Carolyn M. Clancy, MD Director Agency for Healthcare

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Initiatives to Improve Quality and Safety in
Health Care
Carolyn M. Clancy, MD Director Agency for
Healthcare Research and Quality 5th Annual
Colorado Patient Safety Conference November 11,
2005
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Medical Errors in History

• In my opinion, physicians kill as many people as
  we generals.
• -- Napoleon Bonaparte
• The physician can bury his mistakes, but the
  architect can only advise his client to plant
  vines.
• -- Frank Lloyd Wright, New York Times, 1953

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Patient Safety Initiatives

• To Err Is Human - 6 years later
• AHRQ role and resources
• Where we are today
• Federal initiatives
• Safety in numbers collaboration and
  communication

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To Err Is Human

• Landmark 1999 Institute of Medicine report
  elevated national awareness on issue of patient
  safety
• Two key conclusions --
• Traditional name, blame and shame response
  ineffective in improving safety
• Safe, high quality care requires a team effort
  and significant communication and collaboration

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Progress Since 1999

• Regulation JCAHO safe practices
  standardization of practices A-
• Workforce and Training PSIC maintenance of
  certification leadership training B
• Error Reporting Systems C
• Information Technology B-
• Malpractice D
• R Wachter. The end of the beginning patient
  safety five years after To Err is Human. Health
  Affair 2004 W4 534-545.

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More Medical Errors in U.S.
Any medical mistake, medical error or test error
in last 2 years
2005 Commonwealth Fund International Health
Policy Survey
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Incorrect Lab/Diagnostic Test
or Delay in Receiving Abnormal Test Result, Past
2 years
Percent reporting either lab test error
2005 Commonwealth Fund International Health
Policy Survey
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Mistake/Medication Error/Lab Error
By Number of Doctors Seen in Past 2 Years
Percent
2005 Commonwealth Fund International Health
Policy Survey
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AHRQ Research Study Critical Care Safety

• Major Finding Patients face a significant risk
  for preventable adverse events and serious
  medical errors in hospital critical care units
• In a study of patients admitted to intensive care
  units
• 20 had an adverse event
• 45 of the adverse events were
  preventable
• Over 90 of incidents occurred
  during routine care

JM Rothschild, CP Landrigan, JW Cronin, et al.,
The critical care safety study the incidence and
nature of adverse events and serious medical
errors in intensive care, Critical Care Medicine.
33(8)1694-1700, August 2005.
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Medical Errors and Nurse Fatigue

• Patients are more at risk when nurses work
  long hours. A tired nurse is more likely to miss
  subtle changes, have more difficulties
  concentrating, and may not catch their own or
  others errors.
• Ann Rogers, Ph.D. R.N.
• University of Pennsylvania

AHRQ-funded grant HS11963
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ICU Infections Down Nearly 80

• Keystone initiative significantly reduced
  infections at 77 Michigan hospitals
• Simple interventions hand washing reminders and
  elevating a patients head while on a ventilator
• Project so successful that 68 ICUs had no
  infections or ventilator-associated pneumonias
  during the 18 months of the project

AHRQ-supported Pronovost study, 10/05
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Colorado Physician and Public Agreement on
Medical Errors
Source Robinson AR, et al., Arch Intern Med,
2002 1622186-2190
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Major Themes Identified at National Research
Summit

• Epidemiology of Errors
• Infrastructure to Improve Patient Safety
• Information Systems
• Knowing Which Interventions Should Be Adopted
• Facilitating the Implementation of What is Shown
  to Work in Improving Safety
• Disseminating Information to Clinicians,
  Policymakers, Patients, and Others

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Patient Safety Initiatives

• To Err Is Human - 6 years later
• AHRQ role and resources
• Where we are today
• Federal initiatives
• Safety in numbers collaboration and
  communication

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AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
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HHS Organizational Focus
NIH Biomedical research to prevent, diagnose and
treat diseases
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HHS Organizational Focus
NIH Biomedical research to prevent, diagnose and
treat diseases
CDC Population health and the role of
community-based interventions to improve health
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HHS Organizational Focus
NIH Biomedical research to prevent, diagnose and
treat diseases
CDC Population health and the role of
community-based interventions to improve health
AHRQ Long-term and system-wide improvement of
health care quality and effectiveness
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AHRQ and Patient Safety

• Identify medical errors and other threats to
  patient safety and understand why they occur
• Advance knowledge of practices that will reduce
  or eliminate the occurrence of medical errors and
  minimize risk of patient harm
• Develop, assemble and disseminate information on
  how to implement best practices for patient
  safety
• Enable providers to monitor and evaluate threats
  to patient safety and the progress being made

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Safety Research Training

• Funded over 225 patient safety and related health
  information technology projects since 2001
• Awarded over 8 million in funding for 15
  Partnerships in Implementing Safety
• Patient Safety Improvement Corps
• New curriculum under development by AHRQ,
  Department of Defense, CMS and Quality
  Improvement Organizations

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Advances in Patient Safety From Research to
Implementation

• Four-volume set of 140 peer-reviewed articles
  representing an overview of patient safety studies

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Advances in Patient Safety
Volume One

• Focuses on research that demonstrates solid,
  broad and rapid progress
• Includes articles on state-of-the-art detection
  and tracking systems
• Examines interventions that address adverse drug
  events
• Explores building a culture of safety

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Advances in Patient Safety
Volume Two

• Covers concepts and examines complex systems of
  care
• Shows how providers can move past the name, blame
  and shame approach to improving safety by
  focusing on system improvement and human factors

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Advances in Patient Safety
Volume Three

• Covers implementation issues and identifies
  barriers to diffusion of patient safety
  improvements and approaches to changing cultures
• Implementation issues are where its at for
  patient safety -- Lucian Leape

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Advances in Patient Safety
Volume Four

• Showcases programs and products, screening tools
  and process simulators
• Provides details on how to overcome barriers to
  success
• Not just the tools but in many cases the
  equivalent of an instruction manual Mary
  Wakefield

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AHRQs Patient Safety Network (PSNet) on the Web

• PSNet is a national one-stop portal of
  resources for improving patient safety and
  preventing medical errors
• Offers wide variety of information on patient
  safety resources, tools, conferences, and more
• Diverse users can customize the site around their
  unique interests and needs by creating a My
  PSNet page
• Website http//psnet.ahrq.gov

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AHRQ Web MM

• AHRQ Morbidity and Mortality website Identifies
  problem areas and potential solutions
• Shares new cases and expert commentaries
• Monthly spotlight case with educational slide set
• Over 28,000 visitors per month
• Website http//webmm.ahrq.gov

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Hospital Survey on Patient Safety Culture

• New tool helps hospitals and health systems
  evaluate employee attitudes about patient safety
  in their facilities or within specific units
• Includes survey guide, survey, and feedback
  report template to customize reports
• AHRQ partnership with Premier, Inc., Department
  of Defense, and American Hospital Association

• www.ahrq.gov/qual/hospculture/ or e-mail
  hrqpubs_at_ahrq.gov

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Educating Patients, Too
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Patient Safety Initiatives

• To Err Is Human - 6 years later
• AHRQ role and resources
• Where we are today
• Federal initiatives
• Safety in numbers collaboration and
  communication

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Where We Are Today

• Substantial momentum and activity
• New legislation that eliminates strong
  disincentives to improving patient safety
• Continued public interest
• Weak business case
• Impossible to know whether safety has improved
  or not
• Is the time right to shift from research and
  voluntary action to bold goals?

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Reporting and Surveillance Systems
Active Reporting Systems
Indicators From Administrative Data
Medical Record Monitoring Systems
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Physicians Identified Barriers to Successful
Error Reduction

• Difficulty in defining errors
• More training in handling errors
• Who should report errors and have access to
  results
• Fear of malpractice litigation
• Need for greater legal safeguards

Source Robinson AR, et al., Arch Intern Med,
2002 1622186-2190
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Where We Are Today

• Implementing patient safety legislation
• Requires detailed assessment of existing
  measurement systems
• Bill includes mandate for GAO evaluation in 2010
• New opportunities for improving safety
• MMA ? increased focus on medication safety
• Ambulatory care urgent need to decrease errors
  due to poor coordination

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Possible Goals

• Reduce medication errors by 50
• Reduce high-harm errors by 90
• Reduce nosocomial infections
• Reduce errors due to lost tests, results by 50
• Others

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Next Steps

• Identify candidate measures and data sources
• Review of existing measures
• Errors, harms, and/or safe practices?
• Broad public call
• Establish baselines
• Collaborate with stakeholders
• Partnership with NQF

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Patient Safety Initiatives

• To Err Is Human - 6 years later
• AHRQ role and resources
• Where we are today
• Federal initiatives
• Safety in numbers collaboration and
  communication

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AHRQ Health IT Research

• Promote access to Health IT
• Over 166 million investment to date
• Over 100 grants to communities, hospitals,
  providers, and health care systems to help in all
  phases of the development and use of Health IT
• Grants spread across 43 states
• Special focus on small and rural hospitals and
  communities.

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Health IT Opportunities

• Reengineer processes to improve patient
  safety
• As we migrate to a health IT infrastructure, put
  effective processes in place as the same time
• Augment health IT applications for error
  reduction, CPOE and other decision support tools
• Build in the necessary disciplines and team
  approaches

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Health IT and Patient Safety
Key challenges

• Tap and collect ongoing resources
• Convince clinicians to buy in
• Understand existing workflow
• Understand HIT impact on workflow
• Data standards/integration
• Get vendors to make needed changes

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Building HIT Evidence Base

• Electronic Health Records
• Clinical Decision Support
• Electronic Prescribing
• Use of hand-held devices
• AHRQ National Resource Center on Health
  Information Technology

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HIT, Quality and Safety

• Outpatient Advanced CPOE and EMR
• Avoid 2.1 million adverse drug events
• Inpatient CPOE and EMR
• Decrease serious medication errors by 55
• Healthcare information exchange and
  interoperability between settings
• Improve decision-making at the point-of- care
  through complete information access

Source CITL
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AHRQ Research Study CPOE

• Major Finding While computerized physician order
  entry (CPOE) is expected to significantly reduce
  medication errors, systems must be implemented
  thoughtfully to avoid facilitating certain types
  of errors
• Study looked at clinicians experience in using
  one CPOE system at a major urban teaching
  hospital
• Implementation problems can be minimized through
  testing before products are marketed and through
  adaptation to meet the needs of individual
  clinical settings

R. Koppel, J. Metlay, A. Cohen, et al., Role of
computerized physician order entry systems in
facilitating medication errors, Journal of the
American Medical Association, March 9, 2005
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E-Prescribing Standards

• Contracts administered by AHRQ on behalf of
  Centers for Medicaid and Medicare Services
• Pilot testing of electronic prescribing standards
  and how they interact with e-prescribing workflow
• Testing will be conducted during 2006
• Results will be reported to Congress in 2007 and
  used to develop final e-prescribing standards

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Low Health IT Adoption Rate

• Only 14.1 percent of all medical group practices
  use an electronic health record
• Only 12.5 percent of practices with five or fewer
  FTE physicians have EHRs

AHRQ contract 290-00-0017 University of
Minnesota
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Patient Safety Act of 2005

• Creates Patient Safety Organizations (PSOs)
• Establishes Network of Patient Safety Databases
• Mandates Comptroller General to study
  effectiveness of Act (by 2010)
• Is completely voluntary

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Legislation Goals

• Encourage providers to identify correct medical
  errors threats to patient safety by ensuring
  that their work with PSOs cannot be used against
  them in courts or in disciplinary proceedings
• Encourage aggregation of cases by among PSOs,
  creating a network of patient safety databases

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Patient Safety Organization

• Private or public entity
• Meets PSO criteria complies with
  policies/procedures
• Self-certifies initially every 3 years
  thereafter
• Certification is accepted by Secretary or not
  may be revoked

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PSO Criteria

• Mission to improve quality safety
• Has appropriately qualified staff
• Within 24 months of listing, has contracts with
  more than 1 provider
• Is not part of a health insurer
• Collects data in standardized manner
• Uses work product to provide feedback
  assistance minimize patient risk

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PSO Activities

• Conducts efforts to improve patient safety
  quality
• Collects analyzes data, reports, records, root
  cause analyses
• Develops/disseminates information to improve
  patient safety
• Encourages culture of patient safety
• Maintains procedures to keep work product
  confidential

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Patient Safety Databases

• Interactive evidence-based management resource
• Capacity to accept, aggregate, analyze
  voluntarily reported non-identifiable data
• Data to be used to analyze national regional
  statistics, including trends patterns of health
  care errors
• Information to be reported annually (National
  Healthcare Quality Report)

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Patient Safety Initiatives

• To Err Is Human - 6 years later
• AHRQ role and resources
• Evidence of progress
• Federal priorities
• Safety in numbers collaboration and
  communication

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• 2,600 hospitals implementing changes in care
  proven to prevent avoidable deaths
• Interventions include rapid response teams,
  evidence-based care for acute myocardial
  infarction, and prevention of adverse drug
  events, central line infections, surgical site
  infections and ventilator-associated pneumonia

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SCIP Collaboration

• Surgical Care Improvement Program (SCIP)
• Collaboration between AHRQ, Centers for Medicare
  Medicaid Services, the Centers for Disease
  Control and many private sector partners
• Initiative designed to eliminate surgical
  complications such as postoperative pneumonia and
  surgical site infections

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On the Road to Safety
Have you ever noticed....anybody going slower
than you is an idiot, and anyone going faster
than you is a maniac? George Carlin
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Your questions?