hospital harm index presentation to maps exploratory work group for tracking safety progress april...
TRANSCRIPT
Hospital Harm Index
Presentation to MAPS Exploratory Work Group for Tracking Safety Progress
April 10, 2013
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November 30, 1999:
The Institute of Medicine
Committee on Quality of Health Care in America
announces its first report:
To Err is Human: Building a Safer Health System
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Care-associated injuries in hospitals
account for
44,000 – 98,000 preventable deaths per year
in the United States
More people die from hospital-based preventable medical injuries than from breast cancer or AIDS or motor vehicle accidents
Brennan et al. New Engl J Med 1991
Thomas et al. 1999
Injuries drive direct health care costs totaling
$9 – 15 billion per yearThomas et al. 1999
Johnson et al. 1992
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Key Findings in IOM report:
• Injuries occur because of system failures
• Preventing injuries means designing safer systems of care
• Organizations, not individual physicians and nurses, control those systems of care
Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine , 2000.
Harm Index• Harm Index was developed to provide a
single value that reflects the priority focus adverse events.
• The measurement shows the variance from expected, displayed as a single composite.
• Expected events are goal values, based on historical performance and targets
• Harm Index = Actual Events – Expected Events
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Priority Focus Adverse Events
• Inpatient Falls With Harm• Clostridium difficile (C-Diff)• Cent. Line Assoc. Blood Stream Infection
(CLABSI)• Catheter Assoc. Urinary Tract Infections
(CAUTI)• Wrong Site Surgery/Procedure• Pressure Ulcers
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Harm Index Calculations – Hospital Level
Allina Health Hospital January 2013 Hospital Level
Falls Goal = 0.76 Harmful Falls / 1,000 Patient Days
0.76
Inpatient Days 15,096Expected Falls Based on Days(0.76 x (15,096 /1,000)) = 11.5
11.5
Actual Harmful Falls Jan 2013 9Lives Positively Affected (Harm Index) 2.5
The following table shows actual January 2013 results, of the harm index calculation for falls for a single Allina Health Hospital.
Harm Index Calculations – Hospital Level
• Clostridium difficile • Reduce CDI run rate from 8.72 per 10,000 patient
days to 7.2 CDI per 10,000 patient days.• Utilizes the same basic calculation as falls• (Actual C. diff Patients - (Goal x (Days / 10,000)))
• Catheter Assoc. Urinary Tract Infection • Reduce CAUTI pooled rate to 3.0 per 1,000
catheter days in specific areas.• (Actual CAUTI Pts – (Goal x (Cath Day / 1,000)))
Harm Index Calculations – Hospital Level• Wrong Site Surgery
• Achieve absolute zero• (Actual Wrong Site Patients – 0 Expected)
• Pressure Ulcer• Reduce reportable pressure ulcers• Number of reportable PU <= 10 annually• (Actual Reportable PU – 10 Expected)
• Central Line Assoc. Blood Stream Infections • Reduce to 25th percentile of national rate• Number of CLABSI <= 4 annually• (Actual CLABSI Patients – 4 Expected)
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Other Patient Safety Indicators
1. Hand Hygiene Compliance
2. # PVSRs Reported (Voluntary Incident
Reporting System)
3. Effective Opioid Management (Clinics)
In Addition:
4. 3 Years of AHRQ Patient Safety Culture Survey (Hospitals)
5. 2 Years of AHRQ Patient Safety Culture Survey (Clinics)