Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook".

Objective: To evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them.

Development and Validation of Quality Measures for Testosterone Prescribing.

Context: Accurate measures to assess appropriateness of testosterone prescribing are needed to improve prescribing practices.

Objective: This work aimed to develop and validate quality measures around the initiation and monitoring of testosterone prescribing.

Methods: This retrospective cohort study comprised a national cohort of male patients receiving care in the Veterans Health Administration who initiated testosterone during January or February 2020.

Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population.

Background: Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations.

Objective: To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs).

Beyond Medication Adherence: The Role of Patients' Beliefs and Life Context in Blood Pressure Control.

Objective: Despite numerous interventions to address adherence to antihypertensive medications, continued high rates of uncontrolled blood pressure (BP) suggest a need to better understand patient factors beyond adherence associated with BP control. We examined how patients' BP-related beliefs, and aspects of life context affect BP control, beyond medication adherence.

Methods: We conducted a cross-sectional telephone survey of primary care patients with hypertension between 2010 and 2011 (N=103; 93 had complete data on all variables and were included in the regression analyses).

The Patient Safety Indicator Perioperative Pulmonary Embolism or Deep Vein Thrombosis: Is there associated surveillance bias in the Veterans Health Administration?

Background: Studies disagree whether surveillance bias is associated with perioperative venous thromboembolism (VTE) performance measures. A prior VA study used a chart-based outcome; no studies have used the fully specified administrative data-based AHRQ Patient Safety Indicator, PSI-12, as their primary outcome. If surveillance bias were present, we hypothesized that inpatient surveillance rates would be associated with higher PSI-12 rates, but with lower post-discharge VTE rates.

Does Surveillance Bias Influence the Validity of Measures of Inpatient Complications? A Systematic Review.

Surveillance bias may threaten the accuracy of inpatient complication measures. A systematic literature review was conducted to examine whether surveillance bias influences the validity of selected Patient Safety Indicator- and health care associated infection-related measures. Ten venous thromboembolism (VTE) articles were identified: 7 trauma related, 3 postoperative, and 1 central line-associated bloodstream infection (CLABSI) article.

Results of a Regional Effort to Improve Warfarin Management.

Background: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system.

Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA).

Do Acute Myocardial Infarction and Heart Failure Readmissions Flagged as Potentially Preventable by the 3M Potentially Preventable Readmissions Software Have More Process-of-Care Problems?

Background: The 3M Potentially Preventable Readmissions (3M-PPR) software matches clinically related index admission and readmission diagnoses that may signify in-hospital or postdischarge quality problems. To assess whether the PPR algorithm identifies preventable readmissions, we compared processes of care between PPR software-flagged and nonflagged cases.

Methods And Results: Using 2006 to 2010 national VA administrative data, we identified acute myocardial infarction and heart failure discharges associated with 30-day all-cause readmissions, then flagged cases (PPR-Yes/PPR-No) using the 3M-PPR software.

A Systematic Review of Patient Safety Measures in Adult Primary Care.

Safety measure development has focused on inpatient care despite outpatient visits far outnumbering inpatient admissions. Some measures are clearly identified as outpatient safety measures when published, yet outcomes from quality improvement studies also may be useful measures. The authors conducted a systematic review of the literature to identify published articles detailing safety measures applicable to adult primary care.

Measuring readmissions after surgery: do different methods tell the same story?

Background: Readmission is widely used as a quality metric to assess hospital performance. However, different methods to calculate readmissions may produce various results, leading to differences in classification with respect to hospital performance. This study compared 2 commonly used approaches to measure surgical readmissions: the 30-day all-cause hospital-wide readmissions (HWRs) and the potentially preventable readmissions (PPRs).

Do pneumonia readmissions flagged as potentially preventable by the 3M PPR software have more process of care problems? A cross-sectional observational study.

Background: In the USA, administrative data-based readmission rates such as the Centers for Medicare and Medicaid Services' all-cause readmission measures are used for public reporting and hospital payment penalties. To improve this measure and identify better quality improvement targets, 3M developed the Potentially Preventable Readmissions (PPRs) measure. It matches clinically related index admission and readmission diagnoses that may indicate readmissions resulting from admission- or post-discharge-related quality problems.

Partnering With VA Stakeholders to Develop a Comprehensive Patient Safety Data Display: Lessons Learned From the Field.

Health care systems are increasingly burdened by the large numbers of safety measures currently being reported. Within the Veterans Administration (VA), most safety reporting occurs within organizational silos, with little involvement by the frontline users of these measures. To provide a more integrated picture of patient safety, the study team partnered with multiple VA stakeholders and engaged potential frontline users at 2 hospitals to develop a Guiding Patient Safety (GPS) tool.

What is the value of adding Medicare data in estimating VA hospital readmission rates?

Objective: To determine the effects of including diagnostic and utilization data from a secondary payer on readmission rates and hospital profiles.

Data Sources/study Setting: Veterans Health Administration (VA) and Medicare inpatient and outpatient administrative data for veterans discharged from 153 VA hospitals during FY 2008-2010 with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia.

Study Design: We estimated hospital-level risk-standardized readmission rates derived using VA data only.

Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling and payment?

Objective: To assess whether use of the AHRQ Patient Safety Indicator (PSI) composite measure versus modified composite measures leads to changes in hospital profiles and payments.

Data Sources/study Setting: Retrospective analysis of 2010 Veterans Health Administration discharge data.

Study Design: We used the AHRQ PSI software (v4.

Medical and surgical readmissions in the Veterans Health Administration: what proportion are related to the index hospitalization?

Background: Readmissions are an attractive quality measure because they offer a broad view of quality beyond the index hospitalization. However, the extent to which medical or surgical readmissions reflect quality of care is largely unknown, because of the complexity of factors related to readmission. Identifying those readmissions that are clinically related to the index hospitalization is an important first step in closing this knowledge gap.

Validity of ICD-9-CM codes for the identification of complications related to central venous catheterization.

Two complications of central venous catheterization (CVC), iatrogenic pneumothorax and central line-associated bloodstream infection (CLABSI), have dedicated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Despite increasing use of ICD-9-CM codes for research and pay-for-performance purposes, their validity for detecting complications of CVC has not been established. Complications of CVCs placed between July 2010 and December 2011 were identified by ICD-9-CM codes in discharge records from a single hospital and compared with those revealed by medical record abstraction.

Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators.

Background: The Patient Safety Indicators (PSIs) use administrative data to screen for select adverse events (AEs). In this study, VA Surgical Quality Improvement Program (VASQIP) chart review data were used as the gold standard to measure the criterion validity of 5 surgical PSIs. Independent chart review was also used to determine reasons for PSI errors.

Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicator Rates Among Veteran Dual Users.

This study compares rates of 11 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) among 266 203 veteran dual users (ie, those with hospitalizations in both the Veterans Health Administration [VA] and the private sector through Medicare fee-for-service coverage) during 2002 to 2007. PSI risk-adjusted rates were calculated using the PSI software (version 3.1a).

Using AHRQ patient safety indicators to detect postdischarge adverse events in the Veterans Health Administration.

Patient safety indicators (PSIs) use inpatient administrative data to flag cases with potentially preventable adverse events (AEs) attributable to hospital care. This study explored how many AEs the PSIs identified in the 30 days post discharge. PSI software was run on Veterans Health Administration 2003-2007 administrative data for 10 recently validated PSIs.

Comparing 2 methods of assessing 30-day readmissions: what is the impact on hospital profiling in the veterans health administration?

Background: The Centers for Medicare and Medicaid Services' (CMS) all-cause readmission measure and the 3M Health Information System Division Potentially Preventable Readmissions (PPR) measure are both used for public reporting. These 2 methods have not been directly compared in terms of how they identify high-performing and low-performing hospitals.

Objectives: To examine how consistently the CMS and PPR methods identify performance outliers, and explore how the PPR preventability component impacts hospital readmission rates, public reporting on CMS' Hospital Compare website, and pay-for-performance under CMS' Hospital Readmission Reduction Program for 3 conditions (acute myocardial infarction, heart failure, and pneumonia).

Improving the identification of postoperative wound dehiscence missed by the Patient Safety Indicator algorithm.

Background: The Patient Safety Indicator (PSI) Postoperative Wound Dehiscence (PWD) is an administrative data-based algorithm that flags cases using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 54.61 (abdominal wall disruption reclosure). We examined how often PWD missed events and explored ways to improve event identification.

Development and testing of tools to detect ambulatory surgical adverse events.

Objectives: Numerous health-care systems in the United States, including the Veterans Health Administration (VA), use the National Surgical Quality Improvement Program (NSQIP) to detect surgical adverse events (AEs). VASQIP sampling methodology excludes many routine ambulatory surgeries from review. Triggers, algorithms derived from clinical logic to flag cases where AEs have most likely occurred, could complement VASQIP by detecting a higher yield of ambulatory surgeries with a true surgical AE.

Improving identification of postoperative respiratory failure missed by the patient safety indicator algorithm.

The Patient Safety Indicator postoperative respiratory failure (PRF) flags cases using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for acute respiratory failure or mechanical ventilation/intubation. The authors examined how frequently PRF missed events and ways to improve event identification. A total of 125 high-risk unflagged cases were selected based on predicted probability and presence of clinically relevant codes.

Examining the relationship between processes of care and selected AHRQ patient safety indicators postoperative wound dehiscence and accidental puncture or laceration using the VA electronic medical record.

This study examines whether Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) Postoperative Wound Dehiscence (PWD) and Accidental Puncture or Laceration (APL) events reflect problems with hospital processes of care (POC). The authors randomly selected 112 PSI-flagged PWD/APL discharges from 2002-2007 VA administrative data, identified true cases using chart review, and matched cases with controls. This yielded a total of 95 case-control pairs per PSI.