Patient Safety Awareness WeekPatient Safety Is a Public Health Issue

Jeff Brady, MD, MPH, Director, Center for Quality Improvement and Patient Safety

Agency for Healthcare Research and Quality (AHRQ), Rear Admiral, U.S. Public Health Service

Patrick Conway, MD, Deputy Administrator for Innovation & Quality, Chief Medical Officer,

Centers for Medicare and Medicaid Services

CAPT Arjun Srinivasan, MD, Associate Director for Healthcare Associated Infection Prevention

Programs, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention

Tejal K. Gandhi, MD, MPH, CPPS, President and CEO, National Patient Safety Foundation

President and CEO, NPSF Lucian Leape Institute

Thursday, March 17, 2017

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Patient Safety Awareness Week Is Here

Thank you for the work that you do!

Everyone in the health care process plays a role in delivering safe care

We are all united in the goal of keeping patients and those who care for them free from harm

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Patient Safety Is a Public Health Issue

Learn more.

Download the full PDF report for free at:

www.npsf.org/free-from-harm

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Patient Safety Is a Public Health Issue

Harms caused during care involve

– Significant mortality and morbidity

– Quality of life implications

– Adversely affect patients in every care setting

Not unlike obesity, airplane motor vehicle crashes, breast cancer and other public health imperatives

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Magnitude of Harm is Significant As many as 440,000 patient deaths annually

(James 2013).

~1 in 10 patients develops an adverse event during hospitalization (AHRQ).

~1 in 2 surgeries had a medication error and/or an adverse drug event (Nanji et al. 2015).

>12 million patients each year experience a diagnostic error in outpatient care (Singh et al. 2014).

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Solution Requires United Effort

Work underway at the federal, state and local levels

Some important progress has been made

– Partnership for Patients initiative resulted in ~1.3 million reduction in hospital-acquired conditions from 2011-2013

More work to be done

– Everyone has a role to play in keeping patients safe and free from harm

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We Are All Patients

Spread the Word

Don a gown; snap a pic; and share.

Add hashtags #unitedforpatient

safety #PSAW2016

Don’t forget to link to NPSF!

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CAPT Arjun Srinivasan, MD Associate Director for Healthcare Associated Infection Prevention

ProgramsDivision of Healthcare Quality Promotion

Centers for Disease Control and Prevention

What Is “Public Health?”

• Public health promotes and protects the health of people and the communities where they live, learn, work and play.

– While a doctor treats people who are sick, those of us working in public health try to prevent people from getting sick or injured in the first place.

• We work in close partnership with all stakeholders to get this done.

• We work at the federal, state and local levels.

Source: Trust for America’s Health 10

Approaching Healthcare-associated Infections from the Public Health

Perspective

• We do NOT view healthcare-associated infections as “someone’s fault”

• Nor do we view them as “an inevitable price of medical care”

• We view healthcare-associated infections as failures of a system.

– By making strategic improvements to healthcare delivery processes, we can prevent infections

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Healthcare-associated Infections

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Michigan (103 ICUs)

Prevention of Central Line Associated Blood Stream Infections

0

2

4

6

8

10

0 18

103 ICUs at 67

Michigan

hospitals, 18

months

BSIs

/1

000

ca

thete

r d

ays

Pronovost et al, NEJM 2006

~ 70% prevented13

Prevention Happening; More Needed

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HAI Prevention Strategy

Data

NHSN

Emerging Infections Program

Partnerships

Research

Prevention Epicenters

SHEPheRD

Prevented

Preventable

Prevention approach unknown

HAIs

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A National Program for Preventing Healthcare-associated Infections

Identifying best practices

Education and training

To implement those practices

Measurement

Research

To expand implementation and develop new interventions

National goals

National policies

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Healthcare Infection Control Practices Advisory Committee (HICPAC)

Federal advisory committee that provides guidance regarding:

• Infection Control• Strategies for

Surveillance• Prevention• Control of

healthcare-associated infections

• Antimicrobial Resistance

• Any related events

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• Nation’s leading system to track healthcare-associated infections (HAI), including antibiotic resistance and antibiotic use

• Vital for local, state, and national HAI prevention

• Over 17,000 healthcare facilities enrolled in all 50 states

• Allows targeted prevention

National Healthcare Safety Network (NHSN)

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Prevention Epicenters

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The Next Critical Frontier in Healthcare-associated Infections: Antibiotic Resistance

Many healthcare-associated infections are caused by bacteria that are resistant to the antibiotics we would like to use to treat them

Antibiotic resistance has a major impact on the health of the US

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Combating Antibiotic Resistance

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What Will it Take to Combat Antibiotic Resistance?

Ongoing efforts to prevent infections and the spread of resistant bacteria

Better use of antibiotics

Better tracking of resistance and antibiotic use

Better coordination and collaboration

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A Coordinated Approach

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Jeff Brady, MD, MPHDirector, Center for Quality Improvement and Patient Safety

Agency for Healthcare Research and Quality (AHRQ)Rear Admiral, U.S. Public Health Service

Unprecedented Reductions in Harm

and the Impact of this Improvement

Between 2010 and 2014:

• 17% reduction in rates of hospital-acquired conditions

• Over 2.1 million adverse events and infections averted in hospitals

• 87,000 deaths averted due to reduced adverse hospital events.► ~50,000 lives saved for 2011, 2012, and 2013 combined► ~37,000 lives saved for 2014

• $19.8 billion in health spending savings

* National patient safety efforts save 87,000 lives and nearly $20 billion in 12/1/15 HHS press release: http://www.hhs.gov/about/news/2015/12/01/national-patient-safety-efforts-save-lives-and-costs.html.

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Patient Safety in the United States:

National Progress, but Harm Persists

2010: 145 Harms/1000 Discharges

2011: 142 Harms/1000 Discharges

2012: 132 Harms/1000 Discharges

2013: 121 Harms/1000 Discharges

2014: 121 Harms/1000 Discharges

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Why is it so hard

to make health care safer?

• COMPLEXITY ► Health care delivery is complex (technical, organizational,

administrative, etc.)

• FLAWED SYSTEMS ► Health care systems (at all levels) are not designed to

optimize safety or to address systems-based problems

• INEFFECTIVE COMMUNICATION► Poor Communication is a common contributor to patient

harm

• WEAK INCENTIVES ► The business case for patient safety is inadequate (but

improving)

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How AHRQ Makes a Difference

• AHRQ invests in research and evidence to

understand how to make health care safer and

improve quality

• AHRQ creates materials to teach and train

health care systems and professionals to

catalyze improvements in care

• AHRQ generates measures and data used to

track and improve performance and evaluate

progress of the U.S. health system

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AHRQ’s Patient Safety Priorities

• Causes of harm associated with health care

and understanding why it occurs and how to

prevent it

• Apply knowledge to accelerate patient safety

improvement in all health care settings

• Prevent HAIs, reduce antibiotic resistance

• Improve communication and engagement

among providers and between clinicians and

patients

• Build capacity in the health care system to

address safety issues33

The Research Continuum:

Discovery to Implementation

ResearchTesting &

DemonstrationImplementation

Measurement

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Patient Safety Tools and Training

• Patient Safety Culture Surveys

• TeamSTEPPS® team training materials

• Comprehensive Unit-based Safety Program (CUSP) toolkits to reduce CLABSI, CAUTI, etc.

• Re-Engineered Discharge (RED) tools to reduce avoidable hospital readmissions

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Three Domains of AHRQ’s

CARB*- Related Efforts

• AHRQ maintains a robust program of research and implementation projects aimed to:

o Improve the use of antibiotics through antibiotic stewardship

o Interrupt the transmission of antibiotic-resistant bacteria

o Prevent healthcare-associated infections (HAIs) in the first place

* Combating Antibiotic-Resistant Bacteria

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What’s on the Horizon

• Diagnostic erroro IOM report, September 2015

o Area of growing concern in patient safety field

• Increased funding for ambulatory care patient

safety projects

• Continued focus on HAIs, including antibiotic

resistance through support of CARB effort

• Patient/provider communication and

engagement37

Funding Opportunities

• AHRQ supports investigator-initiated research

that addresses patient safety issues.

• Two recent opportunities focus on diagnostic

safety in all settings:► Incidence and factors that contribute to diagnostic

failure

► Strategies and interventions to improve diagnostic

safety

• Other opportunities include: safe medication

use, health care simulation, and HAI

prevention.

www.ahrq.gov/funding38

AHRQ Patient Safety Network

(AHRQ PSNet)

• PSNet is a national “one-stop” portal of resources for improving patient safety and preventing medical errors

• Offers wide variety of information on patient safety resources, tools, conferences, and more

http://psnet.ahrq.gov

http://webmm.ahrq.gov39

Looking Ahead: 2015 NPSF Report

• Free from Harm: Accelerating Patient Safety

Improvement Fifteen Years after To Err Is

Human

• Calls for total systems approach and

establishment of a culture of safety

• Recommendations build on current state of

health care, moving the field forward

• Aligns with AHRQ’s approach, understanding

how to make the system a safer place for

clinicians to practice and patients to seek

care

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Visit Our Web Site

www.ahrq.gov

www.ahrq.gov/professionals/quality-patient-safety/index.html 41

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Patrick Conway, MDDeputy Administrator for Innovation & Quality

Chief Medical OfficerCenters for Medicare and Medicaid Services

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CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people

Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented Care

Systems and Policies Fee-For-Service Payment

Systems

Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care

Systems and Policies Value-based purchasing Accountable Care Organizations Episode-based payments Medical Homes Quality/cost transparency

Public and Private sectors

Evolving future stateHistorical state

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Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system.

Delivery System Reform requires focusing on the way we pay providers, deliver care, and distribute information

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

}“

{

PayProviders

Deliver Care

DistributeInformation

FOCUS AREAS“

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During January 2015, HHS announced goals for value-based payments within the Medicare FFS system

'Jaw-dropping': Medicare deaths, hospitalizations AND costs reduced

1999 2013 Difference

All-cause mortality 5.30% 4.45% -0.85% (approx. 300,000 deaths per year)

Total Hospitalizations/100,000 beneficiaries

35,274 26,930 -8,344 (approx. 3 million hospitalizations per year)

In-patient Expenditures/Medicare fee-for-service

beneficiary

$3,290 $2,801 -$489

End of Life Hospitalization (last 6 months)/100 deaths

131.1 102.9 -28.2

Sample consisted of 68,374,904 unique Medicare beneficiaries (FFS and Medicare Advantage).

Findings were consistent across geographic and demographic groups.

Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013; Harlan M. Krumholz, MD, SM;

Sudhakar V. Nuti, BA; Nicholas S. Downing, MD; Sharon-Lise T. Normand, PhD; Yun Wang, PhD; JAMA. 2015;314(4):355-365.; doi:10.1001/jama.2015.8035 46

•Bold goal to dramatically improve patient safety across the country

•Over $500 million investment

•Working with over 3700 hospitals representing 80+% of patient admissions across the country

•Measuring results, testing improvements, and sharing of best practices

•Significant national improvements in patient safety

Partnership for Patients (PfP)

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Partnership for Patients contributes to safety improvements

Ventilator-

Associated

Pneumonia

Early

Elective

Delivery

Central Line-

Associated

Blood Stream

Infections

Venous

thromboembolic

complications

Re-

admissions

Leading Indicators, change from 2010 to 2013

62.4% ↓ 70.4% ↓ 12.3% ↓ 14.2% ↓ 7.3% ↓

Data shows from 2010 to 2014…

87,000

2.1 million

PATIENT HARM

EVENTS AVOIDED

$20 billion

IN SAVINGS

2010 to Interim 2014: 145 to 120 HACs

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145 142132 121

121 120

2.1 million fewer HACs $19.8 billion in costs averted

87,000 fewer HAC-related deaths

• Severe Sepsis and Septic Shock (mandatory)

• Clostridium Difficile, including antimicrobial stewardship

• Hospital-Acquired Acute Renal Failure

• Airway Safety

• Iatrogenic Delirium

• Procedural Harm (pneumothorax, bleed, etc.)

• Undue Exposure to Radiation

• Failure to Rescue

• Results Beyond the 40/20 Aims on HACs and readmissions

• Hospital Culture of Safety – Including Worker Safety

Partnership for Patients (PfP)Leading Edge Advanced Practice Topics (LEAPT), 2013 - 2014

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HEN “1.0” (2011-2014) HEN “2.0” (2015-2016)

Awards 26 organizations 17 organizations

Geographic Coverage 50 states & Puerto Rico 50 states & Puerto Rico

Period of Performance 3 years 1 year (12 months)

An extension of the PfP model test is underway

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The innovative work of LEAPT has continued to spread under PfP 2.0

HENs have proposed to work on former LEAPT topics, including:

• Sepsis & Septic Shock

• Clostridium difficile (C. diff)

• Antibiotic Stewardship

• Culture of Safety including worker safety

• Undue Exposure to Radiation

• Failure to Rescue

HENs have proposed to add new emerging topics to their repertoire:

• Pediatric Safety• Early intervention for

mental health• Safe diabetes

management• Multi-drug resistant

organisms • Expanded ADE sub-

topics (e.g. anti-epileptics)

• Peripheral Intravenous Infiltrations/Extravasations

• Unplanned Extubations• Pain Management• …And more!

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Percentage of Hospitals Meeting Each Person and Family Engagement Metric, July 2013 and November 2014

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Hospital Compare - Focus on Patient Safety

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• Patient safety is an essential component of CMS’s work. We must prevent harm. We need your help.

• CMS is encouraging networks and their participants to seek out opportunities for synergy, alignment, and collaboration across the health care system in order to achieve impact for patients and their families.

• Alignment of powerful forces is central to our proven ability to generate breakthrough results.

• CMS is committed to collaboration and sustaining the work on patient safety.

Moving Forward in Active Partnership

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Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation

• The model will support over 140,000 clinician practices over the next four years to improve on quality and enter alternative payment models

Phases of Transformation

• Two network systems will be created

1) Practice Transformation Networks: peer-based learning networks designed to coach, mentor, and assist

2) Support and Alignment Networks: provides a system for workforce development utilizing professional associations and public-private partnerships

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Eliminate patient harm

Focus on better care, smarter spending, and healthier people within the population you serve

Engage in accountable care and other alternative payment contracts that move away from fee-for-service to model based on achieving better outcomes at lower cost

Invest in the quality infrastructure necessary to improve

Focus on data and performance transparency

Test new innovations and scale successes rapidly

Relentlessly pursue improved health outcomes

What can you do to help our system achieve the goals of Better Care, Smarter Spending, and Healthier People?

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Submit A Question

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Visit Our New Interactive Website

www.UnitedForPatientSafety.org

Take the Pledge | Join a Discussion | Share Best Practices | Add Your Voice

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