Safety Data for Safer Care: From Knowing to Doing Carolyn M. Clancy, MD Director 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 technology Other safety initiatives Future directions More Medical Errors in U.S. Any medical mistake/error or test error in last 2 years 50% 34% 30% 25% 27% 25% 23% 22% UK GER NZ AUS CAN US 0% “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 50% 31% 33% 27% 28% 25% 23% 14% GER AUS UK CAN NZ US 0% “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 50% 25% 20% 15% 16% 17% 14% 10% GER US NZ CAN UK AUS 0% “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 portfolio The growing role of health information technology Other safety initiatives Future directions 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 Patient Safety Net “One-stop” portal of resources for improving patient safety and preventing medical errors Information on patient safety resources, tools, conferences, http://psnet.ahrq.gov and more Customize the site by creating “My PSNet” page Web M&M Morbidity and Mortality website identifies problem areas and potential solutions Shares new cases and expert commentaries http://webmm.ahrq.gov 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 reports 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 technology 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 providers – 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 patients Safety Data for Safer Care Safety in numbers AHRQ’s safety portfolio The growing role of health information technology 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 2010) • 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 results) 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 confidential Network of Patient Safety Databases Interactive evidence-based management resource 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 injuries 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 evaluation - 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 process P4P and Patient Safety Pay for ‘safety enhancing activities’ (efforts to promote safety culture; effective implementation of HIT) NO or decreased payments for harmful care Prerequisite: capacity for seamless electronic reporting of performance measures and adverse events Is health care getting safer? No Is health care getting safer? No Yes Is health care getting safer? No Yes X Yes, but we need more and better data, and we need to build our partnerships as we build the evidence base Your questions?
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