1. 1 Patient safety indicators Yolanda Agra Varela. MD; Ph.D Sennior Adviser National Quality Agency. Ministry of Health Dublin 29 June 2006 Patient Safety. A national priority for the Spanish Health System

2. 2 STRATEGY Nº 8: To improve patient safety in the NHS To improve awareness and culture To improve awareness and culture To develop an information system on PS To develop an information system on PS To perform best practices in all Health Regions To perform best practices in all Health Regions STRATEGY Nº 8: To improve patient safety in the NHS To improve awareness and culture To improve awareness and culture To develop an information system on PS To develop an information system on PS To perform best practices in all Health Regions To perform best practices in all Health Regions PATIENT SAFETY: A PRIORITY FOR THE SPANISH NHS

3. 3 AWARENESS AND CULTURE INFORMATION -Communication campaign -National Conference: ENEAS -International Conference: November 2006 RESEARCH -Sponsoring National RP -Review Group on PS (agreement with Iberoamerican Cochrane Collaboration) PROFESSIONAL PERCEPTION Validated questionnaire “Hospital Survey on Patient Safety Culture” TRAINING -Basic training in all Regions -Risk Management Tool Kit: on-line -Training for managers and directors -Advanced Qualification on PS -Medication and safety -Material for University training

4. 4 Incidence of Patients with AE 30.121 14.70014.1791.0141.0973.745 14.179 6.579 5.624 INTERNATIONAL ADVERSE EVENTS INCIDENCE STUDIES SPAIN 2005

5. 5 INFORMATION SYSTEMS ADVERSE EVENTS ADVERSE EVENTS  Comparative Analysis of the International Information Systems of AE  Design a notification system of Adverse Events for the NHS, taking into consideration legal aspects INDICATORS INDICATORS  Agreement on national indicators on PS (AHRQ, OCDE)

6. 6 TO IMPROVE BEST PRACTICES IN ALL REGIONS  To improve patient identification  To implement PS Units  To prevent nosocomial infections  To promote good practices in clinical settings to prevent: -Anaesthesia-Related Complications -Hip Fractures in Surgical Patients -Pressure ulcers in Hospital Patients -Pulmonary Thromboembolism (PTE) and Deep Venous Thrombosis (DVT) in Surgical Patients -Infection in Surgical Wounds -Wrong-Site Surgery -Medication Errors and -Ensure Last Wishes of patients

7. 7 NATIONAL HEALTH SYSTEM

8. 8 PUBLIC HEALTH CARE Population covered 0.6 % 200,000 people Population not covered High income people De facto universal coverage 99.4 % 40 million people UNIVERSAL COVERAGE NATIONAL HEALTH SYSTEM

9. 9 779 HOSPITALS 157,926 BEDS 4 Beds per 1,000 inhabitants 326 (42%) 103,736 (66%) 574 Acute Care Hospitals 92 Mental Health Hospitals 113 Long-Term Care Centres 69,000 Physicians 103,000 Nurses 65% 85% PUBLIC FUNDED CENTRES IN-PATIENT HEALTH CARE - 2005 256 (40 %)

10. 10 PUBLIC HOSPITALS 1 consultation / per inhab. 55 million 55 million consultations 85% 17 million 17 million emergency cases 335 emergency case / 1,000 inhab. 77% 3 million 3 million surgeries 51 operations / 1,000 inhab.62% 4.5 million 4.5 million admissions 80 admissions / 1,000 inhab.70% STRUCTURE AND ORGANISATION SPECIALISED CARE NATIONAL HEALTH SYSTEM

11. 11 MINIMUM BASIC DATA SET Mandatory Administrative data Hospital Data Base Quarterly (MBDS) Health Region Data Base validation Regional Data Base National Data Base Hospital activity + Discharge records (ICD9-CM)

12. 12 SURGERY-RELATED COMPLICATIONS OBSERVATIONSINDICATOR CODE CASES PER YEAR Total (%) and discharges 2000200120022003 D: All surgical discharges Underreporting OECD: all hospitalized patients Underreporting: other sources are needed Wound Infection 998.5, 998.51, 998.59 23,960 (2.14) 1,117,478 25,537 (2.15) 1,186,381 26,573 (2.20) 1,203,129 27,888 (2.26) 1,230,378 D: All surgical discharges. Excl. obstetrics and newborn OECD adn AHRQ: also exlclude vena cava procedures Underreporting: other clinical records needed PTE-DVT 415.1, 11,19 45111,4519,4511, 4512,4518 20,010 (1.96) 1,018,443 20,957 (1.94) 1,078,437 21,268 (1.95) 1,088,100 22,978 (2.07) 1,109,453 D: All surgical discharges > 18 OECD: some diseases excluded Should we excluded them? Hip fracture 820 1,479 (0.14) 1,025,416 1,411 (0.13) 1,093,463 1,474 (0.13) 1,113,593 1,586 (0.14) 1,140,475 D: All surgical discharges OECD: all medical and surgical discharges Underreporting: surgical record should be reported Foreign body 998.4 173 (0.015) 1,117,478 201 (0.017) 1,186,381 202 (0.016) 1,203,129 193 (0.016) 1,230,378 Wrong site E876.5 3103-

13. 13 OBSTETRIC-RELATED COMPLICATIONS OBSERVATIONSINDICATOR CODE CASES PER YEAR Total (%) and discharges 2000200120022003 D: all newborn OCDE and AHRQ: live birth excluding subdural or cerebral hemorrage, injury skeleton, (767.3, 767.4) preterm and osteogenesis imprefecta (756.51) Not all Hospitals have clinical records for the newborn Birth trauma 767.0, 7673, 7674, 7677-9 3,332 (1.22) 272,470 3,423 (1.17) 291,558 3,379 (1.11) 303,918 3,202 (0.98) 320,903 D: 650, 651-659. Not all included OECD: vaginal delivery Vaginal 664-665 DRGs: 372-375 24,646 (9.07) 271,527 27,534 (9.8) 279,561 29,740 (11.36) 261,622 35,518 (12.75) 278,483 D: procedures 74.0, 74.99 OECD: cesarean delivery Cesarea DRGs: 370-371 265 (0.47) 56,086 272 (0.43) 63,375 314 (0.46) 67,993 372 (0.50) 73,644

14. 14 OTHER MEDICAL CARE COMPLICATIONS OBSERVATIONSINDICATOR CODE CASES PER YEAR Total (%) and discharges 2000200120022003 D:All discharges> 5 days.Excl: neonates and obstetrics Hemiplegia, paraplegia, quadriplegia Should be excluded? Underreporting: Nurse records should be included Pressure ulcers 707.0 11362 (0.75) 1,516,545 12971 (0.83) 1,552,007 13589 (0.86) 1,572,436 15254 (0.95) 1,610,410 D: All discharges. Excl: neonates and neoplasm Underreporting OECD: also exclude immunocompromised (codes?) Underreporting: other sources are needed Infections 999.3, 996,62 6901 (0.24) 2,859,960 6887 (0.23) 2,932,521 7617 (0.25) 2,979,440 8541 (0.28) 3,073,553 D: All discharges. Excl: neonates Underreporting: other data base needed Transfusional reactions 999.6, 999.7, not: E8760 ( % 0 ) 14 (0.004) 3,148,050 17 (0.005) 3,237,692 21 (0.006) 3,287,200 19 (0.006) 3,386,01 3

15. 15 ADVANTAGES OF MBDS Agreement at National level for a Minimum Basic Data Set Common standards for codification at national level (ICD-9-CM) Resources exists in the Hospitals (clinical documentation units) High Coverage: Almost 100% discharges are codified in public Hospitals and >25% in private (depending on the Region) High Coverage: Almost 100% discharges are codified in public Hospitals and >25% in private (depending on the Region) High qualification of the experts in codification in public hospitals Exhaustive codification: adverse events could be detected through MBDS Useful for identifying problems for further analysis

16. 16 LIMITATIONS OF THE DATA Clinical records: incomplete diagnosis information (comorbidity and elderly patients) Discharge records are the usual source of codification (not all diagnoses and procedures are included e.g.surgery discharges) Private acute care Hospitals (60%) not included in the MBDS Variability in codification related with qualification and DRG,s use of the data for reimbursement Second diagnosis: Prehospitalization vs in-patient complication Variability among Regions

17. 17 CONSEQUENCES Differences in the quality of codifications among Hospitals Lower rates of complications in comparison with specific studies: Underreporting Unknown variability among Regions National Specific software in development : delay in data reporting Oriented to assess cost and not quality of care

18. 18 ACTIONS FOR IMPROVEMENT To increase the number of private Hospitals with codification To improve professional awareness (managers and clinicians) Feed-back : Give to them to improve the quality of care, not as punishment To improve expert skills in codification in all Hospitals Systematic quality control for clinical records and MBDS Review all clinical records (not only discharge records) should be a requirement to perform the MBDS For a real picture we would need: review other data bases and clinical records and develop specific adhoc audits and studies For a real picture we would need: review other data bases and clinical records and develop specific adhoc audits and studies

19. 19 The challenge: Comparing these Indicators among the OECD countries