Influencing Health Care: Safety

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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

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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
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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)

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To continuously improve the safety and quality
of care
INFORMATION
PUBLIC POLICY
MEASUREMENT
ACCREDITATION
PATIENT SAFETY
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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.

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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
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Safety and Regulatory Issues

• Persistent Accreditation Issues
• Precision of standards
• Consistency of surveyors
• Perceptions of relevance
• Intermittent nature of process
• Shared Visions, New Pathways

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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.

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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

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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)

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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

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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.

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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

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Percent of 3231 events
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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

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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

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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
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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
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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

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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

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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

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Wrong-site Surgeries
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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)

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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

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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.

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WWW.QualityCheck.org
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SIP Measure Reporting
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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
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Strategic Surveillance System - Release 1.0
(Corporate Dashboard View by Measure Set)
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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

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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

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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

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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.

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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
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Joint Commission InternationalCenter for Patient
Safety

• Partnering for Solutions in Systems Improvement

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• Collaboration Partnering
• Patient Safety Solutions
• Information Distribution
• Educational Programs
• Patient Safety Research
• Public Policy-Advocacy
• Patient Safety Legislation
• Patient Safety Organizations

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• 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

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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!

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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

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What Is On The Radar Screen?
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Physician Engagement in Safety