Influencing Healthcare - Safety and Measurement

Influencing Health Care:
Safety & Measurement
Peter Angood MD FACS FCCM

Vice President & Chief Patient Safety Officer
Joint Commission (JCAHO)
Chief Patient Safety Officer & Co-Director
Joint Commission International Center for
Patient Safety

Chicago, USA
> 5 Years After The IOM Report:
“To Err Is Human”
 Regulation/Accreditation: A-
 Workforce Training Issues: B
 Information Technology: B-
 Error Reporting Systems: C
 Malpractice System: D+
Wachter, RM; Health Affairs; 11/2004
Mission:
 To continuously improve the safety and
quality of care provided to the public
through the provision of health care
accreditation and related services that
support performance improvement in health
care organizations.

 Free-standing not-for-profit organization
with deemed status by federal Center for
Medicare and Medicaid Services (CMS)
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)

“To continuously improve the
safety and quality of care”
The Joint Commission on Accreditation of Healthcare Organizations
~ Overlapping Strategies ~
 Committed to continually
enhance the value of its
accreditation and certification
programs.
• The Joint Commission will strive to
ensure that they are patient-centered,
data-driven, relevant, and integral to
the performance improvement activities
of health care organizations.
Commitment: To continually enhance the value of Joint Commission
accreditation and certification programs to ensure that they are patient-
centered, data-driven, relevant and integral to the performance
improvement activities of health care organizations.
As of December 30, 2005.


Ambulatory Care 1,234
Assisted Living 72
Behavioral Health Care 1,821
Critical Access Hospitals 268
Home Care 3,422
Hospitals 4,342
Laboratory 1,947
Long Term Care 1,364
Networks 21
Office Based Surgery 221
Total 14,712
Accredited Programs


Disease-Specific Care 229
Health Care Staffing 70
Total 299
Certified Programs
This is the core competency of the Joint Commission
Safety and Regulatory Issues
Persistent Accreditation Issues:
 Precision of standards
 Consistency of surveyors
 Perceptions of relevance
 Intermittent nature of process

Shared Visions, New Pathways
~ Overlapping Strategies ~
 Committed to developing,
utilizing, and maintaining valid
and reliable performance
measures.
• These measures are needed to support
a credible, data-driven accreditation
process and the publication of
meaningful comparative performance
information for the public.
 Requirements that define
performance expectations with
respect to structure, process, and
outcomes that must be substantially
in place in an organization to
enhance the safety and quality for
patient care

 Performance Measurement Data
 Adverse Event Reporting
Standards
Core Measure Identification Process
Library of hospital priority measurement areas
• Acute myocardial infarction (implemented
2002)
• Heart failure (implemented 2002)
• Community acquired pneumonia (implemented
2002)
• Pregnancy and related conditions
(implemented 2002)
• Surgical infection prevention (Implemented
July 2004)
• Intensive care (Scheduled July 2005)
• Pain management (In development)
• Children’s asthma (In development)
• Hospital Based Inpatient Psychiatric Services
(In development)
• DVT (In development)
• Sepsis (In development)
Performance Measurement
 Environment is rapidly evolving
 US Federal Gov’t – accelerating change
 Link between performance measurement and
accreditation
 Alignment with Hospital Quality Alliance
(HQA-2003) & National Quality Forum (NQF-
1999) important
 Accreditation:
• contractual agreement to collect on 3
measure sets
• AMI, CHF, Pneumonia, SIP or Pregnancy
& Related Conditions
~ Overlapping Strategies ~
 Committed to making patient
safety an imperative in all
accredited organizations.
• This will be accomplished through the
standards and policies of the Joint
Commission and through collaboration
with other patient safety leadership
organizations.
Sentinel Event Policy
Established in January 1996:
• To have a positive impact in improving
care
• To focus attention on underlying
causes and risk reduction
• To increase the general knowledge
about sentinel events, their causes and
prevention
• To maintain public confidence in the
accreditation process
Percent of 3231 events
Sentinel Event Alerts
1. Potassium chloride
2. Policy issues
3. Policy issues
4. Policy issues
5. Policy issues
6. Wrong site surgery
7. Suicide
8. Restraint deaths
9. Infant abductions
10. Transfusion errors
11. High Alert Medications
12. Op/post-op
complications
13. Impact of SE Alert
14. Fatal falls
15. Infusion pumps
16. Proactive risk reduction
17. Home fires (O2 therapy)
18. Kernicterus

19. Look-alike, sound-alike
drugs
20. Kreutzfeldt-Jakob disease
21. Medical gas mix-ups
22. Needles & sharps injuries
23. Dangerous abbreviations
24. Wrong-site surgery #2
25. Ventilator-related events
26. Delays in treatment
27. Bed rail deaths & injuries
28. Nosocomial infections
29. Surgical fires
30. Perinatal deaths
31. Anesthesia awareness
32. Kernicterus #2
33. PCA by proxy
34. Intrathecal vincristine
35. Wrong route / wrong tube
36. Medication reconciliation
37. Device Connections
National Patient Safety Goals
 Selection of the Goals and
requirements is guided by a panel of
experts:
Sentinel Event Advisory Group
 Each year, a set of Goals & their
Requirements are identified from a
variety of sources
 The Goals and their Requirements are
field reviewed & published by mid-year
for the coming calendar year
NPSG Compliance Data for 2003—2006
NPSG requirement 2003 2004 2005 2006
1a: Two identifiers 3.8% 4.1% 3.9% 3.8%
1b: Time out before surgery 8.9% 8.0% 17.1% 7.7%
2a: Read-back verbal orders 7.4% 8.2% 11.6% 9.6%
2b: Standardize abbreviations 23.5% 24.8% 39.5% 11.5%
2c: Improve timeliness of reporting --- --- 7.6% 17.3%
2e: Hand-off communications --- --- --- 5.8%
3a: Concentrated electrolytes 3.0% 1.9% 1.3% ---
3b: Limit concentrations 0.6% 0.9% 1.5% 0.0%
3c: Manage look-alike/sound-alike
drugs
--- ---
1.9% 5.8%
3d: Label medications & solutions --- --- --- 7.7%
4a: Preoperative verification 1.5% 5.4% 5.5% 1.9%
4b: Surgical site marking 6.2% 4.6% 3.8% 3.8%
7a: CDC hand hygiene guidelines --- 1.2% 3.6% 7.7%
7b: HC-associated infection & RCA --- 0.1% 0.0% 0.0%
8a: Medication reconciliation – list --- --- 0.0% 3.8%
8b: Medication reconciliation –
reconcile
--- ---
0.3% 7.7%
9a: Fall risk assessment --- --- 3.0 ---
9b: Fall prevention program --- --- --- 7.7%
Alternatives Approaches to the NPSGs
NPSG requirement 2004 Requests 2005 Requests
1a: Two identifiers 3 1
1b: Time out before surgery 1 1
2a: Read-back verbal orders 6 0
2b: Standardize abbreviations 15 17
2c: Timeliness of reporting -------- 1
3a: Concentrated electrolytes 90 1
3b: Limit concentrations 10 35
3c: Look-alike/sound-alike drugs -------- 14
4a: Preoperative verification 6 1
4b: Surgical site marking 54 0
5a: Free-flow protection 42 4
6a: Alarm maintenance & testing 1 0
6b: Alarm settings & audibility 4 0
7a: CDC hand hygiene guidelines -------- 78
7b: Infection-related sentinel events -------- 0
8a: Medication reconciliation -------- 10
8b: Medication information to next provider -------- 0
9a: Fall risk assessment -------- 3
2005 National Patient Safety Goals
1. Patient identification
2. Communication among caregivers
3. Medication safety
4. Wrong-site surgery
5. Infusion pumps
6. Clinical alarm systems
7. Health care-associated infections
8. Reconciliation of medications
9. Patient falls
10. Flu & pneumonia immunization
11. Surgical fires
12. NPSG implementation by network
components
1. Patient identification
2. Communication among caregivers
3. Medication safety
4. Wrong-site surgery Universal Protocol
5. Infusion pumps
6. Clinical alarm systems
7. Health care-associated infections
8. Reconciliation of medications
9. Patient falls
10. Flu & pneumonia immunization
11. Surgical fires
12. NPSG implementation by network
components
13. Patient involvement
14. Pressure ulcers
2006 National Patient Safety Goals
Provisions of the Universal Protocol
 Preoperative verification process
• Relevant pre-op tasks completed and
information is available and correct

 Surgical site marking
• Unambiguous mark, visible after prep & drape
• Right/left, multiple structures or levels

 “Time out” immediately before starting
• Involves entire team; active communication
• Fail-safe model: “No go” unless all agree

 Applicable to invasive procedures in all settings
Wrong-site Surgeries
Surveying and Scoring the
National Patient Safety Goals
 Must implement all applicable Goals &
Requirements or implement an
acceptable alternative(s)
 Evaluated in the PPR and during all full
accreditation surveys and for-cause
surveys
 Surveyors evaluate actual performance,
not just intent
 Failure to comply with one or more
requirements of a Goal will result in a
“Requirement for Improvement”
 NPSG requirements that are also in the
standards will only be scored once (no
“double jeopardy”)
 Aggregate data
• Data from 2003 - 2005 surveys posted
on Joint Commission web site
 Individual health care organizations:
• Compliance with specific requirements
• Quality Reports - on web site since
2004
Public Disclosure of Compliance
with National Patient Safety Goals
~ Overlapping Strategies ~
 Committed to ensure that the
accreditation process is publicly
accountable.
• The Joint Commission will provide
meaningful and useful information about
the performance of accredited
organizations to the public.
WWW.QualityCheck.org
SIP Measure Reporting
Strategic Surveillance System - Release 1.0
(Corporate Summary & Comparison of Organization Level PFP Points)
System ABC’s PFP Point Total Average = (3282.50/11) = 299
System ABC compared to other groups of hospitals from PFP Studies:
PFP Means Across Various Groups of Hospitals -
2004 Studies
299
163
190
206
243
348 348
0
50
100
150
200
250
300
350
400
NYCHHC Solucient
Benchmark
Group
US News
Benchmark
Group
Random
Control Group
For Cause
Group
Conditional
Accreditation
Status
Preliminary
Denial of
Accreditation
Status
Group Name
P
F
P

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System
ABC
Strategic Surveillance System - Release 1.0
(Corporate Dashboard View by Measure Set)
Hospital Quality Alliance
 2003 - Voluntary reporting of 10 selected
measures from JCAHO & CMS focused
towards AMI, CHF & Pneumonia
 2004 - Medicare Modernization Act created
formal link to measures and hospital
reimbursement
 2005 – expanded to all measures and
included SIP measures set
 2007 – reported patient experience of care
survey (H-CAPS) & risk-adjusted measures
for 30-day mortality of AMI & CHF to be
gathered by CMS
Institute of Medicine 2005
 Performance Measurement
recommendations includes IOM’s
starter set of measures for hospital
performance that is > HQA measures
 2006 - Deficit Reduction Omnibus Act
adopts IOM recommendations for
inclusion in a new “value-based
purchasing” (P4P) framework to be
implemented by 2009

 State-based initiatives increasing
HQA & NQF Changes
 Joint Commission remains committed
& flexible to evolving performance
measurement environment
 Deficit Reduction Act creates impetus
for HQA & NQF to accelerate
expansion of the array of measures in
the production process:
• SCIP
• ICU Measure Set
• Pediatric Asthma
• Nursing-Sensitive
• AHRQ Quality Indicators
~ Overlapping Strategies ~
 Committed to addressing
pressing public policy issues that
impact the quality and safety of
health care.
• The Joint Commission will convene
thought leaders and subject-matter
experts and will issue public policy
recommendations.
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Topics
# of
Downloads
 Nursing Shortage– white paper 967,308
 Emergency Preparedness – white paper 113,359
 Organ Donation – white paper 92,647
 Medical Liability – white paper 292,033
 Improving the Quality of Pain Management
Through Measurement and Action
638,938
 Universal Protocol 157,880
 Universal Protocol Implementation Guidelines 127,798
 “Do Not Use” List 104,860
 Standing Together Emergency Planning Guide 587,554
 Speak Up Brochure 154,535
 Universal Protocol Brochure (Wrong Site Surgery) 95,798
 Organ Donation Brochure 46,937
 Infection Control Brochure 150,934
 Medication Management Brochure 50,446
Joint Commission
International
Center for Patient Safety
Partnering for Solutions in Systems Improvement
Collaboration & Partnering
Patient Safety “Solutions”
Information Distribution
Educational Programs
Patient Safety Research
Public Policy-Advocacy

Patient Safety Legislation &
Patient Safety Organizations
Definition:
 A Safety Solution is any system
design or intervention that has
demonstrated the ability to prevent or
mitigate patient harm stemming from
the processes of health care
Measurement Issues
 Are outcomes & performance
measurement feasible?
 Can reliable risk adjustment be
performed for patient & providers?
 How to overcome cultural variability &
resistance to reporting?

 Cult of the RCT phenomenon…
 Development of measures is not enough
for systems change!
Measurement Issues
 Infection-Related Issues:
• VAP
• Central Line Infection
• Blood Stream Infection
• Sepsis
• Surgical Wound Infection
 WHO Alliance: Global Challenge
 Taxonomy/Classification Systems
 Professional Society & Organizations

 Barriers & Solutions…
What Is On The Radar Screen?
Physician Engagement in Safety