Maimonides Evening of Research
Fellow Winner
Alexandra Shumyatsky, PharmD, CPHQ
Quality Management
Dashing to Zero Harm: Can a Simple Dashboard Minimize Hospital Acquired Safety Events?
This quality improvement initiative was performed at Maimonides Medical Center (MMC), a 711-bed acute care tertiary hospital, located in Brooklyn, New York. The AHRQ/CMS PSI 90 measure was developed to screen for hospital-acquired complications and adverse events; the CMS Star Rating from July/2019 reported MMC’s PSI 90 ratio was 1.91, statistically worse than the national ratio of 1.00. This led to the creation of a visual “No-Harm Dashboard”, which would identify adverse events and allow for timely clinical interventions and documentation improvement through a multidisciplinary approach. The goal of the initiative was to decrease our PSI 90 composite ratio to 1.00 over three years.
The “No-Harm Dashboard” was implemented in 2019 to improve and monitor our PSI-90 ratio, which was statistically worse than the national average. Developed by the Quality team in collaboration with IT, the dashboard captured adverse events using claims data aligned with CMS specifications. The Quality team conducted monthly case reviews to determine whether events were present upon admission or hospital acquired, and opportunities for appropriate documentation were also evaluated. For hospital-acquired events, provider compliance with evidence-based protocols was assessed, and cases were referred to relevant departments for peer review. Data trends guided organizational priorities and led to multidisciplinary taskforces. The Plan, Do, Check, Act (PDCA) framework was applied and strategies included: team building, staff involvement, process mapping, cause-and-effect analysis, goal setting, action planning, assigning responsibility and creating a timeline for implementation. Taskforce progress and data trends were shared monthly with hospital leadership and the Board of Trustees.
We achieved our goal of PSI 90 with a composite ratio of 1.01 by December 2022 and maintained that success through the subsequent reporting periods, with the most recent odds ratio of 0.99 in 2024. The No Harm Dashboard has shown an overall 74% reduction of patient safety indicator events in 2019 vs. 2023 (131 events vs. 34 events) which has resulted in 1.9 million dollars saved.
This initiative has benefited patient safety, and improved publicly reported metrics emphasized by CMS and Leapfrog. This initiative highlighted the importance of optimizing quality improvement efforts by monitoring timely data trends and promoting collaborative teamwork with the owners of the process and frontline staff.