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Concerns About Using the Patient Safety Indicator-90 Composite in Pay-for-Performance Programs

Ravi Rajaram, MD1; Cynthia Barnard, MBA2; Karl Y. Bilimoria, MD, MS3
[+] Author Affiliations
1Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
2Department of Quality Strategies, Northwestern Memorial Hospital, Chicago, Illinois
3Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern Memorial Hospital and Northwestern University, Chicago, Illinois
JAMA. 2015;313(9):897-898. doi:10.1001/jama.2015.52.
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This Viewpoint discusses how the Center for Medicare and Medicaid’s use of Patient Safety Indicator-90 in pay-for-performance programs falls short in its attempt to accurately and fairly measure patient harm.

In 2003, the Agency for Healthcare Research and Quality (AHRQ) released 20 patient safety indicators (PSI) to facilitate measurement of adverse events. Though intended for internal quality measurement and improvement, several PSIs are now being widely publicly reported, including on the Centers for Medicare & Medicaid’s (CMS’s) Hospital Compare website. Additionally, on October 1, 2014 (fiscal year 2015), CMS began using AHRQ’s Patient Safety for Selected Indicators (PSI-90) as a core metric in 2 of its pay-for-performance programs: the Hospital-Acquired Condition (HAC) Reduction program and the Hospital Value-Based Purchasing (VBP) program. PSI-90 is a composite measure consisting of 8 weighted component PSI measures (Table).1 In the HAC Reduction program, PSI-90 is responsible for 35% of the overall score, and the poorest-performing hospital quartile will have their CMS payments reduced by up to 1% (~$330 million). In the Hospital VBP Program, CMS will reallocate 1.5% (~$1.4 billion) of its diagnosis related group payments to hospitals according to their overall score, 30% of which is composed of PSI-90 and 4 other outcome measures. Thus, the PSI-90 composite measure has been given substantial weight in attempting to align the financial interests of hospitals with the quality of care they provide.

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