Transcript 22 percent of Medicare SNF residents experienced

Resident Safety
James E. Lett, II, MD, CMD
Perfection: or,
The Unicorn in the Room
We know that patient safety is the
bedrock of quality care
Institute of Medicine: Quality Care
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IOM elements of “Quality”
• Safe: avoiding injuries to patients from the care that is intended to help them
• Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care
• Effective: providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse)
• Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and
energy
• Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status
• Patient-Centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions
“STEEEP” Framework outlined by the Institute of Medicine (“IOM”)
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Is There a Problem?
• In 1999, the Institute of Medicine in its landmark report, "To Err is
Human," pointed out that at least 44,000 people, and perhaps as many as
98,000 people, die in hospitals each year as a result of medical errors that
could have been prevented. IOM called for the building of a safer
healthcare delivery system.
• In 2009, ten years after the original IOM report, Consumers Union, the
non-profit publisher of Consumer Reports, concluded in its report "To Err is
Human - To Delay is Deadly": "Despite a decade of work, we have no
reliable evidence that we are better off today. More than 100,000 patients
still needlessly die every year in U.S hospitals and healthcare settings."
MEDICARE ATYPICAL ANTIPSYCHOTIC DRUG CLAIMS
FOR ELDERLY NURSING HOME RESIDENTS
• Fourteen percent of elderly nursing home residents
had Medicare claims for atypical antipsychotic drugs.
• Eighty-three percent of Medicare claims for atypical
antipsychotic drugs for elderly nursing home
residents were associated with off-label conditions
• Twenty-two percent of the atypical antipsychotic
drugs claimed were not administered in accordance
with CMS standards regarding unnecessary drug use
in nursing homes.
Office of the Inspector General, 2011
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CMS Press Call
• Held on September 19, 2014
• Stakeholder participation
– AHCA
– LeadingAge
– AHQA
– AMDA
– Advancing Excellence
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-09-19.html
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CMS 2015 & 2016 Goals
• Reduce the national prevalence of antipsychotic
medication use in long-stay nursing home residents:
– By 25 percent by the end of 2015
– By 30 percent by the end of 2016
• Discover ways to implement new practices:
– To enhance quality of life
– To protect residents from substandard care
– To promote goal-directed, person-centered care
approaches
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-09-19.html
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OIG Adverse Events in Post-Acute
Care
• Search: OIG Adverse Events SNF
• Adverse Events in Skilled Nursing Facilities:
National Incidence Among Medicare
Beneficiaries (OEI-06-11-00370)
• Link: https://oig.hhs.gov/reports-andpublications/oei/a.asp#adverse_care
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Population
• 692 Medicare-paid SNF stays that the
following criteria:
– began within 1 day of discharge from a hospital
– had a length of stay of 35 days or less
– ended in August 2011.
• Drawn from a population of 100,771
beneficiaries
– Included long-stay and short-stay population
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Incidence Rate of Adverse and
Temporary Harm Events (stays < 35
days)
• 22 percent of Medicare SNF residents
experienced adverse events during their SNF
stays
– 21,777 post-acute Medicare SNF residents
experienced at least 1 adverse event
• An additional 11 percent of residents
experienced temporary harm events
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Source: OIG, Adverse Events in Skilled Nursing Facilities, OEI-06-11-00370, February 2014.
Incidence Rate of Adverse and
Temporary Harm Events (cont.)
Per 1,000
Resident Days
Per 100
Admissions
Adverse Events
14
21
Temporary Harm Events
11
16
Adverse and temporary
harm events
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Category
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Incidence Rate of Adverse and
Temporary Harm Events (cont.)
• 1.5 percent of Medicare SNF residents
experienced events that contributed to their
deaths
– 1,538 SNF residents experienced adverse events
that contributed to their deaths during the study
month.
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Incidence Rate of Adverse and
Temporary Harm Events (cont.)
Medication
Events
• Medication-induced change in mental status
• Internal bleeding due to medication
• Fall with injury secondary to medication
Resident
Care Events
• Fall with injury related to resident care
• Acute kidney injury or insufficiency secondary to
fluid maintenance
• Exacerbations of preexisting conditions resulting
from an omission of care
Infection
Events
• Aspiration pneumonia and other respiratory
infections
• SSI associated with wound care
• CAUTI
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Incidence Rate of Adverse and
Temporary Harm Events (cont.)
Patient Harm by Category of Harm
100%
90%
80%
37%
43%
70%
60%
50%
40%
Medication
37%
30%
Resident Care
40%
Infections
20%
10%
26%
17%
0%
Adverse Events
Temporary Harm Events
Source: OIG, Adverse Events in Skilled Nursing Facilities, OEI-06-11-00370,
February 2014
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Preventability of Events
Preventability Assessment
Preventable—Harm could have been avoided through improved
assessment or alternative actions
Clearly preventable
Likely preventable
Not preventable—Harm could not have been avoided given the
complexity of the resident’s condition or care required
Clearly not preventable
Likely not preventable
Unable To Determine Preventability
Percentage of
All Events
59%
13%
46%
37%
11%
26%
4%
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Costs to Medicare
– 59% of those who experienced events went to a
hospital for care
• 19% percent hospitalization rate among observed population
• Projected Medicare reimbursements for inpatient
stays and ED visits because of adverse events in
SNFs:
– $208 million – Estimated reimbursements monthly
– $136 million – Estimated reimbursements monthly for
preventable events
• $2.8 billion – Extrapolated reimbursements for
FY 2011
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The “Culture of Safety”
• Culture
– “The way we do things around here”
• Patient Safety
– Avoiding injuries from care intended to help
patients
– Not harming our residents
• The issue
– How can we provide care without “collateral
damage” to our residents?
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Describing Harm
• Commission vs. Omission: Event resulting from medical
intervention vs. event resulting from lack of medical
intervention
• Near Miss: An event or situation that did not produce patient
injury, but only because of chance. This good fortune might
reflect robustness of the patient (e.g., a patient with penicillin
allergy receives penicillin, but has no reaction) or a fortuitous,
timely intervention (e.g., a nurse happens to realize that a
physician wrote an order in the wrong chart). This definition is
identical to that for close call. AHRQ
• Cascade Event: A series of multiple, related adverse events
counted as a single harm
Cascade event
•
•
•
•
•
•
Agitated lady (pain) 
Prescribed antipsychotic for disruptiveness 
Lethargic  Incontinent 
Foley catheter placed 
UTI  Septic 
Hospitalized  Dies
Center for Innovation in Quality
Patient Care: Johns Hopkins
Show Leadership’s Commitment and Encourage
Accountability
“Your organization’s leaders, including CEOs and trustees, must
show that they are dedicated to patient safety. They also have
the power to keep the organization focused on safety. They can
do this by creating strategic safety goals, making safety issues a
standing agenda item at meetings, and discussing safety issues
with transparency in organization wide and unit/departmentwide meetings. Accountability increases when upper- and midlevel managers know that top leaders are interested in safety
and are following trends in adverse events.”
The CEO as Alpha Dog
• Prioritize patient safety with personal
leadership
– By statements & example
• Open meetings with safety subjects
– Demand measurement of appropriate outcomes
& performance w/report to you each meeting
– AP’s, falls, unanticipated deaths
– Answers should make sense to you
The CEO as Alpha Dog
• Periodic safety rounds where demonstrate
knowledge of those resident safety measurement
results
• Ask front line staff: “How do you think the next
resident may be harmed?”
– They know & they will tell you
– Then act on their statements: credibility
• Near misses: The window to future harm
• Reporting all events, not just “the bad ones”
Re-thinking the Obvious
• “…without solid data, improving safety is
nothing more than a marketing ploy with little
or no substance.” Peter Pronovost, MD, PhD. Safe Patients, Smart Hospitals
• Consider: If your CFO financial report was: “I
think things look pretty good this month.”
Re-thinking the Obvious
• Re-think the concept of “Stuff Happens” – in
fact is inevitable - in this frail population
– “Raccoon eyes”
• A patient safety breach is some resident being
harmed
• Keeping residents safe includes freedom from
emotional, medical care, medication-induced
& physical injuries, and can be caused by
actions and inaction.
“Just Culture”
• Overcoming the barrier of fear of reporting
personal near-misses or events causing harm
• All events & near misses to be honestly
reported & evaluated
– Anonymously if necessary
– Monthly QI review with structural changes as
necessary
Staff Empowerment & Supportive
Policies
• Safety issues are typically d/t poor systems or
negative culture, not poor staff
– “I told the doctor she was allergic to PCN, but…”
– “I told the nurse he was getting weaker & should
be evaluated before therapy, but he said send the
resident there anyway & …”
– “I told the pharmacy we needed a special pump
for the morphine drip, but they said use the old
one we had, & …”
The Power of the Team
• Engage residents & families
– “Put a suit on him.”
• Acknowledge & demand a team approach to
care
– “The $25K diaper”
Select a Champion
• Characteristics observed with successful
champions:
– Had authority to drive change
• Actual/Perceived/Access
– Title/job description less important than ability to
motivate staff
– Training/education skills
– Innovative
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Utilize the Medical Director &
Consultant Pharmacist
• Designate M/D time to safety issues monthly
• Regular review of unplanned transfers out to ED/Hospital
by M/D & nursing with report at QI Committee
• Review of charts in fall residents or those injured
• Screen for high-risk medications & evaluate usage – with
CP
• Chart review for residents with 9 (?) or more medications
• Screen for high-risk combinations (i.e., multiple anticoagulants)
System to Report and Analyze Error
• Electronic Occurrence Reporting System
– Quantros/Dr Quality/ORM
– Web based
– Confidential and Peer Review protected
• ALL staff encouraged to file reports online
– Patient injury
– Adverse drug reactions
– Near-misses
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https://qxpert.quantros.com/orm/jsp/
JeffersonLogin.jsp
Click here to report an occurrence (a.k.a. variance or incident) anonymously. You do
not need a User ID or Password to do this. Please assist us in creating a safer
healthcare environment for the customers we serve
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Reporting and Analyzing Error
• Can be as simple as a locked box outside the
DON office
• Confidential and Peer Review protected
• QI Cte review monthly
• Focus on non-punative, systems-based
analysis
• Formulate basis of Patient Safety In-services
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Ambulatory Patient Safety
Quality Care
Patient Safety
•
•
•
•
Capture errors that occur
Analyze errors
Follow-up on analysis
Safety projects will emerge
–
–
–
–
–
–
Medication
Communications
Team work
Test results
Pt education about safety
Family education about safety
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Create a Culture of Patient Safety
• Enhance library with Patient Safety materials
– Journal of Patient Safety; Patient Safety & Quality Healthcare
Journal
– Seminal textbooks
• Crossing the Quality Chasm
• To Err is Human
• Enhance clinic technology for Patient Safety
– Drug Interaction software on all computers and handhelds
• In-services: DON, M/D, Administrator … You?
• Safety discussions in morning report
– “Mrs. Jones fell yesterday ……..”
• Clinic leadership makes “Patient Safety Rounds”
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Create a Culture of Patient Safety
• AHRQ Patient Safety Culture Survey
http://www.ahrq.gov/qual/hospculture/
– Outpatient format available in PDF or Word
– Results display template on PowerPoint
• Involve entire clinic in patient safety culture
survey
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Patient Safety Culture Survey
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Sample culture Survey result slide:
Overall Perceptions of Safety
Survey Items
• 1. Patient safety is never sacrificed to get more
•
work done. (A15)
• 2.Our procedures and systems are good at
• preventing errors from happening. (A18)
•R3. It is just by chance that more serious
• mistakes don’t happen around here. (A10)
•R4. We have patient safety problems in this
• unit. (A17)
R
% Strongly Disagree/
Disagree
5
% Neither
25
15
20
% Strongly Agree/
Agree
70
25
60
30
80
50
15
Indicates reversed-worded items.
NOTE: The item letter and number in parentheses indicate the item’s survey location.
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Page
5
Why a Safety Culture is Important
Studies by Bryan Sexton, a former faculty
member at Johns Hopkins University School of
Medicine who created the robust Safety
Attitudes Questionnaire, show a positive
correlation between a high culture of safety
score with higher staff retention and improved
clinical outcomes, including:
Why a Safety Culture is Important
•
•
•
•
•
•
•
•
Reduced length of stay
Fewer medication errors
Lower rates of ventilator-associated pneumonia
Lower rates of bloodstream infection rates
Fewer decubitus ulcers
Higher employee morale
Lower staff burnout
Less absenteeism
Why a Safety Culture is Important
• Without a system, or culture, of safety you
rely on luck and/or heroic individuals to avert
patient harm events. Ultimately, luck runs out
and heroes burn out.
The Elusiveness of Patient Safety
Patient Safety is largely invisible.
When patient safety is effective
– nothing happens!
The Patient Safety Imperative
• Hospital 30-day readmission penalties:
Hospital & soon SNF
• VBBP for SNF
• Rise of the Baby Boomers
• 5 Star rating: Recent “adjustment”
– 30% lost one or more stars
– Additional of antipsychotic use
• Survey: Annual & Complaint-related
The Patient Safety Imperative
(cont.)
• Liability: Falls the top suit type filed
• Staff turnover
• Resource expenditure
– Time with unhappy families
– Cost of staff time & supplies to care for injuries
• False Claims Act potential
• Environmental forces: The ACA
Re-hospitalizations Update:
• Medicare FFS hospital 30-day readmission rate
based upon 2012 data has fallen to 18.4%
Gerhardt G et al. Medicare readmission rates showed meaningful decline in 2012. Medicare and Medicaid Research
Review. March 2, 2013.
• Annual cost of readmissions to Medicare is
$17.5 billion
Armour S. Hospital readmissions for U.S. medicare patients decline. Bloomberg. Feb 28, 2013.
• Appears to be no “right” 30-day readmission
rate, but pressure to reduce the rate will
continue
SNF Readmissions to Hospital
• In 2006 there were 1.70 million SNF episodes, of
which 419,669 (23.5%) re-hospitalized within 30 days
• From 2000-2006 the re-hospitalization rate increased
by 29% - from 18.2% to 23.5%
• Total Medicare reimbursements associated with
these re-hospitalizations - $4.34 billion
Mor, Intrator, et al. Health Affairs, Jan 2010
Acute Care Utilization After SNF
Discharge
• 55, 980 Medicare beneficiaries >65 who were
hospitalized SNF  discharged home
– January 2010 thru August 2011
• Acute care utilization within 30 days of SNF
discharge was 22.1% (37.5% w/in 90 days)
– 14.8% re-hospitalization
– 7.2% ED visit w/o hospitalization
• Greater likelihood: male, dual eligible, > Charlson
score, certain dx (neoplasm, respiratory dz), for
profit SNF or fewer LPN hours per pt. day
Toles, Anderson et al. Restarting the cycle: incidence and predictions of first acute care use after nursing home discharge. JAGS 2014,62:7985.
Improving Medicare Post-Acute Care
Transformation (IMPACT) Act of 2014
Section 2: amends title XVIII of the Social Security
Act to add a new section 1899B which requires PAC
providers (HHA, SNF, IRF & LTCH) to report:
• Pt. standardized assessment data
• Standardized quality measures, &
• Resource use measures
• By 10/1/18 for all but HHA which must report by
1/1/19
Value-Based Purchasing Program:
Not Just for the Hospital Anymore
Bill further directs the HHS Secretary:
• Est. a SNF value-based purchase program (SNF VBP)
• Applying first a readmission measure, later to be replaced
w/resource use measure
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•
•
•
Est. measure performance standards for VBP
Methodology to assess performance for each SNF
Rank the performance scores
Increase federal per diem per SNF by the VBP (which
may be a zero percentage!)
• Reduce per diem by 2% beginning FY2019 to fund
• Report performance publically on NH Compare
IMPACT Act Measures
1. Percent w/Pressure Ulcers that are new or
worsened
2. Percent experiencing one or more falls with
major injury
3. All-cause 30-day readmission to hospital
4. Percent w/admission & discharge functional
assessment & a care plan that addresses
function
Raising the Ante: Rise of the “Baby
Boomers”
• Clinical expectations
• Survey expectations: as clinical expectations ramp
up, so will regulatory oversight
• Liability considerations
• Family expectations
Raising the Ante: Environmental
Considerations
• Increasingly, governmental & market forces
will pressure the Post-Acute market as your
residents become part of programs to
reduce hospital admissions & readmissions
• Federal: The Affordable Care Act:
–
–
–
–
Accountable Care Organizations
Hospital Readmission Reduction Program
Bundled Payments
Community Based Care Transitions Program
Raising the Ante: Environmental
Considerations (cont.)
• Market: Care Transition programs:
– Care Transitions Initiative
– Transition Care Model
– Better Outcomes for Older Adults through Safer
Transitions (BOOST)
– Re-Engineered Discharge (Project RED)
– Interventions to Reduce Acute Care Transfers
(INTERACT)
We need creativity
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A Consumer’s View
1. Focus on what is right for the patient.
2. Don't be mired in the way things "have always been done."
Let technology help you in caring for patients.
3. Realize that any new technology or technique may have
unintended changes to daily routine, but remember that
this is better than having an adverse event.
4. Ensure changes help caregivers better manage their own
daily work days.
5. Get closer to the patient.
Michael Wong, Founder, Physician-Patient Alliance for Health & Safety
• Resident Council, or Resident focus group, to
assess safety perspectives
• Family focus group to assess safety
perspectives
• Local hospital assistance for expertise, or
involvement in a safety program with them
Delivering on our Promise of Quality
Medical Care
Quality Care
Patient Safety
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“Leadership is the ability to address
problems that make the world better.
It’s about inviting people into the
process and providing hope that they
can make a change.”
Peter Pronovost, MD, PhD. Safe Patients, Smart Hospitals