Professionals

Medicare Patient Safety Monitoring System (MPSMS)

• Project Overview
• What's New
• Tools & Resources
• FAQs
• Our Partners
• Project Team

Project Overview

With the 1999 release of the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, patient safety has become the center of attention for the nation's health care delivery system. The first step to improving patient safety is an understanding of the magnitude of the problem. The Medicare Patient Safety Monitoring System (MPSMS) is one major step to providing that understanding on a national level.

The MPSMS is a nationwide surveillance system designed to identify rates of specific adverse events within the hospitalized fee-for-service Medicare population. An adverse event is defined as an unintended patient harm, injury or loss more likely associated with the patient's interaction with the health care delivery system than from diseases the patient may have. The MPSMS is created under the auspices of the Department of Health and Human Services' (DHHS) Patient Safety Task Force. The Centers for Medicare & Medicaid Services (CMS), an agency of DHHS, is leading the coordination and development of the MPSMS. In 2001, CMS selected Qualidigm, Connecticut's Quality Improvement Organization (QIO), to provide administrative and technical support to develop the system.

Goals:

Through its role as administrators of the Medicare system, CMS has an unparalleled responsibility to insure the health of millions of Americans. The dual fiduciary duties of protecting the Medicare Trust Fund and improving the safety of the health care system affords CMS access to the breadth and depth of information necessary to achieve the goals.

The major goals of MPSMS are to:

• Provide an understanding of the magnitude of specific patient safety issues among the hospitalized fee-for-service Medicare population.
• Provide baseline and trend data to support national patient safety improvement initiatives.
  

Approach:

Historically, patient harm associated with health care delivery was determined through physician review of medical records. Based on their clinical judgment, physician reviewers determined if an adverse event had occurred. Because physician time is costly, this type of review process is commonly used for small studies. The annual MPSMS sample size ranges from 25,000 to 40,000 inpatient medical records. Thus, using a physician review process would be too expensive. Also, physician review results often reflect an individual physician's judgment and experience and therefore, the results are not always replicable.

The MPSMS team was challenged with developing a cost-effective, accurate and reliable method to identify and count specific adverse events using documentation from a large, randomly selected national sample of Medicare beneficiary inpatient medical records and associated Medicare administrative data. The data were to be collected from the medical records using an abstraction process performed by clinical and non-clinical abstractors at the Medicare Clinical Data Abstraction Center (CDAC), one of CMS's contractors. Because abstractors are not meant to apply clinical judgment and experience, the MPSMS team developed clinical algorithms representing clinical thought processes to determine if, during the hospitalization, the patient was exposed to a specific health care delivery process and if an associated adverse event had occurred. Based on the information required in the algorithm, the MPSMS created a data collection tool with specific questions and instructions requiring no clinical judgment to be used by the abstractors. The questions and instructions were programmed into electronic data collection software already in use by the CDAC. The algorithm is the basis for analysis of the data collected by the abstractors. Thus, the clinical decision-making to determine if an exposure and an associated harm had occurred was accomplished through data analysis, eliminating the need for review of the medical record by a physician. To increase efficiency and improve reliability, data available in the Medicare enrollment and claims databases are electronically pre-populated into the data collection software. Pre-populated information includes patient demographics, identification of patients who had surgical procedures, identification of adverse events that occurred within 30 days after a procedure, hospital readmissions, death within 30 days of discharge and other information as determined by the specific measure.

Partners:

• Currently the MPSMS is counting the national rates for 20 adverse event measures. Central venous catheter adverse events, adverse drug events, inpatient acquired pressure ulcers, in-hospital falls, hospital-acquired infections and postoperative adverse events are examples of the measures.
• During the first four years over 205,000 medical records have been abstracted.
• Inter-rater reliability of the data collected has been maintained between 97 and 98 percent.
• The cost of abstraction has been estimated to be less than one-fourth the cost of physician review.
• Using the administrative data, MPSMS has been able to accurately and reliably link and aggregate adverse events with various patient characteristics.
• Four years of MPSMS findings have been reported and reviewed by CMS, other federal agencies and a group of national experts in patient safety. The findings are consistent with expert expectations and many smaller studies.
• During the national Commonwealth Fund "Quality Improvement Colloquium" held in November 2004, MPSMS measures were rated 14 on a 1-15 point scale (15 was the highest score) by national patient safety experts. This was the best rating among all national measures reported in the 2004 National Healthcare Quality Report (NHQR).
• An article by the CMS Government Task Leader and the Qualidigm MPSMS team entitled "Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance and Transparency" has been published by the Agency for Healthcare Research and Quality in Advances in Patient Safety: From Research to Implementation in April 2005.
  

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What's New

• Five years of MPSMS findings have been reported and reviewed by CMS, other federal agencies and a group of national experts in patient safety. MPSMS findings are consistent with expert expectations and many smaller studies. MPSMS findings have been reported in the 2004 - 2007 National Healthcare Quality Reports (NHQRs) and will be published in future reports.

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Tools & Resources

For information regarding the algorithms, data collection tools, data analysis and findings, please contact:

Michael Pineau, RN, MS
Project Manager
860.632.3737
mpineau@qualidigm.org
mpineau@ctqio.sdps.org

MPSMS Publications

David R. Hunt, MD, Nancy Verzier, MSN, RN, Susan L. Abend, MD, Courtney Lyder, ND, MS, Lisa Jaser, RPh, PharmD, Nancy Safer, RN, MSN, Paul Davern RPh, MBA. “Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance and Transparency,” AHRQ’s compendium of patient safety research Advances in Patient Safety: From Research to Implementation, 2005.

2004 National Healthcare Quality Report
2005 National Healthcare Quality Report
2006 National Healthcare Quality Report
2007 National Healthcare Quality Report

2004 National Healthcare Disparities Report
2005 National Healthcare Disparities Report
2006 National Healthcare Disparities Report
2007 National Healthcare Disparities Report

Agency for Healthcare Research & Quality Advancing Excellence in Healthcare

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FAQs

What adverse events are currently being measured?

• Currently, the MPSMS is counting the national rates for Medicare beneficiaries in the following adverse event categories: central venous catheter (CVC) associated blood stream infections, CVC associated mechanical adverse events, CVC associated blood stream infection (BSI) adverse drug events, inpatient acquired pressure ulcers and ventilator associated pneumonia, hip and knee replacements as well as the postoperative rates of venous thrombeolic events, cardiac events, and pneumonia.
• The following adverse event measures were added in 2005: in-hospital patient falls, hospital acquired methicillin resistant staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE), adverse events associated with femoral artery puncture for catheter angiographic procedures, contrast nephropathy associated with catheter angiography, and catheter associated urinary tract infections replaced the post-operative urinary tract infection measure.

What is an example of a measure algorithm?

The algorithm used to determine central venous catheter (CVC) adverse events follows:

CVC - Associated Blood Stream Infection (BSI)

How many years of data are available for each measure?

• Two years of data are available for the following measures: In-hospital Patient Falls; Hospital-acquired Methicillin Resistant Staphylococcus Aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE); Catheter Associated Urinary Tract Infection (replaces Postoperative UTI); Adverse Events Associated with Femoral Artery Puncture for Catheter Angiographic Procedures; and Contrast Nephropathy Associated with Catheter Angiography.
• Three years of data (2005) are available for the following measures: Postoperative Cardiac Events; Adverse Drug Events Associated with Anticoagulants (Warfarin, Heparin and Low-Molecular Weight Heparin); Adverse Events Associated with Hypoglycemic Agents; Adverse Events Associated with Digoxin; Hospital-acquired Antibiotic Associated Clostridium Difficile; and Hospital-acquired Pressure Ulcers.
• Two years of data (2002 and 2003) are available for CVC-associated Infections at the Insertion Site and Ventilator-associated Pneumonia. The CVC-associated Infections at the Insertion Site measure has been retired. Collection of Ventilator-associated Pneumonia was resumed in 2005.
• Five years of data are available for the following measures: CVC-associated BSI and Mechanical Adverse Events; Postoperative Venous Thromboembolic Events, Pneumonia, and Urinary Tract Infections; and Adverse Events Associated with Hip and Knee Joint Replacements.

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Our Partners

Centers for Medicare & Medicaid Services (CMS)
Rebecca Kliman, MPH
Government Task Leader
Office of Clinical Standards and Quality

Federal Agency Workgroup (FAWG) Members
Agency for Healthcare Research and Quality (AHRQ)
Centers for Disease Control and Prevention (CDC)
Food and Drug Administration (FDA)
Veteran’s Health Administration (VHA)

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Qualidigm MPSMS Project Team

Project Manager
Michael Pineau, RN, MS
860.632.3737
mpineau@qualidigm.org
mpineau@ctqio.sdps.org

Project Coordinator
Nancy Safer, RN, MSN
860.632.3733
nsafer@qualidigm.org

Administrative Assistant
Linda Edwards
860.632.6306
ledwards@qualidigm.org

Analyst
Yun Wang, PhD, JD

Chief Operations Officer
Maxine Goldsmith, RN, MBA

Medical Librarian
Lynda Grayson, RN, MLS

Project Overview | What's New | Tools & Resources | FAQs | Our Partners |Project Team