Unit 10: Measuring Patient Safety This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office.

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Presentation transcript:

Unit 10: Measuring Patient Safety This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

Objectives At the end of this segment, the student will be able to: Explain the attributes of an effective reporting system Examine the importance of standardized and structured health information Discuss how HIT can facilitate data collection and reporting for improving quality and patient safety Component 12/Unit 102 Health IT Workforce Curriculum Version 2.0/Spring 2011

Exercise Please answer each question with a score of 1 to 5. 1 is below average, 3 is average and 5 is above average. How smart am I? How hard do I work? How kind am I? How tall am I? How good is the quality of care you provide? Component 12/Unit 103 Health IT Workforce Curriculum Version 2.0/Spring 2011

Component 12/Unit 104 Health IT Workforce Curriculum Version 2.0/Spring 2011 Wrong-site Surgeries Reviewed by Year Image: AHRQ.gov

Structure Context Have we created a culture of safety? ProcessOutcome Have we reduced the likelihood of harm? How often do we do what we are supposed to? How often do we harm? Conceptual model for measuring safety Component 12/Unit 105 Health IT Workforce Curriculum Version 2.0/Spring 2011

Examples Structure measures: do you have a smoking cessation program Process measure: % of patients who receive smoking cessation education or time spent with patients Outcome measure: % of patients who quite smoking Component 12/Unit 106 Health IT Workforce Curriculum Version 2.0/Spring 2011

What can be measured as a valid rate? Rate requires –Numerator - event –Denominator - those at risk for event –Surveillance for events and those at risk Minimal Error –Random error –Systematic error Component 12/Unit 10 7 Health IT Workforce Curriculum Version 2.0/Spring 2011

Potential Biases Selection bias –example identifying sepsis patients Measurement bias –Definition of event –Definition of those at risk –Surveillance –Missing data Analytic bias Component 12/Unit 108 Health IT Workforce Curriculum Version 2.0/Spring 2011

Sources Variation in Safety measures True variation in Safety Variation in data quality/definition/methods of collection Variation in case mix Variation historical rates Chance Component 12/Unit 10 9 Health IT Workforce Curriculum Version 2.0/Spring 2011

How to measure Medication safety Component 12/Unit 1010 Health IT Workforce Curriculum Version 2.0/Spring 2011

Improving Sepsis Care (n= 19 ICUs) 11 Health IT Workforce Curriculum Version 2.0/Spring 2011 Component 12/Unit 10 Image: Johns Hopkins University

12 Health IT Workforce Curriculum Version 2.0/Spring 2011 Component 12/Unit 10 Improving Sepsis Care (n= 19 ICUs) Image: Johns Hopkins University

It is Ok to have non-rate measures Self reported measures are generally not valid as rates A common mistake is interpreting a non- rate measure as a valid rate 13 Health IT Workforce Curriculum Version 2.0/Spring 2011 Component 12/Unit 10

How to get more valid data Structure data entry or data collection forms - clarify who what when where and how Pilot test entry to see if staff understand Train and evaluate competency Evaluate data quality (look at data) –Missing data, outliers, repeat values Ask if the consumer of the data believes it is valid and useful Component 12/Unit 1014 Health IT Workforce Curriculum Version 2.0/Spring 2011

Quality Report Generally present data over time in annotated run chart Clearly label x and y axis (usually time period) Select time period so that you have about 25 observations per time period Ask users of the data for feedback on making it more useful Component 12/Unit 1015 Health IT Workforce Curriculum Version 2.0/Spring 2011

Impact on Catheter-Related Bloodstream Infections(BSI) VAD PolicyChecklistLine Cart Daily goals 16 Health IT Workforce Curriculum Version 2.0/Spring 2011 Component 12/Unit 10

Reference The Joint Commission. Speak Up. Available from: A8A2-412F-88D4-E1762BCC5C26/0/UP_Poster.pdf Crit Care Med 2004;32(10):2014. Component 12/Unit 10 Health IT Workforce Curriculum Version 2.0/Spring