Session: Implementing Process Change to Find the Real Patient Safety Indicator Solutions

Editor's Note

“We like to say PSIs [patient safety indicators] are a marathon, not a sprint. Small progress is still progress,” said Holly Taylor, DNP, RN, CNOR, NPD-BC, CNAMB, Quality Management Coordinator at the University of Arkansas for Medical Sciences (UAMS) at this OR Manager Conference session.

Taylor and fellow UAMS quality management coordinator, Michelle Lee Davis, BSN, BA, RN, CNOR, discussed the plan to implement the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI 90) at UAMS. They defined PSIs as providing information on potentially avoidable safety events that represent improvement possibilities for care delivery, and they added that PSI 90 was implemented at UAMS to reduce variation in clinical documentation and effectively target adverse events and complications. 

“Our goal is long-term progress to lead us closer to the goal we want to achieve; we know it’s not going to improve overnight,” noted the speakers, adding that this process change took place over a timeline of 3 years.  

In 2020, management guidance teams (MGT) and tactical teams were developed for each implemented PSI. These teams initially selected three PSI 90 categories due to higher expected rates in each category. By the end of 2022, the rest of the PSI 90 categories were implemented.

Here are five main benefits of the PSI 90 process:

• greater physician engagement stemming from a greater understanding of administrative coding
• improved communication between coding physician advisors and surgeons
• cases easier to code due to clear OP documentation
• improved resident education on the importance of clear documentation and the effects of administrative coding
• more career opportunities for perioperative nurses who leverage unique skill sets.