1. Copyright 2010 Health Data Solutions, Inc.  Risk management software project started by the Pioneer Health Network  Risk Managers wanted a better way to identify trends and issues needing attention.  Final product improved entire risk management process

2. Mistakes Cost Money $$ Musician losses arm due to mishandled injection: $6.7 million verdict $$ Neglect leads to gangrene, death: $10.7 million verdict $$ Errors at girl’s birth: $3.7 million verdict $$ Negligent post-op monitoring cost $1.5 million $$ Dementia patient wanders, killed by car: $850,000 $$ Delayed diagnosis yields $2 million $$ Unlocked wheelchair wheels lead to $250,000 fall $$ Miscommunication costs $1.65 million $$ Failure to respond to elevated Troponin results in heart attack, anoxic brain damage: $4.75 million settlement $$ Aspiration death: $2.06 million verdict $$ Hypoglycemic event leads to brain damage and $4 million settlement $$ Death from infection: $13.5 million settlement

3. Ways to Make it All Work Honesty Patient safety first Public relations Team work Good documentation system*

4. The Problem and Tracking Quality “The problem is not bad people; the problem is that the system needs to be made safer...” “More people die from medical errors than motor vehicle accidents...” Estimated as high as 98,000 deaths a year attributed to medical errors. IOM (2000). To Err is Human: Building a Safer Health System “Without ongoing tracking of quality to assess…progress in meeting the six aims for improvement (Safe, Effective, Patient-centered, Timely, Efficient, Equitable), patients, healthcare practitioners, policy makers, educators and purchasers cannot identify progress or understand where improvement efforts are most needed.” IOM (2001). Crossing the Quality Chasm: A New Health System for the 21 st Century, p. 40

5. National Patient Safety and Clinical Quality Efforts AHRQ ISMP IHI Ambulatory & Hospital Quality Alliances CMS Leapfrog Group Partnership for Pt. Safety NCQA Nat’l Quality Forum JC Nat’l Pt. Safety Foundation NPSF QUALITY CHOIR Attribution: Jerod Loeb, Joint Commission 5M Campaign HCUP PSO’sSentinel Event Reporting Data collection Safety Goals Hospital Core Nursing Sensitive Serious Reportable Events Cancer Care Thoracic Surgery Safe Practices Rewards Program Safe Practices ACE 9 th Scope of Work SCIPHCAHPS Collaboratives 100K Campaign Hospital Compare

6. “In God we trust; all others must bring data" -- W. Edwards Deming Quote at the bottom of an email signature of a Director Quality/Patient Safety & Dietary Services at a CAH in Ohio

7. Patient Safety Performance Measurement Data Evolution Data Collection Data Reporting Data Analysis Inform Strategy Typical Effort Desired Effort Healthcare Providers make significant investments in collecting data for regulatory or accreditation purposes The goal is to push the Effort Curve to the right through increased staff competency, use of tools and automation of data collection 1 fr Hill, Terry, Rural Hospital Performance Improvement and Balanced Scorecard

8. Quality Data Check  Electronic incident management software program.  Allows for electronic entry, investigation and trending of incidents.  Uploads data to web based application (webQDC) to provide aggregate reporting. Copyright 2010 Health Data Solutions, Inc.

9. The application and data reside on your own hospital network

10. Copyright 2010 Health Data Solutions, Inc. Data input screens are simple to use and navigate

11. Copyright 2010 Health Data Solutions, Inc. A paper reporting form is also available

12. Copyright 2010 Health Data Solutions, Inc. The investigation form is built into the system. The investigation can be assigned to a ‘reviewer’ electronically which adds to efficiency Assign SOC’s to all individuals involved in incident

13. Copyright 2010 Health Data Solutions, Inc. Final Review Committee Form Record any comments or recommendations made by the review committee

14. Report Capabilities Copyright 2010 Health Data Solutions, Inc.

16. Personnel Report  Report sorted by department and personnel  Identify Trends  Use the information for evaluations  Identify individual education and training needs Copyright 2010 Health Data Solutions, Inc.

19. CAH-Aggregate Data Report Copyright 2010 Health Data Solutions, Inc. Trending information can be uploaded to our website and reports generated for a region. Uploading is voluntary and no incident specific or PHI is collected. Regional data can be analyzed to support regional quality improvement projects. Trending reports can then determine effectiveness of project.

20. Copyright 2010 Health Data Solutions, Inc. Procedure/Test Occurrences by Severity CAH- Aggregate

21. For more information or to request a demonstration: Jason Friesen, President Health Data Solutions 620 276-7700 jason@healthdatasolutions.org www.healthdatasolutions.org