The Current Status of Oregon Patient Safety Efforts

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The Current Status of Oregon Patient Safety
Efforts

• Maureen Wright M.D.
• Portland, Oregon
• 02/04/04

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The Landscape

• Stakeholders
• Key Aspects of Patient Safety
• Where are we now?
• Opportunities and Challenges
• What dont we know?
• Research
• Barriers

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Stakeholders

• Purchasers
• Consumers
• Government

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Stakeholders (Continued)

• Medical Groups
• Nursing
• Health Plans
• Hospitals
• Long Term Care
• Pharmacy
• Professional Organizations
• Quality Oversight Organizations

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Purchasers

• Encourage disclosure of quality performance
  information
• Establish quality and safety incentives
• Encourage use of evidence-based medicine
• Leapfrog and other quality standards
• Educate employees

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Consumers

• True northpatients and their experiences
  Donald Berwick
• Overlapping areas of influence and needpatients,
  families, communities, society.
• Physician Charter
• Primacy of Patient Welfare
• Patient Autonomy

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State of Oregon

• Public Health Role
• Policy/Planning/Convening/Facilitating
• Regulatory Functions
• Public Purchaser (PEBB)

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Key Aspects of Patient Safety

• Leadership
• Creating a Learning Environment
• Developing a Culture of Safety
• System Improvements
• Information Technology
• Teamwork and Collaboration
• Patient-centered care

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Leadership

• Patient Safety goals and objectives communicated
• Safety principles are considered when designing
  and maintaining products/programs/processes
• Establish a visible commitment to patient safety
• Patient Safety orientation

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Leadership (examples)

• Patient Safety Workgroup State of Oregon and 10
  Partners
• Executive Patient Safety Walk Rounds
• Limited Immunity for Reporting
• Reporting System

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Leadership Patient Safety Workgroup

• Convened by state in partnership with 10
  stakeholders
• Goal address need for a patient safety reporting
  system in Oregon
• Met 10 times between 9/02 and 4/03
• Drafted House Bill 2349

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An Incident/Event Reporting Systeminput analysis
output
Limited Immunity For Reporting confidential ground
ed in systems eliminate blame
Leadership Walk Rounds open discussion data
collection feedback
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Questions

• Can you think of a patient you recently cared
  for who was harmed by us?
• What will be the reason(s) underlying harm to
  the next patient you care for?
• Are you aware that our hospital is developing a
  blame free or limited immunity policy? Do you
  know what that means?

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Creating a Learning Environment

• Culture of Safety requires a non punitive
  environment to address patient adverse events
  involving medical staff and employees
• Lessons learned are evaluated and acted on
• Recognition and reporting of errors and hazardous
  conditions are encouraged and rewarded

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Creating a Learning Environment

• There is a system of analysis and feedback of
  information about errors and close calls that
  result in changes and improvements to procedures
  and systems
• Patient Safety intelligence from various sources
  are integrated into Patient Safety improvement
  planning

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Creating Learning Environment (examples)

• Ambulatory Records Certification
• Northwest Physicians Mutual
• Oregon Health Care Quality Corporation

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Learning Ambulatory Records Certification

• Oregon Medical Association physicians and
  representatives in partnership with health plan
  and hospital leadership work towards fulfilling
  NCQA requirements
• Current structure lends itself to expanding
  further into improving patient safety and quality
  of care. Exploration stage.

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Learning Northwest Physicians Mutual

• The Quality Factor Program
• Voluntary teams of clinicians and nursing staff
  seeking to improve patient safety by reducing the
  frequency and severity of errors, injury or harm
  inflicted upon patients.
• Creating learning organizations committed to
  durable change

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Learning Quality Corporation

• Created by Oregon Healthcare Purchasers
  Coalition, a separate nonprofit 501(c3)
• Designed as a forum for promoting best practices
  and improving the quality of health care through
  community-wide collaboration
• Current projects
• automated clearinghouse for information on care
  of patients with chronic disease
• Targeted practice variation analysis

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System Improvements

• Information Technology
• Teamwork and Collaboration

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Information Technology

• Electronic health records
• Secure data exchange systems
• Uniform data standards

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Information Technology (example)

• Drug Allergy Screening

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Lithium Reorder
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Electronic Record presents user w/ Results,
Detail and Override
Reason and Comments fields with lithium
order
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Clicking on Reason for Override ellipsis gives
category list
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Reason selected
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User allowed to e-auth medication order
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Teamwork and Collaboration

• Care delivery process improvements that enhance
  teamwork and communication and avoid reliance on
  memory and vigilance are implemented
• Patient care processes include briefings prior to
  procedures
• Accurate and timely patient information is
  available

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Teamwork and Collaboration

• Interdisciplinary team training including
  physicians is routinely conducted in high
  performance areas such as the ED, OR and ICU and
  for cardiac arrest teams

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Teamwork and Collaboration (examples)

• Decreasing Surgical Site Infections
• Oregon Home Health Quality Improvement Project
• Long Term Care Restraint Reduction Program

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Teamwork and Collaboration (example)
CMS National Surgical Infection Prevention
Project OMPRO Salem Hospital Primary Objective
To decrease morbidity and mortality associated
with surgical site infection (SSI)
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Desired Clinical Outcome Decreased SSIs

• How do we reduce SSIs?
• What processes of care lead to the desired
  clinical outcome?
• Literature review and expert panel used identify
  processes linked to improved outcomes

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National Performance Measures

• Proportion of patients who receive antibiotics
  within 1hr before incision
• Proportion of patients who receive antibiotics
  with c/w published recommendations
• Proportion of patients whose antibiotics are
  discontinued w/i 24hr. after surgery

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Implementation of Surgical Site Infection
Prevention Measures by Oregon Hospitals
Data source Baseline is from medical record
review for care provided to eligible patients,
7/1/0012/31/00. Remeasurement is from CY 2002.
Only FFS patients were included in both baseline
and 2002 measurement.
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Teamwork and Collaboration (example)

• Oregon Home Health Quality Improvement Activities
• Project funded by Medicare, OMPRO and home health
  agencies work on Outcome Based Quality
  Improvement. 41 measures
• Management of Oral Medications

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Teamwork and Collaboration (example)

• Tuality Home Care and Salem Home Care Strategies
• Aide and physical therapy assistant responsible
  for asking are you on new medications or have
  you had any recent medication changes
• Special attention to patients with impaired
  physical and cognitive ability
• Special attention to patients on 5 or more meds

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Teamwork and Collaboration (example)

• Quality in Long Term Care Its All about People
• Restraints more harm than good
• What is their goal in trying to get up?
• What did they used to do for work?
• Its people stuff, anyone can figure it out

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Restraint Reduction Efforts in Oregon
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Patient-Centered Care

• Patients are included in safety planning by
  encouraging them to participate in their care
• Patient Perspectives are sought to shape patient
  safety priorities and initiatives

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Patient-Centered Care

• Stakeholders embrace the responsibility and
  ethical obligation to communicate when
  unanticipated outcomes have occurred. This
  includes an explanation of the outcome and its
  effects, provided in a timely, truthful and
  compassionate manner.

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Patient-Centered Care (examples)

• Foundation for Accountability
• Oregon Medical Association Workshops on Health
  Literacy
• Communication of Unanticipated Adverse Outcomes

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Patient-centered care (example)

• Foundation for Accountability (FACCT)
• Mission to improve health care for Americans by
  advocating for an accountable and accessible
  system where consumers are partners in their care
• Patient Power Network support policies and
  actions that promote quality, improve customer
  service and reduce mistakes in medical care

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Patient-centered care (example)

• Oregon Medical Association workshops on Health
  Literacy
• Functional illiteracy prevalence high
• Inability to read instructions on use of
  medication and treatment course contributes to
  unwitting errors on the part of the patient

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Patient-centered care (example)

• Patient Communication
• Communication of Unanticipated Adverse Outcomes
  and Medical Error
• Workshops through the OMA, Physician and
  Affiliated Clinician CME, Hospitals, The
  Foundation for Medical Excellence

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Opportunities and Challenges

• Research
• Most clear successes of translating research
  into practice have focused on under use of
  effective treatments there has been less focus
  on misuse or overuse
• Carolyn Clancy M.D. AHRQ

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Opportunities and Challenges

• Current Research
• The Effect of Healthcare Working Conditions on
  Patient Safety
• How do we build multi-institutional and
  interdisciplinary research programs to improve
  patient safety?
• How do we improve medication safety in long term
  care environment?

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Opportunities and Challenges

• Current Research (continued)
• How do we improve Medication Safety in the
  outpatient arena?
• Decision Science Research Institute How do
  Consumers View the Risk of Medical Errors?
• How do we detect medication prescribing errors in
  the ambulatory setting?

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Opportunities and Challenges

• Current Research (continued)
• Making Sure in Cardiac Care Describe and
  understand the human and technological processes
  used in cardiac care to assure safety

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Opportunities and Challenges

• Will public reporting lead to improvements in
  patient outcome?
• Which standards and processes are the best to
  improve patient safety?
• Who decides on the legitimacy of standards?
• How do we pay for it?

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Opportunities and Challenges

• How do we create a transparent, non punitive
  reporting system in the setting of our current
  punitive (and unfair) malpractice environment?
  

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Opportunities and Challenges

• What does quality health care mean?
• Does safe care mean access to care?

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• Human performance will never be perfect.
• Keep inevitable mistakes from becoming
  consequential

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Structuring the Conversation on System Change

• Culture is critical
• Change from bottom up
• Top down will result in rejection

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Discussion