PSI 90: Understanding the Fulcrum of Quality and Safety in Healthcare

Give me a lever long enough and a fulcrum on which to place it, and I shall move the world.” -Archimedes

The current structure of healthcare and the associated focus on quality and safety is rooted in over 100 years of improvement initiatives. As challenges in healthcare and safety continue to evolve, the need to monitor, quantify, and track quality metrics has become the fulcrum for change in the healthcare system.  

Patient Safety Indicators (PSIs), as defined by the Agency for Healthcare Research and Quality (AHRQ), represent one component of this fulcrum, as a means to track clinical outcomes and performance. There are a total of 26 PSIs that denote potentially avoidable safety events for patients following surgeries, procedures, and childbirth. The PSIs are identified through the hospitalization discharge record and associated with coding and billing data. As a healthcare system, if you understand the importance of PSIs, you can better position yourself to leverage change and foster improvement in quality of care and reporting.

The PSI structure includes PSI 90, which is a composite of select PSIs that serves as an overview for hospital-level quality and potential areas for improvement. This composite includes the PSIs for pressure ulcers, iatrogenic pneumothorax, hospital fall with hip fracture, postoperative hemorrhage or hematoma, postoperative acute kidney injury requiring dialysis, postoperative respiratory failure, postoperative pulmonary embolism (PE) and deep vein thrombosis (DVT), postoperative sepsis, postoperative wound dehiscence, and abdominopelvic accidental puncture and laceration. As suggested by AHRQ, this PSI 90 indicator is intended to be used to monitor performance in national and regional reporting, as well as for comparative reporting and quality improvement at the provider level.

At the National Reporting level, the Centers for Medicare & Medicaid Services (CMS) has historically used PSIs as part of their Value Based Purchasing Program (VBP), which rewards acute-care hospitals with incentive payments for the quality of care provided in the inpatient hospital setting. Of note, CMS removed PSI 90 from the Hospital Value Based Purchasing program in the 2019 fiscal year, with future inclusion to be determined. The PSI 90 composite influences other publicly reported data, however, such as Star Ratings. The Star Ratings system allows people to make informed healthcare decisions based on quality measures that are assigned scores. Star Ratings also account for other measures beyond safety, such as mortality, readmission, and patient experience.

Navigating through PSIs requires a multidisciplinary process, including clinical documentation and coding specialist review, physician champion assessment, and finance team support for pre-bill review. Although there is often a misconception that coding alone drives PSIs, we know that a successful lever for change is also built upon provider education, accurate documentation, and a solid understanding of the inclusion and exclusion criteria for PSIs. This includes often overlooked opportunities for correct data abstraction when defining admission source and discharge disposition.

Implementing a multidisciplinary approach allowed our team to optimize PSI 90 outcomes. One example is our work with PSI 03, Pressure Ulcer Rate. The inclusion criteria for PSI 03 is comprised of patients discharged with any secondary ICD-10 diagnosis code of not present on admission (POA) for a stage 3, stage 4, or unstageable pressure ulcer. Our PSI 03 review team includes a wound care specialist whose expertise allows for timely identification of clinical and documentation opportunities. Through use of our concurrent query process, when applicable, the clinical documentation improvement (CDI) team can ask providers if a skin impairment was present on admission. If the query is answered as POA-Yes or POA of W (clinically unable to determine), the PSI is excluded.  

Another opportunity identified to help optimize PSI 90 outcomes involved focused work on PSI 09, Postoperative Hemorrhage or Hematoma Rate. Through consistent review and understanding of the inclusion/exclusion criteria, the CDI and coding team can identify when there is a clinical and/or documentation and coding opportunity. One of the exclusion rules for this quality metric includes any listed ICD-10-CM diagnosis code for coagulation disorder. When you drill down into this code set, coagulation disorder includes a multitude of risk factors for bleeding, including “hemorrhagic disorder due to extrinsic circulating anticoagulants,” “qualitative platelet defects,” and “thrombocytopenia, unspecified.” If patients are identified as having any one of these conditions that contribute to an inability to achieve hemostasis, PSI 09 is excluded.

Once armed with the knowledge of PSI 90 and its role as a framework or “fulcrum” in safety and quality reporting, healthcare systems can improve and grow from an industry outlier to a top performer.

Furthermore, with a solid understanding of the inclusion/exclusion criteria for all PSIs, and through a multidisciplinary approach to quality and safety reviews, healthcare systems can build the lever they need to make an impact on value-based care and quality reporting.