Patient Safety Priorities

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• 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

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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

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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?

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Overview

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

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Current Landscape Patient Safety Activities
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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)

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Current Landscape Patient Safety Activities
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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

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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

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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)

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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)

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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