0. Stephen Pavkovic, RN, MPH, JD Director, Patient Safety UHC
The UHC PSO Experience
Stephen Pavkovic, RN, MPH, JD
Director, Patient Safety
UHC
AHRQ Annual Conference
Bethesda, MD
September 11, 2012

1. About UHC
UHC is Chicago-based alliance of 116 academic medical centers and 258 of their affiliated hospitals
UHC provides clinical, operational and financial comparative data and informatics
UHC Performance Improvement Solutions
Imperatives for Quality
UHC/AANC Nurse Registry Program™
UHC-AAMC Faculty Practice Solutions Center™
National Initiatives Support
Patient Safety Program
Patient Safety Net®
Integrated Claims, Complaints and Incidents Modules

2. AMC Members Across the Nation
This map represents the impressive roster of Member organizations throughout the U.S.

3. Representing the Nation’s Leading AMCs
Note: Customized to include the member audience for the presentation as well as other selected peers.

4. Presentation Overview
Foundation
What is a PSO?
Why Common Formats?
UHC Patient Safety Program
UHC PSN, Powered by Datix
UHC Performance Improvement PSO
Common Formats facilitated research and findings

5. Created by Patient Safety and Quality Improvement Act – 2005
What is a PSO?
Created by Patient Safety and Quality Improvement Act –
The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients
Regulations provide Federal legal privilege and confidentiality protections to information that is assembled and reported by providers to a PSO or developed by a PSO for the conduct of patient safety activities.
PSWP - patient safety work product
The Act also significantly limits the use of this information in criminal, civil, and administrative proceedings.
The Act includes provisions for monetary penalties for violations of confidentiality or privilege protections.

6. The Act regulates PSOs membership:
What is a PSO?
Patient Safety and Quality Improvement Act defines how patient safety event information is collected, developed, analyzed and maintained.
The Act regulates PSOs membership:
PSOs are required to work with more than one provider
Excludes insurance companies
Establishes a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for providers, PSOs, and other entities.
For analyzing national and regional statistics, including trends and patterns of patient safety events.
The NPSD utilizes common formats and will promote interoperability among reporting systems. The Department of Health and Human Services will provide technical assistance to PSOs.
76 PSO listed – 2012.

7. Common Formats

8. Common Formats
Common Formats are a set of common definitions and reporting formats, used to specify the clinical definitions and technical requirements that allow health care providers to exchange data with PSOs and the NPSD in an interoperable and standardized manner.
Ensure consistency in reporting patient safety event information
Provide analysis of patient safety event information and give feedback to health care providers
Facilitate a learning environment that reduces future risk to patients
Inpatient Hospital based
Ambulatory care in development

9. Common Formats
Leveling the field for comparative data reporting permitting “apples to apples” comparisons
Contents:
Definition of Event
Scope of Reporting
Risk Assessments and Preventative Actions
Circumstances of Events

11. UHC Patient Safety Program
UHC-Datix
PSN® Suite
PSN® Incident Reporting Tool
Claims Management
Module
Complaints Module
Reports and Research
Managers have access to dashboard reports
Rich source of data for research with 2.2 million patient safety events
Aggregate Data Provides Comparisons Among Organizations
UHC PI Patient Safety Organization
PSN® serves as the data collection tool for UHC PI PSO
AHRQ-Listed PSO since 2008
Common Format (v 1.1) compliant
Federal Confidentiality & Privilege Protection
Community of Learners
Education and Member Success Sharing Opportunities
Safety Stories
Data mining and Aggregate Analysis Reports & Collaboratives
Project Collaboratives

12. Overview of Patient Safety Net®
Internet-based incident reporting system with point of care for adverse events and near misses (unsafe conditions)
Real time triage, routing and analysis of patient safety events by location, event type or harm score
AHRQ Common Format (v1.1) compliant
Shared UHC taxonomy with customizable questions
Integrated Patient Complaint and Claims modules to identify prevention opportunities

13. PSN® Front Line Event Report Components
Patient Information
Event Basics
Reporter Information
Event Detail
Organization
Specific Information
Harm Score
Each organization may customize the properties of selected questions in the event report.

14. FLR submits event report
PSN® Manager Workflow
FLR submits event report
/Event Report goes to appropriate managers
Location Mgr
Pharmacist Mgr
Ancillary Mgr
Physician Mgr
Q/R Mgr
Managers can:
View and edit the event report
Read and audit other manager reviews
Consult with managers
Enter and ‘submit’ their own reviews commenting on contributing factors, corrective actions, and costs incurred
Attach documents
Quality/Risk (Q/R) Managers also:
‘Submit’ a report to PSN – which changes the status to ‘closed’
Unsubmit a report
Delete a report
Submit a report to UHC PSO, if applicable
Consultant
The Q/R manager actively ‘closes’ the report to submit to PSN data repository – report auto submits after 45 days

15. PSN® - How to submit to PSO
PSO Specific Legal Disclaimer
Individual file management
Batch file management

16. UHC Patient Safety Net® (PSN®) by the Numbers
Since 2004, over 2.2 million events
1.5 million AHRQ Common Format (v1.1) reports
103 sites representing:
20,500 Assigned passwords
19,000 staffed beds
138 Obstetrics and Obstetric Inpatient Units
119 Operating Room Departments
114 Emergency Departments
82 Radiation Departments and Radiation Oncology Units
61 Blood Banks
33 Pediatrics ICUs
23 Burn Units

17. UHC Patient Safety Net® (PSN®) Research Overview
Common Formats facilitate aggregate research and shared user experience
“Found in the NET” and PSN-based research:
Epidural medication misadministration 2009, N= 31
Transfusion related events, 2011, N= 29,506
Medication CPOE events, 2012
Annual falls survey

18. ADD Harmscore

19. UHC Patient Safety Net® (PSN®) Harm Score Survey
Shared user experience promotes applied learning
2011 Survey of 921 managers at 89 PSN users sites
Review of 9 clinical scenarios with AHRQ (v1.1)
harm score assignment
2012 Survey of 13,000 managers at 102 PSN user sites
Review of 9 clinical scenarios with AHRQ (v1.2)
Inter-rater agreement demonstrated “moderate” agreement
v1.1 – Fleiss’ kappa value = 0.51
V1.2 – Fleiss’ kappa value = 0.47
Submitted for publication – September 2012

20. PPC submission
Preparing for UHC PI PSO event submission via PPC to NPSD
Falls
Transfusions
Medications
Currently Testing
Internal goal to be first PSO to successfully submit to NPSD

21. UHC Performance Improvement PSO
First PSO member submission: September 2009
Total UHC PSN reports: 1,032,981 through June 2012
103 PSN Sites - Program Participants - eligible for PSO membership
47 PSO members in 21 States
19 Submitting members
Total PSO Submissions, from all event types: 66,976

22. PSN® User Groups for Analysis Organization
PSN Program Participants “Non PSO” N = 56 (of 103)
PSO Members N = 47
Total 101 Members
47 PSO Members
19 PSO Submitters
PSO Submitters
N = 19 (of 47)

23. Top Event Type and Distribution by PSN® User Group

24. Harm Score Distribution for 1,032,981 PSN® Events

25. Harm Score Distribution by PSN® User Group
Steve:
For this slide can you flip the listing
Non-PSO first at top of page
PSO middle.
PSO Submitter at bottom.

26. “PSO Submitter” Rates Org ID Submit to PSN PSO Submission Rate 1
18,691
95.99% 2
3,357
93.09% 3
6,577
86.03% 4
6,081
56.50% 5
15,772
47.76% 6
43,999
45.69% 7
15,354
30.62% 8
16,273
20.84% 9
27,530
3.21% 10
344
2.33% 11
16,874
.95% 12
3,845
.34% 13
3,365
.06% 14
16,658
.05% 15
5,339
.02% 16
19,437
.01% 17
31,440 18
11,760 19
12,666

27. PSO Submitted Event Distribution by Harm Scores (v 1.1)

28. PSO Submitted Event Distribution by Harm Scores (v 1.1)

29. Findings
Distribution of harm scores assignment is similar for all of PSN® Top submitted event types is similar for all of PSN® No physical barriers to PSO submission Percentage of total events submitted to PSO varies widely among PSO members Distribution of harm score for events submitted to PSO varies widely

30. Contributing Factors to PSO Submission Variation
Member Factors Safety culture Litigation posture Legislative climate in venue 11 States represented in 19 submitting organizations Submission guidelines Other factors…

31. Take Home Messages
Common Formats facilitate the collection and evaluation of patient safety data
PSOs provide a method to collect and share patient safety information
UHC PSO members’ submission practices vary widely

32. Thank you. Julie Cerese, UHC Vice President Steve Thomas, UHC Data Analyst Questions? Stephen Pavkovic, RN, MPH, JD Director Patient Safety UHC