PSI-15 Lafayette General Health 2017 Nicholas E. Davies Enterprise Award of Excellence Rachel Brunt, RN, BSN, MBA-HCA, CIC, CPHQ, Director Quality Jessie Hanks, BS, RHIA, Director HIM
Lafayette General Health Who we are 7 Inpatient facilities (incl. Academic) 43 Ambulatory sites: 18 specialties 1 Ambulatory surgery center 4,043 FTEs 68 Employed Physicians 1,700 Non-Employed Medical Staff Acute HIMSS Level 6 (LGMC & UHC) Our patients 29,000 Admissions 180,000 ED visits 23,000 Surgical cases 335,000 Outpatient visits Top Service lines: Cardiology Neurology Orthopedics Fiscal Year 2016 (Sept. 2015 - Sept.2016)
Information Systems automation journey 2003 2012 2014 2016 CPOE, Documentation, ED, Pharmacy, Revenue Cycle System re-install, Surgery, Cerner Patient Accounting, Quality Alignment Remote Hosting Women s Health, Care Management, Registries, CommonWell, EPCS, HealthyLink clinics Hospitals acquired: Radiology, PACS, Laboratory Ambulatory ASP, Oncology Integrated Ambulatory, Sepsis, PSI-15 process, New CDI software EDW, HealthyLink hospital system, Palm Scanning, Patient Observer 2006 2013 2015 2017
Local Problem
LGMC 2015 HAC Penalty: $672,000 CMS hospital acquired condition (HAC) penalty Greatest opportunity PSI-15 accidental puncture or laceration Previous workflow Retrospective process Physician coding variation Accidental puncture or laceration codes not used appropriately Review of rates by Quality Committee only Unique factors to southeast Louisiana patients High obesity rates 1, multiple co-morbidities Patients with multiple abdominal surgeries High unemployment: low socio-economic population that postpones treatment 2 1 Reference the appendix for Louisiana obesity rates 2 Reference the appendix for Lafayette vs National unemployment rates
Baseline PSI-15 rate 6 5 4 3 2 1 0 PSI-15 Accidental Puncture or Laceration Rates per 1,000 discharges Calendar Year 2015 average: 1.85 per 1,000 discharges Rate per 1,000 discharges Average CY 2015 Numerator: Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with any secondary ICD-9-CM or ICD-10-CM diagnosis codes for accidental puncture or laceration during a procedure. Denominator: Surgical and medical discharges, for patients ages 18 years and older. Surgical and medical discharges are defined by specific DRG or MS-DRG codes. Agency for Healthcare Research and Quality. (2015). AHRQ Quality Indicatory ICD-9-CM and ICD-10-CM/PCS Specification Enhanced Version 5.0: Patient safety indicatory #15 (PSI#15) accidental puncture or laceration rate.
CMS Hospital Specific Reports: PSI-15 As the national rate declined, LGMC rates increased 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 PSI-15 national risk-adjusted rate per 1,000 discharges vs. LGMC risk-adjusted rate 1,000 discharges 1.81 1.43 1.46 1.39 July 1, 2012 through June 30, 2014 July 1, 2013 through June 30, 2015 National Risk-Adjusted Rate per 1,000 Eligible Discharges [c] LGMC Risk-Adjusted Rate per 1,000 Eligible Discharges [e] Data source: CMS Hospital Specific Reports for PSI-15
Design Implementation Governance
Governance Governance for new process Executive team CEO, CNO, VP Quality, CMO, CMIO Clinical Transformation Committee Quality committee Board of trustees VP Medical Affairs, Assistant VP Medical Affairs Multidisciplinary team completed chart review for each patient Physicians Quality department HIM Information systems Surgery department Goals: Develop concurrent process for review, improve coding, physician education, and improve PSI-15 rates to top decile
Design and Implementation Design & build Training plan Support plan Adoption Timeline: Started summer 2015 HAC report published Dec. 2015 New process implemented Jan. 2016 Lessons learned: Importance of collaboration and communication Surgeons unware of the impact of particular words in operative reports HIM coders communicated to surgeons how they capture coding information and the guidelines they must follow Quality department communicated with surgeons to ensure awareness of current rates and opportunities Importance of concurrent review process (previously ~6 weeks delayed)
How Health IT was Utilized
How Health IT was Utilized IS business intelligence analyst created Cerner EHR report using AHRQ PSI-15 specifications Allowed quality and HIM to generate real-time reports listing all patients with a diagnosis code included in the PSI-15 numerator Patients with PSI-15 code reviewed by CDI specialist and CMO Query sent to surgeon for clarification if necessary Result: Increased accuracy of accidental puncture or laceration code Increased confidence PSI-15 rate reflected actual accidental puncture or laceration events
HIM/Quality Concurrent PSI-15 Process Provide a flow chart that breaks down each step of the workflow and where in the process IT is leveraged Green Star = Health IT utilization
Cerner PSI-15 Report Provide screenshots from the solution that show the IT intervention and explain how clinicians respond Cerner ExplorerMenu Report: Retrieves patients with qualifying codes for accidental puncture or laceration Run monthly Chart review initiated for patients listed Screenshot from Cerner EHR
Coding Review for PSI-15 3M Encoder with PSI-90 indicator (PSI-15 code for accidental puncture and laceration) Screenshot from 3M encoder
CDI Review for Coding Opportunity CDI specialist identifies coding opportunity in Streamline and submits query to provider, if necessary Screenshot from Streamline
Value Derived
HIM PSI-15 Review Metric Total CY 2016 # of PSI-15 cases 21 # of cases reviewed by CDI 21 # of cases overturned by coding opportunities 3 2016 PS1-15 code overturn:14% Total potential PSI-15 HAC cases 18 # of cases sent for query 4 # of cases sent for 3rd review/cmo and overturned 0 Total HAC PSI-15 cases 18 Data source: LGMC HIM Department
Decrease in PSI-15 rate 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 LGMC PSI-15: Accidental puncture or laceration rates per 1,000 discharges 1.85 1.21 Baseline - CY 2015 Measurement Period - CY 2016 Data source: Cerner EHR ExporerMenu reports
2016 PSI-15 rate by month 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 LGMC PSI-15: Accidental Puncture or Laceration (CY2016) Rates per 1,000 discharges Rate per 1,000 discharges Baseline - CY 2015 Data source: Cerner EHR ExporerMenu reports
Penalty avoidance: $707,293 Improved PSI-15 rates contributed to an avoidance of a HAC penalty of approximately $707,293 for FY 2019. Pay for performance dashboard: Estimates potential penalty Data retrieved from Premier Quality Advisor
Next Steps Incorporate PSI into Physician Peer Review process - to ensure quality care delivery. Physician Scorecards physician review for each specialty involved in a case that has a PSI. Complete Phase Two Go Live With Streamline Health CDI Solution Utilize new quality alerts in Streamline streamline potential quality accounts
Thank you
Appendix
LGH Patient Population Percent of population 40 35 30 25 20 15 10 5 Percent of adults aged 18 years and older who have obesity 0 2011 2012 2013 2014 2015 Year Louisiana National Linear (Louisiana) Obese is defined as body mass index (BMI) 30.0; BMI was calculated from self-reported weight and height (weight [kg]/ height [m²). Respondents reporting weight < 50 pounds or 650 pounds; height < 3 feet or 8 feet; or BMI: <12 or 100 were excluded. Pregnant respondents were also excluded. Centers for Disease Control and Prevention. (2017). Nutrition, Physical Activity, and Obesity: Data, Trends and Maps. Retrieved from https://www.cdc.gov/nccdphp/dnpao/data-trends-maps/index.html
LGH Patient Population 12 Lafayette Metro vs. U.S. National Average Unemployment Rate 10 Percent Unemployment 8 6 4 2 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Lafayette Metro National Linear (Lafayette Metro) U.S. Department of Labor, Bureau of Labor Statistics. (2017). Retrieved from https://www.bls.gov/data/#unemployment
PSI-15 rate 2015 through 2016 PSI-15: Accidental Puncture or Laceration Rates per 1,000 discharges 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 New process implemented Data source: Cerner EHR ExporerMenu reports