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Influencing Health Care: Safety

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Title: Influencing Health Care: Safety


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
  1. Look-alike, sound-alike drugs
  2. Kreutzfeldt-Jakob disease
  3. Medical gas mix-ups
  4. Needles sharps injuries
  5. Dangerous abbreviations
  6. Wrong-site surgery 2
  7. Ventilator-related events
  8. Delays in treatment
  9. Bed rail deaths injuries
  10. Nosocomial infections
  11. Surgical fires
  12. Perinatal deaths
  13. Anesthesia awareness
  14. Kernicterus 2
  15. PCA by proxy
  16. Intrathecal vincristine
  17. Wrong route / wrong tube
  18. Medication reconciliation
  19. 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
NPSG requirement 2003 2004 2005 2006
1a Two identifiers 3.8 4.1 3.9 3.8
1b Time out before surgery 8.9 8.0 17.1 7.7
2a Read-back verbal orders 7.4 8.2 11.6 9.6
2b Standardize abbreviations 23.5 24.8 39.5 11.5
2c Improve timeliness of reporting --- --- 7.6 17.3
2e Hand-off communications --- --- --- 5.8
3a Concentrated electrolytes 3.0 1.9 1.3 ---
3b Limit concentrations 0.6 0.9 1.5 0.0
3c Manage look-alike/sound-alike drugs --- --- 1.9 5.8
3d Label medications solutions --- --- --- 7.7
4a Preoperative verification 1.5 5.4 5.5 1.9
4b Surgical site marking 6.2 4.6 3.8 3.8
7a CDC hand hygiene guidelines --- 1.2 3.6 7.7
7b HC-associated infection RCA --- 0.1 0.0 0.0
8a Medication reconciliation list --- --- 0.0 3.8
8b Medication reconciliation reconcile --- --- 0.3 7.7
9a Fall risk assessment --- --- 3.0 ---
9b Fall prevention program --- --- --- 7.7
19
Alternatives Approaches to the NPSGs
NPSG requirement 2004 Requests 2005 Requests
1a Two identifiers 3 1
1b Time out before surgery 1 1
2a Read-back verbal orders 6 0
2b Standardize abbreviations 15 17
2c Timeliness of reporting -------- 1
3a Concentrated electrolytes 90 1
3b Limit concentrations 10 35
3c Look-alike/sound-alike drugs -------- 14
4a Preoperative verification 6 1
4b Surgical site marking 54 0
5a Free-flow protection 42 4
6a Alarm maintenance testing 1 0
6b Alarm settings audibility 4 0
7a CDC hand hygiene guidelines -------- 78
7b Infection-related sentinel events -------- 0
8a Medication reconciliation -------- 10
8b Medication information to next provider -------- 0
9a Fall risk assessment -------- 3
20
2005 National Patient Safety Goals
  1. Patient identification
  2. Communication among caregivers
  3. Medication safety
  4. Wrong-site surgery
  5. Infusion pumps
  6. Clinical alarm systems
  7. Health care-associated infections
  8. Reconciliation of medications
  9. Patient falls
  10. Flu pneumonia immunization
  11. Surgical fires
  12. NPSG implementation by network components

21
2006 National Patient Safety Goals
  1. Patient identification
  2. Communication among caregivers
  3. Medication safety
  4. Wrong-site surgery Universal Protocol
  5. Infusion pumps
  6. Clinical alarm systems
  7. Health care-associated infections
  8. Reconciliation of medications
  9. Patient falls
  10. Flu pneumonia immunization
  11. Surgical fires
  12. NPSG implementation by network components
  13. Patient involvement
  14. 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
Topics of Downloads
Nursing Shortage white paper 967,308
Emergency Preparedness white paper 113,359
Organ Donation white paper 92,647
Medical Liability white paper 292,033
Improving the Quality of Pain Management Through Measurement and Action 638,938
Universal Protocol 157,880
Universal Protocol Implementation Guidelines 127,798
Do Not Use List 104,860
Standing Together Emergency Planning Guide 587,554
Speak Up Brochure 154,535
Universal Protocol Brochure (Wrong Site Surgery) 95,798
Organ Donation Brochure 46,937
Infection Control Brochure 150,934
Medication Management Brochure 50,446
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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