Transcript Safety Data for Safer Care: From Knowing to Doing

Safety Data for Safer Care:
From Knowing to Doing
Carolyn M. Clancy, MD
Director
U.S. Agency for Healthcare Research and Quality
1st OECD Health Care Quality Indicators Seminar
On Improving Patient Safety Data Systems
Dublin, Ireland -- June 30, 2006
Safety Data for Safer Care
 Safety in numbers
 AHRQ’s safety portfolio
 The growing role of
health information
technology
 Other safety initiatives
 Future directions
More Medical Errors in U.S.
Any medical mistake/error or test error in last 2 years
50%
25%
0%
22%
23%
UK
GER
25%
27%
NZ
AUS
30%
CAN
34%
US
“Taking the Pulse of Health care Systems”
Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05
Failure to Discuss Medications
% of patients who said prior medications were not reviewed at discharge
50%
23%
25%
27%
28%
UK
CAN
31%
33%
NZ
US
14%
0%
GER
AUS
“Taking the Pulse of Health care Systems”
Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05
Hospital/ER Readmissions
% of patients readmitted as a result of complications
50%
25%
10%
0%
GER
14%
15%
16%
17%
US
NZ
CAN
UK
20%
AUS
“Taking the Pulse of Health care Systems”
Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05
 18-month voluntary effort
 Over 3,000 U.S. hospitals representing 75% of
all U.S. hospital beds
 122,342 lives saved – a HUGE milestone
 Many millions more lives changed as we build
momentum for continuous improvement of
patient safety
Safety Data for Safer Care
 Safety in numbers
 AHRQ’s safety
portfolio
 The growing role of
health information
technology
 Other safety initiatives
 Future directions
AHRQ and Patient Safety
 Identify medical errors and other threats
to patient safety and understand why they
occur
 Advance knowledge of practices that will
reduce or eliminate the occurrence of
medical errors and minimize risk of
patient harm
 Develop, assemble and disseminate
information on how to implement best
practices for patient safety
 Enable providers to monitor and evaluate
threats to patient safety and the progress
being made
Patient Safety Net
 “One-stop” portal of
resources for
improving patient
safety and preventing
medical errors
http://psnet.ahrq.gov
 Information on patient
safety resources,
tools, conferences,
and more
 Customize the site by
creating “My PSNet”
page
Web M&M
 Morbidity and
http://webmm.ahrq.gov
Mortality website
identifies problem
areas and potential
solutions
 Shares new cases
and expert
commentaries
 Monthly spotlight
case with slide set
 28,000 visitors/mo.
Hospital Survey on
Patient Safety Culture
 Helps hospitals and health
systems evaluate employee
attitudes about patient
safety in their facilities or
specific units
 Includes survey guide,
survey, and feedback report
template to customize
reports
 AHRQ partnership with
Premier, Inc., Department of
Defense, and American
Hospital Association
We’re Educating Patients, Too
New Public Awareness Ads
Maybe I should have told
my doctor about all the
medications I was taking...
Safety Data for Safer Care
 Safety in numbers
 AHRQ’s safety portfolio
 The growing role of
health information
technology
 Other safety initiatives
 Future directions
HIT and Safety: Lessons
 The “T” in HIT isn’t just for
Technology -- it also needs
to include:
 Tools
 Teamwork
 Trust
 Evidence is important, but
 Evidence isn’t everything –
we also need VISION!
Health IT Opportunities
Reengineer processes to
improve patient safety
 As we migrate to a health IT
infrastructure, put effective processes in
place as the same time
 Augment health IT applications for error
reduction, CPOE and other decision
support tools
 Build in the necessary disciplines
and team approaches
How Do We Measure Success?
 Long term goals of the Quality/
Safety/Health IT Portfolios
– Improve medication safety
– Improved decision-making for patients and
providers
– Improve high-risk transitions in care
Health IT Research Funding
 Over 100 grants to
hospitals, providers, and
health care systems to
promote access to health
information technology
 Projects in over 40 states
 Special attention to best
practices that can improve
quality of care in rural,
small community, safety
net and community health
center care settings
AHRQ HIT
Investment:
$166 Million
Meds Safety and Health IT
 Maximize the effectiveness of e- prescribing
between physicians and community pharmacies
 Use patient-centered medication information
systems for frail elders
 Integrate prescribing tools with decision support
(checking dosage, contraindications, and drug
interactions) into provider practice
 Implement decision support functions, including
the influence of weight based dosing on
pediatric adverse drug events
Warfarin Interaction Alert
Safety
alert!
 Blood thinner warfarin is
one of top 15 most
prescribed drugs in U.S.
 In AHRQ-supported study,
doctors using computerized
alert system ordered 15
percent fewer prescriptions
for drugs that can interact
with warfarin
AC Feldstein et al, Archives of Internal Medicine, May 8, 2006
AHRQ's Ambulatory Patient
Safety Program
 Five year goal: measurably improving the
safety and quality of care for patients in
ambulatory environments
 Develop, deploy and evaluate ambulatory
health IT systems – focus on both
technology and system solutions
 Rapid research in AHRQ’s real-world
research networks
– What is the relationship between health IT, safety
and quality (including efficiency)?
– How can we derive the greatest benefit - - clinical
and financial – from health IT investments? from
patient safety investments?
– How can we move what we know works into widescale practice?
What is the rationale for a
focus on ambulatory care?
 Health care services continue to shift into the
ambulatory arena
 Ambulatory care and transitions in care are
high-risk for patient safety
 Patient safety research and improvement has
focused on hospitals
 Ambulatory care requires:
– Complex information management
– Coordination of care for chronically ill and elderly
patients
Safety Data for Safer Care
 Safety in numbers
 AHRQ’s safety portfolio
 The growing role of
health information
technology
 Other safety initiatives
 Future directions
Patient Safety Act of 2005
• Creates “Patient Safety
•
•
•
•
Organizations (PSOs)
Establishes “Network of Patient
Safety Databases”
Mandates Comptroller General to
study effectiveness of Act (by 2010)
Is completely voluntary
Would be impossible without health
IT backbone
PSO Objectives
 To generate information relevant to preventing




harm to patients from health care
(aggregate/analyze incident data; disseminate
results)
To employ interoperable terms, definitions of
patient safety incidents
To simplify task of reporting incidents
To provide benchmarking & trend reports
To share de-identified data for use in
improving patient safety
Solving a Safety Data Problem
 U.S.providers fear that patient safety analyses
can be used against them in court or in
disciplinary proceedings
 State laws offer inadequate protection (e.g.,
large providers cannot share analyses
system-wide without risk)
 Patient safety improvement is hampered by
the inability to aggregate data; by analyzing
large numbers of events, patterns of failures
could be more rapidly identified
PSO Activities
 Conducts efforts to improve patient safety




and quality
Collects & analyzes data, reports, records,
root cause analyses
Develops/disseminates information to
improve patient safety
Encourages culture of patient safety
Maintains procedures to keep work product
confidential
Network of Patient Safety
Databases
 Interactive evidence-based management
resource
 Capacity to accept, aggregate, & analyze nonidentifiable data voluntarily reported by PSOs,
providers, & others
 Data to be used to analyze national & regional
statistics, including trends & patterns of health
care errors
 Information to be made public & reported
annually (in AHRQ’s National Healthcare
Quality Report)
Next Steps
 Develop & publish proposed rules governing
operations of PSOs
 Finish inventory of data elements, definitions
& encoding schemes
 Consider options for fostering development of
a network of patient safety databases
 Plan for inclusion of patient safety information
on performance, trends AHRQ’s NHQR/DR
Targeted Injury Detection System
 AHRQ’s ACTION Network is supporting three
studies to develop and implement targeted
injury detection systems to reduce inpatient
injuries
 Addresses adverse drug events, hospital
acquired infection and pressure ulcers/injuries
 Systems will be designed for deployment
deploy in large urban hospitals and small rural
hospitals across U.S.
 Will be compatible with diverse electronic
health record systems
Systems-level Error-Proofing
 Rapid-cycle learning from
lean manufacturing
systems, e.g. Toyota
production system
 High Reliability
Organization (HRO)
systems can be adapted
into hospital settings, e.g.
airline safety systems
 Empowered employees
and committed leadership
are keys to success
“Fail Safe” Hospitals
 Organizational infrastructure:
- certified patient safety officer as part of line management;
- Culture of Safety (organization-wide training; rewards for reporting;
transparency; etc.)
 Measurement infrastructure:
- AHRQ-standard concurrent and retrospective trigger systems
- Culture of Safety-based voluntary reporting system
- certified pharmacist (or equivalent) performing real-time ADE
evaluation
- certified chart reviewers (random sample or full census)
- participates (sends data) to central (AHRQ) data repository
- external audits of injury detection data systems
 Implemented safe practices:
- NQF / AHRQ evidence-based safe practices (~30, at present)
- IHI 100,000 Lives campaign
Improving Patient Safety Through
Simulation Research
 New AHRQ RFA for
research / evaluation of
simulation and the
roles it can play in
improving safe delivery
of care
 Total amount of $2.4
million to fund 8-10
new grants
 First projects to start
this fall
AHRQ RFA-HS-06-030
Safer Hospitals by Design
 U.S. hospital building
boom - $23 billion
spent in 2005 alone
 Creates opportunity to
design safer hospitals
and incorporate
Health IT
 Small but growing
body of research can
help inform planning
and construction
process
P4P and Patient Safety
 Pay for ‘safety enhancing
activities’ (efforts to
promote safety culture;
effective implementation of
HIT)
 NO or decreased payments
for harmful care
 Prerequisite: capacity for
seamless electronic
reporting of performance
measures and adverse
events
Is health care getting safer?
No
Is health care getting safer?
No
Yes
Is health care getting safer?
No
Yes
X
Yes, but we need more
and better data, and we
need to build our
partnerships as we build
the evidence base
Your questions?