Patient Safety Priorities - PowerPoint PPT Presentation


Title: Patient Safety Priorities


1
  • Patient Safety Priorities
  • Patient Safety Committee
  • September 8, 2008
  • Paula Griswold, Executive Director,
    MA Coalition for the Prevention
    of Medical Errors
  • Alice Bonner, PhD, RN, Executive Director,
    Massachusetts Long Term Care Foundation

2
Next Steps for the HCQCCs Patient Safety
Committee
  • Develop a comprehensive map of the landscape of
    Patient Safety efforts in all healthcare settings
  • Identify overlaps and gaps in current Patient
    Safety efforts
  • Develop and prioritize criteria that will allow
    the Council to make an impact by focusing on the
    gaps and allowing the Council to build on
    current Patient Safety efforts

3
Council Reaching Out for Input Where to Focus
Attention/How It Can Be Most Effective
  • The Council is asking
  • What are you doing for Patient Safety? Why are
    you doing it?
  • Where do you see the gaps in Patient Safety
    efforts?
  • What priorities do you see for HCQCC? Based on
    what criteria?

4
Overview
  • Current Landscape of Patient Safety Activities
  • Potential Priorities for Future Patient Safety
    Goals
  • Criteria for Selecting Priorities
  • Recommendations

5
Current Landscape Patient Safety Activities
6
Current Landscape - Patient Safety Activities
Within Settings
  • Still getting responses from members and others
  • Seems to be a fair description more
    expectations, infrastructure, and activities in
    larger settings
  • Hospitals, nursing homes CMS, DPH, Joint
    Commission, private payers
  • Cf. Small physician groups, for example
  • might respond to complaints/problems
  • might have malpractice insurer office review
  • If not affiliated with hospital, may have no peer
    review or PCA review
  • Board/Payer/PCA maintenance of certification
    ABMS Patient Safety Training module
  • QIO/Payers outpatient quality measures show
    reliability of care
  • Consider Ask all health care providers, with
    support from their professional association, to
    have some patient safety program ( safety as
    systems design/reliability of care)

7
Current Landscape Patient Safety Activities
8
Current Landscape - Patient Safety Activities
Across Settings - Transitions
  • MA Care Transitions Task Force
  • Why focus on transitions in care?
  • What are opportunities to improve quality and
    reduce cost?
  • Examples of current programs

8
9
MA Care Transitions Task Force
  • Purpose
  • To bring together people from various
    organizations across the state who are working on
    care transitions
  • Membership to date
  • MA LTC Foundation (co-chair), MA Health Data
    Consortium (co-chair), MA Coalition for the
    Prevention of Medical Errors, Evercare, Dovetail
    Health, Umass-Memorial Health Care, Winchester
    Hospital, Partners Healthcare, Brockton Hospital,
    Boston Medical Center,, Masspro, Hebrew Senior
    Life, MONE, MHA, Home Care Alliance, DPH, CMS

10
MA Care Transitions Task ForceGoals
  • To improve the quality of care coordination and
    communication when patients are transferred from
    one level of care (or location) to another
  • Transitions include a patient moving from primary
    care to specialty physicians anywhere within the
    hospital patients moving from the ED to various
    departments patients discharged from the
    hospital or SNF to home, assisted living or
    other arrangements
  • (adapted from NTOCC)

11
Care Transitions
  • Definition a handoff between practitioners,
    often when the patient moves from one setting to
    another
  • Why are transitions perilous?
  • Patients are especially vulnerable to medication
    errors and post-discharge adverse events
    (Forster, 2003)
  • Factors that contribute can be related to 3
    categories the hospital care system, the
    patients characteristics or the clinicians
    characteristics
  • How big a problem is this?
  • 38 million U.S. hospital discharges in 2003
  • Patients with recurrent hospitalizations
    accounted for 13 of hospitalized patients, but
    60 of resources
  • 843,167 hospital discharges annually in
    Massachusetts
  • 11.6 to SNF
  • 16 home with services (2006 data)

12
Care Transitions
  • In a study by Forster et al, 20-25 of patients
    experienced an adverse event during the
    transition from hospital to home
  • One third of adverse events are associated with
    disability
  • Half of adverse events are associated with use of
    additional health services
  • One third of the adverse events were deemed
    preventable (Forster, Ann Int Med, 2003)

13
Care Transitions
  • What can go wrong?
  • Treatments not received
  • Medications duplicated or omitted
  • Follow up appointments missed
  • Unknown advanced directives with subsequent
    episode of care
  • Medication errors (commission, omission)
  • Adverse events lead to ED or hospital readmission

14
Care Transitions
  • Where are the cost savings?
  • Acute care readmissions
  • In HF patients, potential savings of 5,000 per
    patient over one year (Naylor, JAGS, 2004)
  • Delayed long term care placement
  • Fewer caregiver missed days of work and fewer
    caregiver episodes of illness
  • Where are costs increased?
  • Upfront costs of program implementation
  • Home health and home support services

15
Current MA Care Transitions Initiatives (selected
examples)
  • RED (Re-Engineered Discharge) at Boston Medical
    Center
  • Transitioning Care at Partners
  • Evercare of New England implementing Transition
    Coaching model
  • Dovetail Health discharge support initiatives
  • MA LTC Foundation Improving Care Transitions
    Initiative
  • POLST Transitions pilot project, HCQCC EOL
    subcommittee

16
Care Transitions Relationship to Other MA
Quality Initiatives
  • Masspro and RIQP are examining care transitions
    in 9th SOW
  • IHI/ Commonwealth planning grant to develop
    prototypes of transition tools with 5 healthcare
    systems/regions, including Berkshire Health
    System
  • Office of Healthy Aging, Office on Health and
    Disability, DPH has a grant on chronic disease
    self-management and healthy aging
  • Eric Coleman and NTOCC willing to lend support to
    local initiatives
  • BOOST project, involving Society of Hospital
    Medicine on AHRQ website
  • Mt Auburn Hospital, other systems have
    transitions initiatives

17
Identifying Priorities for Future Patient Safety
Goals
  • Consulted Coalition members held four small
    group discussions to identify priorities
  • All four groups identified
  • Communication - inter-professional,
    inter-personal between patient and caregiver,
    inter-organizational including shared learning,
    and inter-facility including transitions of care
  • Transitions - including within hospitals and
    between settings, especially hospital discharge
    in age of hospitalists, focus on infections
    during transitions
  • Medication Safety - including anticoagulation
    management, medication errors at outpatient
    pharmacies, and after hospital discharge to home
    or to long term care

18
Identifying Priorities for Future Patient Safety
Goals
  • Additional areas identified by some groups
    include
  • Focus, focus, focus the importance of setting
    priorities, so that providers can succeed with
    improvement efforts.
  • Having a safe place for sharing and collaborative
    learning across institutions
  • Primary care practitioner availability is
    becoming a patient safety issue threatening
    coordination and continuity of care
  • Use of multidisciplinary teams for patient care
    (including in facilities and medical home model)
  • Payment reform continue changing the way health
    care is paid to support these changes

19
Criteria Recommended for Selecting Priority Goals
  • Greatest opportunity to reduce harm to patients
  • Build on existing requirements and existing
    priorities for greatest likelihood of success
  • Add value consider helping create cooperation
    and synergy among different sectors that are
    otherwise working in silos/independently
  • Look for win wins for significant improvement
    potential for safety/quality and cost reductions

20
Recommendations for Future Patient Safety
Priorities
  • Retain focus on current goals
  • - Infections in hospitals
  • - Serious Reportable Events in hospitals,
  • including preventing harm from falls and
    pressure ulcers
  • Expand care sites for elimination of Serious
    Reportable Events Falls and Pressure Ulcers
  • - work already underway in skilled nursing
    facilities, home health around falls
  • - include SNF and home health as well as
    hospitals in goal (e.g., falls)
  • - work with Massachusetts Falls Prevention
    Coalition
  • Expand sites of care for Preventing
    Infections/Harm from Infections
  • - Dialysis centers
  • - Long term care facilities work already
    underway
  • - Coordination across sites of care
  • - Task small group to clarify elements of goal
  • - infection prevention, antibiotic
    stewardship/prescribing, nursing assessment

21
Recommendations for Future Patient Safety
Priorities
  • Set goal that all health care providers, with
    support from their professional association,
    create a basic Patient Safety Program
  • someone responsible for patient safety
  • internal reporting of adverse events
  • correct problems and measure effectiveness
  • proactively think about where there is the
    greatest potential for harm and design systems to
    prevent harm
  • promote safety culture

22
Recommendations for Future Patient Safety
Priorities
  • Improve Transitions of Care, including
    communication
  • Safety is not a silo related to several other
    areas of quality
  • A. Generic elements for all transitions,
    including at least
  • information transfer
  • explicit handoff of care responsibility from
    provider to provider
  • ensure follow-up of pending results
  • meet patient/family needs
  • focus on the process, not just the forms
  • B. Specific focus on hospital discharge
    transition
  • To home, with or without home health/hospice
  • To skilled nursing facility

23
Recommendations for Future Patient Safety
Priorities
  • Improve Transitions of Care, including
    communication ( contd)
  • C. Coordinates with other requirements/
    incentives Joint Commission, NQF, Leapfrog, DPH,
    Masshealth P4P (future), payers
  • D. Coordinates with other improvement efforts
  • Interface with all related HCQCC Committees
  • fit with HCQCC chronic care model
  • fit with HQCC - End of Life work POLST
  • Fit with Massachusetts State Quality Institute
    Chronic Care Model
  • Fit other projects mentioned
  • E. Consider Care Transitions Task Force as
    Clinical Advisory Committee for this work

24
Recommendations for Future Patient Safety
Priorities
  • Next steps recommended, if these priorities
    chosen
  • Small task forces to define explicit wording of
    goal
  • Basic patient safety program
  • Aim/Scope for infection prevention
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Patient Safety Priorities

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If not affiliated with hospital, may have no peer review or ... 16% home with services (2006 data) Care Transitions ... Home health and home support services ... – PowerPoint PPT presentation

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Transcript and Presenter's Notes

Title: Patient Safety Priorities


1
  • Patient Safety Priorities
  • Patient Safety Committee
  • September 8, 2008
  • Paula Griswold, Executive Director,
    MA Coalition for the Prevention
    of Medical Errors
  • Alice Bonner, PhD, RN, Executive Director,
    Massachusetts Long Term Care Foundation

2
Next Steps for the HCQCCs Patient Safety
Committee
  • Develop a comprehensive map of the landscape of
    Patient Safety efforts in all healthcare settings
  • Identify overlaps and gaps in current Patient
    Safety efforts
  • Develop and prioritize criteria that will allow
    the Council to make an impact by focusing on the
    gaps and allowing the Council to build on
    current Patient Safety efforts

3
Council Reaching Out for Input Where to Focus
Attention/How It Can Be Most Effective
  • The Council is asking
  • What are you doing for Patient Safety? Why are
    you doing it?
  • Where do you see the gaps in Patient Safety
    efforts?
  • What priorities do you see for HCQCC? Based on
    what criteria?

4
Overview
  • Current Landscape of Patient Safety Activities
  • Potential Priorities for Future Patient Safety
    Goals
  • Criteria for Selecting Priorities
  • Recommendations

5
Current Landscape Patient Safety Activities
6
Current Landscape - Patient Safety Activities
Within Settings
  • Still getting responses from members and others
  • Seems to be a fair description more
    expectations, infrastructure, and activities in
    larger settings
  • Hospitals, nursing homes CMS, DPH, Joint
    Commission, private payers
  • Cf. Small physician groups, for example
  • might respond to complaints/problems
  • might have malpractice insurer office review
  • If not affiliated with hospital, may have no peer
    review or PCA review
  • Board/Payer/PCA maintenance of certification
    ABMS Patient Safety Training module
  • QIO/Payers outpatient quality measures show
    reliability of care
  • Consider Ask all health care providers, with
    support from their professional association, to
    have some patient safety program ( safety as
    systems design/reliability of care)

7
Current Landscape Patient Safety Activities
8
Current Landscape - Patient Safety Activities
Across Settings - Transitions
  • MA Care Transitions Task Force
  • Why focus on transitions in care?
  • What are opportunities to improve quality and
    reduce cost?
  • Examples of current programs

8
9
MA Care Transitions Task Force
  • Purpose
  • To bring together people from various
    organizations across the state who are working on
    care transitions
  • Membership to date
  • MA LTC Foundation (co-chair), MA Health Data
    Consortium (co-chair), MA Coalition for the
    Prevention of Medical Errors, Evercare, Dovetail
    Health, Umass-Memorial Health Care, Winchester
    Hospital, Partners Healthcare, Brockton Hospital,
    Boston Medical Center,, Masspro, Hebrew Senior
    Life, MONE, MHA, Home Care Alliance, DPH, CMS

10
MA Care Transitions Task ForceGoals
  • To improve the quality of care coordination and
    communication when patients are transferred from
    one level of care (or location) to another
  • Transitions include a patient moving from primary
    care to specialty physicians anywhere within the
    hospital patients moving from the ED to various
    departments patients discharged from the
    hospital or SNF to home, assisted living or
    other arrangements
  • (adapted from NTOCC)

11
Care Transitions
  • Definition a handoff between practitioners,
    often when the patient moves from one setting to
    another
  • Why are transitions perilous?
  • Patients are especially vulnerable to medication
    errors and post-discharge adverse events
    (Forster, 2003)
  • Factors that contribute can be related to 3
    categories the hospital care system, the
    patients characteristics or the clinicians
    characteristics
  • How big a problem is this?
  • 38 million U.S. hospital discharges in 2003
  • Patients with recurrent hospitalizations
    accounted for 13 of hospitalized patients, but
    60 of resources
  • 843,167 hospital discharges annually in
    Massachusetts
  • 11.6 to SNF
  • 16 home with services (2006 data)

12
Care Transitions
  • In a study by Forster et al, 20-25 of patients
    experienced an adverse event during the
    transition from hospital to home
  • One third of adverse events are associated with
    disability
  • Half of adverse events are associated with use of
    additional health services
  • One third of the adverse events were deemed
    preventable (Forster, Ann Int Med, 2003)

13
Care Transitions
  • What can go wrong?
  • Treatments not received
  • Medications duplicated or omitted
  • Follow up appointments missed
  • Unknown advanced directives with subsequent
    episode of care
  • Medication errors (commission, omission)
  • Adverse events lead to ED or hospital readmission

14
Care Transitions
  • Where are the cost savings?
  • Acute care readmissions
  • In HF patients, potential savings of 5,000 per
    patient over one year (Naylor, JAGS, 2004)
  • Delayed long term care placement
  • Fewer caregiver missed days of work and fewer
    caregiver episodes of illness
  • Where are costs increased?
  • Upfront costs of program implementation
  • Home health and home support services

15
Current MA Care Transitions Initiatives (selected
examples)
  • RED (Re-Engineered Discharge) at Boston Medical
    Center
  • Transitioning Care at Partners
  • Evercare of New England implementing Transition
    Coaching model
  • Dovetail Health discharge support initiatives
  • MA LTC Foundation Improving Care Transitions
    Initiative
  • POLST Transitions pilot project, HCQCC EOL
    subcommittee

16
Care Transitions Relationship to Other MA
Quality Initiatives
  • Masspro and RIQP are examining care transitions
    in 9th SOW
  • IHI/ Commonwealth planning grant to develop
    prototypes of transition tools with 5 healthcare
    systems/regions, including Berkshire Health
    System
  • Office of Healthy Aging, Office on Health and
    Disability, DPH has a grant on chronic disease
    self-management and healthy aging
  • Eric Coleman and NTOCC willing to lend support to
    local initiatives
  • BOOST project, involving Society of Hospital
    Medicine on AHRQ website
  • Mt Auburn Hospital, other systems have
    transitions initiatives

17
Identifying Priorities for Future Patient Safety
Goals
  • Consulted Coalition members held four small
    group discussions to identify priorities
  • All four groups identified
  • Communication - inter-professional,
    inter-personal between patient and caregiver,
    inter-organizational including shared learning,
    and inter-facility including transitions of care
  • Transitions - including within hospitals and
    between settings, especially hospital discharge
    in age of hospitalists, focus on infections
    during transitions
  • Medication Safety - including anticoagulation
    management, medication errors at outpatient
    pharmacies, and after hospital discharge to home
    or to long term care

18
Identifying Priorities for Future Patient Safety
Goals
  • Additional areas identified by some groups
    include
  • Focus, focus, focus the importance of setting
    priorities, so that providers can succeed with
    improvement efforts.
  • Having a safe place for sharing and collaborative
    learning across institutions
  • Primary care practitioner availability is
    becoming a patient safety issue threatening
    coordination and continuity of care
  • Use of multidisciplinary teams for patient care
    (including in facilities and medical home model)
  • Payment reform continue changing the way health
    care is paid to support these changes

19
Criteria Recommended for Selecting Priority Goals
  • Greatest opportunity to reduce harm to patients
  • Build on existing requirements and existing
    priorities for greatest likelihood of success
  • Add value consider helping create cooperation
    and synergy among different sectors that are
    otherwise working in silos/independently
  • Look for win wins for significant improvement
    potential for safety/quality and cost reductions

20
Recommendations for Future Patient Safety
Priorities
  • Retain focus on current goals
  • - Infections in hospitals
  • - Serious Reportable Events in hospitals,
  • including preventing harm from falls and
    pressure ulcers
  • Expand care sites for elimination of Serious
    Reportable Events Falls and Pressure Ulcers
  • - work already underway in skilled nursing
    facilities, home health around falls
  • - include SNF and home health as well as
    hospitals in goal (e.g., falls)
  • - work with Massachusetts Falls Prevention
    Coalition
  • Expand sites of care for Preventing
    Infections/Harm from Infections
  • - Dialysis centers
  • - Long term care facilities work already
    underway
  • - Coordination across sites of care
  • - Task small group to clarify elements of goal
  • - infection prevention, antibiotic
    stewardship/prescribing, nursing assessment

21
Recommendations for Future Patient Safety
Priorities
  • Set goal that all health care providers, with
    support from their professional association,
    create a basic Patient Safety Program
  • someone responsible for patient safety
  • internal reporting of adverse events
  • correct problems and measure effectiveness
  • proactively think about where there is the
    greatest potential for harm and design systems to
    prevent harm
  • promote safety culture

22
Recommendations for Future Patient Safety
Priorities
  • Improve Transitions of Care, including
    communication
  • Safety is not a silo related to several other
    areas of quality
  • A. Generic elements for all transitions,
    including at least
  • information transfer
  • explicit handoff of care responsibility from
    provider to provider
  • ensure follow-up of pending results
  • meet patient/family needs
  • focus on the process, not just the forms
  • B. Specific focus on hospital discharge
    transition
  • To home, with or without home health/hospice
  • To skilled nursing facility

23
Recommendations for Future Patient Safety
Priorities
  • Improve Transitions of Care, including
    communication ( contd)
  • C. Coordinates with other requirements/
    incentives Joint Commission, NQF, Leapfrog, DPH,
    Masshealth P4P (future), payers
  • D. Coordinates with other improvement efforts
  • Interface with all related HCQCC Committees
  • fit with HCQCC chronic care model
  • fit with HQCC - End of Life work POLST
  • Fit with Massachusetts State Quality Institute
    Chronic Care Model
  • Fit other projects mentioned
  • E. Consider Care Transitions Task Force as
    Clinical Advisory Committee for this work

24
Recommendations for Future Patient Safety
Priorities
  • Next steps recommended, if these priorities
    chosen
  • Small task forces to define explicit wording of
    goal
  • Basic patient safety program
  • Aim/Scope for infection prevention
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