Navigating the complexities of PSI 90 for better quality reporting

Navigating the complexities of PSI 90

I recently revisited a trail I hiked 6 years ago. Not only am I 6 years older, but I also hiked solo this time. Hiking in the high desert in summer is not for the faint of heart and requires planning and perseverance (with a lot of luck thrown in).  

As I started my hike, I had one original objective: to access a side quest off the trail I had not hiked. But I also told myself that depending on how I was feeling, I would hike the rest of the trail versus just looping back (and yes, I had appropriate supplies and water for a full 6-mile hike). 

I reached my side quest and reached a decision point. I could either hike back (2 miles) or complete the loop (3 miles). The temperature was rising and my confidence was a bit too high, and I chose the 3 miles. I came to a portion that I did not hike 6 years ago and alone, in the sun and heat, I had to proceed through this tricky section. 

Each step of those last three miles I had to navigate, assess, refocus and problem-solve. It reminded me of navigating healthcare quality reporting: instead of focusing on patient care, you're stuck navigating complicated metrics and measures like PSI 90.
 

What is PSI 90 and why does it matter for quality reporting?

PSI 90 is a composite measure developed by the Agency for Healthcare Research and Quality (AHRQ) and utilized by Centers for Medicare & Medicaid Services (CMS) to evaluate hospital safety performance. It combines multiple patient safety indicators, such as pressure injuries, falls with injury, central line-associated bloodstream infections, and postoperative sepsis, into one score. These indicators help hospitals identify potentially preventable adverse events using administrative claims data.

Accurate documentation is crucial for accurate PSI 90 scores. If documentation is unclear, a condition that did not actually occur might be reported, negatively impacting your score. But just as important is the accuracy of the present on admission status of these conditions and risk adjustment for the expected rates of these measures. Clinical documentation specialists and coding teams are essential in capturing the “clinical truth,” preventing inaccuracies, and ensuring your score reflects your true quality of care.
 

How AHRQ and CMS weight PSI 90

Not all indicators in PSI 90 are weighted equally. AHRQ and CMS assign weights based on two factors: the frequency of events and the associated harm. Severe, high-frequency complications (like postoperative sepsis) carry more weight than rarer or less severe events (such as iatrogenic pneumothorax).

This weighting helps prioritize quality improvement efforts. By identifying which complications heavily impact your score, you can direct clinical and documentation-related resources and initiatives to areas with the greatest risk. For example, targeting documentation and care protocols for sepsis can significantly improve patient outcomes and improve PSI 90 scores.
 

Current state of PSI 90

AHRQ publicly reports all-payer PSI 90 scores which can be (and are) used by payers and states as a part of contracted reimbursement and as a part of accountable care organization performance. CMS is currently utilizing their modified (based on Medicare/Medicare Advantage population) PSI 90 score as a part of the Hospital Acquired Conditions Reduction Program (HACRP) quality payment program (1/6 of total score) and part of their Hospital Star Ratings program. 

CMS is creating a set of electronic clinical quality measures (eCQMs) with a phased roll out for mandatory reporting which may signal a shift from PSI 90 to the eCQMs but that has not been formally announced and due to the phased-in mandatory reporting, cannot be utilized until FY2028 at the earliest. Hence, it is still imperative to focus on all payer and Medicare/Medicare Advantage PSIs for the foreseeable future.
 

Common challenges with patient safety metrics

Many opportunities surrounding PSI 90 performance are focused on unclear documentation and unclear present on admission (POA status). For instance, if a patient arrives with a deep tissue injury not fully documented until day three, it could be coded as a hospital-acquired condition. This documentation gap skews your metrics and misrepresents your performance.

Treating PSI 90 as merely a regulatory burden is another common pitfall. In reality, it was created first and foremost as a powerful clinical tool. Accurate documentation ensures your metrics reflect the care you provide and helps leadership focus on the right quality of care initiatives where documentation is clear.
 

The role of clinical documentation integrity

A strong clinical documentation integrity (CDI) program prevents inaccuracies by ensuring precise and complete documentation. CDI specialists bridge the gap between clinical care and administrative coding. They review records in real time, clarifying conditions and POA status before discharge. This proactive approach ensures accurate data and better quality scores.

By investing in CDI programs, you can ensure patient records are precise, reflecting the severity of illness, mortality risk, and true quality of care. Accurate documentation also aligns quality measures with reimbursement, reducing administrative burdens and improving outcomes.

But also, do not forget risk-adjustment. The methodology utilizes demographic information (age and sex) but also utilizes certain secondary diagnoses to risk-adjust expected rates of PSIs. CDI and coding efforts must be equally focused on both the actual PSIs but also on risk-adjustment efforts. In my next blog, I will delve into the risk-adjustment methodology and strategies for improvement.
 

Interpreting PSI 90 results

To use PSI 90 effectively, review your raw data and weighted scores. Identify the indicators driving your composite score, such as high rates of pressure injuries or postoperative respiratory failure. Use this information to target clinical education and process improvements where they’ll have the greatest impact.

Focus on specific indicators each quarter and celebrate small victories as complication rates drop. Share these successes to foster a culture of continuous improvement and collaboration across departments.
 

Moving forward with confidence

Quality reporting will continue to evolve, but the goal remains the same: delivering safe, effective care to every patient. Understanding PSI 90 helps you move from reacting to scores to proactively creating safer care environments.

Educate your teams on the importance of documentation and foster a culture where it’s viewed as integral to patient care. When everyone understands how their actions impact quality measures, your organization can align around continuous improvement.

By embracing PSI 90 as a tool for clinical excellence, you can focus more on helping patients heal and thrive. Together, we can navigate these complexities and move healthcare forward.
 

Cheryl Manchenton is a senior inpatient consultant and project manager for Solventum.