The links below will take you to quality and safety marker (QSM) information for the July–September 2017 quarter. You can download the full July–September 2017 QSM results (1.3 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 3, 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 expected marker level. Northland DHB is the only DHB to be in the lower group in the current quarter.

  • 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. Hauora Tairāwhiti is the only DHB in the lower group in quarter 3, 2017.

  • 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, 12 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 DHB and Hauora Tairāwhiti’s 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 September 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 8.3 per 100,000 admissions, and shown a significant improvement. The new median excludes the latest quarter’s data as there remains the possibility that these figures may change slightly.

The 76 in-hospital falls resulting in a fractured hip is significantly lower than the 113 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 $1.72 million in the year ending September 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 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 $2.36 million in total avoidable costs since October 2016.

Hand hygiene

National compliance with the five moments for hand hygiene remains high. Nationally, DHBs maintained an average of 85 percent compliance in quarter 3, 2017, compared with 62 percent in 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 hand hygiene outcome marker is healthcare associated Staphylococcus aureus bacteraemia per 1000 bed-days. In quarter 2, 2017, the calculation method for the denominator changed to ensure the definition for calculating DHB bed-days is applied consistently. Figure 7 (monthly healthcare associated Staphylococcus aureus bacteraemia per 1000 bed-days) displays the recalculation of the entire series using the new method. The median has decreased from 0.13 to 0.11.

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 from quarter 3, 2013 to quarter 2, 2017.

Over the last quarter, the SSII programme has worked with DHBs to reconcile and review the historic programme data. Changes have been made to historic data as a result of this process. These changes are reflected in this report. In this report, the group boundaries for the process markers have changed to match the SSII programme reports.

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 2, 2017, 97 percent of hip and knee arthroplasty procedures involved the giving of an antibiotic within 60 minutes before knife to skin. Nine DHBs achieved the national goal. The boundary between the middle and lower groups is now 95 percent, rather than 80 percent. There has been a slow increase for the measure since the start of the SSII programme. Nine DHBs achieved the national goal.

  • Upper group: 100 percent
  • Middle group: 95–99 percent
  • Lower group: < 95 percent
Process marker 2: Right antibiotic in the right dose – cefazolin 2g or more or cefuroxime 1.5g or more

In the current quarter, 97 percent of hip and knee arthroplasty procedures received the recommended antibiotic and dose. Eighteen DHBs reached the threshold level of 95 percent compared with only three in the baseline quarter.[3] The boundary between the middle and lower groups is now 90 percent, rather than 80 percent.

  • Upper group: ≥ 95 percent
  • Middle group: 90–94 percent
  • Lower group: < 90 percent
Outcome marker

The outcome marker is surgical site infections per 100 procedures. Previous reports had a 12-month baseline period beginning March 2013. Recent work to reconcile and review the historic programme data showed considerable variation in data quality in the first three to four months’ worth of data collected. In this report we have excluded the months March to June 2013 from our analysis. July 2013 was the point at which all 20 DHBs were participating in the programme. The effects of this recalculation are minimal. A shift in the median is detected from August 2015 with the reduction being from 1.18 percent SSIs during the baseline period to 0.93 percent following this.

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 fourth QSM (quality and safety marker) report for cardiac surgery. Since quarter 3, 2016, all five DHBs performing cardiac surgery have submitted process and outcome marker data from all cardiac surgery procedures, including coronary artery bypass graft with both chest and honor site and with chest site only. 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. Southern DHB all 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. Capital & Coast DHB, Southern DHB and Waikato DHBs achieved this target along with Auckland DHB adult service.

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 paediatric service, Canterbury DHB, Capital & Coast DHB, and Waikato DHB all achieved the target.

The outcome marker is surgical site infections per 100 procedures rate. In quarter 2, there were 31 surgical site infections in 676 procedures, an infection rate of 4.6 percent. This is between the previous three quarters, which had infection rates of 4.9 percent (quarter 3 2016), 5.8 percent (quarter 4 2016) and 4.4 percent (quarter 1 2017). 

Safe surgery

This is the fifth report for the safe surgery QSM, which measures levels of teamwork and communication around the paperless surgical safety checklist.

The safe surgery QSM now includes a start-of list briefing measure, to reinforce the importance of the briefing as a safe surgery intervention. The measure is described as “was a briefing including all three clinical teams, done at the start of the list?”.

Figure 12 shows 12 out of the 20 DHBs reported this was happening, in quarter 3, 2017. With no specific target to this part of the measure, the aim is to have all 20 DHBs increasingly undertaking and reporting briefings over time.

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 13 shows, for each part of the checklist, how many audits were undertaken. Fifteen out of the 20 DHBs achieved 50 audits for all three parts in quarter 3, 2017 (see Figure 13).

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. Of the fourteen DHBs who achieved 50 audits in each checklist, eight achieved the 100 percent uptake target in at least one part of the checklist, during the current quarter (see Figure 14). 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 15 shows, Capital & Coast DHB and West Coast DHB achieved the target in all three parts and nine 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 fifth 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 or DVT/PE, 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[4] , the sepsis risk adjustment model results are shown in the two charts of Figure 16. 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 last chart is the control chart of the O/E ratio. All the significant risk factors are controlled; no shift is seen.

Figure 17 shows the DVT/PE risk adjustment model results in two 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. 

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

QSM Q3 Figure 18

QSM Q3 Figure 19

Within the five DHBs that have implemented eMedRec, only Northland and Taranaki DHBs reported process markers. The other three DHBs are in the process of aligning their definitions and will be able to report once this has been completed. 

QSM Q3 Figure 20

Local DHB report

Using the interactive charts (below) to read individual quality and safety marker (QSM) information 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] 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). 

 

Last updated 13/12/2017