The Anatomy of AHRQ Quality Indicators
While there are various quality indicators at work in healthcare today, likely the most well-known are the quality indicators from AHRQ, the Agency for Healthcare Research and Quality. AHRQ is the health services research arm of the U.S. Department of Health and Human Services (HHS). Health services research examines how people get access to health care, how much care costs, and what happens to patients as a result of this care.
The main goals of health services research are to:
- Identify the most effective ways to organize, manage, finance, and deliver high-quality care
- Reduce medical errors
- Improve patient safety
There are 4 categories of AHRQ quality indicators.
- PQIs, or Prevention Quality Indicators, are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for “ambulatory care sensitive conditions”. These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. These indicators can be used as a screening tool.
- IQIs, or Inpatient Quality Indicators, provide a perspective on hospital quality of care using hospital administrative data. These indicators reflect:
- quality of care inside hospitals and include inpatient mortality for certain procedures and medical conditions
- utilization of procedures for which there are questions of overuse, underuse and misuse
- volume of procedures for which there is some evidence that a higher volume of procedures is associated with lower mortality
- PDIs, or Pediatric Quality Indicators, can be used with hospital inpatient discharge data to provide a perspective on the quality of pediatric healthcare. Specifically, PDIs screen for problems that pediatric patients experience as a result of exposure to the healthcare system and that may be amenable to prevention by changes at the system or provider level. The focus is on potentially preventable complications and iatrogenic events for pediatric patients treated in hospitals and on preventable hospitalizations among pediatric patients. PDIs apply to the special characteristics of the pediatric population; screen for problems that pediatric patients experience as a result of exposure to the healthcare system and that may be amenable to prevention by changes at the provider level or area level; and, to help to evaluate preventive care for children in an outpatient setting, and most children are rarely hospitalized
- PSIs, or Patient Safety Indicators, are used most often by CDI and coding professionals in the inpatient hospital environment. These set of indicators provide information on potential in hospital complications and adverse events following surgeries, procedures and childbirth. They are used to help hospitals:
- identify potential adverse events that might need further study
- provide the opportunity to assess the incidence of adverse events and in-hospital complications using administrative data found in the typical discharge record
- include indicators for complications occurring in hospital that may represent patient safety events
While not included in the make-up of an AHRQ quality indicator, per se, deep understanding of the Complications of Care guideline contained in the Official Guidelines for Coding and Reporting, I.B.16, is mandatory in order to begin to determine if a condition is a PSI.
OGCR I.B.16 Complication of Complications of Care
Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.
As seen in the guideline, we should first understand that not all conditions that occur during or following medical care or surgery are complications. Coding Clinic 1Q 2014, pp 13-14 tells us that “…there must be more than a routinely expected condition or occurrence.”
It is rare to see a definitive term used in a guideline, yet we see the use of the word “must” in I.B.16 in stating, “There must be a cause-and-effect relationship between the care provided and the condition and an indication in the documentation that it is a complication.” As you can see, documentation must contain two points; first, the cause-and-effect (linking) and second, documentation of a complication. This is indisputable and to skirt this issue is not wise.
Another point to fully understand is that the determination of a complication is not based on assumptions or thoughts; it is based on documentation, as stated in I.B.16, “Code assignment is based on the provider’s documentation…” This is echoed in the aforementioned coding clinic, “The coder cannot make the determination whether something that occurred during surgery is a complication or an expected outcome. Only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication. If it is not clearly documented, the coder should query the physician for clarification.” Of course, the word “coder” is not a limiting term; this guideline applies to all who review records for potential complications, which includes the CDI professional, quality personnel, auditors, etc.
The Technical Specifications, found on the AHRQ website under each indicator, provide a breakdown of the calculations used to formulate each PSI; each technical specification document includes a brief description of the measure, numerator information, denominator information as well as specific ICD-10-CM/PCS codes that are included and/or excluded.
A review of the description, which is a brief summary of the indicator, provides an overall impression of the indicator. This overview doesn’t contain specific codes, however, but does contain the verbiage that will be further delineated in the denominator and numerator.
The denominator indicates the number of persons treated by a health care entity during a defined time period who were at risk of, or eligible for, the numerator event. There are inclusions and/or exclusions listed for the individual technical specification.
Lastly, the numerator describes the number of persons in the denominator who received the appropriate diagnostic test or treatment (e.g., aspirin for heart attack), or the number who experienced an adverse outcome (e.g., respiratory failure after surgery). This too outlines specific inclusions and/or exclusions for the individual specification.
An understanding of documentation and coding guidelines regarding complications of care, as well as the inclusions and exclusions in the AHRQ quality indicators can assist in correctly interpreting quality indicators and assigning the appropriate code.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of CDI Education