The links below will take you to quality and safety marker (QSM) information for the April–June 2017 quarter. You can download the full April–June 2017 QSM results (1.3 MB, pdf) or view the commentary and interactive charts below.
- Hand hygiene
- Surgical site infection improvement – orthopaedic surgery
- Surgical site infection improvement – cardiac surgery
- Safe surgery
- Medication safety
- Local DHB report
Nationally, 92 percent of older patients* were assessed on their falls risk in quarter 2, 2017. The rate has remained around the expected achievement level of 90 percent since quarter 4, 2013, in spite of some variations in a few quarters. At the district health board (DHB) level, 14 out of 20 DHBs achieved the expected marker level. Northland DHB is the only DHB that has been in the lower group for the last three consecutive quarters and we need to understand what is contributing to this (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 95 percent of patients assessed as being at risk of falling had an individualised care plan completed. This measure has increased 18 percentage points compared with the baseline in quarter 1, 2013. Achievements at DHB level vary but, overall, where an individual has been assessed at risk of falling, completion of individualised care plans for that population group need to be at a consistently high level. Northland and Tairawhiti DHBs are currently in the lower group.
- 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). Only five DHBs sat at the top right corner in quarter 1, 2013, but in the current quarter, 14 DHBs are in this ‘ideal’ box (see Figure 3). This is a pleasing result and we look for future improvement and for it to be sustained at this level. However, Northland and Tairawhiti DHBs’ results remain low for both assessment and care planning.
There were 76 falls resulting in a fractured neck of femur (broken hip) in the 12 months ending June 2017. The median of monthly falls has reduced from eight to six since December 2014.
To control the impact of changes in the number of admissions per month, Figure 4 shows in-hospital falls causing a fractured neck of femur per 100,000 admissions. The median of this measure was 12.6 in the baseline period of July 2010 to June 2012. It has moved down since September 2014, to 9.2 per 100,000 admissions, and shown a significant improvement. The new median excludes the latest quarter’s data to preserve robustness.
The 76 in-hospital falls resulting in a fractured hip is significantly lower than the 111 we would have expected this year, given the falls rate observed in the period between July 2010 and June 2012. The reduction is estimated to have saved $1.66 million in the year ending June 2017, based on an estimate of $47,000 for a fall with a fractured neck of femur.
The estimate may be too conservative, as it assumes all patients who fall and break their hip in hospital return home. We know at least some of these patients are likely to be admitted to aged residential care on discharge from hospital.
Admission to aged care is a far more expensive proposition – estimated at $135,000 each time it occurs. If we conservatively estimate that 20 percent of the patients who avoided a fall-related fractured neck of femur were admitted to a residential care facility, the reduction in falls represents $2.28 million in total avoidable costs since July 2016.
National compliance with the five moments for hand hygiene remains high. Nationally, DHBs maintained an average of 84 percent compliance in quarter 2, 2017, compared with the baseline in quarter 3, 2012.
- Upper group: ≥ 70 percent before quarter 3, 2014, 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
Figure 7 shows the monthly healthcare associated Staphylococcus aureus bacteraemia per 1000 bed-days. It indicates a recent decline in variation, but no sign of a significant shift in trend.
As the Commission uses a 90-day outcome measure for surgical site infection, the data runs one quarter behind other measures. Information in this section relates to hip and knee arthroplasty procedures in quarter 1, 2017.
Process marker 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, 2017, 97 percent of hip and knee arthroplasty procedures involved the giving of an antibiotic within 60 minutes before knife to skin. There has been a slow increase for the measure since the start of the Surgical Site Infection Improvement (SSII) programme. Six DHBs achieved the national goal.
- Upper group: 100 percent
- Middle group: 80–99 percent
- Lower group: < 80 percent
Process marker 2: Right antibiotic in the right dose – cefazolin 2g or more or cefuroxime 1.5g or more
In the current quarter, 16 DHBs reached the threshold level of 95 percent compared with only three in the baseline quarter.
- Upper group: ≥ 95 percent
- Middle group: 80–94 percent
- Lower group: < 80 percent
The median surgical site infection rate has shown a significant improvement, dropping to 0.91 percent since June 2015, compared with 1.36 percent during the baseline period of April 2013 to March 2014.
During the reduction period, there are a couple of spikes in February and September 2016. Examination of the September DHB-level data shows the number of surgical site infections increased by one or two cases in seven DHBs compared with their baseline levels of zero or one case per month. Figures in both February and September are higher outliers. They indicate some one-time occurrences of a special cause.
This is the third QSM report for cardiac surgery. Since quarter 3, 2016, all five DHBs performing cardiac surgery have submitted process and outcome marker data. There are three process markers and one outcome marker, which are similar to the QSMs for orthopaedic surgery.
Process marker 1 is ‘timing’, which requires an antibiotic to be given 0–60 minutes before knife to skin. The target is 100 percent of procedures achieving this marker. Canterbury DHB and Southern DHB achieved the target this quarter.
Process marker 2 is ‘dosing’, which requires the antibiotic prophylaxis of choice to be ≥ 2 g or more of cefazolin for adults and ≥ 30 mg/kg of cefazolin for paediatric patients, not to exceed the adult dose. The target is that either dose is used in at least 95 percent of procedures. All five DHBs performing cardiac surgery for adult or paediatric patients achieved this target.
Process marker 3 is ‘skin preparation’, which requires use of an appropriate skin antisepsis in surgery using alcohol/chlorhexidine or alcohol/povidone iodine. The target is 100 percent of procedures achieving this marker. Auckland DHB (for paediatric patients), Canterbury DHB, Capital & Coast DHB, Southern DHB and Waikato DHB all achieved the target.
The outcome marker is the surgical site infection rate. In quarter 1, there were 30 surgical site infections in 693 procedures, an infection rate of 4 percent. This is an improvement on the previous two quarters, which had infection rates of 5 percent (quarter 3, 2016) and 6 percent (quarter 4, 2016).
This is the fourth report for the safe surgery QSM, which measures levels of teamwork and communication around the paperless surgical safety checklist.
Direct observational audit was used to assess the use of the three surgical checklist parts: sign in, time out and sign out. A minimum of 50 observational audits per quarter per part is required before the observation is included in uptake and engagement assessments. Rates are greyed out in the tables below where there were fewer than 50 audits.
Figure 12 shows, for each part of the checklist, how many audits were undertaken. Eleven out of the 20 DHBs achieved 50 audits for all three parts in quarter 2, 2017 (see Figure 12).
Uptake (all components of the checklist were reviewed by the surgical team) rates are only presented where at least 50 audits were undertaken for a checklist part. Uptake rates were calculated by measuring the number of audits of a part where all components of the checklist were reviewed against the total number of audits undertaken. The components for each part of the checklist are shown in the poster on the right. Of the eleven DHBs who achieved 50 audits in each checklist, six achieved the 100 percent uptake target in at least one part of the checklist, during the current quarter (see Figure 13). Data are not presented where audits were less than 50.
The levels of team engagement with each part of the checklist were scored using a seven-point Likert scale developed by the World Health Organization. A score of 1 represents poor engagement from the team and 7 means team engagement was excellent. The target is that 95 percent of surgical procedures score engagement levels of 5 or above. As Figure 14 shows, Capital & Coast DHB and West Coast DHB achieved the target in all three parts and six other DHBs achieved the target in one or two parts for the latest quarter. Data are not presented where audits were less than 50. As this is only the fourth quarter in which DHBs have measured the impact of the safe surgery programme, the focus is still on embedding the programme and the auditing method. Better results are expected in subsequent quarters.
The postoperative sepsis rate and the deep-vein thrombosis/pulmonary embolism (DVT/PE) rate are the two outcome markers for safe surgery. These rates have fluctuated over time. To understand the factors driving these changes and to provide risk-adjusted outcomes in the monitoring and improvement of surgical quality and safety, we have developed a risk-adjustment model for these two outcome measures.
This model is used to identify how likely patients being operated on were to develop sepsis or DVT/PE based on their conditions, health history, the operation being undertaken and so forth. From this, we can calculate how many patients we would have predicted develop sepsis or DVT/PE based on historic trends. We can then compare how many actually did develop sepsis, to create an observed/expected (O/E) ratio. If the O/E ratio is more than 1 then there are more sepsis or DVT/PE cases than expected, even when patient risk is taken into account. A ratio of less than 1 indicates fewer sepsis or DVT/PE cases than expected.
Due to the edition changes of ICD-10-AM codes, a new definition has been investigated, discussed and finalised by the Expert Advisory Group of the Safe Surgery programme. Based on the new definition, the sepsis risk adjustment model results are shown in the three charts of Figure 15. The first chart shows the number of sepsis cases we would expect to see based on the model (red line) and the observed number of sepsis cases that were observed over time (blue line). The second chart compares the observed rate and expected rate by controlling the impact from the changes in the number of operations. The last chart is the control chart of the O/E ratio. All the significant risk factors are controlled; no shift is seen.
Figure 16 shows the DVT/PE risk adjustment model results in three charts. Using the same methodology as above, the O/E ratio control chart showed that there were 11 consecutive quarters that the observed numbers were below the expected numbers since quarter 2, 2013 This indicates a statistically significant downwards shift, taking into account the increasing number of high-risk patients treated by hospitals and more complex procedures undertaken by hospitals.
The QSM for medication safety focuses on medicine reconciliation. This is a process by which health professionals accurately document all medicines a patient is taking and their adverse reactions history (including allergy). The information is then used during the patient’s journey across transitions in care. An accurate medicines list can be reviewed to check the medicines are appropriate and safe. Medicines that should be continued, stopped or temporarily stopped can be documented on the list. Reconciliation reduces the risk of medicines being:
- 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 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.
Within the five DHBs that have implemented eMR, Northland DHB and Taranaki DHB reported. The other three DHBs are in the process of system upgrades or tests and will be able to report in the near future.
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.
 In quarter 1, 2015, 1.5 g or more of cefuroxime was accepted as an alternative agent to 2 g or more of cefazolin 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.
 New codes in ICD-10-AM edition 8 are used in defining postoperative sepsis. They are R651 (Systemic inflammatory response syndrome [SIRS] of infectious origin with acute organ failure. severe sepsis) and R572 (sepsis shock).