Docstoc

PowerPoint Slides - AHRQ Slide Template

Document Sample
PowerPoint Slides - AHRQ Slide Template Powered By Docstoc
					Clinical Insights into Implementing the AHRQ
 Indicators for Hospital Quality Improvement

               Patrick S. Romano, MD MPH
          Professor of Medicine and Pediatrics
               UC Davis School of Medicine
 AcademyHealth 2006 Child Health Services Research Meeting
                       June 24, 2006
                  Acknowledgments
Funded by AHRQ
Support for Quality Indicators II (Contract No. 290-04-0020)
 Mamatha Pancholi, AHRQ Project Officer
 Marybeth Farquhar, AHRQ QI Senior Advisor
 Mark Gritz and Jeffrey Geppert, Project Directors, Battelle Health
  and Life Sciences

Data used for analyses:
Nationwide Inpatient Sample (NIS), 1995-2003. Healthcare Cost and
   Utilization Project (HCUP), Agency for Healthcare Research and
   Quality
State Inpatient Databases (SID), 1997-2003 (38 states). Healthcare
   Cost and Utilization Project (HCUP), Agency for Healthcare
   Research and Quality
                       Acknowledgments
We gratefully acknowledge the data organizations in participating states that contributed data
to HCUP and that we used in this study: the Arizona Department of Health Services; California
Office of Statewide Health Planning & Development; Colorado Health & Hospital Association;
Connecticut - Chime, Inc.; Florida Agency for Health Care Administration; Georgia: An
Association of Hospitals & Health Systems; Hawaii Health Information Corporation; Illinois
Health Care Cost Containment Council; Iowa Hospital Association; Kansas Hospital
Association; Kentucky Department for Public Health; Maine Health Data Organization;
Maryland Health Services Cost Review; Massachusetts Division of Health Care Finance and
Policy; Michigan Health & Hospital Association; Minnesota Hospital Association; Missouri
Hospital Industry Data Institute; Nebraska Hospital Association; Nevada Department of Human
Resources; New Jersey Department of Health & Senior Services; New York State Department
of Health; North Carolina Department of Health and Human Services; Ohio Hospital
Association; Oregon Association of Hospitals & Health Systems; Pennsylvania Health Care
Cost Containment Council; Rhode Island Department of Health; South Carolina State Budget &
Control Board; South Dakota Association of Healthcare Organizations; Tennessee Hospital
Association; Texas Health Care Information Council; Utah Department of Health; Vermont
Association of Hospitals and Health Systems; Virginia Health Information; Washington State
Department of Health; West Virginia Health Care Authority; Wisconsin Department of Health &
Family Services.
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Validate or test key hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Validate or test key hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
       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
        >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
      “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.
  benchmark)
          Norton Healthcare Surgery Report Card
brief description             desired   AUD      NH     SW    SUB     KCH      KY     U.S.
% surgeries w/
                               low      0.15     0.23         0.30    0.19     0.22   0.22
postoperative bleeding
% abdominal surgeries w/
                               low      0.00     0.20         0.22    0.24     0.16   0.20
postop wound dehiscence
% w/ pneumothorax
                               low      0.09     0.08         0.05    0.07     0.07   0.08
resulting from medical care
% surgeries w/ postop
                               low      0.05     0.09         0.05    0.03     0.09   0.11
physiologic derangement
% surgeries w/ postop
                               low      0.6      1.6          0.6      0.9     0.8    0.4
respiratory failure
% surgeries w/ postop PE or
                               low      1.1      1.5          0.8      0.8     0.9    0.9
DVT
% surgeries w/ postop
                               low      5.2      3.1          1.8       0      1.9    1.2
sepsis
% craniotomy patients who
                               low      6.5      6.8          6.6              7.4    7.4
die (AHRQ risk-adjusted)

Red or green if outside 99% C.I. based on U.S.    September 14, 2005 posting
                “Why we did it”
 Accountability as a public asset
  – Clinical care is, in fact, our “widget”
  – We talk about our financials with bond raters, the
    press, etc.; why not our clinical performance?
 Proactively influence the the public reporting
  arena
  – Clinical over purely financial
  – Transparent over proprietary
  – Evidence based over arbitrary
 Get the organization moving in a direction that
  is inherently inevitable
 Improve our care; “We’ll manage what we
  measure and report”
          Impact of implementing the Norton
               Healthcare report card

       We are still in business.
       Better data; less time arguing about the
        measure and more time improving
        performance.
    –     Unused data never become valid.
    –     Even a lousy indicator can drive
          improvement.
       Limited public reaction
       Mostly favorable physician response
       Strong desire to be “within normal limits”
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Validate or test key hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
2005 National Reports on
 Quality and Disparities
          National trends in PSI rates, 2000-2003 KID
               Extremely rare events (<0.01%)
0.005%

0.005%
                                   Foreign body left in during procedure
0.004%

0.004%

0.003%

0.003%

0.002%

0.002%

0.001%
                                  Transfusion reactions (ABO/Rh)
0.001%

0.000%
                        2000                                         2003

Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
          National trends in PSI rates, 2000-2003 KID
                    Rare events (0.01-0.1%)
0.10%

0.09%                          Accidental puncture and laceration

0.08%
                                        Postop abdominopelvic wound dehiscence
0.07%

0.06%

0.05%
                                            Iatrogenic PTX - neonate
0.04%

0.03%

0.02%
                                     Iatrogenic PTX - nonneonatal
0.01%

0.00%
                        2000                                           2003

Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
        National trends in PSI rates, 2000-2003 KID
             Low-frequency events (0.1-0.5%)
0.4%



0.4%

                                                   Decubitus ulcer
0.3%

                              Selected infections due to medical care
0.3%



0.2%

                                    Postop hemorrhage/hematoma
0.2%



0.1%
                       2000                                             2003


Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
        National trends in PSI rates, 2000-2003 KID
           Medium-frequency events (0.5-5.0%)
5.0%


4.5%                              Pediatric heart surgery mortality

4.0%


3.5%


3.0%
                                               Postop sepsis

2.5%


2.0%


1.5%                   Postop respiratory failure

1.0%
                       2000                                           2003

Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
          National trends in PSI rates, 2000-2003 KID
                High-frequency events (>5.0%)
40%

38%

36%

34%

32%
                                       Perforated appendix
30%

28%

26%

24%

22%

20%
                      2000                                    2003

Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
          National trends in PSI rates, 2000-2003 KID
           Potentially avoidable hospital conditions
0.20%
                              Gastroenteritis/dehydration
0.18%
                                                                Asthma
0.16%

0.14%

0.12%

0.10%

0.08%
                                  UTI
0.06%

0.04%                             Diabetic short-term complications

0.02%

0.00%
                       2000                                              2003

Kids’ Inpatient Database 2000 and 2003. AHRQ Healthcare Cost and Utilization Project.
AHRQ PDI Version 3.0b Unadjusted Rates.
              Area Level PDI by Geographic Region
0.900
0.800
0.700
0.600
                                                                                             Northeast
0.500                                                                                        Midwest
0.400                                                                                        South
0.300                                                                                        West

0.200
0.100
0.000
                Asthma                Diabetes           Gastroenteritis               UTI

        Kids’ Inpatient Database 2003. AHRQ Healthcare Cost and Utilization Project.
        AHRQ PDI Version 3.0b Risk-adjusted Rates.
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Validate or test key hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
         NACHRI Pediatric Patient Safety
          Indicator (PSI) Collaborative
   Ran the AHRQ PSIs on NACHRI’s Case Mix database, containing 3
    million discharges from approximately 70 children’s hospitals.
   Developed the NACHRI Pediatric PSI Collaborative, a self-selected group
    of 20 hospitals interested in pursuing this analysis further
   Published a manuscript entitled “Relevance of the AHRQ PSIs for
    Children’s Hospitals” in the January 2005 journal Pediatrics.
   Developed and released a Patient Safety Indicator Toolkit (available
    through NACHRI’s website) with sample press release, op ed, Q&A, and
    background documents for hospitals to educate their communities and the
    media on the relevance and utility of PSIs for pediatrics.
   Developed an online, secure chart review tool that allowed Collaborative
    participants to review the preventability of patients flagged as having any
    of 11 selected PSI events.
   Fostered a relationship with AHRQ and Stanford/UC Davis to update each
    other on NACHRI’s findings and the PedQI development work.
           NACHRI Pediatric Patient Safety
            Indicator (PSI) Collaborative
Collaborative Participants
   AL / Children’s Hospital of Alabama / Dr. Crayton Farguson*
   CA / Lucile Packard CH at Stanford / Dr. Paul Sharek*
   CA / UC-Davis / Dr. James Marcin**
   DC / Children’s National Medical Center / Dr. Tony Slonim*
   CA / Mattel Children’s at UCLA / Ms. Mary Kimball**
   FL / All Children’s / Dr. Jack Hutto*
   KY / Kosair Children’s Hospital / Dr. Ben Yandell*
   LA / Children’s Hospital New Orleans / Ms. Cindy Nuesslein*
   MD / Johns Hopkins Children’s Center / Dr. Marlene Miller*
   MA / Children’s Hospital Boston / Drs. Daniel Nigrin and Don Goldmann
   MI / C.S. Mott Children’s Hospital – U Mich / Dr. Aileen Sedman*
   MO / Children’s Mercy Kansas City / Dr. Cathy Carroll*
   OH / The Children’s Medical Center Dayton / Dr. Thomas Murphy*
   OH / Cincinnati Children’s Medical Center / Drs. Uma Kotagal, Joseph Luria*
   OH / Children’s Hospital Columbus / Dr. Thomas Hansen*
   OH / Children’s Hospital MC of Akron / Dr. Michael Bird
   PA / Children’s Hospital of Philadelphia / Drs. James Stevens, Joel Portnoy
   TX / Texas Children’s Hospital / Dr. Joan Shook*
   TX / Children’s Medical Center of Dallas / Dr. Fiona Levy, Ms. Kathy Lauwers*
   WI / Children’s Hospital of Wisconsin / Dr. Matthew Scanlon*
      Key findings from NACHRI’s PSI
          physician case reviews

“…while 40% to 50% may seem low for positive predictive
  value, in terms of real patients, this means that 4 or 5
  out of 10 children had a preventable event for this
  indicator. This is worth looking at and the things we
  are finding in some instances, will allow for immediate
  changes that may impact outcomes for future patients.”
  [Collaborative physician reviewer]
           Examples from NACHRI’s PSI
             physician case reviews
   During removal of non functioning port cath the end of the catheter
    was noted to be "irregular and not smoooth cut". It appeared the tip
    had been embolized for an unknown duration…
   During replacement of pacemaker lead, a fragment of the lead broke
    off, embolized and ended up lodged (puncture) in the anterolateral
    papillary muscle.
   No notation in original operative note or nursing record that
    sponge/needle counts were done and correct.
   Count was reported as correct. Sponge discovered on xray due to
    complaints of abdominal pain by patient.
   Child with bone tumor who had mandible removed with subsequent
    bone graft and much packing in wound. This was supposedly
    removed before extubation, but at the time of extubation a remaining
    pack blocked her airway causing reintubation with pack removal.
              Examples from NACHRI’s PSI
                physician case reviews
   …occurred during the insertion of a PICC line. The record indicates on the first attempt a
    artery paralleling the basilar vien was cannulated.
   Urethral injury after a transurethral ablation of posterior urethral valves as well as bleeding
    post circumcision… both required suturing to repair.
   14 year old feamle with spinal bifida and urinary and fecal incontinence who underwent
    appendicovesicostomy, continent cecostomy, bladder neck sling for urinary incontinence and
    enteroenterostomy. … a small perforation was made in the vagina and was repaired.
   6 week old with pyloric stenosis who underwent laparoscopic pyloromyotomy. A small gastric
    mucosal perforation occurred at the end and required opening the abdomen to repair.
   Colon was perforated during liver transplant.
   Pt underwent transrectal drainage of abscess on 7/29 with foley used to drain bladder. Pt
    developed hematuria and required surgery exploration when bladder puncture was
    discovered from surgery.
   Laparoscopic procedure using harmonic scalpel. Bleeding noted. converted to open
    procedure. Aorta repaired.
   Laparascopic appendectomy. Small opening made in cecum. Repaired at the time of surgery.
   After d/c from spinal fusion, patient presented to clinic with drainage from operative site.
    Seroma noted. Admitted and returned to OR. … lacerated baclofen pump catheter.
   Rib removed to use for laryngeal reconstruction--pleura was punctured.
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Test interesting hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
Effect of work hours reform in NY teaching
     hospitals on smoothed PSI rates
        Poulose BK, et al., Ann Surg 2005;241:847-860
Effect of work hours reform in NY teaching
     hospitals on smoothed PSI rates
        Poulose BK, et al., Ann Surg 2005;241:847-860
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Validate or test key hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
             Approaches to assessing
                construct validity

 Is the outcome indicator associated with explicit
  processes of care (e.g., appropriate use of
  medications)?
 Is the outcome indicator associated with implicit
  process of care (e.g., global ratings of quality)?
 Is the outcome indicator associated with nurse
  staffing or skill mix, physician skill mix, or other
  aspects of hospital structure?
 Is the outcome indicator associated with other
  meaningful outcomes of care?
               Estimating the impact of preventing each PSI event
                           on mortality, LOS, charges
                       NIS 2000 analysis by Zhan & Miller, JAMA 2003;290:1868-74

Indicator                                      Δ Mort (%)     Δ LOS (d)    Δ Charge ($)
Postoperative septicemia                              21.9         10.9        $57,700
Postoperative thromboembolism                           6.6          5.4           21,700
Postoperative respiratory failure                     21.8           9.1           53,500
Postoperative physiologic or metabolic                19.8           8.9           54,800
derangement
Decubitus ulcer                                         7.2          4.0           10,800
Selected infections due to medical care                 4.3          9.6           38,700
Postoperative hip fracture                              4.5          5.2           13,400
Accidental puncture or laceration                       2.2          1.3            8,300
Iatrogenic pneumothorax                                 7.0          4.4           17,300
Postoperative hemorrhage/hematoma                       3.0          3.9           21,400
               Estimating the impact of preventing each PSI event
                           on mortality, LOS, charges
                 Zhan & Miller, JAMA 2003; key findings replicated by Rosen et al., 2005

Indicator                                                   Δ Mort (%)         Δ LOS (d)        Δ Charge ($)
Birth trauma                                                  -0.1 (NS)         -0.1 (NS)          300 (NS)
Obstetric trauma –cesarean                                    -0.0 (NS)                  0.4          2,700
Obstetric trauma - vaginal w/out instrumentation                0.0 (NS)               0.05       -100 (NS)
Obstetric trauma - vaginal w instrumentation                    0.0 (NS)               0.07             220
Postoperative abdominopelvic wound                                     9.6               9.4         40,300
dehiscence
Transfusion reaction*                                         -1.0 (NS)          3.4 (NS)       18,900 (NS)
Complications of anesthesia*                                    0.2 (NS)         0.2 (NS)             1,600
Foreign body left during procedure†                                    2.1               2.1         13,300



* All differences also NS for transfusion reaction and complications of anesthesia in VA/PTF.
† Mortality difference NS for foreign body in VA/PTF.
  Some PSI rates are significantly higher in
African-Americans or Hispanics than in whites
         Coffee RM, et al., Med Care 2005;43:I-48 to I-57
   Some PSI rates are significantly lower in
African-Americans or Hispanics than in whites
        Coffee RM, et al., Med Care 2005;43:I-48 to I-57
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Test interesting hypotheses (research)
 Is it a coding/documentation issue?
 Is it a quality issue?
 Questions and answers
        Coding/documentation issues

 There is a basic tension between using administrative
   data for reimbursement and for defining quality
   indicators
    –   Submitting bills quickly versus coding from a complete
        record
    –   Maximizing the coding of complications and comorbidities
        versus only coding diagnoses “out of the norm.”
 Variation in QI rates might be due to variation in:
    –   Data availability (e.g., number of diagnosis codes, admission
        type, external cause of injury codes)
    –   Documentation completeness and accuracy
    –   ICD-9-CM and DRG coding
    –   Performance (e.g., processes of care, staffing)
               ICD-9-CM Coding
Adherence to best practices in coding and compliance
   with coding guidelines will ensure fair reimbursement
   and accurate measurement of quality indicators

 Use the highest possible level of specificity
   – Avoid overuse of NEC and NOS designation
 Follow guidelines re coding of secondary diagnoses
   – Only codes that impact treatment or complications
 Follow guidelines re coding of procedures
   – Only significant procedures to be reported
    ICD-9-CM Coding: Specificity

 Highest level of specificity
   – Avoid overuse of NEC and NOS
     designation
 Examples:
 Using 512.8 for “pneumothorax NOS”
  would exclude a case from the numerator
  for iatrogenic pneumothorax (512.1)
      Coding of secondary diagnoses
   For reporting purposes the definition for "other diagnoses" is
    interpreted as additional conditions that affect patient care in
    terms of requiring:
    clinical evaluation; or
    therapeutic treatment; or
    diagnostic procedures; or
    extended length of hospital stay; or
    increased nursing care and/or monitoring.

   UHDDS…defines Other Diagnoses as “all conditions that
    coexist at the time of admission, that develop subsequently, or
    that affect the treatment received and/or the length of stay.
    Diagnoses that relate to an earlier episode which have no
    bearing on the current hospital stay are to be excluded.”
   Coding of secondary diagnoses
 “Abnormal findings (laboratory, x-ray, pathologic, and
  other diagnostic results) are not coded and reported
  unless the physician indicates their clinical
  significance.”
 “If the findings are outside the normal range and the
  physician has ordered other tests to evaluate the
  condition or prescribed treatment, it is appropriate to
  ask the physician whether the abnormal finding should
  be added.”
 “All conditions that occur following surgery…are not
  complications… there must be more than a routinely
  expected condition or occurrence… there must be a
  cause-and-effect relationship between the care
  provided and the condition…”
                  A case study of birth trauma
               Dallas-Fort Worth Hospital Council
                            1999         1999       1999        1999        1999          1999        1999              1999            Stat
Participating Hospitals     Num          Den        Obs         RiskAdj     Exp           LoCI        HiCI               CI             Sig
State of Texas (THCIC PUDF)*       831     305519        2.72        2.72          2.72        2.44        3.00
Hosp A                               6       3255        1.84        1.82          2.75       -0.91        4.55     ( 0.00, 4.55 )       o
Hosp B                               3       1324        2.27        2.27          2.72       -2.00        6.54     ( 0.00, 6.54 )       o
Hosp C                              55       1815      30.30        30.28          2.72      26.63        33.94   ( 26.63, 33.94 )        -
Hosp D                               1       1427        0.70        0.66          2.89       -3.47        4.79     ( 0.00, 4.79 )       o
                            2000         2000       2000        2000        2000          2000        2000              2000            Stat
Participating Hospitals     Num          Den        Obs         RiskAdj     Exp           LoCI        HiCI                CI            Sig
State of Texas (THCIC PUDF)*       831     326095        2.55        2.55          2.55        2.28        2.82
Hosp A                               3       3303        0.91        0.90          2.58       -1.81        3.61     ( 0.00, 3.61 )       o
Hosp B                               2       1604        1.25        1.27          2.51       -2.61        5.14     ( 0.00, 5.14 )       o
Hosp C                              45       1752      25.68        25.66          2.55      21.94        29.38   ( 21.94, 29.38 )        -
Hosp D                               2       1484        1.35        1.36          2.54       -2.68        5.39     ( 0.00, 5.39 )       o
                            2001         2001       2001        2001        2001          2001        2001              2001            Stat
Participating Hospitals     Num          Den        Obs         RiskAdj     Exp           LoCI        HiCI                CI            Sig
State of Texas (THCIC PUDF)*       763     333101        2.29        2.29          2.29        2.02        2.56
Hosp A                               8       3099        2.58        2.58          2.29       -0.21        5.37     ( 0.00,   5.37 )     o
Hosp B                               4       1553        2.58        2.58          2.29       -1.37        6.53     ( 0.00,   6.53 )     o
Hosp C                              53       1915      27.68        27.66          2.29      24.11        31.22   ( 24.11,    31.22 )    -
Hosp D                               1       1618        0.62        0.59          2.40       -3.29        4.46     ( 0.00,   4.46 )     o
                        Confusion about coding
Birth Trauma―Injury to Neonate
Numerator:
       Discharges with ICD-9-CM codes for birth trauma in any diagnosis field per 1,000 liveborn births.

Birth Trauma
ICD-9-CM diagnosis codes:

7670   Subdural and cerebral hemorrhage (due to trauma or to intrapartum anoxia or hypoxia)
7673   Injuries to skeleton (excludes clavicle)
7674   Injury to spine and spinal cord               Code Index under “Molding, head”
7677   Other cranial and peripheral nerve injuries
7678   Other specified birth trauma                  lists 767.3
7679   Birth trauma, unspecified




                             ICD-9-CM Coding Manual Definition
767.3 Other Injuries To Skeleton Due To Birth Trauma
Fracture of: long bones, skull
767.4 Injury To Spine And Spinal Cord Due To Birth Trauma
{Dislocation} {Fracture} {Laceration} {Rupture} of spine or spinal cord due to birth trauma
     ICD-9-CM Coding: Procedures

 Coding of procedures
  “The UHDDS requires all significant procedures to be
  reported… A significant procedure is defined as one
  that meets any of the following conditions:
  Is surgical in nature
  Carries an anesthetic risk
  Carries a procedural risk
  Requires specialized training.”

  What about central venous catheters?
           Examples of ICD-9-CM limitations
              “Selected infections due to medical care”
             “Postoperative hemorrhage or hematoma”
999.3 Other infection
Infection following infusion, injection, transfusion, or vaccination
Sepsis following infusion, injection, transfusion, or vaccination
Septicemia following infusion, injection, transfusion, or vaccination
Excludes: the listed conditions when specified as:
         due to implanted device (996.60-996.69)
         postoperative NOS (998.51-998.59)

998.1 Hemorrhage or hematoma or seroma complicating a procedure
Excludes: hemorrhage, hematoma or seroma:
        complicating cesarean section or puerperal perineal wound (674.3)
        due to implanted device or graft (996.70-996.79)
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
                  Coding Resources
   American Health Information Management Association (AHIMA)
     –   www.ahima.org
   American Hospital Association
     –   www.hospitalconnect.com/ahacentraloffice/ahaco/index.jsp
   National Center for Health Statistics
     –   www.cdc.gov/nchs/icd9.htm
   Centers for Medicare and Medicaid Services
     –   www.cms.gov
   AHIMA Resources and Practice Briefs
     –   www.ahima.org/infocenter/practice_tools.asp
     –   Developing a Coding Compliance Policy Document
     –   Developing a Physician Query Process
     –   Ongoing Coding Reviews: Ways to Ensure Quality
     –   HIM’s Role in Monitoring Patient Safety
     –   Internet Resources for Coding and Reimbursement Practices
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Test interesting hypotheses (research)
 Is it a coding issue?
 Is it a quality issue?
 Questions and answers
             Relevance of AHRQ PSIs for Children’s Hospitals
                              Sedman A, et al. Pediatrics 2005;115(1):135-145

PSI                                   No. reviewed     Preventable   Nonpreventable   Unclear
                                      (total events)     (PPV %)
Complications of anesthesia            74 (503)        11 (15%)           37            25
Death in low-mortality DRG            121 (1282)       16 (13%)           89            16
Decubitus ulcer                       130 (2300)       71 (55%)           47            10
Failure to rescue                     187 (5271)        15 (8%)           148           11
Foreign body left in                   49 (235)        25 (51%)           14            10
Postop hemorrhage or hematoma         114 (1571)       40 (35%)           51            23
Iatrogenic pneumothorax               114 (1113)       51 (45%)           42            21
Selected infection 2° to med care     152 (7291)       63 (41%)           45            39
Postop DVT/PE                        126 (1956)        36 (29%)           61            29
Postop wound dehiscence                41 (232)        19 (46%)           16            6
Accidental puncture or laceration    133 (4020)        86 (65%)           19            26
        Linking the PedQIs to quality
 New collaboration with NACHRI to conduct chart reviews
  for PedQIs, focused on confirming the event, describing
  how it occurred, confirming correct risk stratification, and
  assessing preventability.
 Build collaborative network with other partners, in which
  UC/Stanford/Battelle will provide:
    –   Standardized, pretested abstraction tools
    –   Abstraction guidelines and resources
    –   Training programs for chart reviewers
    –   Online tools for data collection, management, and cleaning
    –   Summarized data reports for partners with suggestions for
        improvement (based on data from entire network)
    –   Optional chart over-reading to establish reliability/validity
        Goals of collaborative projects
 Tier indicators based on validity or potential
  usefulness for CQI and public reporting; flag
    indicators that don’t make the grade
   Inform NQF review process
   Modify indicator definitions if possible to improve
    sensitivity/specificity
   Identify omitted risk factors to improve risk-
    adjustment
   Identify key loci of preventability (opportunities
    for improvement): what should providers with
    high rates look for in evaluating their care?
    What can hospitals learn from the leaders?
        Overview of insights (?)
 Why use the PedQIs?
   – Establish accountability
   – Surveillance/track performance over time and
       across hospitals/units/services
   – Trigger case finding, root cause analyses,
       identification of clusters
   – Evaluate impact of interventions
   – Test interesting hypotheses (research)
 Is it a coding issue?
 Is it a quality issue?
 Questions and discussion
     More Information on AHRQ QIs

Quality Indicators Technical Assistance:
 E-mail:
  support@qualityindicators.ahrq.gov
 Website:
  http://qualityindicators.ahrq.gov/
 Telephone:
  (888) 512-6090 (voice mail)

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:61
posted:2/18/2011
language:English
pages:52