Author(s): Adrien Ross, MSN, RN, CPHQ
Quality Improvement Specialist, Lead
Corewell Health

Adrien Ross MSN, RN, CPHQ is a graduate of University of Michigan and received her Master of Science in Nursing Degree in 2012. She is a Certified Professional of Healthcare Quality since 2022. In 2006, she joined Corewell Health in Grand Rapids working in the Medical Intensive Care Unit where she worked as a bedside Registered Nurse, served as shared leadership chair, and a Nursing Supervisor. She transitioned to the quality department in 2013 where she has worked with a variety of different service lines and leaders, including Emergency Department, Radiology, Cardiovascular Services, and Digestive Services. Since 2013, Adrien has served multiple roles within the quality department, with most recently being a Lead, Quality Improvement Specialist supporting work with Patient Safety Indicators. Adrien has been a member of NAHQs Healthcare Quality Certification Committee since 2022. In 2022, she presented at the Vizient Conference in Las Vegas, NV on Quality, Documentation, and Coding Collaborate to Reduce Patient Safety Indicators. In 2019, she presented at the Michigan Annual Critical Access Hospital Conference on Using High Reliability Principles to Improve Stroke Care.

Competency Domain: Quality Review & Accountability

Description: CHW has had multiple years of financial penalties and opportunities to improve outcomes related to PSIs. In 2022, CHW had a PSI 90 rate of 1.17, with an average of 31 PSI 90 component events per month. A comprehensive program was developed and focused on 5 different strategies: Coding/Documentation, Risk Adjustment, Clinical Improvement, Peer Review, and Communication. Due to these strategies, in 2023, CHW saw a 29.9% reduction in PSI 90, and an average of 18 events per month. This equates to 151 less complications experienced by the patients at Corewell Health West. Problem: in 2022, CHW PSI 90 rate was 1.17, which is below average performance. And while public perception, penalties, and performance is important, the data really told us that we are causing preventable harm to our patients, and we needed to act quickly. Measurement: To understand what needed to be focused on a driver diagram was constructed. The overall measurement of performance was through Statistical Process Control Charts for both PSI 90 and the individual PSI. Thorough chart reviews were completed as well to understand opportunities for improvement. Analysis: As part of the analysis, reviewed the data on a weekly and monthly basis. On a weekly basis we reviewed how many PSIs, the number of queries sent, as well as all documentation opportunities. On a monthly basis the team reviewed the individual PSIs and the PSI 90 rate. Implementation: A comprehensive framework was developed to work on 5 different strategies based on review of historical data, evidence-based practice, and individual case review. The 5 strategies implemented include:1. Coding and documentation2. Risk Adjustment3. Peer Review4. Clinical Quality Improvement5. Communication Results/Discussion As a result of this work, CHW saw a 29.9% decrease (1.17 to 0.82) from 2022 to 2023, with 151 less patient safety events. The reduction in PSI 90 also resulted in for the first time in 11+ years an avoidance of a HACRP penalty.

Evaluation: Complete Poster Evaluation