State of AHRQ Part II Improvements in Patient Safety: The Future is Now

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State of AHRQ Part IIImprovements in Patient
Safety The Future is Now

• AHQA Annual Meeting
• Technical Conference
• March 12, 2004

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Session Objectives

• Describe the major components of AHRQs patient
  safety portfolio and their applicability to QIOs
• Describe AHRQs Patient Safety Indicators (PSIs)
  and their utility for identifying risk and
  hazards to patient safety
• Describe the elements of safety culture and
  explain how to use the safety culture assessment
  tool developed by the Quality Interagency
  Coordination (QuIC Task Force)

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Congressional Mandate for AHRQ
The director of AHRQ shall conduct and support
research and build private-public partnerships to

• identify the causes of preventable health care
  errors and pat injury in health care delivery
• develop, demonstrate, and evaluate strategies for
  reducing error and improving patient safety and
• disseminate such effective strategies throughout
  the health care industry.

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Congressional Funding for Patient Safety

• FY 01 50 Million
• FY 02 55 Million
• FY 03 55 Million
• FY 04 79.5 Million
• FY 05 84 Million (proposed)

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Funding Program Areas

• Identifying risk and hazards
• Reporting System Demonstrations (16 projects)
• Working Conditions (22 projects)
• Building Capacity
• Centers of Excellence in Patient Safety Research
  (3 centers)
• Developing Centers of Excellence in Patient
  Safety Research (18 projects)
• Patient Safety Improvement Corps

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Funding Program Areascontinued

• Raising awareness
• Dissemination and education (6 grants)
• User Liaison Program with states
• Conferences and workshops
• Identify proven patient safety practices
• System best practices (6 projects)
• Computer application (11 projects)
• EPC report on evidence based patient safety
  practices

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Funding Program Areascontinued

• Challenge patient safety improvements
• Risk assessment (6 projects)
• Implementing safe practices (7 projects)
• Transforming through information technology
• FY 04 initiative with 3 RFAs focusing on
  implementing technologies, demonstrating value of
  technologies, and planning for technology
  implementation
• Receipt date 04/22/04
• Applications at www.ahrq.gov, funding
  opportunities

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Porter Question

• SO WHAT?
• How can AHRQs research improve
• quality and patient safety?

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Tools and Products

• Software
• Web-based Tools
• Survey Instruments
• Educational Interventions

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Software

• Decision support
• ADHD
• HIV management
• Diagnostic errors in emergency cardiac care
• Electronic event detection methods
• Risk factor identification
• Falls and delirium
• Adverse event chart review

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Web-based Tools

• Website on infusion devices
• Endoscopic sinus surgery simulator
• Voluntary event reporting
• MisssouriPro patient safety information
• Communicating with patient and families
• Diagnostic errors
• Safety Toolkit for clinicians and patients

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Survey Instruments

• Handheld computer barrier survey
• Evaluating medication safety practices in the
  ambulatory care setting
• Regional patient safety staff and management
• Communicating about errors physicians,
  pediatric, clinical staff
• Leadership self-assessments

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Educational Interventions

• Anticipating the human factors of next generation
  infusion devices
• Inter-professional curriculum on patient safety
  for health professionals
• Statewide hospital summits
• Integrating risk management with patient safety
• Falls management program for nursing facilities

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Patient Safety Research Using Administrative Data

• Chunliu Zhan
• Agency for Healthcare Research Quality
• March , 2004

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Administrative Data

• By-product of administering/reimbursing health
  services (also called claims data)
• Common data elements admission date, discharge
  date and status, primary and varying numbers of
  secondary ICD-9-CM diagnosis and procedure
  codes,DRG, payment, demographic
• Available from Government payers (Medicare,
  Medicaid, Veterans Affairs) and private insurance
  companies

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Administrative Data Patient Safety Research

• 1970s Wennbergs pioneer work on small-area
  variation in practice patterns
• 1980s Outcomes burden of illness
• Early 1990s Iezzoni and colleagues Complication
  Screening Program (CSP)
• Mid 1990s AHRQ Quality Indicators (QI)
• 2002 AHRQ Patient Safety Indicators (PSI)

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AHRQ Patient Safety Indicators (PSIs)

• One of the Quality Indicator Sets
• Inpatient Quality Indicator (IQI)
• Prevention Quality Indicator (PQI)
• AHRQ PSIs
• conservatively identify never events
• are indicators not definitive measures
• use with administrative data
• Reporting at institutional-level QI, not public
  level

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AHRQ PSI (20 indicators)
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Administrative Data Merits

• Large number of records
• Continuous
• National coverage
• Cheap
• Power for studying rare events

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Administrative Data Flaws

• ICD-9-CM coding Incomplete, coding errors,
  coding variation across hospitals, DRG creep
• PSI high false negative, low false positive
• Limited clinical details for risk analysis and
  risk adjustment
• Small but statistically significant findings
• Many potential sources of bias

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Potential Uses I II Screening Tool and Risk
Factors

• Screening Tool
• Iatrogenic Pneumothorax (n3931)
• ID cases to guide medical records abstraction
• and in-depth analysis
• Risk Factors
• Guide medical record abstraction to study root
  cause
• Patients admitted for pleurisy and undergone
  thoracentesis have high risk for developing
  iatrogenic pneumothorax

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Potential Use III Incidence tracking

• Foreign body Left (n536)
• Extrapolate to 2,700 US cases 0.002 in
• medical admissions and 0.024 in surgical
• admissions, in 2002.
• Nosocomial infection (n11,449)
• Extrapolate to 5,700 US cases 0.147 in
• medical admissions and 0.307 in surgical
• admissions, in 2002.

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Potential Use IV Public Reporting

• Possible for tracking at state/national level
  used in the annual National Healthcare Quality
  Report (NHQR)
• Challenges Incomplete, erroneous ICD-9-CM
  codes, coding variation across hospitals, limited
  clinical details and risk adjusters
• Not recommended for provider comparison

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Potential Use V Impacts

• Foreign Body Left
• 2.08 extra days
• 13,000 extra charges
• 2.14 excess mortality
• Nosocomial infection
• 9.58 extra days
• 39,000 extra charges
• 4.31 excess mortality

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Potential Use V Impacts (continued)

• Total Impact
• 18 of the 20 PSIs (excluding death in
• low mortality DRGs and failure to rescue)
• ? 2.4 million hospital days
• 9.2 billion
• 32,600 deaths attributable

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Research Resources

• Chunliu Zhan, Marlene Miller Excess Length of
  Stay, Costs, and Mortality Attributable to
  Medical Injuries during Hospitalization An
  Administrative Data-Based Analysis
• JAMA. October 8, 190(14), 1868-1874, 2003
• Chunliu Zhan, Marlene Miller Administrative
  Data-Based Patient Safety Research A Critical
  Review Quality and Safety of Health Care.
  12(Suppl 2), 58-63, 2003

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For More Information

• AHRQ Website
• WWW.AHRQ.GOV
• http//www.qualityindicators.ahrq.gov/data/hcup/p
  si.htm
• Denise Remus, AHRQ QI expert
• dremus_at_ahrq.gov

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Hospital Survey on Patient Safety

• Jim Battles
• Agency for Healthcare Research Quality
• March , 2004

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Culture and Safety
According to the Institute of Medicine (IOM), the
biggest challenge to moving toward a safer health
system is changing the culture from one of
blaming individuals for errors to one in which
errors are treated not as personal failures, but
opportunities to improve the system and prevent
harm
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What is Safety Culture

• The safety culture is the product of individuals
  and group values, attitudes, perceptions,
  competencies, and patterns of behavior that
  determine the commitment to, and the style and
  proficiency of, an organizations health and
  safety management.
• A positive safety culture is characterized by
  communications founded on mutual trust, by shared
  perceptions of the importance of safety, and by
  confidence in the efficacy of preventive measures.

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Measuring Safety Culture

• The IOM and other organizations have stressed the
  need to measure the safety culture in healthcare
• There have been a number of attempts to develop
  such a measure including efforts within the
  federal government
• However, no valid and reliable instrument existed
  within the public domain that could be used with
  confidence

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Survey Purpose and Instrument Development

• The survey is intended to help hospitals assess
  the extent to which their cultures emphasize the
  importance of patient safety, facilitate open
  discussion of error, encourage error reporting,
  and create an atmosphere of continuous learning
  and improvement
• The Quality Interagency Coordination Task Force
  (QuIC) Medical Errors Workgroup sponsored the
  development which required OMB clearance
• AHRQ funded the project under contract to Westat

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Steps in Development

• A literature review pertaining to safety, error
  and accidents, and error reporting was conducted.
  
• Hospital employees and managers were interviewed
  to identify key patient safety and error
  reporting issues.
• Existing published and unpublished safety culture
  assessment tools were reviewed.
• Psychometric analysis of two federally funded
  instruments from the VA and the NHLBI funded
  MERS-TM project
• Testing was conducted to determine reliability
  and usability of the instrument.
• All dimensions of the instrument were shown to
  have acceptable levels of reliability (defined as
  Cronbachs alpha equal to or greater than 0.60

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Measures Overall Outcomes

• Overall perceptions of safety (.74)
• Overall patient safety grade (.84)

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Dimensions of Patient Safety Culture

• Supervisor/manager expectations actions
  promoting patient safety (.75)
• Organizational learning--Continuous improvement
  (.76)
• Teamwork within units (.83)
• Communication openness (.72)
• Feedback communication about error (.78)
• Non-punitive response to error (.79)
• Staffing (.63)
• Hospital management support for patient safety
  (.83)
• Teamwork across hospital units (.80)
• Hospital handoffs transitions (.80)

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Dimensions of Patient Safety Culture

• Each of these dimensions serves as a different
  component of an organizations safety culture
• Safety culture can be defined as the set of
  values, beliefs, and norms about whats
  important, how to behave, and what attitudes are
  appropriate when it comes to patient safety in a
  work group.

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The QuIC Instrument Comparison

• The QuIC instrument is a public domain instrument
  and is intended for free use by institutions
• Relatively short with 51 items - easily be
  completed by hospital personnel without undue
  burden
• Several instruments are longer with some shorter
  but none as reliable
• Outstanding psychometric properties that have
  been fully tested

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The QuIC Instrument Comparisoncontinued

• Measures culture across ten domains and two
  outcome measures which are all extremely reliable
  (with Chronbachs alpha gt.06)
• Several other instruments do not contain separate
  domains that have demonstrated reliability
• Others must be analyzed only as single items
  rather than as underlying dimensions
• Other instruments have not been as comprehensive

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Thank You

• Jbattles_at_ahrq.gov ehogan_at_ahrq.gov
  czhan_at_ahrq.gov
• Agency for Healthcare Research and Quality
• Center for Quality Improvement and Patient Safety
• 540 Gaiter Road, Rockville, MD 20850