The links below will take you to quality and safety marker (QSM) information for the April–June 2016 quarter. You can download the full April–June QSM results as a PDF or view the commentary and interactive charts below.

Falls

Nationally, 91 percent of older patients* were given a falls risk assessment in quarter 2, 2016. There has been a shift upwards, back to expected achievement levels, since the drop in the previous quarter. At the district health board (DHB) level, 14 out of 20 DHBs achieved the target. Results from Hutt Valley DHB, Hauora Tairāwhiti, Southern DHB and Taranaki DHB improved significantly compared with the previous quarter. Bay of Plenty DHB showed significantly lower results compared with the national target of 90 percent (see Figure 1).

  • Upper group: ≥90 percent
  • Middle group: 75–89 percent
  • Lower group: <75 percent

*Patients aged 75+ (55+ for Māori and Pacific peoples)

About 94 percent of patients at risk of falling received an individualised care plan. This measure, for nearly all DHBs, is sitting at its highest level and shown an increase of 18 percentage points compared with the baseline in quarter 1, 2013.

  • Upper group: ≥90 percent
  • Middle group: 75–89 percent
  • Lower group: <75 percent

When assessments and care plans are plotted against each other, a trend of movement over time is shown from the bottom left corner (low assessment and individualised care plan) to the top right corner (high assessment and individualised care plan). Compared with only five DHBs sitting at the top right corner in quarter 1, 2013, in the current quarter, 14 DHBs are in this ‘ideal’ box (see Figure 3). This is a pleasing result and we look for it to be sustained at these levels.

There were 70 falls resulting in a fractured neck of femur in the 12 months ending June 2016. The median of monthly falls reduced from eight to six since December 2014 and this improvement has been remained in the latest quarter.
To control the impact from the changes in the number of admissions per month, Figure 4 shows the in-hospital falls causing fractured neck of femur per 100,000 admissions. The median of this measure shifted down since November 2014 from 12 to eight per 100,000 admissions. While the rate in February 2016 was a high outlier, it does not indicate any shift in trend. Within these 20 months, 18 are below the original median level. This is the seventh quarter that this outcome marker has shown a significant improvement.

This number of 70 falls is significantly lower than the 111 falls we would have expected in this year, given the falls rate observed in the period from July 2010 to June 2012. This reduction is estimated to have saved $1.9 million in the year ending June 2016, based on an estimate of $47,000[1] for a fall with a fractured neck of femur.

However, this estimate may be too conservative, as it assumes all patients who fall and break their hip in hospital return home. We know that at least some of these patients are likely to be admitted to aged residential care on discharge from hospital.

This is a far more expensive proposition – estimated at $135,000 a time.[2] If we conservatively estimate that 20 percent of the patients who avoided falls were admitted to a residential care facility, the reduction in falls represents $2.6 million in total avoidable costs since July 2015. 

Hand hygiene

National compliance with the five moments for hand hygiene remains high. Nationally, DHBs achieved an average of 82 percent compliance in quarter 2, 2016.

  • Upper group: ≥70 percent before quarter 3, 2014, and then 75 percent in quarters 3 and 4, 2014, and then 80 percent since quarter 1, 2015
  • Middle group: 60 percent to target
  • Lower group: <60 percent
  • Hand hygiene national compliance data is reported on three times every year, therefore no data point is shown specifically for quarter 4 in any year

The run chart below shows the monthly healthcare associated Staphylococcus aureus bacteraemia per 1000 bed-days fluctuates considerably month-by-month, with no signs of a significant shift. The data has been corrected following the identification of historical data errors.

Surgical site infection

As the Commission uses a 90-day outcome measure for surgical site infection, the data run one quarter behind other measures. Information in this section relates to hip and knee operations in quarter 1, 2016.

Process measure 1: Antibiotic administered in the right time

For primary procedures, an antibiotic should be administered in the hour before the first incision (‘knife to skin’). As this should happen in all primary cases, the threshold is set at 100 percent. In quarter 1, 2016, 97 percent of hip and knee arthroplasty procedures were given an antibiotic within 60 minutes before ‘knife to skin’. There has been a slow increase for the measure since the start of the programme. Eight DHBs achieved the national goal.

  • Upper group: =100 percent
  • Middle group: 80–99 percent
  • Lower group: <80 percent
Process measure 2: Right antibiotic in the right dose – cefazolin 2g or more or cefuroxime 1.5g or more

In quarter 1, 2015, 1.5g or more of cefuroxime was accepted as an alternative agent to cefazolin 2g or more for routine antibiotic prophylaxis for hip and knee replacements. It improved the results of this process measure for MidCentral DHB significantly, from 10 percent before the change to 96 percent immediately after the change. It also increased the national result from 90 percent to 95 percent in quarter 1, 2015. In the current quarter, 17 DHBs reached the threshold level of 95 percent compared with only three in the baseline quarter.

  • Upper group: percentage ≥95 percent
  • Middle group: 80–94 percent
  • Lower group: <80 percent
Process measure 3: Appropriate skin antisepsis in surgery using alcohol/chlorhexidine or alcohol/povidone iodine

Skin preparation using either chlorhexidine or povidone iodine in alcohol is recommended for all orthopaedic procedures, so the threshold is set at 100 percent. Appropriate skin antisepsis is clearly normal practice across DHBs, as the rounded national compliance rate of 99 percent attests.

  • Upper group: =100 percent
  • Middle group: 80–99 percent
  • Lower group: <80 percent

A significant improvement in the surgical site infection rate has shown since August 2015 compared with the baseline rate of 1.6 percent in quarter 3, 2013. This improvement has been remained for six consecutive months. It indicates a significant reduction in the infection rate, with the median dropping down from 1.3 percent to 0.9 percent. During the reduction period, there is a spike of 2.1 percent in February 2016. The monthly number of surgical site infection cases is very small for each DHB, which range from 0 to 3. Given the small number of infections, a DHB who has one or two more cases of infection in a particular month will show a great increase in the infection rate. Although February’s result shows a spike from the current trend, closer examination of the DHB level data shows no special cause variation. We will continue to monitor the rate and will speak with those DHBs with unusual higher rate in February to better understand any causes.

Safe surgery

A new quality and safety marker aimed at measuring levels of teamwork and communication was rolled out during the 2015–16 financial year. The first public reporting will be in December 2016 on data for quarter 3, 2016.

The postoperative sepsis rate and the deep-vein thrombosis/pulmonary embolism rate are the two outcome markers for safe surgery. We are in the process of developing a risk-adjustment model for use in the near future to:

  • help us understand the factors driving changes in these two measurements over years
  • provide risk-adjusted outcomes in the monitoring and improvement of surgical quality and safety.

Medication safety

We introduced a quality and safety marker for medication safety in September 2014. It focuses on medicine reconciliation – a process by which health care professionals accurately document all medicines a patient is taking and their adverse reactions history (including allergy). The information is then used across health care. An accurate medicines list can be reviewed to check medicines are appropriate and safe. Medicines which should be continued, stopped or temporarily stopped can be documented on the list. Doing this reduces the risk of medicines being:

  • omitted
  • prescribed at the wrong dose
  • prescribed to a patient who is allergic
  • prescribed when they have the potential to interact with other prescribed medicines.

The introduction of electronic medicine reconciliation (eMR) allows medicine reconciliation to be done more routinely, including at discharge. There is a national programme to roll out eMR throughout the country; five DHBs have implemented the system to date.

Figure 12: Structure marker, implementation of eMR 

Structure marker, implementation of eMR

Figure 13: Structure markers, eMR implementation

Structure markers, eMR implementation

Within these five DHBs, Northland DHB and Taranaki DHB are able to produce the results of these process measures. The other three DHBs are in the process of system upgrades or tests and will be able to report in the near future.

Figure 14: Process markers, electronic medicine reconciliation 

Process markers, eMR

Local DHB report

Using the interactive charts (below) to read individual QSM results for each DHB.

  • Use the drop-down box on the homepage below to access a list of DHBs.
  • Select your DHB.
  • Use the tabs along the top to look at reports on falls and SSI over time.
  • Return to the homepage to select a different DHB.
  • Results can be downloaded as a PDF by using the 'download' button on the bottom right of each page.


References

[1] de Raad J-P. 2012. Towards a value proposition: scoping the cost of falls. Wellington: NZIER.

[2] ibid.

Last updated 13/10/2016