Effectiveness of key indicatorsas instrument in detecting risks in healthcare

Ine Borghans

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Methods of Supervision

Thematic

Incidences

Quality syste

m

Risk Indicators

Suspicions criminal offenses

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Methods of Supervision

Thematic

Incidences

Quality syste

m

Risk Indicators

Suspicions criminal offenses

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Risk indicators

Used in ‘Risk-based' supervision

To render the risk of healthcare services measurable and transparent.

Developed in cooperation with the health care providers.

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Canary indicator of the coal mine

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Hospital adverse events often result in a longer length of stay (see references on next slide)

We developed a new indicator that uses the unexpectedly long length of stay (UL-LOS) as a potential risk factor for unsafe care.

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References1. Hoonhout LH, de Bruijne MC, Wagner C, Asscheman H, van der Wal G, van Tulder MW. Nature, occurrence and consequences

of medication-related adverse events during hospitalization: a retrospective chart review in the Netherlands. Drug Saf. 2010 10/01;33(10):853-64.

2. Hoonhout LH, de Bruijne MC, Wagner C, Zegers M, Waaijman R, Spreeuwenberg P, et al. Direct medical costs of adverse events in Dutch hospitals. BMC Health Serv.Res. 2009;9:27.

3. Sari AB, Sheldon TA, Cracknell A, Turnbull A, Dobson Y, Grant C, et al. Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. Qual.Saf Health Care 2007 12;16(6):434-9.

4. Ehsani JP, Jackson T, Duckett SJ. The incidence and cost of adverse events in Victorian hospitals 2003-04. Med.J.Aust. 2006 06/05;184(11):551-5.

5. Cho SH, Ketefian S, Barkauskas VH, Smith DG. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs.Res. 2003 03;52(2):71-9.

6. Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1 946 831 operations in children. Arch.Surg. 2010 11;145(11):1085-90.

7. Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS, et al. Factors associated with complications in older adults with isolated blunt chest trauma. West J.Emerg.Med. 2009 05;10(2):79-84.

8. Williams DJ, Olsen S, Crichton W, Witte K, Flin R, Ingram J, et al. Detection of adverse events in a Scottish hospital using a consensus-based methodology. Scott.Med.J. 2008 11;53(4):26-30.

9. Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Costs of adverse events in intensive care units. Crit.Care Med. 2007 11;35(11):2479-83.

10. Rice-Townsend S, Hall M, Jenkins KJ, Roberson DW, Rangel SJ. Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures. J.Pediatr.Surg. 2010 06;45(6):1126-36.

11. Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, et al. Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr.Laeger 2001 Sep 24;163(39):5370-8.

12. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004 May 25;170(11):1678-86.

13. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals I: occurrence and impact. N.Z.Med.J. 2002 Dec 13;115(1167):U271.

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Indicator: Percentage of patients with an unexpectedly long length of stay (UL-LOS)

Methods:• Based on a prolonged length of stay of more than 50%• Standardisation for patients’ age, primary diagnosis and main

procedure• Three strata of hospitals:

31 general hospitals24 tertiary teaching hospitals8 university medical centres

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Why based on a prolonged length of stayof more than 50%?

• to include patients that stayed longer because of complications and adverse events

• and not patients that just stayed a little bit longer because of variations in the treatment, such as in logistics

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Example

- patient of 18 years old- appendicitis - appendectomy

Expected LOS 3,4 dagen3,4 + 1,7 = 5,1 days

Actual LOS 6 days or more: UL-LOS

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Results

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How does the Inspectorate use this indicator?

Most important problem: hospitals without UL-LOS percentage

Other hospitals: High percentage is an important signal

Inspectors ask to inspect detailed information per specialism

Patients with UL-LOS: record reviewing to learn what went wrong

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PRO’s and CON’s of working with one key indicatorPro:• Les administrative burden for caregivers• Much easier for the inspector

Contra:High demands regarding to this specific indicator:• validity• reliability• comparability

Outcomes are not compensated by other indicators!

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Canary indicator of the coal mine

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Aviation: dashboard with some key indicators

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3 Indicators which may reveal risk of unsafe care

Sub-optimal quality of care

Unexpectedly long LOS*

Unplanned readmissions**

Higher than expected mortality***UN

DE

SIR

ABLE

OUT

COMES

* Indicator described in this thesis**Indicator yet to be developed*** Indicator already available (HSMR)

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Thanks for your attention!