and older).  Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal or secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

PSI 07 – Central Venous Catheter-Related Blood Stream Infection Rate

Central venous catheter-related bloodstream infections (secondary diagnosis) per 1,000 medical and surgical discharges (patients 18 years and older or obstetric cases).  Excludes cases with a principal or secondary diagnosis of a central venous catheter-related  bloodstream infection present on admission, stays less than 2 days, cases with an immunocompromised state or cancer.

PSI 08 – In Hospital Fall with Hip Fracture Rate

In hospital fall with hip fracture (secondary diagnosis) per 1,000 discharges (patients 18 years and older).
Excludes discharges with principal diagnosis of a condition with high susceptibility to falls (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury), diagnoses associated with fragile bone (metastatic cancer, lymphoid malignancy, bone malignancy), a principal or secondary diagnosis of hip fracture present on admission, and obstetric cases.

PSI 09 – Perioperative Hemorrhage or Hematoma Rate

Perioperative hemorrhage or hematoma cases involving a procedure to treat the hemorrhage or hematoma following the first surgery per 1,000 surgical discharges (patients 18 years and older).  Excludes cases with a diagnosis of coagulation disorder; a principal or secondary diagnosis of perioperative hemorrhage or hematoma present on admission; where the only operating room procedure is for treatment of perioperative hemorrhage or hematoma; obstetric cases.

PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate

Postoperative acute kidney failure requiring dialysis per 1,000 elective surgical discharges (patients ages 18 years and older).  Excludes cases with principal or secondary diagnosis of acute kidney failure present on admission; secondary diagnosis of acute kidney failure and dialysis procedure before or on the same day as the first operating room procedure; with cardiac arrest, severe cardiac arrhythmia, cardiac shock, chronic kidney failure; a principal diagnosis of urinary tract obstruction, and obstetric cases.

PSI 11 – Postoperative Respiratory Failure Rate

Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases per 1,000 elective surgical discharges (patients 18 years and older).  Excludes cases with principal or secondary diagnosis of acute respiratory failure present on admission; cases in which tracheostomy is the only operating room procedure or in which tracheostomy occurs before the first operating room procedure; neuromuscular disorders; laryngeal, oropharyngeal or craniofascial surgery involving significant risk of airway compromise; esophageal resection, lung cancer, lung transplant or degenerative neurological disorders; respiratory or circulatory diseases; and obstetric discharges.

PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate

Perioperative pulmonary embolism or proximal deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges (patients 18 years and older).  Excludes discharges with a principal or secondary diagnosis of pulmonary embolism or proximal deep vein thrombosis present on admission; in which interruption of the vena cava or a pulmonary arterial thromboembolectomy occurs before or on the same day as the first operating room procedure; with extracorporeal membrane oxygenation; with acute brain or spinal injury present on admission; and obstetric cases.

PSI 13 Postoperative Sepsis Rate

Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges (patients 18 years and older). Excludes cases with a principal or secondary diagnosis of sepsis present on admission, a principal or secondary diagnosis of infection present on admission, and obstetric cases.

PSI 14 – Postoperative Wound Dehiscence Rate

Postoperative reclosures of the abdomen wall with a diagnosis of disruption of internal operative wound per 1,000 abdominopelvic surgery discharges (patients 18 years and older).  Excludes cases in which the abdominal wall reclosure occurs on or before the day of the first abdominopelvic surgery, cases with an immunocompromised state, stays less than two (2) days, and obstetric cases.

PSI 15 – Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate

Accidental punctures or lacerations (secondary diagnosis) per 1,000 discharges (patients 18 years and older) who have undergone a second abdominopelvic procedure which follows one or more days after an index abdominopelvic procedure.  Excludes cases with accidental puncture or laceration as a principal or secondary diagnosis that is present on admission, and obstetric cases.

PSI 17 – Birth Trauma Rate – Injury to Neonate

Birth trauma injuries per 1,000 newborns.  Excludes preterm infants with a birth weight less than 2,000 grams, and cases with osteogenesis imperfect.

PSI 18 – Obstetric Trauma Rate – Vaginal Delivery with Instrument

Third and fourth degree obstetric traumas per 1,000 instrument-assisted vaginal deliveries.

PSI 19 – Obstetric Trauma Rate – Vaginal Delivery Without Instrument

Third and fourth degree obstetric traumas per 1,000 vaginal deliveries.  Excludes cases with instrument-assisted deliveries.

Many hospitals have teams established to monitor PSIs.  The effective teams have representatives from Physicians, Nursing, QA, Risk Management, and of course, Coding.  It’s important to understand that codes from the initial bill (which are captured for reports and rebilling information) get passed on to this agency, but the corrected codes will not, this is a strong reason why concurrent reviews are preferred over retrospective.   Active teams can also identify needs for education, training, and even make suggestions to AHQR to improve the PSI system (https://info.ahrq.gov/).

John Franz

Patient Safety Indicators PSI

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