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Influencing Health Care: Safety & Measurement

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Influencing Health Care: Safety & Measurement Peter Angood MD FACS FCCM Vice President & Chief Patient Safety Officer Joint Commission (JCAHO) Chief Patient Safety ... – PowerPoint PPT presentation

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Title: Influencing Health Care: Safety & Measurement


1
Influencing Health CareSafety Measurement
  • Peter Angood MD FACS FCCM
  • Vice President Chief Patient Safety Officer
  • Joint Commission (JCAHO)
  • Chief Patient Safety Officer Co-Director
  • Joint Commission International Center for Patient
    Safety
  • Chicago, USA

2
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3
gt 5 Years After The IOM ReportTo Err Is Human
  • Regulation/Accreditation A-
  • Workforce Training Issues B
  • Information Technology B-
  • Error Reporting Systems C
  • Malpractice System D

Wachter, RM Health Affairs 11/2004
4
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
  • Mission
  • To continuously improve the safety and quality of
    care provided to the public through the provision
    of health care accreditation and related services
    that support performance improvement in health
    care organizations.
  • Free-standing not-for-profit organization with
    deemed status by federal Center for Medicare and
    Medicaid Services (CMS)

5
To continuously improve the safety and quality
of care
INFORMATION
PUBLIC POLICY
MEASUREMENT
ACCREDITATION
PATIENT SAFETY
6
Overlapping Strategies
  • Committed to continually enhance the value of its
    accreditation and certification programs.
  • The Joint Commission will strive to ensure that
    they are patient-centered, data-driven, relevant,
    and integral to the performance improvement
    activities of health care organizations.

7
Commitment To continually enhance the value of
Joint Commission accreditation and certification
programs to ensure that they are
patient-centered, data-driven, relevant and
integral to the performance improvement
activities of health care organizations.
As of December 30, 2005.
This is the core competency of the Joint
Commission
8
Safety and Regulatory Issues
  • Persistent Accreditation Issues
  • Precision of standards
  • Consistency of surveyors
  • Perceptions of relevance
  • Intermittent nature of process
  • Shared Visions, New Pathways

9
Overlapping Strategies
  • Committed to developing, utilizing, and
    maintaining valid and reliable performance
    measures.
  • These measures are needed to support a credible,
    data-driven accreditation process and the
    publication of meaningful comparative performance
    information for the public.

10
Standards
  • Requirements that define performance expectations
    with respect to structure, process, and outcomes
    that must be substantially in place in an
    organization to enhance the safety and quality
    for patient care
  • Performance Measurement Data
  • Adverse Event Reporting

11
Core Measure Identification Process
  • Library of hospital priority measurement areas
  • Acute myocardial infarction (implemented 2002)
  • Heart failure (implemented 2002)
  • Community acquired pneumonia (implemented 2002)
  • Pregnancy and related conditions (implemented
    2002)
  • Surgical infection prevention (Implemented July
    2004)
  • Intensive care (Scheduled July 2005)
  • Pain management (In development)
  • Childrens asthma (In development)
  • Hospital Based Inpatient Psychiatric Services (In
    development)
  • DVT (In development)
  • Sepsis (In development)

12
Performance Measurement
  • Environment is rapidly evolving
  • US Federal Govt accelerating change
  • Link between performance measurement and
    accreditation
  • Alignment with Hospital Quality Alliance
    (HQA-2003) National Quality Forum (NQF-1999)
    important
  • Accreditation
  • contractual agreement to collect on 3 measure
    sets
  • AMI, CHF, Pneumonia, SIP or Pregnancy Related
    Conditions

13
Overlapping Strategies
  • Committed to making patient safety an imperative
    in all accredited organizations.
  • This will be accomplished through the standards
    and policies of the Joint Commission and through
    collaboration with other patient safety
    leadership organizations.

14
Sentinel Event Policy
  • Established in January 1996
  • To have a positive impact in improving care
  • To focus attention on underlying causes and risk
    reduction
  • To increase the general knowledge about sentinel
    events, their causes and prevention
  • To maintain public confidence in the
    accreditation process

15
Percent of 3231 events
16
Sentinel Event Alerts
  • Potassium chloride
  • Policy issues
  • Policy issues
  • Policy issues
  • Policy issues
  • Wrong site surgery
  • Suicide
  • Restraint deaths
  • Infant abductions
  • Transfusion errors
  • High Alert Medications
  • Op/post-op complications
  • Impact of SE Alert
  • Fatal falls
  • Infusion pumps
  • Proactive risk reduction
  • Home fires (O2 therapy)
  • Kernicterus
  • Look-alike, sound-alike drugs
  • Kreutzfeldt-Jakob disease
  • Medical gas mix-ups
  • Needles sharps injuries
  • Dangerous abbreviations
  • Wrong-site surgery 2
  • Ventilator-related events
  • Delays in treatment
  • Bed rail deaths injuries
  • Nosocomial infections
  • Surgical fires
  • Perinatal deaths
  • Anesthesia awareness
  • Kernicterus 2
  • PCA by proxy
  • Intrathecal vincristine
  • Wrong route / wrong tube
  • Medication reconciliation
  • Device Connections

17
National Patient Safety Goals
  • Selection of the Goals and requirements is guided
    by a panel of experts
  • Sentinel Event Advisory Group
  • Each year, a set of Goals their Requirements
    are identified from a variety of sources
  • The Goals and their Requirements are field
    reviewed published by mid-year for the coming
    calendar year

18
NPSG Compliance Data for 20032006
19
Alternatives Approaches to the NPSGs
20
2005 National Patient Safety Goals
  • Patient identification
  • Communication among caregivers
  • Medication safety
  • Wrong-site surgery
  • Infusion pumps
  • Clinical alarm systems
  • Health care-associated infections
  • Reconciliation of medications
  • Patient falls
  • Flu pneumonia immunization
  • Surgical fires
  • NPSG implementation by network components

21
2006 National Patient Safety Goals
  • Patient identification
  • Communication among caregivers
  • Medication safety
  • Wrong-site surgery Universal Protocol
  • Infusion pumps
  • Clinical alarm systems
  • Health care-associated infections
  • Reconciliation of medications
  • Patient falls
  • Flu pneumonia immunization
  • Surgical fires
  • NPSG implementation by network components
  • Patient involvement
  • Pressure ulcers

22
Provisions of the Universal Protocol
  • Preoperative verification process
  • Relevant pre-op tasks completed and information
    is available and correct
  • Surgical site marking
  • Unambiguous mark, visible after prep drape
  • Right/left, multiple structures or levels
  • Time out immediately before starting
  • Involves entire team active communication
  • Fail-safe model No go unless all agree
  • Applicable to invasive procedures in all settings

23
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24
Wrong-site Surgeries
25
Surveying and Scoring theNational Patient Safety
Goals
  • Must implement all applicable Goals
    Requirements or implement an acceptable
    alternative(s)
  • Evaluated in the PPR and during all full
    accreditation surveys and for-cause surveys
  • Surveyors evaluate actual performance, not just
    intent
  • Failure to comply with one or more requirements
    of a Goal will result in a Requirement for
    Improvement
  • NPSG requirements that are also in the standards
    will only be scored once (no double jeopardy)

26
Public Disclosure of Compliance with National
Patient Safety Goals
  • Aggregate data
  • Data from 2003 - 2005 surveys posted on Joint
    Commission web site
  • Individual health care organizations
  • Compliance with specific requirements
  • Quality Reports - on web site since 2004

27
Overlapping Strategies
  • Committed to ensure that the accreditation
    process is publicly accountable.
  • The Joint Commission will provide meaningful and
    useful information about the performance of
    accredited organizations to the public.

28
WWW.QualityCheck.org
29
SIP Measure Reporting
30
Strategic Surveillance System - Release
1.0(Corporate Summary Comparison of
Organization Level PFP Points)
System ABCs PFP Point Total Average
(3282.50/11) 299 System ABC compared to other
groups of hospitals from PFP Studies
System ABC
31
Strategic Surveillance System - Release 1.0
(Corporate Dashboard View by Measure Set)
32
Hospital Quality Alliance
  • 2003 - Voluntary reporting of 10 selected
    measures from JCAHO CMS focused towards AMI,
    CHF Pneumonia
  • 2004 - Medicare Modernization Act created formal
    link to measures and hospital reimbursement
  • 2005 expanded to all measures and included SIP
    measures set
  • 2007 reported patient experience of care survey
    (H-CAPS) risk-adjusted measures for 30-day
    mortality of AMI CHF to be gathered by CMS

33
Institute of Medicine 2005
  • Performance Measurement recommendations includes
    IOMs starter set of measures for hospital
    performance that is gt HQA measures
  • 2006 - Deficit Reduction Omnibus Act adopts IOM
    recommendations for inclusion in a new
    value-based purchasing (P4P) framework to be
    implemented by 2009
  • State-based initiatives increasing

34
HQA NQF Changes
  • Joint Commission remains committed flexible to
    evolving performance measurement environment
  • Deficit Reduction Act creates impetus for HQA
    NQF to accelerate expansion of the array of
    measures in the production process
  • SCIP
  • ICU Measure Set
  • Pediatric Asthma
  • Nursing-Sensitive
  • AHRQ Quality Indicators

35
Overlapping Strategies
  • Committed to addressing pressing public policy
    issues that impact the quality and safety of
    health care.
  • The Joint Commission will convene thought leaders
    and subject-matter experts and will issue public
    policy recommendations.

36
PUBLIC POLICY INITIATIVES
PUBLIC POLICY
37
Joint Commission InternationalCenter for Patient
Safety
  • Partnering for Solutions in Systems Improvement

38
  • Collaboration Partnering
  • Patient Safety Solutions
  • Information Distribution
  • Educational Programs
  • Patient Safety Research
  • Public Policy-Advocacy
  • Patient Safety Legislation
  • Patient Safety Organizations

39
  • Definition
  • A Safety Solution is any system design or
    intervention that has demonstrated the ability to
    prevent or mitigate patient harm stemming from
    the processes of health care

40
Measurement Issues
  • Are outcomes performance measurement feasible?
  • Can reliable risk adjustment be performed for
    patient providers?
  • How to overcome cultural variability resistance
    to reporting?
  • Cult of the RCT phenomenon
  • Development of measures is not enough for systems
    change!

41
Measurement Issues
  • Infection-Related Issues
  • VAP
  • Central Line Infection
  • Blood Stream Infection
  • Sepsis
  • Surgical Wound Infection
  • WHO Alliance Global Challenge
  • Taxonomy/Classification Systems
  • Professional Society Organizations
  • Barriers Solutions

42
What Is On The Radar Screen?
43
Physician Engagement in Safety
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