Going from Worst to Top 10 Percentile: A PSI Review Team Success Story

August 17, 2023

This activity will highlight the implementing an interdisciplinary team to review cases assigned with a Patient Safety Indicator (PSI) or Hospital Acquired Condition (HAC) can have significant positive outcomes. This approach ensures documentation capture and accurate PSI/HAC reporting. At Lehigh Valley Health Network, a PSI Review team has improved Lehigh Cedar Crest rank for PSI09 Perioperative Hemorrhage and Hematoma rate from the worst ranked 2019 Academic Medical Center to a top ten performer. As a result of this work, a PSI Dashboard was created to track progress and identify other PSIs where improvement in systems of care may be required.

Target Audience

This activity is intended for physicians, nurses, executive healthcare professionals, quality professionals, and all other healthcare professionals. 

Learning Objectives

At the conclusion of this activity, participants should be able to:

  • Identify the importance of improving PSI and HAC measures that gauge the quality of care provided at healthcare organizations.
  • Discuss the importance of a multidisciplinary team approach to reducing the risk of payment penalties and improving performance scores in relation to PSI and HACs.
  • Identify key stakeholders/roles to include in a PSI Review team.

Additional Information

Course summary
Available credit: 
  • 1.00 ACHE
  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 ANCC
  • 1.00 CPHQ – Certified Professional Healthcare Quality
  • 1.00 General CE - Attendance
Course opens: 
Course expires: 
Event starts: 
08/17/2023 - 11:00am CDT
Event ends: 
08/17/2023 - 12:00pm CDT

Faculty Presenters/Planning Committee

Kimberly J. Fenstermacher, BSN, RN, CCDS
Supervisor, Quality Outcomes CDI
Clinical Documentation Integrity Department
Lehigh Valley Health Network

Shannon Hale, MHA, RN, CPHQ
Performance Improvement Program Director
Vizient, Inc.

Michele CG Hartzell, PA-C, MBA    
Assistant Chief Quality and Patient Safety Officer
Lehigh Valley Health Network

Matthew M. McCambridge, MD, MHQS, FACP, FCCP, CPHQ, CPPS
Senior Vice President and Chief Quality and Patient Safety Officer
Lehigh Valley Health Network


Identification, Mitigation, and Disclosure of Relevant Financial Relationships

As an accredited provider of continuing education, Vizient, Inc. is dedicated to ensuring this activity presents learners with only accurate, balanced, scientifically justified recommendations, and is free from promotion, marketing, and commercial bias. In accordance with The Standards for Integrity and Independence in Accredited Continuing Education, all planners, faculty, and others in control of the educational content have disclosed the absence or existence of all financial relationships (of any dollar amount) with ineligible companies within the past 24 months.

It is Vizient’s policy that owners and employees of ineligible companies, and any individuals who refuse to disclose the absence or existence of financial relationships with any ineligible companies are disqualified from participating as planners or faculty.

Disclosure of Financial Relationships:

Absence of Relevant Financial Relationships

Vizient, Inc., Jointly Accredited for Interprofessional Continuing Education, defines companies to be ineligible as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

An individual is considered to have a relevant financial relationship if the educational content an individual can control is related to the business lines or products of the ineligible company.

No one in a position to control the content of this educational activity have relevant financial relationships with ineligible companies.

Statement of content validity

Vizient, Inc. educational activities are intended to assist healthcare teams advance their professional responsibilities in accordance with the definition of continuing education. It is the policy of Vizient, Inc. to review and ensure that all content and recommendations for patient care within accredited CE is evidenced-based, based on current science and clinical reasoning while ensuring the content is fair and balanced. All recommendations must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation. Vizient, Inc. does not permit accredited continuing education if it advocates for unscientific approaches to diagnosis or therapy, or if the education promotes recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.

FDA off-label/unapproved usage

Faculty/Presenters are required to identify any new and evolving topics for which there is a lower/absence of evidence base. This is to ensure that our content does not advocate for, or promote, practices that are not, or not yet adequately based on current science, evidence, and clinical reasoning. Faculty/Presenters are required to disclose any discussion of (1) off-label/unapproved or investigational uses of FDA approved commercial products or devices and/or (2) products or devices not yet approved in the United States.

Disclaimer: The education provided through this activity is for continuing education purposes only. The views and opinions expressed in this activity are those of the faculty/presenters and do not necessarily reflect the views of Vizient, Inc.

Joint Accreditation Statement:

In support of improving patient care, Vizient, Inc. is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.


Designation Statements:


This activity is designated for 1.0 contact hours.


Vizient, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).  Physicians should claim only the credit commensurate with the extent of their participation in the activity.


This program has been approved by the National Association for Healthcare Quality for a maximum of 1.0 CPHQ continuing education credits for this event.


By attending the Going from Worst to Top 10 Percentile: A PSI Review Team Success Story offered by Vizient, Inc., participants may earn up to 1.0 ACHE Qualified Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

All attendees must self-report their attendance in order for this credit to be applied toward their advancement or recertification as Fellows of ACHE.


Vizient, Inc. will award all other healthcare professionals who successfully complete the activity a Certificate of Participation. Various state license boards and credentialing bodies accept certificates of participation from accredited CE activities to meet CE requirements for license renewals and re- certification. It is the responsibility of the participant to contact their state licensing board and/or certifying body for verification on credit eligibility reciprocity.

Available Credit

  • 1.00 ACHE
  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 ANCC
  • 1.00 CPHQ – Certified Professional Healthcare Quality
  • 1.00 General CE - Attendance
Please login or register to take this course.