Assess whether a unit's complication rate is a real signal (a3e791)

Situation

Sepsis BPA alert-override log arrived with a unit that is an outlier after risk adjustment for mortality-and-morbidity reviewer. That is a Healthcare Outcomes Review decision on a unit's complication rate in a rural hospital with long transfer times.

Decision

Mortality-and-morbidity reviewer in a rural hospital with long transfer times must choose Proceed under protocol / Pause the pathway / Escalate safety review / Hold using sepsis BPA alert-override log after a unit that is an outlier after risk adjustment.

Hypotheses to test

• Authorize Proceed under protocol now; sepsis BPA alert-override log already has the discriminator after a unit that is an outlier after risk adjustment.
• Keep Pause the pathway in force until sepsis BPA alert-override log is completed after a unit that is an outlier after risk adjustment for mortality-and-morbidity reviewer.
• Treat sepsis BPA alert-override log as Escalate safety review because both readings appear after a unit that is an outlier after risk adjustment.
• Refuse a Healthcare close: mortality-and-morbidity reviewer does not have the page a unit's complication rate turns on in sepsis BPA alert-override log.

Analysis required

• Quantify who is harmed if sepsis BPA alert-override log is wrong.
• Separate a documented exception from an OCR-relevant gap in a rural hospital with long transfer times.
• Validate clinical-outcome evidence and protocol steps in sepsis BPA alert-override log after a unit that is an outlier after risk adjustment.
• For this Healthcare Outcomes Review file, read sepsis BPA alert-override log against a unit that is an outlier after risk adjustment and write the one fact that would move a unit's complication rate for mortality-and-morbidity reviewer.

Recommendation

Choose Proceed under protocol / Pause the pathway / Escalate safety review / Hold on this Healthcare / Outcomes Review packet (sepsis BPA alert-override log after a unit that is an outlier after risk adjustment). The follow-on Outcomes Review action is what mortality-and-morbidity reviewer does next: implement the option, assign an owner, and log the missing fact.

Command returns