Influencing Healthcare - Safety and Measurement

8/12/2019 Influencing Healthcare - Safety and Measurement

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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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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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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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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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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

Influencing Healthcare - Safety and Measurement

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