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

• Look-alike, sound-alike drugs
• Kreutzfeldt-Jakob disease
• Medical gas mix-ups
• Needles sharps injuries
• Dangerous abbreviations
• Wrong-site surgery 2
• Ventilator-related events
• Delays in treatment
• Bed rail deaths injuries
• Nosocomial infections
• Surgical fires
• Perinatal deaths
• Anesthesia awareness
• Kernicterus 2
• PCA by proxy
• Intrathecal vincristine
• Wrong route / wrong tube
• Medication reconciliation
• 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
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Alternatives Approaches to the NPSGs
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2005 National Patient Safety Goals

• Patient identification
• Communication among caregivers
• Medication safety
• Wrong-site surgery
• Infusion pumps
• Clinical alarm systems
• Health care-associated infections
• Reconciliation of medications
• Patient falls
• Flu pneumonia immunization
• Surgical fires
• NPSG implementation by network components

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2006 National Patient Safety Goals

• Patient identification
• Communication among caregivers
• Medication safety
• Wrong-site surgery Universal Protocol
• Infusion pumps
• Clinical alarm systems
• Health care-associated infections
• Reconciliation of medications
• Patient falls
• Flu pneumonia immunization
• Surgical fires
• NPSG implementation by network components
• Patient involvement
• 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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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