Partnership for Health and Accountability PHA Quality

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Partnership for Health and Accountability
(PHA)Quality Patient Safety

• Orientation for New Peer Review Contacts Staff

Revised 03/17/09
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Objectives

• Become familiar with the organizational structure
  of the Georgia Hospital Association (GHA) and the
  Partnership for Health and Accountability (PHA)
  Quality and Patient Safety Program.
• Know where to find the tools you need online
• Know who to call for help

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PHA Contacts
Kathy McGowan, MPH Director Quality/Patient
Safety 770-249-4519 kmcgowan_at_gha.org
Joyce Reid, RN, MS Director Community
Connections 770-249-4545 jreid_at_gha.org

• Pam Jackson
• PHA Program Assistant
• 770-249-4548
• pdjackson_at_gha.org
• Jan Potter, MS
• Communication Specialist
• 770-249-4549
• jpotter_at_gha.org
• Michelle Sprouse, BS
• Technical Analyst
• 770-249-4533
• msprouse_at_gha.org

• Jackie Childers, MPH, CPHQ
• Patient Safety Specialist
• 770-249-4546
• jchilders_at_gha.org
• Sue Fuller, RN, CPSO
• Patient Safety Specialist
• 770-249-4511
• sfuller_at_gha.org
• Lynne Hall, RN, BSN
• Quality Improvement Specialist
  
• 770-249-4525
• lhall_at_gha.org

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Supporting Georgia Hospitals in Quality and
Patient Safety
Public Recognition
Networking
Sharing Successful Strategies
Meeting External Requirements
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Overview

• Forces Shaping GHAs PHA Program

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True Partnership
Individuals, providers, and the community must
work together and be held accountable for their
specific role in achieving health and safety
improvements
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PHA Vision and Purpose

• The Partnership for Health Accountability (PHA)
  is recognized as the statewide and national
  leader in patient safety and quality
• To promote
• Accountability
• Best practices
• Patient safety
• To improve quality of care statewide

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PHAs Relationship with DCH

• Department of Community Health (DCH)
• The Georgia Department of Community Health (DCH)
  was created in 1999 to serves as the lead agency
  for health care planning and purchasing issues in
  Georgia. The General Assembly created DCH by
  consolidating four agencies involved in
  purchasing, planning and regulating health care.
  DCH is also designated as the single state agency
  for Medicaid.
• Department of Community Health (DCH) Mandate
• Improve Patient Safety and Quality of Care
• Condition of Participation for Medicaid and
  State Merit patients
• As of July 1, 2001, all hospitals must
  participate in an approved statewide patient
  safety program

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Overview Reports

• Public Reports and Peer Review Protected Reports

One side
On the other side
Patient Safety Quality Confidential sharing of
sensitive data
Community User friendly information
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Patient SafetyPeer Review Protection
Submission of Peer Review Data
According to the GA Peer Review Law, data must be
sent from one peer review committee to another.
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The Accountability and Health Safety (AHS)
Committee

• Established in 2000 as a Peer Review Organization
  according to Georgia Code 31-7-131
• Federal Patient Safety Organization (PSO)
  Legislation Signed into law July 29th 2005
• GHA filed for PSO status March 2009.
• GHAREF approved our PSO status on March 18,
  2009.
• PHA Peer Review Policies and Procedures
  Available in Peer Review Contact Tool Kit at
  http//www.gha.org/pha/toolkits/index.asp

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PHA Peer Review Contact

• PHAs designated peer review contact is
• Kathy McGowan, MPH, Director
• PHA requires written requests/confidentiality
  agreements for peer review data to be shared with
  the hospitals peer review contact
• PHAs Accountability and Health Safety (AHS)
  committee and sub-committees are peer review
  committees

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PHA Organizational Structure
Georgia Hospital Association Research and
Education Foundation (GHAREF)
Health (Public)
Outcomes and Patient Safety (Provider)
Partnership for Health and Accountability
Executive Committee
Multi-Disciplinary Advisory Council
Accountability and Health Safety Committee (AHS)
Partners
Technical Support
Peer Review Panel
Best Practices
Patient Safety Network
Ad Hoc Task Forces
Physician Clinical Process Team
Event Reporting
Quality Index
Pay-4-Performance
TIPS Program
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PHAs Role

• Provide feedback on submitted data
• Hospital Relative Quality Index
• Trend and statistical process control charts
• Web-based reports
• Successful strategies from TELNETs/Webinars
• NQF/AHRQ Indicators
• Provide technical assistance
• Promote risk reduction through education and best
  practices
• 4. Provide mentoring and educational support

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Hospital Peer Review Contacts

• The Peer Review Contact (PRC) is the healthcare
  organization (HCO) liaison to PHAs AHS Program
  and is responsible to ensure that
• All required data is submitted to PHA
• PHA reports and educational materials are
  distributed to the appropriate hospital and
  physician staff
• PHA is notified when the PRC changes
• Email reminders of meeting dates/webinar
  information are fowarded to appropriate staff so
  they can register in a timely manner
• Promotion of PHA patient safety and quality
  programs

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PHA Reporting Requirements

• Builds on existing data initiatives and/or
  requirements
• Data Requirements are located under the
  SUBMISSIONS Tab http//www.gha.org/pha/data/phada
  tarequirements.pdf

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Required Data Submissions

• Hospitals are required to submit data for
• Process Measures (Core Measures)
• Medication Safety Plans
• Voluntary submissions include
• Structure (Self Assessments and surveys)
• Reportable Events (voluntary)

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Regulatory Requirements
Standardized Definitions Meets Requirements for
DCH CMS JCAHO

• Outcome Measures (CARE, AHRQ ? ?
• Patient Quality Indicators - PQIs)
• Core Measures (Process Measures) ? ? ?
• Medication Safety ? ?
• Patient Safety Issues ? ? ?
• (AHRQ Patient Safety Indicators-PSIs, NPSGs)
• Adverse / Sentinel / Near Misses ? ? ?
• Survey Employee Culture of Safety (COPS) ? ? ?
• (AHRQ / CMS / JCAHO)

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PHA Offerings

• Analytical Service Unit (ASU) - HERMES
• COPS (Culture of Patient Safety)
• Care2 (Patient Outcomes/Quality Improvements
• CARECORE (Joint Commission submissions)
• HighRisk (AHRQ indicators, PSIs)
• MedEval (Physician performance)
• Health Planner (Hospital care costs/market
  position)
• ASU/Care website http//www.gha.org/care/

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PHA Offerings cont.

• Quality Services
• Quality Index
• Best Practices Committee
• Core Measure Abstracting Support
• CARE2 Technical Support
• Physician Power Hours

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PHA Offerings cont.

• Teams for Infection Prevention Success (TIPS)
• http//www.gha.org/pha/TIPS

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PHA Offerings cont.

• Patient Safety Network
• Quality Patient Safety Awards
• National Patient Safety Goals (NPSGs)
• Medication Safety
• Never Events HACs (Hospital Acquired
  Conditions)
• HAIs Healthcare Associated Infections
• VTE DVT PE
• Reportable Events
• Accreditation Updates (Joint Commission, CMS,
  other)
• Toolkits

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• AHRQ Developed, tested, piloted
• PHA / Analytical Service Unite (ASU) Web-based
  application
• Nominal Pricing
• Tremendous Flexibility
• Contact Faizah Muheb, MPH, MBA, Director
  Analytical Services Unit (ASU)
• Phone [phone]
• Email fmuheb_at_gha.org

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PHA Offerings cont.

• Moving Georgia to the Top Ten Program
• Physician Power Hours
• Regional Pilot Program
• Physician Subcommittees
• AMI/CHF
• PNEUMONIA
• Education
• Reliability Processes
• Engagement and Recognition
• Leadership Subcommittee
• Trustees Subcommittee

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PHA Offerings cont.

• Moving Georgia to the Top Ten
• Reliable System Process Initiative - Resar
• Dr. Roger Resar, an IHI faculty member, will be
  providing education and consultation over a 12
  month period at no cost to hospitals. He will
  provide additional coaching to 20 pilot
  hospitals. There will be three calls per month
  (1) general call regarding reliable system
  process (2) heart failure and (3) pneumonia.

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PHA Offerings cont.
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Center for Rural Health

• The Center for Rural Health is organized as a
  not-for-profit association exclusively for
  charitable, scientific, and educational purposes
  and to develop policies and positions to benefit
  rural health in the state of Georgia. The Center
  is organized through the Georgia Hospital
  Association Research and Education Foundation
  (GHAREF).
• Members consist of acute care and critical access
  hospital organizations which are members of GHA
  and meet the following criteria
• Have an average daily hospital inpatient census
  of 75 or fewer
• Are located in a country with a population of
  75,0000 or fewer or
• Are designated as a Critical Access Hospital
  (CAH)
• http//www.gha.org/pha/ruralhealth/Toolkit/index.a
  sp

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Critical Access Hospitals - CAHs

• There are 34 Critical Access Hospitals in
  Georgia
• Over 30 more eligible to become CAHs
• GHA/PHA working with CAHs in order to
• Protect rural Georgians access to
  patient-centered quality and safe care
• Identify needs of rural hospitals related to
  improving access to quality services
• Act in advisory capacity to ORHS
• Provide Education to hospital management
• Seek Manage External Funding
• Enhance Rural Health Networks
• http//www.gha.org/pha/CAH

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PHA Web-based Reporting

• Available on the PHA web page
• http//www.gha.org/pha/data/index.asp
• Submit responses on line
• Confidentiality and added security
• Peer Review Contacts have higher security level
• Your GHA user ID password
• Use of encrypted ID for hospital confidentiality
• On line data feedback

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Core Measure Requirements

• Acute Care Hospitals submit 4 clinical measures
  to PHA through their data vendor
• AMI
• Heart Failure
• Pneumonia
• Pregnancy
• SCIP
• Exceptions
• Critical Access Hospitals submit only 1
  clinical measure.
• Specialty hospitals - None applicable

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CAH Upload Data from CART Tool to HeRMES Website

• Secure Web Site https//www.hermesdb.net
• For Upload Assistance Contact
• Samantha Cobb CARE Liaison
• 770-249-4550
• scobb_at_gha.org

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Hospital Reports Process Outcome

• Secure website password login
• Link www.gha.org/pha/DataReporting/reports.asp
• Data Definitions
• Description of charts contents
• Trend Charts
• Compares hospital process outcome performance
  to relative benchmarks
• PHA Relative Hospital Quality Index - RHQI

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PHA Trend Reports Aggregate Data Analysis
http//www.gha.org/pha/DataReporting/reports.asp
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PHA Trend Chart
Use to monitor core / ORYX measures. Meets
compliance JCAHO Standard PI.2.20
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Statistical Process Control SPC Chart
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Core Measure Tool Kit Challenges Solutions
http//www.gha.org/pha/coremeasure/
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PHA Hospital Quality Index

• http//www.gha.org/pha/DataReporting/reports.asp
  
• Process Core Measures
• Outcomes
• Mortality
• LOS
• Re-Admits
• AHRQ Patient Safety Indicators

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PHA Event Reporting

• Opportunity to prove that anonymous required
  reporting works
• Web-based user friendly
• Shared learnings through Safety Alerts Peer
  Review Protected Process
• Anonymous Required Reporting versus
• Mandatory Public Reporting

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PHA Event Reporting
http//www.gha.org/pha/patientsafety/event_reporti
ng/index.asp
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PHA Event Reporting
LIVE VERSION
DEMO VERSION
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PHA Event Reporting Medical Errors Reporting
Categories Requirements
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PHA Reportable Event Timeline
Reportable Event
If reportable to ORS, must report within 24
hours.
45 days
10 days
HCO Anonymously Notifies PHA
HCO completes PHAs Reportable Event web tool
HCO Completes Root Cause Analysis
PHA will proactively and periodically distribute
Safety Alerts according to member input
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Shared Learnings

• Safety Alerts Available at

http//www.gha.org/pha/publications/SafetyAlerts/i
ndex.asp
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PHA Bulletin Boardshttp//www.gha.org/pha/resourc
es/bulletinboards/index.asp

• Designed for both staff and community
• Can download and print
• Complete bulletin board
• Separate graphics
• Graphics designed to print on commercially
  available paper
• Posters available on request

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PHA Bulletin Boardshttp//www.gha.org/pha/resourc
es/bulletinboards/index.asp
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PHA Toolkits
http//www.gha.org/pha/toolkits/index.asp
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PHA Publications Insights 2008 A Consumer Guide
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Patient Safety Week
March 8th -14th 2009

• The theme for this year is "Hand to Hand" and it
  incorporates the idea of handwashing PHA
  Organized Activities
• Patient Safety Award Applications
• Tee Shirts, Bookmarks
• Bulletin Boards

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PHA - Quality Award Winners
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Two Sides to the PHA Fence
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PHA Community Priorities Areas for 2009

• Navigating the Health System
• Transition of Care
• Care Collaboratives - Shared Learning Community
  Benefit Statewide Report
• Date Warehouse - Community Needs Assessment