The links below will take you to quality and safety marker (QSM) information for the July–September 2016 quarter. You can download the full July–September QSM results (699KB, pdf) or view the commentary and interactive charts below.

Falls

Nationally, 90 percent of older patients* were given a falls risk assessment in quarter 3, 2016. The rate has remained at 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 target. Bay of Plenty DHB showed significantly lower results over the last few quarters compared with the national target of 90 percent (see Figure 1). We will engage with the DHB to better understand the reasons for the variance.

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

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

About 93 percent of patients at risk of falling received an individualised care plan. This measure has increased 15 percentage points compared with the baseline in quarter 1, 2013. Variances in achievement levels need to be understood, but overall where an individual has been assessed at risk of falling, then 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, 11 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 64 falls resulting in a fractured neck of femur in the 12 months ending September 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 changes in the number of admissions per month, Figure 4 shows in-hospital falls causing fractured neck of femur per 100,000 admissions. The median of this measure has moved down since November 2014, from 12 to 8 per 100,000 admissions. While the rate in February 2016 was a high outlier, it does not indicate any shift in trend. Within these 23 months, 22 were below the original median level. This is the eighth quarter where this outcome marker has shown a significant improvement.

These in-hospitals patient outcomes have been reported as world-leading,[1, 2, 3] with New Zealand referred to as the first country to achieve such results at a national level.

If New Zealand is to sustain these gains and continue to improve, it will be vital to maintain our focus in this area of high harm.

The number of 64 in-hospital falls resulting in a fractured hip is significantly lower than the 110 we would have expected in this year, given the falls rate observed in the period between July 2010 and June 2012. The reduction is estimated to have saved $2.2 million in the year ending September 2016, based on an estimate of $47,000[4] for a fall with a fractured neck of femur.

The estimate may be too conservative, however, 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.[5] 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 $3.0 million in total avoidable costs since October 2015.

Hand hygiene

National compliance with the five moments for hand hygiene remains high. Nationally, DHBs achieved an average of 83 percent compliance in quarter 3, 2016, the highest since the baseline 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

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 2, 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 2, 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 programme. Six 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 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. In the current quarter, 15 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
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. Thirteen DHBs achieved the target compared with nine at the baseline quarter.

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

The surgical site infection rate has shown a significant improvement since August 2015, compared with the baseline rate of 1.6 percent in quarter 3, 2013. The improvement remains in this quarter, with the median dropping down from 1.3 percent to 0.8 percent. During the reduction period, there is a spike of 2.1 percent in February 2016. Examination of the DHB–level data shows no special cause variation.

Safe surgery

This is the first report of a new quality and safety marker, which measures levels of teamwork and communication.

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 (sign in, time out and sign out) are required before the observation is included in uptake and engagement assessments. Rates are greyed out in the tables below where there are fewer than 50 audits.

Figure 12 shows for each part of the checklist, how many audits were undertaken. Eight out of 20 DHBs achieved 50 audits for all three parts in quarter 3, 2016 (see Figure 12). Compared with the other two parts, sign out was the least audited part of the checklist.

SSC poster Dec 2016Uptake rates are only presented where at least 50 audits were undertaken for a part. Uptake rates were calculated by measuring the number of audits of a part where all components of the surgical checklist were reviewed against the total number of audits undertaken. The components for each part of the checklist are shown in the image on the right. Hauora Tairāwhiti was the only DHB that met the minimum number of audits for all three parts and also achieved the 100 percent uptake target (see Figure 13).

Hauora Tairāwhiti is the only DHB that met the minimum number of audits in all three markers and also achieved the 100 percent uptake target (see Figure 13).

The levels of team engagement with each part of the checklist were scored using a 7-point Likert scale. This scale was developed by the World Health Organisation. A score of one represents poor engagement from the team, four is average engagement and seven means team engagement was excellent.  The target is that 95 percent of surgical procedures score engagement levels of five or above. As Figure 14 shows, four DHBs achieved the target in one of the three parts. As this is the first quarter in which DHBs have implemented the new auditing method, the focus is on embedding the new method and better results are expected in subsequent quarters.

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 time
  • provide risk-adjusted outcomes in the monitoring and improvement of surgical quality and safety.

Medication safety

The quality and safety marker 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.

Figure 15: Structure marker, implementation of eMR 

Structure marker, implementation of eMR

Figure 16: Structure markers, eMR implementation

Structure markers, eMR implementation

Within the five DHBs that have implemented eMR, 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 17: 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. Jones S, Blake S, Hamblin R, et al. 2016. Reducing harm from falls. NZ Med J 129(1446): 89–103.
  2. Healey F. 2016. Falls prevention as everyday heroism. NZ Med J 129(1446): 14–16.
  3. Wise J. 2016. Individual care plans reduce falls and broken hips in New Zealand hospitals. BMJ 355: i6490.
  4. de Raad J-P. 2012. Towards a value proposition: scoping the cost of falls. Wellington: NZIER.
  5. Ibid.

Last updated 23/12/2016