Performance Data: Performance Data: From Both Sides NowFrom Both Sides Now

Gail R. Bellamy, Ph.D.Gail R. Bellamy, Ph.D.AHRQ 2007 Annual Conference AHRQ 2007 Annual Conference

“Improving Health Care, Improving “Improving Health Care, Improving LivesLives

AcknowledgementAcknowledgement

This project was funded under a This project was funded under a cooperative agreement with the cooperative agreement with the Agency for Healthcare Research and Agency for Healthcare Research and Quality (AHRQ) UC1 HS01 4920-02.Quality (AHRQ) UC1 HS01 4920-02.

BackgroundBackground

Transforming Health Care Quality Transforming Health Care Quality through Information Technology through Information Technology Implementation Grant Implementation Grant ““Partnering to Improve Patient Safety in Partnering to Improve Patient Safety in

Rural West Virginia Hospitals”Rural West Virginia Hospitals” Expansion of 8 hospital patient Expansion of 8 hospital patient

safety pilot projectsafety pilot project

Goals of AHRQ GrantGoals of AHRQ Grant

Focus on rural hospitals, including Focus on rural hospitals, including critical access hospitalscritical access hospitals

Provide a free, confidential event Provide a free, confidential event reporting system to any interested reporting system to any interested rural hospitalrural hospital

Develop a collaborative network Develop a collaborative network among hospitals to share information among hospitals to share information and best practicesand best practices

Performance Data: From the Side Performance Data: From the Side of the Projectof the Project

Number of hospitals enrolledNumber of hospitals enrolled Utilization of ITUtilization of IT

Numbers of reports: 43,000 to dateNumbers of reports: 43,000 to date Nature of reports: Catastrophic/fatal Nature of reports: Catastrophic/fatal

rarely reportedrarely reported

Quarterly Number and Rate of Adverse Event Quarterly Number and Rate of Adverse Event Reports, WV Patient Safety Project 2005-2007Reports, WV Patient Safety Project 2005-2007

Time Period

Total Adverse Events

Bed Days Rate* No. of

Hospitals

2005Q1 1,751 35,513 49 11 2005Q2 2,097 39,718 53 14 2005Q3 2,398 39,658 60 19 2005Q4 2,703 51,736 52 24 2006Q1 2,958 65,079 45 25 2006Q2 3,154 59,286 53 26 2006Q3 3,154 59,361 53 26 2006Q4 3,117 59,848 52 24 2007Q1 3,162 61,257 52 23

Rates of Reported Events, By Type and QuarterRates of Reported Events, By Type and QuarterWV Patient Safety Project, 2005-7WV Patient Safety Project, 2005-7

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2005Q1 2005Q2 2005Q3 2005Q4 2006Q1 2006Q2 2006Q3 2006Q4 2007Q1

Rat

e p

er 1

,000

pa

tien

t d

ays

Unobserved falls

Observed Falls

Elopement

Delay in test/treatment

Lab specimen-related

Staff Injury/exposure

Omitted Med Dose

Wrong Drug

Wrong Dose

Adverse Drug Reaction

Patient Misidentification

Performance Data: From the Side Performance Data: From the Side of the Projectof the Project

ValueValue Interviews with key informantsInterviews with key informants

CEOsCEOs Risk ManagersRisk Managers Floor NursesFloor Nurses

Performance Data: From the Side Performance Data: From the Side of the Hospitalof the Hospital

BenchmarkingBenchmarking Patient Safety Culture SurveyPatient Safety Culture Survey

Patient Safety Culture: Survey Patient Safety Culture: Survey methodologymethodology

Baseline survey completed in Baseline survey completed in conjunction with in-house training on conjunction with in-house training on software (Jan-Oct 2005)software (Jan-Oct 2005)

Midpoint (Jul-Sep 2006) and final (Jul-Midpoint (Jul-Sep 2006) and final (Jul-Sep 2007) surveys mailed to Sep 2007) surveys mailed to hospitals to administer to staffhospitals to administer to staff

Convenience sampleConvenience sample

R1. Staff feel like their mistakes are held against them. (A8)

R2. When an event is reported, it feels like the person is being written up, not the problem. (A12)

R3. Staff worry that mistakes they make are kept in their personnel file. (A16)

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

26

25

25

37

5224

38

37

37

Survey report example: Nonpunitive Survey report example: Nonpunitive Response to ErrorResponse to Error

Hospital Survey on Patient Safety Culture Hospital Survey on Patient Safety Culture Baseline - Remeasurement ComparisonsBaseline - Remeasurement Comparisons

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overa

ll Per

cept

ions o

f Safe

ty

Frequ

ency

of E

vent

s Repo

rted

Super

visor

Man

ager

Exp

ectatio

ns

Organ

izatio

nal L

earn

ing

Team

work W

ithin

Units

Communic

ation

Ope

nnes

s

Communic

ation

Abo

ut E

rror

Nonpun

itive R

espo

nse

to E

rror

Staffin

g

Hosp S

uppo

rt fo

r Pat

ient S

afet

y

Team

work A

cros

s Hos

pital

Unit

Hospita

l Han

doffs

& T

rans

itions

Remeasurement

Baseline

Midpoint survey report example: Nurse Midpoint survey report example: Nurse vs admin. Positive scores by dimensionvs admin. Positive scores by dimension

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overa

ll Per

cept

ions o

f Safe

ty

Frequ

ency

of E

vent

s Repo

rted

Super

visor

Man

ager

Exp

ectatio

ns

Organ

izatio

nal L

earn

ing

Team

work W

ithin

Units

Communic

ation

Ope

nnes

s

Communic

ation

Abo

ut E

rror

Nonpun

itive R

espo

nse

to E

rror

Staffin

g

Hosp S

uppo

rt fo

r Pat

ient S

afet

y

Team

work A

cros

s Hos

pital

Unit

Hospita

l Han

doffs

& T

rans

itions

Admin

Nursing

Performance Data: From the Side Performance Data: From the Side of the Hospitalof the Hospital

BenchmarkingBenchmarking Event RatesEvent Rates

Event CategoriesEvent Categories Unobserved FallsUnobserved Falls Observed FallsObserved Falls ElopementElopement Delay In Tests or TreatmentsDelay In Tests or Treatments All Laboratory Specimen Related Occurrences All Laboratory Specimen Related Occurrences

Except DelaysExcept Delays Injury or Exposure to Hospital StaffInjury or Exposure to Hospital Staff Omitted Medication Doses*Omitted Medication Doses* Wrong Medication Administered*Wrong Medication Administered* Wrong Dose of Drug*Wrong Dose of Drug* Adverse Drug ReactionsAdverse Drug Reactions Patient Misidentification*Patient Misidentification*

Example Report Example Report

Indicator Definition§ Your hospitalAll participating

hospitals

Occurrence type DetailsNumber

of eventsRate*

Percent of events

Range#Percent

of events

Unobserved falls Fall/Accident RelatedThe affected party was a patient and the fall was not observed by hospital staff

8 17.33 16.45% 1.41-4.8 6.34%

Observed patient falls during ambulation, examination, or transfer

Fall/Accident Related

The affected party was a patient and the fall was observed by hospital staff and occurred during transfer or walking

0 0 0% 0-0.52 1.05%

Elopement Environment of Care Patient is missing (AWOL) 0 0 0% 0-0 1.76%

Event Reporting Hospital Comparison Measures April 1,2005 - June 30,2005

Hospital X

Acute Care

Example Report Example Report

Wrong medication administered

Medication Error Wrong drug name 2 2.1 2.66% 0.21-2.82 2.05%

Wrong dose of drug Medication Error Wrong dose 2 2.1 2.66% 0-2.24 1.29%

Adverse drug reaction Adverse Drug Reaction

Any adverse drug reaction such as skin rash, vomiting, or hypotension

0 0 0% 0-0.59 1.67%

Admission Discharge Transfer

Wrong patient, more than one ID, or incorrect ID bracelet

SpecimenWrong label or specimen obtained from wrong patient

Surgery Invasive Procedure

Wrong patient

Treatment Wrong patient

Medication ErrorOrder written, transcribed, dispensed or administered to the wrong patient

Blood TransfusionOrder written, transcribed, dispensed or administered to the wrong patient

Total number of events reported

Patient misidentification

2 2.1 2.66% 0-2.48 2.24%

42 2097

Unobserved FallsUnobserved FallsAcute CareAcute Care

3.79

2.112.4

1.94

2.91

1.82

3.27

3.75

2.64

0

1

2

3

4

5

6

7

8

Ra

te

CAH

NonCAH

All

Sample Hospital

Median Event Rates over 9 QuartersMedian Event Rates over 9 QuartersCritical Access and non Critical Access HospitalsCritical Access and non Critical Access Hospitals

WV Patient Safety Project 2005-7WV Patient Safety Project 2005-7

0

1

2

3

4

5

6

Unobs

erve

d fa

lls

Obs

erve

d Fall

s

Elopem

ent

Delay i

n te

st/tre

atm

ent

Lab

spec

imen

-rela

ted

Staff

Injur

y/exp

osur

e

Omitte

d M

ed D

ose

Wro

ng D

rug

Wro

ng D

ose

Adver

se D

rug

React

ion

Patien

t Misi

dent

ificat

ion

Med

ian

Ra

te/1

,000

Bed

Day

s

CAH

Non CAH

Performance Data: From the Side Performance Data: From the Side of the Hospitalof the Hospital

BenchmarkingBenchmarking Patient Safety IndicatorsPatient Safety Indicators

AHRQ Patient Safety Indicators--WV, 2005 (Risk Adjusted)51XXXX: WV Sample Hospital

Discharges Reported to the WV Health Care Authority

0.001 0.01 0.1 1 10 100 1000

Indicator Rate (Per Thousand Cases)

(0)Complications of Anesthesia

(0.523)Death in Low-Mortality DRGs

(21.5)Decubitus Ulcer-No Prday

(130.1)Failure to Rescue

(0.189)Foreign Body Left in During Proc

(1.6)Iatrogenic Pneumothorax

(2.9)Infection Due to Medical Care

(0.488)Postop Hip Fracture-No Prday

(2.3)Postop Hemor or Hemat-No Prday

(0)Postop Physio Metabo De-No Prday

(16.7)Postop Resp Failure-No Prday

(18.1)Postop PE or DVT-No Prday

(14.7)Postoperative Sepsis

(2.9)Postop Wound Dehiscence-No Prday

(8.8)Accidental Puncture/Laceration

State Range (10th-90th Percentile)

State Median (50th Percentile)

Hospital Risk Adjusted Value

Performance Data: From the Side Performance Data: From the Side of the Hospitalof the Hospital

Measuring improvementMeasuring improvement Falls collaborativeFalls collaborative

Falls collaborative resultsFalls collaborative results

Absolute Change in Number of Falls per 1,000 Patient Days Baseline to Remeasurement

-35 -30 -25 -20 -15 -10 -5 0 5

Hospital A

Hospital B

Hospital C

Hospital D

Hospital E

Hospital F

Hospital G

Hospital H

Hospital I

Hospital J

Hospital K

Falls collaborative resultsFalls collaborative results

Median Falls per Hospital per 1,000 Patient Days10th and 90th Percentiles

0

5

10

15

20

25

Median Falls per 1,000 Patient Days 4/01/06 - 9/30/06 Median Falls per 1,000 Patient Days 12/01/06 - 5/31/07

Med

ian

Fal

ls p

er H

ospi

tal

90th percentile 10th percentile Medians

Performance Data: From both sides Performance Data: From both sides nownow

SustainabilitySustainability Return-on-InvestmentReturn-on-Investment WV Center on Patient SafetyWV Center on Patient Safety

ConclusionsConclusions

From the perspective of the WV AHRQ From the perspective of the WV AHRQ Project Team the implementation Project Team the implementation project was a success.project was a success.

From the perspective of the majority of From the perspective of the majority of participating hospitals the ORM IT participating hospitals the ORM IT product helped them to improve product helped them to improve patient safety by providing timely, patient safety by providing timely, detailed data.detailed data.

Further InformationFurther Information

Gail BellamyGail Bellamy

gbellamy@wvmi.org gbellamy@wvmi.org Patricia RuddickPatricia Ruddick

Pruddick@wvmi.org Pruddick@wvmi.org Karen L. HannahKaren L. Hannah

khannah@wvmi.orgkhannah@wvmi.org

Charles Schade, Charles Schade, MDMD

cschade@wvmi.orgcschade@wvmi.org David LomelyDavid Lomely

dlomely@wvmi.orgdlomely@wvmi.org