Presentation on theme: "Updates in Patient Safety"— Presentation transcript:
1 Updates in Patient Safety Helen Burstin, MD, MPHSenior Vice President, Performance MeasuresNational Quality ForumAcademy HealthJune 8, 2008
2 NQF MissionTo improve the quality of American healthcare by setting national priorities and goals for performance improvement,endorsing national consensus standards for measuring and publicly reporting on performance, andpromoting the attainment of national goals through education and outreach programs.
3 NTTAANational Technology and Transfer Advancement of Act of 1995 (NTTAA)Defines the five key attributes of a “voluntary consensus standards-setting body” (i.e., openness, balance of interest, due process, consensus, and an appeals process)Obligates federal government to adopt voluntary consensus standards (when the government is adopting standards)Encourages federal government to participate in setting voluntary consensus standards
4 DRAFT - Quality Alliance Steering Committee National Framework for Quality and Cost Transparency for High-Value CareAHRQ Foundations OtherNQF National Priorities Partners*NCQA The Joint Commission AMA PCPI Medical Societies Medical Specialty Boards CMS AHRQ Others**Continuously evaluate health and health careSet national priorities and goals to drive improvement and affordabilityQIOs Regional Collaboratives Providers Oversight Organizations Employers Health PlansImprove quality and reduce wasteConsumerOutcomesHigh QualityEquitableAffordablePatient-CenteredDevelop and test evidence-based measuresFed/State Govt Health Plans Employers Consumers ProvidersEstablish effective public policies, payment policies, and consumer incentives to reward or foster better performanceNQFEndorse and maintain measures and incorporate specifications into EHRsDevelop coordinated and streamlined implementation strategies: prioritization, timelines, and process solutionsGenerate public reports on quality and costAggregate data and pilot test and validate standard performance informationQASC Quality Alliances Joint Commission NCQA Medical Specialty BoardsRegional Collaboratives Fed/State Govt Health Plans OthersQASC Regional Collaboratives RHIOs/HIEs CMS States Health Data Stewards
5 Patient Safety 2008IOM “To Err is Human” – 44,000 to 98,000 Americans die each year from preventable medical errorsLittle progress to date - measures of patient safety showed an average annual improvement of just 1 percent (NHQR 2007)Unclear impact of Patient Safety and Quality Improvement Act and emerging Patient Safety Organizations (PSOs)Growing movement toward public reporting and non-payment for “never events”55
7 NQF Roles in Patient Safety Serious reportable events (including linkage to “no pay” events)Cross-cutting patient safety measuresSafe practices updateCommon data formats for patient safetyNational priorities and goal settingEHRs and Decision Support
8 NQF Serious Reportable Events Serious reportable events - serious, largely preventable, and of concern to both the public and healthcare providers28 serious reportable events:Care management eventsSurgical eventsProduct or device errorsEnvironmental eventsPatient protection
9 CMS Policy on Never Events Beginning in FY 2009, cases with these conditions would not be paid at a higher rate unless they were present on admission.Medicare will no longer pay for the additional costs of certain preventable conditions (including certain infections) acquired in the hospital.The rule identifies eight conditions, including three serious preventable events (sometimes called “never events”) that meet the statutory criteria.CMS will work to add an additional 3 conditions to the list next year.99
10 CMS Never Events * NQF Serious Reportable Event Bloodstream infections from using cathetersObjects left in a patient during surgery*Urinary tract infections from cathetersAir embolism, an air bubble in a blood vessel*An infection after heart surgery called mediastinitisBlood incompatibility, giving a dangerously wrong blood type*Bed sores, or pressure ulcersFalls* NQF Serious Reportable Event1010
11 Proposed CMS Never Events Surgical site infections following certain elective proceduresLegionnaires’ diseaseExtreme blood sugar derangementIatrogenic pneumothoraxDeliriumVentilator-associated pneumoniaDVT/PEStaphylococcus aureus septicemiaClostridium difficile associated disease
12 Leapfrog Policy on Never Events Hospitals commit to four actions if any never event* occurs within their facility:apologize to the patientreport the eventperform a root cause analysis, andwaive costs directly related to the event.* Includes all 28 NQF SREs
13 State-level Never Events In 2003, Minnesota became the first state to pass a never-events law that required the reporting of every never-event occurrence.New Jersey enacted a law requiring hospitals to report serious, preventable adverse events to the state and to patients’ familiesConnecticut adopted a mix of 36 NQF and state-specific reportable events for hospitals and outpatient surgical facilities. An Illinois law passed in 2005 will require hospitals and ambulatory surgery centers to report 24 “never events” beginning in Five other states, California, Connecticut, Illinois, Indiana and New Jersey, also have passed similar reporting laws or policies.
14 AHRQ Patient Safety Indicators Death in low-mortality DRGs (PSI 12)Failure to rescue (PSI 4)Foreign body left in during procedure (PSI 5 and 21) *Complications of anesthesia (PSI 1) *Selected infections due to medical care (PSI 7 and 23) *latrogenic pneumothorax (PSI 6 and 22)Postoperative pulmonary embolism or DVT (PSI 12)Postoperative hemorrhage or hematoma (PSI 9 and 27)Postoperative physiologic and metabolic derangements (PSI 10)* NQF Serious Reportable Events1414
16 Safe Practices UpdateFocus on review and maintenance of existing practices based on emerging evidence baseSteering committee: chaired by Charles Denham (TMIT) and Greg Meyer (MGH)Additional practices under consideration for high risk safety areas (including “no pay” events)
17 Criteria for Inclusion: Safe Practices Specificity. The practice must be a clearly and precisely defined process.Benefit. If the practice were more widely utilized, it would save lives endangered by health care delivery... or reduce the likelihood of a serious reportable event.Evidence of effectiveness. There must be clear evidence that the practice would be effective in reducing patient safety events.research studiesexperiential dataresearch findings or experiential data from non-healthcare industries that should be substantially transferableGeneralizabilityReadiness
18 Safe Practices with Expected Changes SP 4: DisclosureSP 14: Medication ReconciliationSP 19: Prevention of Aspiration and VAPSP 21: Surgical Site PreventionSP 23: Influenza PreventionSP 28: DVT/VTE PreventionSP 29: Anticoagulation TherapySP 30: Contrast Media Induced Renal Failure Prevention
19 New Safe Practices under Consideration Hand Offs – HandoversSecond PatientOrgan Donor-shipUrinary Tract InfectionMRSA MDROPediatric ImagingFallsHyperglycemiaRestraintsReliable surgical care
20 Proposed New Practice: Catheter Associated Urinary Tract Infections Safe Practice/Safety ObjectiveThe Problem (Narrative)Additional SpecificationsCare Settings/ ConsiderationsPrevent CAUTIs by implementing catheter use, insertion, and maintenance practices.UTI is the most common HAI; 80% attributable to an indwelling urethral catheter12-16% of hospital inpatients have a urinary catheter during admissionDaily risk of urinary infection 3% to 7% with indwelling urethral catheterProvide and implement written guidelines for catheter use, insertion, and maintenanceUse appropriate technique for catheter insertionEnsure appropriate management of indwelling cathetersAll care settingsPediatric taskforce to reviewExample ImplementationMeasuresNew Horizons/ ResearchHarmonization PartnersAlign with IDSA/SHEA paper: best practice sectionNQF endorsed measuresCDC definition-rate measure NHSNUse of antiseptic solution versus sterile saline for meatal cleaning prior to catheter insertionUse of antimicrobial-coated catheters for selected patients at high risk of infection.TJCCMSIDSASHEACDC
21 Patient Safety Data and Improvement Act 2005 Provides needed legal protections to specially designated Patient Safety Organizations (PSOs) to collect and analyze patient-level informationAllows PSOs to analyze patient safety data (including patient safety events and “near misses”) to discover important quality improvement strategies.Authorizes the Secretary to create and maintain a network of patient safety databasesAHRQ has been charged with developing the common data formats needed for patient safety event reporting and utilization by the PSOs
22 Patient Safety Data Common Data Formats: NQF has been tasked with development of a plan for multi-stakeholder public comment and collation of comments on the common formatsNQF will convene a Common Formats Expert Panel to develop criteria for evaluating feedback on the common formats;review the organized and triaged comments received in response to NQF’s activation of the plan for public comment; andprovide input on the proposed common formats and suggestions for improvement to AHRQ.
23 NQF Strategic Directions We should measure what is important to achieving the best outcomes for patients and populationsNQF Measurement Framework: promote shared accountability and measurement across patient-focused episodes of care:Outcome measuresAppropriateness measuresCost/resource use measures coupled with quality measures.
24 Episode Framework: Acute MI Post AMI Trajectory 1 (T1)Relatively healthy adultFocus on:Quality of LifeFunctional Status20 Prevention StrategiesRehabilitationAdvanced care planningPopulation at Risk10 Prevention(no known CAD)20 Prevention(CAD no prior AMI)
25 Strategic Issues (1) Driving toward high performance Stakeholders have expressed concern with multiple process measures too far removed from desired action that drive attention towards care of single accountable entity – rather than system-level improvementShifting toward composite measuresPotential advantages of composite measures:More understandable to patients and consumersReflects the comprehensive nature of care and potentially more patient centricMore oriented toward outcomes improvementDrives multi-faceted improvement strategies
26 Strategic Issues (2) Moving toward outcomes measurement Growing numbers of measures of morbidity and mortality for certain conditions (e.g., CHF)Very limited set of measures that address functional status, health-related quality of life, and shared decision-makingMeasure disparities in all we doIdentify measures that are disparities-sensitive and routinely stratify quality dataOutlining a framework for collecting race, ethnicity, primary language, and socioeconomic status data in an efficient, effective, patient-centered manner
28 National Priorities Partners Establish national priorities and goals for performance measurement and public reportingFocus measurement and improvement efforts on achievement of these goalsMulti-stakeholder Committee with representation from 27 leadership organizationsCo-chairsDon Berwick, IHIPeggy O’Kane, NCQA28NQF Membership Meeting Priorities Partners: O'Kane
29 Preliminary Priority Areas Healthcare Associated Infections*Composite measure of infection rates in high risk areasAvoidable Harms*Hospital-level mortality ratesHarmonization/global measurement across serious adverse eventsContinuity of Care*Care coordinationMedication reconciliationPatient/family engagementPatient activation & shared decision-making
30 Preliminary Priority Areas OveruseIdentify top 10 areas of overuse in healthcarePopulation healthComposites of key preventive services and healthy lifestyle behaviorsEnd of life/palliative careComposite of symptom management/HRQOLOverutilization of hospital, ED, chemotherapyReliable and effective care management of chronic/acute patient-focused episodesFrameworks completed for AMI and low back pain, ongoing work on cancer and diabetes
31 Composite measure for HAIs Fulfilling Measurement Needs for PrioritiesStandards ready now Urgent to developHospital-levelSSI infection rateComposite measure for HAIs30-day SSI infection rate – hospital or ambulatoryChange in patient-oriented outcomes, including functional status following HAIsSpecific Site of CareAcross the Continuum
32 Decision Support Tools Shared Data Elements“Sweet Spot”Quality MeasuresDecision Support ToolsClinical Guidelines* Including safety measures* Including e-Rx
34 Steps on the pathAmerican Health Information Community (AHIC) Quality Workgroup focused on how Health IT can evolve to effectively support performance measurement.NQF convened a Health IT Expert Panel (HITEP) to identify a set of common data elements to be standardized in order to enable automation of a prioritized set of measures through EHRsHITEP Chair: Paul Tang, MDFinal report to be released shortly
35 Steps on the path NQF expects to reconvene HITEP in the near future: Develop a Quality Data Set that provides the core data elements needed for quality measurement and clinical decision support built off of clinical guidelinesIdentify and prioritize the needed clinical data standards needed for the Quality Data Set HITSPCollect and synthesize clinical workflows within and across healthcare settingsReview condition-specific examples that would demonstrate the workflow issues involved in data aggregation within a single site of care as well as across an episode of care.
36 Not everything that counts can be counted, and not everything that can be counted counts. Albert Einstein
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