Measuring Hospital Standardised Mortality Rates
Death in Low-Mortality DRG's
Patients Experiencing Adverse Events
Patients Informed about an Adverse Event by the Staff
Patients Experiencing of Adverse Event Management
Transition of Care - Patients' Understanding of the Purpose of their Medication
Institution-Wide use of Cultural Assessment
Surveying the Development of the Patient Safety Culture
Decubitus Ulcer
Measuring Hospital Standardised Mortality Rates
PSI 1: Measuring Hospital Standardised Mortality Rates
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Hospital Standardised Mortality Ration (HSMR) was first developed to
monitor the quality of care delivered. Yet, death is the ultimate harm to
a patient regarding patient safety. Thus HSMR is an adequate PSI
(1;2).
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Aim of the PSI The PSI aims at surveillance of institution-wide in-hospital mortality.
Source(s) HSMR was developed by B. Jarman, London.
Extent of Clinically
Testing
Since 1999 HSMR has been used in all National Health Service
hospitals in England, and the results have been published. The method
has also been used and tested in Sweden where it was applied to the
national patients’ registry. Registration of death is statutory, which
increases the data registrations and makes the registration specific.
By testing the method predictive differences in HSMR was found, they
were: the number of in-hospital doctors per 100 beds, number of GPs
per 100000 habitants in the area of interest, the number of acute
admissions, and the part of patients suffering from comobidity like
pneumonia and heart insufficiency (1).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-Wide PSI.
of hospitalisation.
Data Source Administrative data.
Identifying the
institutional context
This PSI is relevant to quality improvement and accreditation.
Care Setting The PSI applies institution-wide.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Age (10 years intervals), sex, comorbidity.
Stratification by
Vulnerable Populations
Age (10 years intervals), sex, elective/acute admission and total time of
hospitalisation.
Standard of Comparison No time frame of the comparison set. Hospital-wide surveillance.
Scoring Only the 85 primary admission diagnoses contributing to 80% of all inhospital
deaths are counted. All transfers between hospitals are
excluded.
To know about differences in primary illness and comorbidity the 15
most often discharge diagnosis (covering chronic diseases and acute
cause of admission) are to be found as the primary diagnosis related to
50% of all in hospital deaths (Please see (1) for further definition)
For each of the 85 included primary discharge diagnoses the yearly
cumulative mortality proportion (CMP) of the hospital is assessed, that
is dividing the number of deaths given a specific diagnoses by the total
number of admissions given the specific diagnosis stratified by age (10
years intervals), sex, elective/acute admission and total time of
hospitalisation.
The expected yearly CMP is assessed for each stratum multiplied by
the total strata specific CMP.
HSMR is assessed as the ratio of the observed versus the expected
CMP for each of the primarily discharge diagnosis multiplied by 100.
By means of stepwise regression analysis risk factors for differences in
HSMR are identified. The steps are: 1) general hospital data (e.g. part
of acute admitted patients 2) individual hospital data (e.g. number of
beds) 3) society related data (e.g. number of GPs per 100000 habitants
in the area). Please see (1) for further scoring advise.
of hospitalisation.
Data Source Administrative data.
Identifying the
institutional context
This PSI is relevant to quality improvement and accreditation.
Care Setting The PSI applies institution-wide.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Age (10 years intervals), sex, comorbidity.
Stratification by
Vulnerable Populations
Age (10 years intervals), sex, elective/acute admission and total time of
hospitalisation.
Standard of Comparison No time frame of the comparison set. Hospital-wide surveillance.
Scoring Only the 85 primary admission diagnoses contributing to 80% of all inhospital
deaths are counted. All transfers between hospitals are
excluded.
To know about differences in primary illness and comorbidity the 15
most often discharge diagnosis (covering chronic diseases and acute
cause of admission) are to be found as the primary diagnosis related to
50% of all in hospital deaths (Please see (1) for further definition)
For each of the 85 included primary discharge diagnoses the yearly
cumulative mortality proportion (CMP) of the hospital is assessed, that
is dividing the number of deaths given a specific diagnoses by the total
number of admissions given the specific diagnosis stratified by age (10
years intervals), sex, elective/acute admission and total time of
hospitalisation.
The expected yearly CMP is assessed for each stratum multiplied by
the total strata specific CMP.
HSMR is assessed as the ratio of the observed versus the expected
CMP for each of the primarily discharge diagnosis multiplied by 100.
By means of stepwise regression analysis risk factors for differences in
HSMR are identified. The steps are: 1) general hospital data (e.g. part
of acute admitted patients 2) individual hospital data (e.g. number of
beds) 3) society related data (e.g. number of GPs per 100000 habitants
in the area). Please see (1) for further scoring advise.
PSI 2: Death in Low-Mortality DRGs
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Death in patients admitted to hospital for an extremely low-mortality
condition or procedure might happen due to adverse events. Thus this
theme is suitable as a measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital deaths in patients
unlikely to die during hospitalisation.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Hannan et al. as a criterion
for targeting “cases that would have a higher percentage of quality of
care problems than cases without the criterion as judged by medical
record review” (3).
Extent of Clinically
Testing
The AHRQ project team developing this PSI conducted empirical
analyses on this PSI. The team concluded: “Deaths in low-mortality
DRGs generally performs well on several different dimensions
including reliability, bias, relatedness of indicators and persistence
over time”. The AHRQ project team reviewed the literature and found
a two-stage implicit review of randomly selected deaths by Hannan et
al. They found that “patients in low-mortality DRGs (<0.5%) were
5.2 times more likely than all other patients who died (9.8% versus
1.7%) to have received “care that departed from professionally
recognised standards,” after adjusting for patient demographic,
geographic, and hospital characteristics. In 15 of these 26 cases (58%)
of substandard care, the patient’s death was attributed at least partially
to that care. The association with substandard care was stronger for
the DRG-based definition of this indicator than for the procedurebased
definition (5.7% versus 1.7%, OR=3.2)”(3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. Mean length of stay was 7.1.days. All together 11411 PSI
events were identified, 46% of PSI events occurred in surgical
hospitalisation and 54% in medical hospitalisation. The observed PSI
rate per 1000 discharges was 3.23 for death in low-mortality DRGs.
This PSI was significantly associated with the AHRQ PSI for failure
to rescue. Statistically significant differences were found for
hospitalisations with this PSI event and those without PSI events for
longer lengths of stay and costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
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descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated no clear trend in the rate over time. It was
concluded, that the PSI is a useful tool for tracking and monitoring
patient safety events. Future research should investigate whether trends
reflect better or worse care or increased attention to documenting
patient safety events (5).
The Agency for Healthcare Research and Quality PSI algorithms were
applied to administrative data across four years of 1.92 million
discharges from children's hospitals. The mean risk-adjusted rates of
PSI events ranged from 0.1 events per 1000 discharges for a foreign
body left in during a procedure to 140 events per 1000 discharges for
failure to rescue. The researchers concluded: “PSIs derived from
administrative data are indicators of patient safety concerns and can be
relevant as screening tools for children's hospitals; however, cases
identified by these indicators do not always represent preventable
events. Some, such as a foreign body left in during a procedure,
iatrogenic pneumothorax, infection attributable to medical care,
decubitus ulcer, and venous thrombosis, seem to be appropriate for
paediatric care and may be directly amenable to system changes. In
their present form, two of the indicators, namely, failure to rescue and
death in low-mortality DRGs, are inaccurate for the paediatric
population, do not represent preventable errors in the majority of
paediatric cases, and should not be used to estimate quality of care or
preventable deaths in children's hospitals”(6).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Deaths in low-mortality DRGs occur significantly
less often among Hispanic people and Asian Pacific Islander than
among white. It was concluded that: ”The AHRQ PSIs are a broad
screen for potential safety events that point to needed improvement in
the quality of care for specific populations” (7).
The results suggest that this PSI may be useful as a measure of patient
safety – Though special thoughts should be given to application of this
PSI to the paediatric population. (3-6).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Disease Disease Specific PSI
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Data definitions In-hospital deaths per 1000 patients in DRGs with less than 0.5%
mortality.
Numerator Description Discharges with dispositions of “deceased”.
Denominator Description Patients, 18 years and older or MDC (pregnancy, childbirth and
puerperium), in DRGs with less than 0.5% mortality rate, based on NIS
2003 low-mortality DRG.
If a DRG is divided into “without/with complications”, both DRGs
must have mortality rates below 0.5% to qualify for inclusion.
Exclude cases with any code for trauma, immunocompromised state, or
cancer.
Data Source Administrative data.
Identifying the
institutional context
The impact of deaths in low-mortality DRGs related to adverse events
makes this PSI important in quality improvement policies.
Care Setting The PSI applies for quality health care.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
Because the denominator includes many heterogeneous patients cared
for by different services, this PSI should be stratified by DRG type i.e.,
adult medical, paediatric medical, adult surgical, paediatric surgical,
psychiatric, obstetric and neonatal (3;4).
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
This indicator should be evaluated separately by type of DRG when
used as an indicator of quality. For example, the PSI Software reports
the low-mortality DRG rate for all the included DRGs and separately
by DRG type: adult medical, adult surgical (with and without an
operating room procedure), paediatric medical, paediatric surgical
(with and without an operating room procedure), and obstetric and
psychiatric (3).
PSI 3: Patients experiencing Adverse Events
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
The ultimate goal is to achieve the best care and outcome for patients
each time they are in touch with the health care system. The frequency
of adverse events is cause for serious concern. A comprehensive
approach to reduce adverse events involves not just health care
organisations but patients as well as patients are an important source of
observations and information about adverse events, though. All though
it is a known fact within patient safety experts that patients
comprehend adverse events as errors, patient’s experiences of adverse
events is considered important as a source for identifying areas for
improvement. Thus patient’s experience of adverse events is an
important measure of patient safety.
Aim of the PSI This PSI aims at surveillance of patient’s experience of the presence of
adverse events (e.g. in diagnosing, medication, procedure, and
communication).
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This PSI is derived from the section on patient safety of the Danish
national patient survey: Patient’s experiences in hospital (9).
Extent of Clinically
Testing
By using a questionnaire attitudes and responses to adverse events
were investigated from the patient’s and the staff’s point of view.
Patients were asked about their experiences with adverse events and
staffs management of adverse events. Comparison of responses to the
same questions was made between the two groups. Twenty percent of
patient had experienced minor adverse events and eight percent large
adverse events during hospitalisation (9).
Another Danish study using mailed questionnaires estimated the
incidence of medical errors; also the extent of agreement between
patients and staff of the type of error was investigated. Errors were
described in free text by informants and rated in categories by a risk
manager. Of the staff 44% had experienced an error within the last
three months in ambulatory or in-patient care, whereas 13% of the
patients had experienced an error. The most frequent error experienced
by staff was: “wrong medicine” and by patients “delayed diagnosis”.
By the descriptions the risk manager found that 44% of the patient
reported errors could be classified as dissatisfaction. The researchers
concluded that patients typically find it difficult to distinguish between
an error and their dissatisfaction, highlighting a need for firm criteria if
patients are to report errors as a basis for improvements. Comparison
of error rates between patients and staff – and indeed between hospitals
- will be misleading until these criteria are reliable and validated (10).
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This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-Wide PSI.
Data definitions Number of patients experiencing an adverse event per 1000 discharges.
Numerator Description Number of patients experiencing an adverse event during
hospitalisation.
Denominator Description Number of patient’s discharges from hospital
Data Source Patient’s Experiences (Satisfaction) Survey.
Identifying the
institutional context
The qualitative and quantitative consequences of adverse events make
this PSI important in quality improvement policies.
Care Setting The PSI applies institution-wide.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific time standards given, but comparison every second year
has shown to be good.
Scoring Scoring according to the manual of the Patient’s Experiences
(Satisfaction) Survey.
PSI 4: Patients Informed about and Adverse Event by the Staff
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Once a serious adverse event has happened it is important to identify it
and take adequately care of the patient and make adequate
improvements. A feature of a positive and highly developed safety
culture is awareness regarding unsafe act and procedures and openness.
Thus patient’s way of finding out about an adverse event is an
important measure of patient safety culture.
It is known facts among patient safety experts, that patient comprehend
adverse events as errors.
Aim of the PSI This PSI aims at surveillance how patients get to know about adverse
events.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This PSI is derived from the section on patient safety of the Danish
national patient survey: Patient’s experiences in hospital, question 19
(9;11).
Extent of Clinically
Testing
Attitudes and responses to adverse events have been investigated from
Danish patient’s and the staff’s point of view, using a questionnaire
survey. Patients were asked about their experiences with adverse
events and staffs handling of adverse events. Comparison of responses
to the same questions was made between the two groups. The
researchers concluded that healthcare staff should, to a larger extent,
inform openly about adverse events and their medical consequences.
Information should be communicated direct to the patient and their
relatives and written in the patient’s record (12).
This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-Wide PSI.
Data definitions Patients informed about the adverse event by the staff per 1000 patient
experienced adverse events.
Numerator Description Number of patients informed about the adverse event by the staff
Denominator Description Number of patients experiencing an adverse event during
hospitalisation.
Data Source Patient’s Experiences (Satisfaction) Survey.
Identifying the
institutional context
The impact of high quality incident management makes this PSI
important in cultural improvement policies.
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Care Setting The PSI applies for institution-wide quality incident management
especially relating to awareness, openness and communication.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific time standards given, but comparison every second year
has shown to be.
Scoring Scoring according to the manual of the Patient’s Experiences
(Satisfaction) Survey.
PSI 5: Patients Experiences of Adverse Event Management
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Once a serious adverse event has happened it is important to identify it
and take adequately care of the patient and make the necessary
preventive improvements. All though it is a known fact within patient
safety experts that patients comprehend adverse events as errors,
patients experiences of adverse event management is considered
important as a source for identifying areas for improvement.
Thus patient’s impressions of adverse event management are an
important measure of patient safety and the related culture.
Aim of The Specific
Indicator
This PSI aims at surveillance of patient’s negative experiences with
adverse event management following an adverse event.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This PSI is derived from the section on patient safety of the Danish
national patient survey: Patient’s experiences in hospital, question 20
(9;11).
Extent of Clinically
Testing
Attitudes and responses to adverse events have been investigated from
Danish patient’s and the staff’s point of view, using a questionnaire
survey. Patients were asked about their experiences with adverse
events and staffs management of adverse events. Comparison of
responses to the same questions was made between the two groups.
The researchers concluded that healthcare staff should, to a larger
extent, inform openly about adverse events and their medical
consequences. Information should be communicated direct to the
patient and their relatives and written in the patient’s record (13).
This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
Indicator category Theme Related PSI: “Medication Errors”.
Data definitions Patients experiencing an adverse event finding staff’s management of
the incident “bad” and “extremely bad” measured on a 5-point Likert
scale per 1000 discharges.
Numerator Description Number of patients, having experienced an adverse event, finding
staff’s incident management “bad” or “extremely bad” measured on a
5-point Likert scale ranging from excellent, good, and neutral to bad
and extremely bad.
Denominator Description Number of patients experiencing an adverse event during
hospitalisation.
Data Source Patient’s Experiences (Satisfaction) Survey.
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Identifying the
institutional context
The impact of high quality patient safety management makes this
indicator important in cultural and clinical improvement policies.
Care Setting The indicator applies for high quality adverse event management.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific time standards given, but comparison every second year
has shown to be good.
Scoring Scores are obtained on a 5-point Likert scale ranging from excellent,
good, and neutral to bad and extremely bad. The numbers of scores of
“bad” and “extremely bad” are cumulated. Scoring according to the
manual of the Patient’s Experiences (Satisfaction) Survey.
PSI 6: Transition of Care – Patient’s Understanding of their Medication
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Communication and transfer of information between healthcare
settings and between professionals and patients are essential
aspects of patient safety. Especially care transition processes are
known to be vulnerable regarding patient safety. Understanding
the purpose of the medication can impact compliance. Adherence
to medications is important as lack of compliance can have fatal
consequences for the patient.
Aim of the PSI This PSI aims at highlighting the quality of staff patient
communication regarding patients understanding of the purpose of
their medication when leaving hospital.
Level of Determination of
Patient Safety
Safety is assessed at the aggregate patient level.
Source(s) This PSI is derived from the “Care Transitions Measure” question
3. Please see www.caretransitions.org
Dr. Coleman and colleagues have designed a measure to assess
the quality of care transitions: the Care Transitions Measure
(CTM ©). The CTM exists in two forms a 15-item unidimensional
version and a three-item version (CTM-3), which is a
subset of the 15 items version. The primary objective of the
development of CTM was a measure that is both substantively and
methodologically consistent with the concept of patientcenteredness,
and useful for the purpose of performance
measurement and subsequent public reporting. CTM assesses
health care professionals accomplished essential care processes
(14).
Extent of Clinically Testing CTM is used in 15 different countries.
Specific CTM items were developed; pilot tested, and refined
using focus groups. By standard qualitative analytic techniques
applied to the written interview transcripts, four key domains were
found for the CTM. The domains were: 1) information transfer; 2)
patient and caregiver preparation; 3) self-management support;
and 4) empowerment to assert preferences. Psychometric testing
of the CTM included content and construct validity, intra-item
variation, and floor/ceiling properties. High internal consistency
and reliability were found. Also applicability for assessment
across multiple sites of care: hospital to home, hospital to skilled
nursing facility, skilled nursing facility to home was good. CTM
demonstrated power to discriminate between: 1) patients
discharged from hospital that did/did not experience a subsequent
emergency visit or readmission for their index condition, and 2)
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health care facilities with differing levels of commitment to care
coordination. The researchers concluded: “CTM may serve to fill
an important gap in health system performance evaluation by
measuring the quality of care delivered across settings” (14).
The developer of TCM-3 have studied the differential item
function by gender, self rated health, age, educational level and
ethnicity. It was found that these variables do not bias the
responses on TCM-3. No risk adjustment was found necessary
(15-17)
Specifications are given for the use of CTM-3 in five domains: 1)
Survey Instrument, 2) Sampling, 3) Survey administration 4)
Scoring and patient mix adjustment and 5) Reporting data (15).
Dr. Coleman and his colleagues also developed a 4-week Care
Transition Intervention program, which was tested in a
randomised controlled trial. Patients with complex care needs
received either treatment as usual or the CTM-intervention:
specific tools, support by a “Transition Coach,” and selfmanagement
skills. Patients in the CTM-program were
significantly less likely to be readmitted and they were more
likely to achieve self-identified personal goals around symptom
management and functional recovery. Findings were sustained for
as long as six months after the program ended (18).
Evidence of Clinically use of
Standards
No evidence of clinically use of standards was found.
PSI category Institution-Wide PSI.
Data definitions Patient’s agreement that they understand the purpose for taking
their medicine measured on a 5-point Likert scale per 100
discharges.
Numerator Description Number of patients agreeing that they understand the purpose of
taking their medication rated as “Agree” or “Strongly agree”
measured on a 5-point Likert scale ranging from “Strongly
Disagree”, “Disagree”, “Don’t know/Don’t remember/Not
applicable” to “Agree” and “Strongly Agree”.
Denominator Description Number of discharges from acute care hospitals.
Exclude:
- Psychiatric patients/ Patients with cognitive disorders
- Paediatric patients under age 18 years
- Patients who die in hospital
- Patients who did not stay at least one night in hospital
- Other patients as required by law or regulation in the state
in which the hospital operates
Data Source The Care Transitions Measure (CTM-3) Question 3.
Identifying the institutional
context
The impact of high quality communication and information makes
this PSI important in safety improvement policies.
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Care Setting The PSI applies institution-wide.
Professionals Responsible for
Health Care
All authorised health care workers.
Lowest Level of Health Care
Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by Vulnerable
Populations
No stratification.
Standard of Comparison Yearly. Please see (15).
Scoring Scores are obtained and scored on a 5-point Likert scale ranging
from “Strongly Disagree”, “Disagree”, “Don’t know/Don’t
remember/Not applicable” to “Agree” and “Strongly Agree”.
Scores of “Agree” and “Strongly Agree”. Scores are cumulated
and frequencies calculated. Specifications are given for the use of
CTM-3 in five domains: 1) Survey Instrument, 2) Sampling, 3)
Survey administration 4) Scoring and patient mix adjustment and
5) Reporting data (15).
PSI 7: Institution-Wide use of Cultural Assessment
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Focus of the works of patient safety has shifted over the time from
investigation of the epidemiology of adverse events and
introduction of innovations aimed at prevention to investigation of
shared attitudes, beliefs, values and assumptions that underlie how
people perceive and act upon safety. It is thought important to try
to grasp these shared characteristics to initiate fundamental and
sustained changes to patient safety.
Thus cultural surveillance is important in developing patient
safety.
Aim of the PSI This PSI aims at surveillance of the use of regular yearly cultural
assessment within the hospital.
Level of Determination of
Patient Safety
Safety is assessed at the aggregate institutional level.
Source(s) PSI is by SimPatIE.
Extent of Clinically Testing We found no evidence for the use of an indicator for monitoring
the frequency of the use of culture assessments.
It is an acknowledged fact in the literature, that measuring the
safety gives the management/organisations a baseline for
developing the culture. Results of regular measures give the
management/organisations the opportunity to plan and carry out
adequate changes to develop patient safety.
A systematic literature review of ten studies was conducted to
review the evidence for a relationship between organisational
culture and health care performance. The reviewer’s found a
considerable variation in the design, study setting, and quality of
reporting and aspects of culture/performance considered.
Researchers of four of the studies found supportive evidence for
an association between culture and performance are linked (19).
A recent study revealed that the overall unit based safety climate
significantly predicted nurse back injuries, medication errors and
urinary tract infections. A more positive safety culture was
associated with fewer incidents (20).
Numerous articles give a general introduction and presentation to
evaluation of safety culture within health care (21-24). Also in
recent years a large number of quantitative tools with differing
characteristics have been developed to access the generic concept
of culture (22;25-27). The instruments vary in focus, aim, method,
application and validity. Not surprisingly, there is not one best
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instrument, as they all have strengths and weaknesses. The
important thing is for organisations to select the instrument that is
most appropriate for their purposes and validated in a relevant
setting.
Evidence of Clinically use of
Standards
Though cultural assessment is in use in numerous hospitals in
Europe, we have not found specific scientific evidence describing
use of cultural assessment as a PSI.
PSI category Institution-Wide PSI.
Data definitions The yearly number of units assessing the patient safety culture per
total number of units in the hospital.
Numerator Description The yearly number of units assessing patient safety culture using a
quantitative measure
Denominator Description Total number of units in the hospital
Data Source Yearly observational cross-sectional survey on the unit wise use
of cultural assessment. The instrument chosen must be suitable,
and it must be validated in a relevant setting.
Identifying the institutional
context
The assessment of patient safety culture is important in general
organisational and clinical improvement policies.
Care Setting The PSI applies for institution-wide high quality culture related to
patient safety.
Professionals Responsible for
heath care
Not applicable as all hospital staff form, interact and influence the
safety culture.
Lowest Level of Health Care
Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Not applicable.
Stratification by Vulnerable
Populations
Not applicable.
Standard of Comparison Yearly monitoring. Comparison with the previous measures.
Benchmarking.
Scoring Frequencies are counted by observation.
PSI 8: Surveying the Development of the Patient Safety Culture
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Patient safety culture has been shown to be related to health care
performance. A more positive/developed safety culture is
associated with fewer incidents. Classification of patient safety
culture can be seen in terms of steps on an evolutionary ladder.
Each level has distinct characteristics and is a progression on the
one before. The more developed the culture the higher on the
ladder (28;29).
A recent study revealed that the overall unit based safety climate
significantly predicted nurse back injuries, medication errors and
urinary tract infections (30). A systematic literature review also
found evidence for a relationship between organisational culture
and health care performance in four of ten studies (19).
Thus the development of the patient safety culture is an
appropriate measure of patient safety.
Aim of the PSI The PSI continuously surveys the development of the patient
safety culture.
Level of Determination of
Patient Safety
Safety culture is assessed at the aggregated unit level.
Source(s) PSI by SimPatIE. Choice of survey instrument is made by the
unit, department or institution.
Extent of Clinically Testing In recent years a large number of quantitative tools with differing
characteristics have been developed to access the generic concept
of culture within health care (22;25-27).
The instruments vary in focus, aim, method, application and
validity. Not surprisingly, there is not one best instrument, as they
all have strengths and weaknesses. The important thing is for
organisations to select the instrument that is most appropriate for
their purposes and validated in relevant setting. The enclosed
overview shows the subjects covered for some well known
internationally used patient safety culture assessment instruments.
Three systematic literature reviews concerning quantitative
instruments for measuring culture were identified.
The first review compared nine different surveys according to
their general characteristics, dimensions covered, psychometric
performance, and their use in studies of patient safety
culture/climate surveys. It was found, that all surveys used Likert
scales, mostly to measure attitudes of individuals. Nearly all
covered five common dimensions of patient safety climate:
leadership, policies and procedures, staffing, communication, and
reporting. The strength of psychometric testing varied. While all
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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had been used to compare units within or between hospitals, only
one described the association between organisational climate and
patient outcomes (31).
The second review of 13 instruments focused on the cultural
dimensions addressed, the number of items for each questionnaire,
the measurement scale adopted, examples of studies that had used
the tool, the scientific properties of the instrument, and its
strengths and limitations. The instruments varied considerably in
terms of their grounding in theory, format, length, scope, and
scientific properties. The reviewers concluded, that the choice of
instrument should be determined by how organisational culture is
conceptualised, the purpose of surveying, intended use of the
results, and availability of resources (19).
The third systematic review of 12 studies was undertaken to study
sample and questionnaire design characteristics (source, no of
items, scale type), construct validity (content validity, factor
structure and internal reliability, concurrent validity), within
group agreement, and level of analysis. There was a lack of
explicit theoretical framework for most instruments; some did not
even report standard psychometric criteria. The reviewers
concluded: “More consideration should be given to psychometric
factors in the design of healthcare safety climate instruments,
especially as these are beginning to be used in large scale surveys
across healthcare organisations” (32).
Evidence of Clinically use of
Standards
Though surveying the patient safety culture systematically is done
in numerous hospitals in Europe, we have not found specific
scientific evidence describing clinical use of the measures as a
PSI.
PSI category Institution-Wide PSI.
Data definitions The development in the unit wise overall mean score of patient
safety culture described as a percentage of improvement/relapse in
relation to last measure.
Numerator Description The unit wise difference in the present and the previous overall
mean score of patient safety culture times 100
Denominator Description The previous overall mean score of patient safety culture for the
unit
Data Source Quantitative measure of patient safety culture. The instrument
chosen must be chosen according to the organisations resources,
aims, needs and other patient safety and quality improvement
activities, and the instrument chosen must be validated in a
relevant setting.
Identifying the institutional
context
The development of the patient safety culture makes this PSI
important regarding improvement policies.
Care Setting The PSI applies for institution-wide culture related to patient
safety.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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Professionals Responsible for
heath care
Not applicable as all hospital staff form, interact and influence the
safety culture.
Lowest Level of Health Care
Delivery Addressed
Unit.
Allowance for Patient
Factors
Not applicable.
Stratification by Vulnerable
Populations
Not applicable.
Standard of Comparison Yearly monitoring. Comparison of the development can be made
between units within the hospital.
Scoring Scoring on the assessment instrument is made according to the
manual of the chosen instrument.
PSI 38: Decubitus Ulcer
Review of OECD PSI/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Decubitus ulcers or bedsores are a common complication of inadequate
care for immobilised patients. The occurrence of a decubitus ulcer in a
hospitalised patient has a serious negative impact on the individual’s
health and often leads to a much prolonged hospital stay. Decubitus
ulcers can be prevented with good quality nursing care. Thus, the
indicator has great clinical plausibility as a patient safety measure.
Aim of the PSI This PSI is intended to flag cases of in-hospital decubitus ulcers.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program (CSP 6, “cellulitis or decubitus
ulcer”). Needleman and Buerhaus identified decubitus ulcer as an
“outcome potentially sensitive to nursing” The American Nurses
Association, its State associations, and the California Nursing
Outcomes Coalition have identified the total prevalence of inpatients
with Stage I, II, III, or IV pressure ulcers as a “nursing-sensitive
quality indicator for acute care settings” (3).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21
covered patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time.
(3).
While the indicator was found to be well operationalised, the biggest
threat to construct validity is the inability to precisely distinguish
between pre-existing and hospital-acquired decubitus ulcers on the
basis of administrative data (33)
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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was 97% male, with a mean age of 65 years, 54% were age 65 and
older. Mean length of stay was 7.1.days. All together 11411 PSI
events were identified, 46% of PSI events occurred in surgical
hospitalisation and 54% in medical hospitalisation. The observed PSI
rate per 1000 discharges was 15.41 the highest of all for decubitus
ulcer. This PSI was not significantly associated with any other PSI
studied. Statistically differences were found for hospitalisations with
this PSI events and those without PSI events for longer lengths of
stay, higher mortality and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (e.g., teaching status, number of beds, and degree of
quality improvement implementation) and baseline safety-related
hospital performance predict future hospital safety-related
performance. Risk-adjusted rates of the PSI for iatrogenic
pneumothorax and failure to rescue demonstrated a consistent rate over
time. After accounting for patient and hospital characteristics,
hospitals' baseline risk-adjusted PSI rates were the most important
predictors of the 2004 risk-adjusted rates for eight PSIs among these
decubitus ulcer. It was concluded, that the PSIs are useful tools for
tracking and monitoring patient safety events. Future research should
investigate whether trends reflect better or worse care or increased
attention to documenting patient safety events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. No differences in the occurrence of this PSI event
were found according to race. It was concluded that: ”The AHRQ
PSIs are a broad screen for potential safety events that point to needed
improvement in the quality of care for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7;8;33;34).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-wide PSI.
Data definitions Cases of decubitus ulcer per 1000 discharges with a length of stay
greater than 4 days.
Numerator Description Discharges with ICD-9-CM code of decubitus ulcer in any secondary
diagnosis field.
Denominator Description All medical and surgical discharges 18 years and older defined by
specific DRGs.
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Exclude cases:
− with length of stay of less than 5 days
− with ICD-9-CM code of decubitus ulcer in the principal diagnosis
field
− MDC 9 (Skin, Subcutaneous Tissue, and Breast)
− MDC 14 (pregnancy, childbirth, and puerperium)
− with any diagnosis of hemiplegia, paraplegia, or quadriplegia
− with an ICD-9-CM diagnosis code of spina bifida or anoxic brain
damage
− with an ICD-9-CM procedure code for debridement or pedicle graft
before or on the same day as the major operating room procedure
(surgical cases only)
− admitted from a long-term care facility (Admission Source=3)
− transferred from an acute care facility (Admission Source=2)
Data Source Administrative data.
Identifying the
institutional context
The impact of decubitus makes this PSI important for both financial
and quality improvement policies.
Care Setting The PSI applies for high quality nursing care.
Professionals Responsible
for Health Care
Nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for : Age, sex, DRG, comorbidity categories
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
