influencing healthcare - safety and measurement
TRANSCRIPT
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Influencing Health Care:
Safety & Measurement
Peter Angood MD FACS FCCM
Vice President & Chief Patient Safety OfficerJoint Commission (JCAHO)
Chief Patient Safety Officer & Co-Director
Joint Commission International Center forPatient Safety
Chicago, USA
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> 5 Years After The IOM Report:
To 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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Mission:
To continuously improve the safety andquality of care provided to the publicthrough the provision of health careaccreditation and related services thatsupport performance improvement in healthcare organizations.
Free-standing not-for-profit organizationwith deemed status by federal Center forMedicare and Medicaid Services (CMS)
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
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To continuously improve the
safety and quality of care
The Joint Commission on Accreditation of Healthcare Organizations
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~ Overlapping Strategies ~
Committed to continuallyenhance the value of itsaccreditation and certification
programs.
The Joint Commission will strive toensure that they are patient-centered,
data-driven, relevant, and integral tothe performance improvement activitiesof 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.
Ambulatory Care 1,234
Assisted Living 72
Behavioral Health Care 1,821
Critical Access Hospitals 268
Home Care 3,422Hospitals 4,342
Laboratory 1,947
Long Term Care 1,364
Networks 21
Office Based Surgery 221
Total 14,712
Accredited Programs
Disease-Specific Care 229
Health Care Staffing 70
Total 299
Certified Programs
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 validand reliable performance
measures.
These measures are needed to supporta credible, data-driven accreditation
process and the publication ofmeaningful comparative performanceinformation for the public.
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Requirements that defineperformance expectations with
respect to structure, process, and
outcomes that must be substantiallyin place in an organization to
enhance the safety and quality for
patient care
Performance Measurement Data
Adverse Event Reporting
Standards
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Core Measure Identification Process
Library of hospital priority measurement areas
Acute myocardial infarction (implemented2002)
Heart failure (implemented 2002)
Community acquired pneumonia (implemented2002)
Pregnancy and related conditions(implemented 2002)
Surgical infection prevention (ImplementedJuly 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 andaccreditation
Alignment with Hospital Quality Alliance(HQA-2003) & National Quality Forum (NQF-1999) important
Accreditation:
contractual agreement to collect on 3measure sets
AMI, CHF, Pneumonia, SIP or Pregnancy& Related Conditions
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~ Overlapping Strategies ~
Committed to making patientsafety an imperative in allaccredited organizations.
This will be accomplished through thestandards and policies of the JointCommission and through collaboration
with other patient safety leadershiporganizations.
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Sentinel Event Policy
Established in January 1996:
To have a positive impact in improvingcare
To focus attention on underlyingcauses and risk reduction
To increase the general knowledge
about sentinel events, their causes andprevention
To maintain public confidence in theaccreditation process
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Percent of 3231 events
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Sentinel Event A lerts
1. Potassium chloride2. Policy issues
3. Policy issues4. Policy issues5. Policy issues6. Wrong site surgery7. Suicide8. Restraint deaths
9. Infant abductions10. Transfusion errors11. High Alert Medications12. Op/post-op
complications13. Impact of SE Alert14. Fatal falls15. Infusion pumps16. Proactive risk reduction17. Home fires (O2 therapy)18. Kernicterus
19. Look-alike, sound-alikedrugs
20. Kreutzfeldt-Jakob disease21. Medical gas mix-ups22. Needles & sharps injuries23. Dangerous abbreviations24. Wrong-site surgery #225. Ventilator-related events
26. Delays in treatment27. Bed rail deaths & injuries28. Nosocomial infections29. Surgical fires30. Perinatal deaths31. Anesthesia awareness32. Kernicterus #233. PCA by proxy34. Intrathecal vincristine35. Wrong route / wrong tube36. Medication reconciliation37. Device Connections
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National Patient Safety Goals
Selection of the Goals andrequirements is guided by a panel ofexperts:
Sentinel Event Advisory Group
Each year, a set of Goals & theirRequirements are identified from avariety of sources
The Goals and their Requirements are
field reviewed & published by mid-yearfor the coming calendar year
NPSG C li D t f 2003 2006
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NPSG Compliance Data for 20032006NPSG 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-alikedrugs
--- ---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 NPSGsNPSG 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 06b: 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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1. Patient identification
2. Communication among caregivers3. 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 fires12. NPSG implementation by network
components
13. Patient involvement
14. Pressure ulcers
2006 National Patient Safety Goals
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Provisions of the Universal Protocol
Preoperative verification process
Relevant pre-op tasks completed andinformation 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 the
National Patient Safety Goals
Must implement all applicable Goals &Requirements or implement anacceptable alternative(s)
Evaluated in the PPR and during all full
accreditation surveys and for-causesurveys
Surveyors evaluate actual performance,not just intent
Failure to comply with one or morerequirements of a Goal will result in aRequirement for Improvement
NPSG requirements that are also in thestandards will only be scored once (nodouble jeopardy)
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Aggregate data
Data from 2003 - 2005 surveys postedon Joint Commission web site
Individual health care organizations:
Compliance with specific requirements
Quality Reports - on web site since
2004
Public Disclosure of Compliance
with National Patient Safety Goals
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~ Overlapping Strategies ~
Committed to ensure that theaccreditation process is publiclyaccountable.
The Joint Commission will providemeaningful and useful information aboutthe 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:
PFP Means Across Various Groups of Hospitals -
2004 Studies
299
163190
206
243
348 348
0
50
100
150
200
250
300
350
400
NYCHHC Solucient
Benchmark
Group
US News
Benchmark
Group
Random
Control Group
For Cause
Group
Conditional
Accreditation
Status
Preliminary
Denial of
Acc reditation
Status
Group Name
PFPP
ointTotal
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 selectedmeasures from JCAHO & CMS focusedtowards AMI, CHF & Pneumonia
2004 - Medicare Modernization Act created
formal link to measures and hospitalreimbursement
2005 expanded to all measures andincluded SIP measures set
2007 reported patient experience of caresurvey (H-CAPS) & risk-adjusted measuresfor 30-day mortality of AMI & CHF to begathered by CMS
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Institute of Medicine 2005
Performance Measurementrecommendations includes IOMsstarter set of measures for hospitalperformance that is > HQA measures
2006 - Deficit Reduction Omnibus Actadopts IOM recommendations forinclusion in a new value-basedpurchasing (P4P) framework to beimplemented by 2009
State-based initiatives increasing
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HQA & NQF Changes
Joint Commission remains committed& flexible to evolving performancemeasurement environment
Deficit Reduction Act creates impetus
for HQA & NQF to accelerateexpansion of the array of measures inthe production process: SCIP ICU Measure Set Pediatric Asthma Nursing-Sensitive AHRQ Quality Indicators
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~ Overlapping Strategies ~
Committed to addressingpressing public policy issues thatimpact the quality and safety of
health care. The Joint Commission will convene
thought leaders and subject-matter
experts and will issue public policyrecommendations.
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PU
BLIC
POLICYINITIATIVES
Topics # ofDownloads
Nursing Shortagewhite 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 ManagementThrough 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
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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 hasdemonstrated the ability to prevent ormitigate patient harm stemming fromthe processes of health care
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Measurement Issues
Are outcomes & performancemeasurement feasible?
Can reliable risk adjustment beperformed for patient & providers?
How to overcome cultural variability &resistance to reporting?
Cult of the RCT phenomenon
Development of measures is not enoughfor 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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Physic ian Engagement in Safety