senior man with protective safety mask on face in a wheelchair and a confident doctor in the medical mask
Blog August 24, 2018

By Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP

Patient Safety Indicators

In 2000, following publication of the Institute of Medicine’s groundbreaking report To Err Is Human, the Agency for Healthcare Research and Quality (AHRQ), was called upon to develop a standardized approach to identifying and reporting patient safety issues.  AHRQ is the health services research arm of HHS.  Health services research examines how people get access to health care, how much care costs, and what happens to patients as a result of this care.

As a result of the call to action, a set of 12 Patient Safety Indicators (PSIs) was developed that described clinical events that could identify potential in-hospital patient safety problems.

AHRQ’s PSIs, which provide a perspective on patient safety and identify problems that could potentially be prevented by implementing system-level changes, quickly grew to be the backbone of standardized patient safety reporting in the United States.

An important component that envelops most PSIs concerns the complication of care guideline (Official Guidelines for Coding and Reporting I.B.16), “Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification.  The guideline extends to any complications of care, regardless of the chapter the code is located in.  It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications.  There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.  Query the provider for clarification, if the complication is not clearly documented. “   Because not all conditions that occur during or following medical care or surgery are classified as complications, it is imperative to adhere to this guideline for PSI reporting.

In addition to adhering to the Complications of Care guideline, the Present on Admission (POA), defined as present at the time the order for inpatient admission occurs, is critical to note because most PSIs describe an in-hospital event.  A condition that is present on admission could be excluded from PSI determination.  “Y” (Yes) and “N” (No) POA indicators are straightforward; however, “U” and “W” indicators need further explanation as they pertain to PSIs.

A “U” POA indicator is defined as the documentation being insufficient to determine if the condition was present at the time of inpatient admission.  CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “U” for the POA Indicator.

A “W” POA indicator is defined as the provider is unable to clinically determine whether the condition was present at the time of inpatient admission. CMS will pay the CC/MCC DRG for those selected HACs that are coded as “W” for the POA Indicator.

PSI Highlights

AHRQ provides a technical specification document for each PSI which provides comprehensive information for each PSI – a brief description of the measure, numerator and denominator information and details on cases that should be excluded from calculations.  While each PSI contains unique properties as outlined in its technical specification, there are a few properties that pertain to several PSIs.  The current version of PSIs is v2018 (for ICD 10), effective June 2018, from which this information is derived.

Denominator Exclusions

Aside from POA exclusions, below are a few of the most common exclusions.  It is important to check the code listing in the technical specification for the exact codes included or excluded for the broader categories.  For example, all cancer codes may not be on the cancer codes listing in the technical specification.

MDC 14 Pregnancy, Childbirth, and Puerperium exclusions

  • PSI 3 Pressure Ulcer Rate
  • PSI 6 Iatrogenic Pneumothorax
  • PSI 7 Central Venous Catheter-Related Blood Stream Infection Rate
  • PSI 8 In Hospital Fall with Hip Fracture Rate
  • PSI 9 Perioperative Hemorrhage or Hematoma Rate
  • PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis Rate
  • PSI 11 Postoperative Respiratory Failure Rate
  • PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
  • PSI 13 Postoperative Sepsis Rate
  • PSI 14 Postoperative Wound Dehiscence Rate
  • PSI 15 Unrecognized Abdominopelvic Accidental Puncture Laceration Rate

Other MDC exclusions:

  • PSI 11 Postoperative Respiratory Failure Rate
    • MDC 4 – diseases/disorders of the respiratory system, and
    • MDC 5 – diseases/disorders of the circulatory system

“Elective surgical” admission source exclusions: 

  • PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
  • PSI 11 – Postoperative Respiratory Failure Rate
  • PSI 13 – Postoperative Sepsis Rate.

Length of Stay (LOS) exclusions: 

  • PSI 3 Pressure Ulcer Rate (LOS < 3 days)
  • PSI 7 Central Venous Catheter-Related Blood Stream Infection Rate (LOS < 2 days)
  • PSI 14 Postoperative Wound Dehiscence Rate (LOS < 2 days)

Trauma Diagnosis Codes exclusions (check trauma diagnosis list in the technical specifications)

  • PSI 2 Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)
  • PSI 8 In-Hospital Fall with Hip Fracture Rate

Immunocompromised State exclusions (check immunocompromised diagnosis list in the technical specifications)

  • PSI 2 Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)
  • PSI 7 Central Venous Catheter-Related Blood Stream Infection Rate

Cancer Diagnosis Codes exclusions (check cancer diagnosis list in the technical specifications)

  • PSI 2 Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)
  • PSI 7 Central Venous Catheter-Related Blood Stream Infection Rate
  • PSI 8 In-Hospital Fall with Hip Fracture Rate (certain types – metastatic cancer, lymphoid malignancy, bone malignancy)

Each PSI contains its own exclusions that are unique to the condition. Below are examples of some of these; though not all-inclusive:

  • Stage III, IV or unstageable pressure ulcers – PSI 3 Pressure Ulcer Rate
  • Any listed diagnosis codes for pleural effusion, procedure codes for thoracic surgery and cardiac procedures – PSI 6 Iatrogenic Pneumothorax Rate
  • Any listed diagnosis code for coagulation disorder – PSI 9 Perioperative Hemorrhage or Hematoma Rate
  • Any listed CM code for degenerative neurological disorder- PSI 11 Postoperative Respiratory Failure Rate. These CM code listing includes, but is not limited to:
    • F0390 dementia, unspecified without behavioral disturbance
    • G0280 dementia in other diseases classified elsewhere without behavioral disturbance
    • G309 Alzheimer’s disease, unspecified
  • Respiratory failure in other conditions (J96.-) – PSI 11 Postoperative Respiratory Failure Rate

Lastly, there have been significant changes to PSI 15.  The denominator is now limited to abdominal and pelvic surgery.   The numerator is limited to accidental punctures or lacerations during a procedure that require a return to the operating room for a second abdominopelvic procedure one day or more after the index abdominopelvic procedure.   Based on these new specifications, the indicator name has been changed from “Accidental Puncture or Laceration Rate” to “Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate.”

You are encouraged to view the current technical specifications on the AHRQ website and develop processes that assist in the proper PSI assignment with the goal of accurate quality public reporting.

Resources

Agency for Healthcare Research and Quality. Technical specifications. v2018.

AHIMA Staff. July 28, 2017. Key AHRQ patient safety indicator updates and strategies for review.