A Comprehensive Approach to Reducing Patient Safety Indicators (PSI-90).

Background: PSI-90, a composite measure comprising ten indicators, reflects the quality of care during hospital stays. The Hospital-Acquired Condition Reduction Program (HACRP), a Centers for Medicare and Medical Services (CMS) program, assesses hospital performance based on quality measures, including PSI-90, with financial implications for poor performers.

Objectives: To evaluate PSI events, establish workflows for accurate documentation, and foster collaboration across clinical and administrative teams, with the ultimate objective of reducing PSI events.

Methods: Essential actions involved designating a PSI nurse reviewer and a quality physician advisor, securing the involvement of executive leadership, adopting computer-assisted coding technology, and promoting teamwork among Clinical Documentation Improvement (CDI), coding, and Health Information Management (HIM) teams.

Results: The collaborative efforts yielded a 45% reduction in PSI events, leading to estimated cost avoidance of $1.4 million, and exemption from HACRP penalties. Lessons learned encompassed the importance of executive leadership support, data-driven decision-making, and ongoing education.

Conclusion: This study shows the significance of collaboration, leadership support, and data utilization in PSI reduction efforts. Furthermore, it shows benefit of a surgical quality officer in advancing patient safety, aligning with ACS recommendations.