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Influencing Health Care: Safety & Measurement Peter Angood MD FACS FCCM Vice President & Chief Patient Safety Officer Joint Commission (JCAHO) Chief Patient.

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Presentation on theme: "Influencing Health Care: Safety & Measurement Peter Angood MD FACS FCCM Vice President & Chief Patient Safety Officer Joint Commission (JCAHO) Chief Patient."— Presentation transcript:

1 Influencing Health Care: Safety & Measurement Peter Angood MD FACS FCCM Vice President & Chief Patient Safety Officer Joint Commission (JCAHO) Chief Patient Safety Officer & Co-Director Joint Commission International Center for Patient Safety Chicago, USA

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3 > 5 Years After The IOM Report: “To Err Is Human” Regulation/Accreditation: A- Regulation/Accreditation: A- Workforce Training Issues: B Workforce Training Issues: B Information Technology: B- Information Technology: B- Error Reporting Systems: C Error Reporting Systems: C Malpractice System: D+ Malpractice System: D+ Wachter, RM; Health Affairs; 11/2004

4 Mission: To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. Free-standing not-for-profit organization with deemed status by federal Center for Medicare and Medicaid Services (CMS) Free-standing not-for-profit organization with deemed status by federal Center for Medicare and Medicaid Services (CMS) Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

5 “ To continuously improve the safety and quality of care” The Joint Commission on Accreditation of Healthcare Organizations

6 ~ Overlapping Strategies ~ Committed to continually enhance the value of its accreditation and certification programs. Committed to continually enhance the value of its accreditation and certification programs. The Joint Commission will strive to ensure that they are patient-centered, data-driven, relevant, and integral to the performance improvement activities of health care organizations.The Joint Commission will strive to ensure that they are patient-centered, data-driven, relevant, and integral to the performance improvement activities of health care organizations.

7 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, Ambulatory Care1,234 Assisted Living 72 Behavioral Health Care 1,821 Critical Access Hospitals 268 Home Care 3,422 Hospitals 4,342 Laboratory 1,947 Long Term Care1,364 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

8 Safety and Regulatory Issues Persistent Accreditation Issues: Precision of standards Precision of standards Consistency of surveyors Consistency of surveyors Perceptions of relevance Perceptions of relevance Intermittent nature of process Intermittent nature of process Shared Visions, New Pathways

9 ~ Overlapping Strategies ~ Committed to developing, utilizing, and maintaining valid and reliable performance measures. Committed to developing, utilizing, and maintaining valid and reliable performance measures. These measures are needed to support a credible, data-driven accreditation process and the publication of meaningful comparative performance information for the public.These measures are needed to support a credible, data-driven accreditation process and the publication of meaningful comparative performance information for the public.

10 Requirements that define performance expectations with respect to structure, process, and outcomes that must be substantially in place in an organization to enhance the safety and quality for patient care Requirements that define performance expectations with respect to structure, process, and outcomes that must be substantially in place in an organization to enhance the safety and quality for patient care Performance Measurement Data Performance Measurement Data Adverse Event Reporting Adverse Event Reporting Standards

11 Core Measure Identification Process Library of hospital priority measurement areas Acute myocardial infarction (implemented 2002)Acute myocardial infarction (implemented 2002) Heart failure (implemented 2002)Heart failure (implemented 2002) Community acquired pneumonia (implemented 2002)Community acquired pneumonia (implemented 2002) Pregnancy and related conditions (implemented 2002)Pregnancy and related conditions (implemented 2002) Surgical infection prevention (Implemented July 2004)Surgical infection prevention (Implemented July 2004) Intensive care (Scheduled July 2005)Intensive care (Scheduled July 2005) Pain management (In development)Pain management (In development) Children’s asthma (In development)Children’s asthma (In development) Hospital Based Inpatient Psychiatric Services (In development)Hospital Based Inpatient Psychiatric Services (In development) DVT (In development)DVT (In development) Sepsis (In development)Sepsis (In development)

12 Performance Measurement Environment is rapidly evolving Environment is rapidly evolving US Federal Gov’t – accelerating change US Federal Gov’t – accelerating change Link between performance measurement and accreditation Link between performance measurement and accreditation Alignment with Hospital Quality Alliance (HQA-2003) & National Quality Forum (NQF- 1999) important Alignment with Hospital Quality Alliance (HQA-2003) & National Quality Forum (NQF- 1999) important Accreditation: Accreditation: contractual agreement to collect on 3 measure setscontractual agreement to collect on 3 measure sets AMI, CHF, Pneumonia, SIP or Pregnancy & Related ConditionsAMI, CHF, Pneumonia, SIP or Pregnancy & Related Conditions

13 ~ Overlapping Strategies ~ Committed to making patient safety an imperative in all accredited organizations. Committed to making patient safety an imperative in all accredited organizations. This will be accomplished through the standards and policies of the Joint Commission and through collaboration with other patient safety leadership organizations.This will be accomplished through the standards and policies of the Joint Commission and through collaboration with other patient safety leadership organizations.

14 Sentinel Event Policy Established in January 1996: To have a positive impact in improving careTo have a positive impact in improving care To focus attention on underlying causes and risk reductionTo focus attention on underlying causes and risk reduction To increase the general knowledge about sentinel events, their causes and preventionTo increase the general knowledge about sentinel events, their causes and prevention To maintain public confidence in the accreditation processTo maintain public confidence in the accreditation process

15 Percent of 3231 events

16 Sentinel Event Alerts 1.Potassium chloride 2.Policy issues 3.Policy issues 4.Policy issues 5.Policy issues 6.Wrong site surgery 7.Suicide 8.Restraint deaths 9.Infant abductions 10.Transfusion errors 11.High Alert Medications 12.Op/post-op complications 13.Impact of SE Alert 14.Fatal falls 15.Infusion pumps 16.Proactive risk reduction 17.Home fires (O2 therapy) 18.Kernicterus 19.Look-alike, sound-alike drugs 20.Kreutzfeldt-Jakob disease 21.Medical gas mix-ups 22.Needles & sharps injuries 23.Dangerous abbreviations 24.Wrong-site surgery #2 25.Ventilator-related events 26.Delays in treatment 27.Bed rail deaths & injuries 28.Nosocomial infections 29.Surgical fires 30.Perinatal deaths 31.Anesthesia awareness 32.Kernicterus #2 33.PCA by proxy 34.Intrathecal vincristine 35.Wrong route / wrong tube 36.Medication reconciliation 37.Device Connections

17 National Patient Safety Goals Selection of the Goals and requirements is guided by a panel of experts: Selection of the Goals and requirements is guided by a panel of experts: Sentinel Event Advisory Group Each year, a set of Goals & their Requirements are identified from a variety of sources Each year, a set of Goals & their Requirements are identified from a variety of sources The Goals and their Requirements are field reviewed & published by mid-year for the coming calendar year The Goals and their Requirements are field reviewed & published by mid-year for the coming calendar year

18 NPSG Compliance Data for 2003—2006 NPSG requirement a: 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 %17.3% 2e: Hand-off communications % 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-alike drugs %5.8% 3d: Label medications & solutions % 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 % 3.6%7.7% 7b: HC-associated infection & RCA % 0.0%0.0% 8a: Medication reconciliation – list %3.8% 8b: Medication reconciliation – reconcile %7.7% 9a: Fall risk assessment b: Fall prevention program %

19 Alternatives Approaches to the NPSGs NPSG requirement 2004 Requests 2005 Requests 1a: Two identifiers 31 1b: Time out before surgery 11 2a: Read-back verbal orders 60 2b: Standardize abbreviations c: Timeliness of reporting a: Concentrated electrolytes 901 3b: Limit concentrations c: Look-alike/sound-alike drugs a: Preoperative verification 61 4b: Surgical site marking 540 5a: Free-flow protection 424 6a: Alarm maintenance & testing 10 6b: Alarm settings & audibility 40 7a: CDC hand hygiene guidelines b: Infection-related sentinel events a: Medication reconciliation b: Medication information to next provider a: Fall risk assessment

20 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

21 1. Patient identification 2. Communication among caregivers 3. 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 fires 12. NPSG implementation by network components 13. Patient involvement 14. Pressure ulcers 2006 National Patient Safety Goals

22 Provisions of the Universal Protocol Preoperative verification process Preoperative verification process Relevant pre-op tasks completed and information is available and correctRelevant pre-op tasks completed and information is available and correct Surgical site marking Surgical site marking Unambiguous mark, visible after prep & drapeUnambiguous mark, visible after prep & drape Right/left, multiple structures or levelsRight/left, multiple structures or levels “Time out” immediately before starting “Time out” immediately before starting Involves entire team; active communicationInvolves entire team; active communication Fail-safe model: “No go” unless all agreeFail-safe model: “No go” unless all agree Applicable to invasive procedures in all settings Applicable to invasive procedures in all settings

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24 Wrong-site Surgeries

25 Surveying and Scoring the National Patient Safety Goals Must implement all applicable Goals & Requirements or implement an acceptable alternative(s) Must implement all applicable Goals & Requirements or implement an acceptable alternative(s) Evaluated in the PPR and during all full accreditation surveys and for-cause surveys Evaluated in the PPR and during all full accreditation surveys and for-cause surveys Surveyors evaluate actual performance, not just intent Surveyors evaluate actual performance, not just intent Failure to comply with one or more requirements of a Goal will result in a “Requirement for Improvement” Failure to comply with one or more requirements of a Goal will result in a “Requirement for Improvement” NPSG requirements that are also in the standards will only be scored once (no “double jeopardy”) NPSG requirements that are also in the standards will only be scored once (no “double jeopardy”)

26 Aggregate data Aggregate data Data from surveys posted on Joint Commission web siteData from surveys posted on Joint Commission web site Individual health care organizations: Individual health care organizations: Compliance with specific requirementsCompliance with specific requirements Quality Reports - on web site since 2004Quality Reports - on web site since 2004 Public Disclosure of Compliance with National Patient Safety Goals

27 ~ Overlapping Strategies ~ Committed to ensure that the accreditation process is publicly accountable. Committed to ensure that the accreditation process is publicly accountable. The Joint Commission will provide meaningful and useful information about the performance of accredited organizations to the public.The Joint Commission will provide meaningful and useful information about the performance of accredited organizations to the public.

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29 SIP Measure Reporting

30 Strategic Surveillance System - Release 1.0 (Corporate Summary & Comparison of Organization Level PFP Points) System ABC’s PFP Point Total Average = ( /11) = 299 System ABC compared to other groups of hospitals from PFP Studies: System ABC

31 Strategic Surveillance System - Release 1.0 (Corporate Dashboard View by Measure Set)

32 Hospital Quality Alliance Voluntary reporting of 10 selected measures from JCAHO & CMS focused towards AMI, CHF & Pneumonia Voluntary reporting of 10 selected measures from JCAHO & CMS focused towards AMI, CHF & Pneumonia Medicare Modernization Act created formal link to measures and hospital reimbursement Medicare Modernization Act created formal link to measures and hospital reimbursement 2005 – expanded to all measures and included SIP measures set 2005 – expanded to all measures and included SIP measures set 2007 – reported patient experience of care survey (H-CAPS) & risk-adjusted measures for 30-day mortality of AMI & CHF to be gathered by CMS 2007 – reported patient experience of care survey (H-CAPS) & risk-adjusted measures for 30-day mortality of AMI & CHF to be gathered by CMS

33 Institute of Medicine 2005 Performance Measurement recommendations includes IOM’s starter set of measures for hospital performance that is > HQA measures Performance Measurement recommendations includes IOM’s starter set of measures for hospital performance that is > HQA measures Deficit Reduction Omnibus Act adopts IOM recommendations for inclusion in a new “value-based purchasing” (P4P) framework to be implemented by Deficit Reduction Omnibus Act adopts IOM recommendations for inclusion in a new “value-based purchasing” (P4P) framework to be implemented by 2009 State-based initiatives increasing State-based initiatives increasing

34 HQA & NQF Changes Joint Commission remains committed & flexible to evolving performance measurement environment Joint Commission remains committed & flexible to evolving performance measurement environment Deficit Reduction Act creates impetus for HQA & NQF to accelerate expansion of the array of measures in the production process: Deficit Reduction Act creates impetus for HQA & NQF to accelerate expansion of the array of measures in the production process: SCIPSCIP ICU Measure SetICU Measure Set Pediatric AsthmaPediatric Asthma Nursing-SensitiveNursing-Sensitive AHRQ Quality IndicatorsAHRQ Quality Indicators

35 ~ Overlapping Strategies ~ Committed to addressing pressing public policy issues that impact the quality and safety of health care. Committed to addressing pressing public policy issues that impact the quality and safety of health care. The Joint Commission will convene thought leaders and subject-matter experts and will issue public policy recommendations.The Joint Commission will convene thought leaders and subject-matter experts and will issue public policy recommendations.

36 PUBLIC POLICY INITIATIVESTopics # of Downloads Nursing Shortage– white paper Nursing Shortage– white paper967,308 Emergency Preparedness – white paper Emergency Preparedness – white paper113,359 Organ Donation – white paper Organ Donation – white paper92,647 Medical Liability – white paper Medical Liability – white paper292,033 Improving the Quality of Pain Management Through Measurement and Action Improving the Quality of Pain Management Through Measurement and Action638,938 Universal Protocol Universal Protocol157,880 Universal Protocol Implementation Guidelines Universal Protocol Implementation Guidelines127,798 “Do Not Use” List “Do Not Use” List104,860 Standing Together Emergency Planning Guide Standing Together Emergency Planning Guide587,554 Speak Up Brochure Speak Up Brochure154,535 Universal Protocol Brochure (Wrong Site Surgery) Universal Protocol Brochure (Wrong Site Surgery)95,798 Organ Donation Brochure Organ Donation Brochure46,937 Infection Control Brochure Infection Control Brochure150,934 Medication Management Brochure Medication Management Brochure50,446

37 Joint Commission International Center for Patient Safety Partnering for Solutions in Systems Improvement

38 Collaboration & Partnering Patient Safety “Solutions” Information Distribution Educational Programs Patient Safety Research Public Policy-Advocacy Patient Safety Legislation & Patient Safety Organizations

39 Definition: A Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care A Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care

40 Measurement Issues Are outcomes & performance measurement feasible? Are outcomes & performance measurement feasible? Can reliable risk adjustment be performed for patient & providers? Can reliable risk adjustment be performed for patient & providers? How to overcome cultural variability & resistance to reporting? How to overcome cultural variability & resistance to reporting? Cult of the RCT phenomenon… Cult of the RCT phenomenon… Development of measures is not enough for systems change! Development of measures is not enough for systems change!

41 Measurement Issues Infection-Related Issues: Infection-Related Issues: VAPVAP Central Line InfectionCentral Line Infection Blood Stream InfectionBlood Stream Infection SepsisSepsis Surgical Wound InfectionSurgical Wound Infection WHO Alliance: Global Challenge WHO Alliance: Global Challenge Taxonomy/Classification Systems Taxonomy/Classification Systems Professional Society & Organizations Professional Society & Organizations Barriers & Solutions… Barriers & Solutions…

42 What Is On The Radar Screen?

43 Physician Engagement in Safety


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