This article is published in sponsorship with Berkeley Research Group (BRG).
In 2000, following publication of the Institute of Medicine’s groundbreaking report To Err Is Human, Dr. John Eisenberg, director of the Agency for Healthcare Research and Quality (AHRQ), held the first National Summit on Medical Error and Patient Safety Research, where he called for development of a standardized approach to identifying and reporting patient safety issues. AHRQ subsequently created a set of 12 Patient Safety Indicators (PSIs) that described clinical events that health systems could use to “identify potential in-hospital patient safety problems for targeted institution-level quality improvement efforts.”
AHRQ’s PSIs, now in their sixth iteration, found an immediate home in a healthcare system struggling to measure and manage quality improvement. They would quickly grow to be the backbone of standardized patient safety reporting in the United States. Consumer Reports, the Healthgrades patient safety ratings, and US News and World Report’s best hospital rankings all rely on PSI data to generate their respective rankings.
The Centers for Medicare and Medicaid Services (CMS) relies on hospital-reported PSI data for a number of its current initiatives, including the Inpatient Quality Reporting (IQR) Program, Hospital Value-Based Purchasing (VBP) Program, and Hospital-Acquired Condition (HAC) Reduction Program. In each program, patient safety scores have a direct impact on a hospital’s Medicare revenue.
In VBP, PSIs live in the Safety domain and account for approximately 3.5 percent of the overall score. The FY 2019 VBP financial risk to hospitals is two percent of inpatient Medicare base revenue. In HAC, PSIs make up all of Domain 1, which accounts for 15 percent of the total score. The FY 2019 HAC financial risk to hospitals is one percent of inpatient Medicare total revenue. The FY 2018 Inpatient Prospective Payment System (IPPS) proposed rule has proposed that PSIs will be suspended for VBP for FY 2019 through FY 2022 and will return with FY 2023 impact year.
Different data elements are critical to the assignment of a PSI, including ICD-10 diagnosis and procedure codes, procedure dates, present on admission indicators, and admission source. Each PSI possesses inclusion criteria (conditions or combination of conditions that drive a PSI assignment) and exclusion criteria (conditions or elements that exclude a patient from being assigned a PSI). A reported PSI rate is also generally risk adjusted, though the methodology may be unique to the program reporting the results. CMS, for example, will use a Medicare-based population risk adjustment for the PSI measure in VBP; others may use AHRQ’s total population-based risk adjustment. The PSI composite measure comprises 10 individual PSIs in version 6 (formerly eight PSIs in version 5), and each PSI is weighted differently in the calculation of the total composite rate.
Key AHRQ PSI Updates
Key updates were made to the PSI program this year for version 6. PSI-8, In-hospital fall with hip fracture, was changed to target all inpatient hip fractures, not just those occurring post-operatively as version 5 measured. PSI-12, Post-operative pulmonary embolism and deep vein thrombosis (DVT), added an exclusion for acute brain or spinal cord injury and removed isolated calf vein DVTs from the inclusion criteria. PSI-15, Unrecognized abdominopelvic accidental puncture/laceration, went through a major change to now include only abdominopelvic surgeries (rather than almost all surgeries), and the inclusion criteria now require a return to the operating room at least one or more days after the initial surgery.
Version 6 adds three new PSIs to the PSI-90 composite: PSI-9, Perioperative hemorrhage and hematoma, PSI-10, Postoperative Acute Kidney Injury, and PSI-11, Postoperative Respiratory Failure. PSI-7, Central venous catheter-related blood stream infection, was removed from the PSI-90 composite in version 6. See Table 1 (below) for the current components of version 6.0 PSI-90.
Reviewing for PSIs should be a vital component of any hospital’s concurrent and retrospective review programs. While PSIs are not officially identified or assigned until a case is coded, clinical documentation specialists (CDSs) can review for potential PSIs without a final coded case. Concurrently, CDSs can review for key clinical indicators and documented conditions that appear to be hospital-acquired, rather than occurring when the patient arrived, such as respiratory failure, DVT, and post-operative sepsis. CDSs should evaluate supporting clinical indicators for these diagnoses; if the clinical indicators do not match the documented conditions, they can query to seek clarification from the treating provider. CDSs should also evaluate if the condition was present on admission. If signs and symptoms associated with the condition are present at the time of order for inpatient admission, the condition can be considered “present on admission.” If the clinical scenario or documentation is unclear, a query may be necessary to confirm the presence of the condition on admission.
CDSs should become familiar with the diagnostic inclusion and exclusion criteria for specific PSIs, and incorporate these into concurrent or retrospective record reviews. Certain diagnoses will exclude a patient from a PSI; for example, an infection present on admission will exclude a patient from PSI-13, Post-operative Sepsis. While generally not considered a component of the CDS review scope, admission source is a key element for assignment of PSI-3, Pressure Ulcers. Nature of admission is another key element for assignment of PSI-11, Post-operative Respiratory Failure, and PSI-13, Post-operative Sepsis. If the patient is an emergent (rather than elective) admission, the patient will be excluded from these PSIs.
Once final coded, cases with a PSI can be flagged and reviewed before a bill is sent.
Hospital coding professionals and CDS staff should be aware of PSI logic and review criteria. A comprehensive review program should include concurrent review for potential PSIs and retrospective review once cases are final coded.
Agency for Healthcare Research and Quality. www.qualityindicators.ahrq.gov.
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