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


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

State of AHRQ Part IIImprovements in Patient
Safety The Future is Now
  • AHQA Annual Meeting
  • Technical Conference
  • March 12, 2004

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)

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.

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)

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

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

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
  • Receipt date 04/22/04
  • Applications at, funding

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

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

  • 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

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

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

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

Patient Safety Research Using Administrative Data
  • Chunliu Zhan
  • Agency for Healthcare Research Quality
  • March , 2004

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

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)

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

AHRQ PSI (20 indicators)
Administrative Data Merits
  • Large number of records
  • Continuous
  • National coverage
  • Cheap
  • Power for studying rare events

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

Potential Uses I II Screening Tool and Risk
  • 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
  • Patients admitted for pleurisy and undergone
    thoracentesis have high risk for developing
    iatrogenic pneumothorax

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.

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

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

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

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

For More Information
  • AHRQ Website
  • http//
  • Denise Remus, AHRQ QI expert

Hospital Survey on Patient Safety
  • Jim Battles
  • Agency for Healthcare Research Quality
  • March , 2004

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
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.

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

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

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

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

Dimensions of Patient Safety Culture
  • Supervisor/manager expectations actions
    promoting patient safety (.75)
  • Organizational learning--Continuous improvement
  • 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
  • Teamwork across hospital units (.80)
  • Hospital handoffs transitions (.80)

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.

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
  • Several instruments are longer with some shorter
    but none as reliable
  • Outstanding psychometric properties that have
    been fully tested

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

(No Transcript)
Thank You
  • Agency for Healthcare Research and Quality
  • Center for Quality Improvement and Patient Safety
  • 540 Gaiter Road, Rockville, MD 20850
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