Safety Data for Safer Care: From Knowing to Doing by 9LJ3d5l


									    Safety Data for Safer Care:
     From Knowing to Doing
            Carolyn M. Clancy, MD
U.S. Agency for Healthcare Research and Quality
1st OECD Health Care Quality Indicators Seminar
    On Improving Patient Safety Data Systems
         Dublin, Ireland -- June 30, 2006
Safety Data for Safer Care

           Safety in numbers
           AHRQ’s safety portfolio
           The growing role of
            health information
           Other safety initiatives
           Future directions
                More Medical Errors in U.S.

      Any medical mistake/error or test error in last 2 years


                                   25%        27%
25%                    23%

            UK         GER         NZ         AUS        CAN         US
                  “Taking the Pulse of Health care Systems”
  Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05
                Failure to Discuss Medications

% of patients who said prior medications were not reviewed at discharge


                                                           31%         33%
                                     27%        28%
 25%                     23%

             GER         AUS         UK        CAN          NZ         US
                    “Taking the Pulse of Health care Systems”
    Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05
                 Hospital/ER Readmissions

      % of patients readmitted as a result of complications


25%                                                                  20%
                                   15%        16%         17%

           GER          US         NZ        CAN          UK        AUS
                  “Taking the Pulse of Health care Systems”
  Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05
 18-month voluntary effort
 Over 3,000 U.S. hospitals representing 75% of
  all U.S. hospital beds
 122,342 lives saved – a HUGE milestone
 Many millions more lives changed as we build
  momentum for continuous improvement of
  patient safety
Safety Data for Safer Care

           Safety in numbers
           AHRQ’s safety
           The growing role of
            health information
           Other safety initiatives
           Future directions
     AHRQ and Patient Safety

 Identify medical errors and other threats
  to patient safety and understand why they
 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
            Patient Safety Net
                         “One-stop” portal of
                          resources for
                          improving patient
                          safety and preventing
                          medical errors
                         Information on patient
                          safety resources,
                          tools, conferences,     and more
                         Customize the site by
                          creating “My PSNet”
                 Web M&M
                         Morbidity and
                          Mortality website
                          identifies problem
                          areas and potential
                         Shares new cases
                          and expert
                         Monthly spotlight
                          case with slide set
                         28,000 visitors/mo.
 Hospital Survey on
Patient Safety Culture

      Helps hospitals and health
       systems evaluate employee
       attitudes about patient
       safety in their facilities or
       specific units
      Includes survey guide,
       survey, and feedback report
       template to customize
      AHRQ partnership with
       Premier, Inc., Department of
       Defense, and American
       Hospital Association
We’re Educating Patients, Too
New Public Awareness Ads

    Maybe I should have told
    my doctor about all the
    medications I was taking...
Safety Data for Safer Care

           Safety in numbers
           AHRQ’s safety portfolio
           The growing role of
            health information
           Other safety initiatives
           Future directions
HIT and Safety: Lessons

      The “T” in HIT isn’t just for
       Technology -- it also needs
       to include:
        Tools
        Teamwork
        Trust
      Evidence is important, but
      Evidence isn’t everything –
       we also need VISION!
 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
     How Do We Measure Success?

 Long term goals of the Quality/
  Safety/Health IT Portfolios
  – Improve medication safety
  – Improved decision-making for patients and
  – Improve high-risk transitions in care
       Health IT Research Funding

 Over 100 grants to
  hospitals, providers, and
  health care systems to
  promote access to health
  information technology
 Projects in over 40 states
 Special attention to best
  practices that can improve    AHRQ HIT
  quality of care in rural,    Investment:
  small community, safety
  net and community health     $166 Million
  center care settings
          Meds Safety and Health IT

 Maximize the effectiveness of e- prescribing
  between physicians and community pharmacies
 Use patient-centered medication information
  systems for frail elders
 Integrate prescribing tools with decision support
  (checking dosage, contraindications, and drug
  interactions) into provider practice
 Implement decision support functions, including
  the influence of weight based dosing on
  pediatric adverse drug events
       Warfarin Interaction Alert

                          Blood thinner warfarin is
Safety                     one of top 15 most
alert!                     prescribed drugs in U.S.
                          In AHRQ-supported study,
                           doctors using computerized
                           alert system ordered 15
                           percent fewer prescriptions
                           for drugs that can interact
                           with warfarin

AC Feldstein et al, Archives of Internal Medicine, May 8, 2006
      AHRQ's Ambulatory Patient
          Safety Program
 Five year goal: measurably improving the
  safety and quality of care for patients in
  ambulatory environments
 Develop, deploy and evaluate ambulatory
  health IT systems – focus on both
  technology and system solutions
 Rapid research in AHRQ’s real-world
  research networks
   – What is the relationship between health IT, safety
     and quality (including efficiency)?
   – How can we derive the greatest benefit - - clinical
     and financial – from health IT investments? from
     patient safety investments?
   – How can we move what we know works into wide-
     scale practice?
        What is the rationale for a
       focus on ambulatory care?
 Health care services continue to shift into the
  ambulatory arena
 Ambulatory care and transitions in care are
  high-risk for patient safety
 Patient safety research and improvement has
  focused on hospitals
 Ambulatory care requires:
   – Complex information management
   – Coordination of care for chronically ill and elderly
Safety Data for Safer Care

           Safety in numbers
           AHRQ’s safety portfolio
           The growing role of
            health information
           Other safety initiatives
           Future directions
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
 • Is completely voluntary
 • Would be impossible without health
   IT backbone
               PSO Objectives

 To generate information relevant to preventing
  harm to patients from health care
    (aggregate/analyze incident data; disseminate
   To employ interoperable terms, definitions of
    patient safety incidents
   To simplify task of reporting incidents
   To provide benchmarking & trend reports
   To share de-identified data for use in
    improving patient safety
       Solving a Safety Data Problem

 U.S.providers fear that patient safety analyses
  can be used against them in court or in
  disciplinary proceedings
 State laws offer inadequate protection (e.g.,
  large providers cannot share analyses
  system-wide without risk)
 Patient safety improvement is hampered by
  the inability to aggregate data; by analyzing
  large numbers of events, patterns of failures
  could be more rapidly identified
            PSO Activities

 Conducts efforts to improve patient safety
  and 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
        Network of Patient Safety
 Interactive evidence-based management
 Capacity to accept, aggregate, & analyze non-
  identifiable data voluntarily reported by PSOs,
  providers, & others
 Data to be used to analyze national & regional
  statistics, including trends & patterns of health
  care errors
 Information to be made public & reported
  annually (in AHRQ’s National Healthcare
  Quality Report)
                  Next Steps

 Develop & publish proposed rules governing
  operations of PSOs
 Finish inventory of data elements, definitions
  & encoding schemes
 Consider options for fostering development of
  a network of patient safety databases
 Plan for inclusion of patient safety information
  on performance, trends AHRQ’s NHQR/DR
      Targeted Injury Detection System

 AHRQ’s ACTION Network is supporting three
  studies to develop and implement targeted
  injury detection systems to reduce inpatient
 Addresses adverse drug events, hospital
  acquired infection and pressure ulcers/injuries
 Systems will be designed for deployment
  deploy in large urban hospitals and small rural
  hospitals across U.S.
 Will be compatible with diverse electronic
  health record systems
Systems-level Error-Proofing

          Rapid-cycle learning from
           lean manufacturing
           systems, e.g. Toyota
           production system
          High Reliability
           Organization (HRO)
           systems can be adapted
           into hospital settings, e.g.
           airline safety systems
          Empowered employees
           and committed leadership
           are keys to success
               “Fail Safe” Hospitals
 Organizational infrastructure:
   - certified patient safety officer as part of line management;
   - Culture of Safety (organization-wide training; rewards for reporting;
       transparency; etc.)
 Measurement infrastructure:
   - AHRQ-standard concurrent and retrospective trigger systems
   - Culture of Safety-based voluntary reporting system
   - certified pharmacist (or equivalent) performing real-time ADE
   - certified chart reviewers (random sample or full census)
   - participates (sends data) to central (AHRQ) data repository
   - external audits of injury detection data systems
 Implemented safe practices:
   - NQF / AHRQ evidence-based safe practices (~30, at present)
   - IHI 100,000 Lives campaign
           Improving Patient Safety Through
                 Simulation Research

                       New AHRQ RFA for
                        research / evaluation of
                        simulation and the
                        roles it can play in
                        improving safe delivery
                        of care
                       Total amount of $2.4
                        million to fund 8-10
                        new grants
                       First projects to start
                        this fall
AHRQ RFA-HS-06-030
Safer Hospitals by Design

            U.S. hospital building
             boom - $23 billion
             spent in 2005 alone
            Creates opportunity to
             design safer hospitals
             and incorporate
             Health IT
            Small but growing
             body of research can
             help inform planning
             and construction
P4P and Patient Safety

        Pay for ‘safety enhancing
         activities’ (efforts to
         promote safety culture;
         effective implementation of
        NO or decreased payments
         for harmful care
        Prerequisite: capacity for
         seamless electronic
         reporting of performance
         measures and adverse
Is health care getting safer?

Is health care getting safer?


Is health care getting safer?



 X    Yes, but we need more
      and better data, and we
      need to build our
      partnerships as we build
      the evidence base
Your questions?

To top