The links below will take you to quality and safety marker (QSM) information for the January–March 2017 quarter. You can download the full January–March 2017 QSM results (1.1 MB, pdf) or view the commentary and interactive charts below.

Falls

Nationally, 92 percent of older patients* were assessed on their falls risk in quarter 1, 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, 13 out of 20 DHBs achieved the target. Bay of Plenty DHB showed an improvement after a few significantly lower results over the last few quarters 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 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 should be at a consistently high level.

  • 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, 13 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.

There were 77 falls resulting in a fractured neck of femur (broken hip) in the 12 months ending March 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. However, there were five consecutive months above the current median since July 2016. It is one point less than the run chart rule, which requires six or more consecutive points above median to indicate a significant shift. It is too early to conclude that the median has shifted upwards, but close monitoring is required of this measure. 

The number of 77 in-hospital falls resulting in a fractured hip is significantly lower than the 109 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 $1.5 million in the year ending March 2017, based on an estimate of $47,000[1] 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 that 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.[2] 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 $2.1 million in total avoidable costs since April 2016.

 

Hand hygiene

National compliance with the five moments for hand hygiene remains high. Nationally, DHBs achieved an average of 84 percent compliance in quarter 1, 2017, the highest rate since 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

The run chart below shows the monthly healthcare associated Staphylococcus aureus bacteraemia per 1000 bed-days. It indicates a decline in variation recently, but with no signs of a significant shift in trend.  

 

Surgical site infection improvement – orthopaedic surgery

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 4, 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 4, 2016, 98 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. Nine 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 2 g or more or cefuroxime 1.5 g or more

In the current quarter, 17 DHBs reached the threshold level of 95 percent compared with only three in the baseline quarter.[3] Taranaki DHB made a significant improvement, from 67 percent in quarter 2 to 94 percent in quarter 4.

  • Upper group: ≥ 95 percent
  • Middle group: 80–94 percent
  • Lower group: < 80 percent
Outcome marker

The median surgical site infection rate has shown a significant improvement, dropping to 0.84 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.    

Surgical site infection improvement – cardiac surgery

This is the second QSM report for cardiac surgery. Since quarter 3, 2016, all five DHBs performing cardiac surgery have summited 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. Capital & Coast DHB and Canterbury 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), Capital & Coast DHB, Southern DHB and Waikato DHB all achieved this target.

The outcome marker is the surgical site infection rate. In quarter 4, there were 40 surgical site infections in 690 procedures, an infection rate of 6 percent.

Safe surgery

This is the third 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 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. Eight out of the 20 DHBs achieved 50 audits for all three parts in quarter 1, 2017 (see Figure 12). 

SSC poster Dec 2016Uptake (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. Two of the eight DHBs achieved the 100 percent uptake target in at least one part of the checklist (see Figure 13).

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, Auckland DHB and Wairarapa DHB achieved the target in all three parts and four other DHBs achieved the target in one or two parts. As this is only the third 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 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[4] for these two outcome measures.

The same model has been run with the latest quarter’s data and it provided some preliminary results. We are in the process of investigating background data and understanding the changes. Once the results are confirmed, we will add them into this report.

Medication safety

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:

  • 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 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.

QSM Jan March 17 F17

QSM Jan March 17 F18

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

 

QSM Jan March 17 F19

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

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.

[3] 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.

[4] In the logistic regression model, postoperative sepsis or DVT/PE is the dependent variable. The health and clinical conditions within 12 months prior to the surgical room procedure, the information about the surgical room procedure and the demographic information of the patient are the independent variables. A stepwise SAS procedure is used to select significant factors. The final model shows that the most significant factors are information about the surgical room procedure, patient’s admission type, health and clinical conditions in the 12 months prior to the surgical room procedure, such as the clinical complicity level. The Charlson Comorbidity Score and intensive care unit stay of the patient in hospital events in that period are also important. Some demographic characteristics also play important roles. Based on those risk factors, a predicted probability of sepsis or DVT/PE is calculated for each room procedure, then it is summed as an expected number of sepsis or DVT/PE over time. An O/E (observed/expected) ratio is calculated using observed number divided by expected number per month.

Last updated 03/07/2017