PSI 90’s transformation into the Patient Safety and Adverse Events Composite

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The fiscal year (FY) 2017 IPPS proposed rule alerted us to some significant changes to Patient Safety Indicator (PSI) 90, one of which is a new name: the Patient Safety and Adverse Events Composite. A fact sheet released by the measure’s owner, the Agency for Healthcare Research and Quality (AHRQ), provides insights into what may lie ahead if the proposed rule’s content is finalized.

Nothing new here

The underlying objective of this modified claims-based quality measure remains the same. The Patient Safety and Adverse Events Composite provides an overview of hospital-level quality as it relates to a set of potentially preventable hospital-related events associated with harmful outcomes for patients.

The measure will also continue to be included in CMS hospital pay-for-performance programs:

• The Hospital-Acquired Condition Reduction Program (HACRP) will adopt the measure in FY 2018
• The Hospital Value-Based Purchasing Program will adopt the measure in FY 2019 after the statutorily required one-year public posting of performance on CMS Hospital Compare under the Inpatient Quality Reporting Program
• PSI performance will still be assessed using an observed over expected ratio, and the risk adjustment methodology will remain the same, although comorbidity variables and coefficient weights will likely be refined

PSIs in the CMS composite will change

CMS has included eight PSIs in the composite used in hospital pay-for-performance programs:

• 3, pressure ulcer
• 6, iatrogenic pneumothorax
• 7, central line?associated bloodstream infection
• 8, postop hip fracture
• 12, preop pulmonary embolism or deep vein thrombosis
• 13, postop sepsis
• 14, postop wound dehiscence
• 15, accidental puncture/laceration

The modified measure will delete PSI 7 from the composite, citing duplication with other similar measures.

Three of the PSIs (8, 12, and 15) will be re-specified, which means that the types of patients included in the PSIs will be revised (see "Revised PSIs" on p. 3).

Composite weights are revised

A new algorithm that considers both the volume of events and their probability of harm will be used. The graph on p. 3 illustrates the proposed impact of each PSI’s performance on the overall composite weight. PSI 15, which at present comprises half of the composite weight, is reduced to 0.82%!

Preparation challenges

Although the HACRP will adopt this modified measure in FY 2018, performance will be based on today’s discharges. Therefore, a review of the revised measure specifications and risk adjustment variables is encouraged. The challenge: The ICD-10-ready specifications for this modified version will not be ready until sometime this summer, and the risk adjustment variables are not anticipated to be ready until next year. AHRQ is evaluating ICD-10 data in its databases to finalize this information.

What to do in the interim?

In the meantime, we recommend the following:

• Continue to use the most recent measure specifications and risk adjustment variables used by CMS for the current PSI 90 cohorts
  • A close review of the ICD-10 drafts by your CDI program experts will likely identify ICD-9 to ICD-10 mappings that do not appear to support the intention of the measure
  • The current ICD-10-ready drafts are just that?drafts?and AHRQ acknowledges that they will likely be refined
• Review the most recent measure specifications for the proposed new cohorts (PSI 9, 10, and 11) to identify CDI risk areas
  • PSI 11, postoperative respiratory failure, has traditionally been a known CDI vulnerability
• Study the proposed re-specified measures to identify CDI opportunities
• Meet with the quality team and determine what version of measures they currently use to assess organizational performance and to get in sync on the versions impactful to CMS value-based outcomes
• Educate your CDI team and providers on PSI documentation needs, and tighten up operational processes to flag discharges that trigger the PSIs
• Don’t forget that PSI 90 is a risk-adjusted measure; the capture of comorbidities for all discharges in the measure denominators is essential to reflect accurate performance

Summary

Strong performance in patient safety events has broad implications. Patient safety events have downstream cost and quality ramifications ranging from the cost to treat the safety event to readmissions and mortality. Data quality is an essential component to appropriate focus and measurement of patient care improvement efforts.

CDI programs that have already established the infrastructure to monitor and effectively impact claims-based quality measures are likely positioned well to navigate these changing waters. Additional information can be located at www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf as well as www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx.

Editor’s note: Newell is the director of CDI quality initiatives for Enjoin. Her team provides health systems with physician-led education and infrastructure design to sustainably address documentation and coding challenges essential to optimal performance under value-based payments across the continuum. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected]. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

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