GHA PSO Patient Safety Advisory Committee

1. GHA PSO Patient Safety Advisory Committee How can the GHA PSO Help You? Kathy McGowan, MPH Director Quality & Patient Safety Georgia Hospital Association

2. GHA PSO Vision • A healthcare environment safe for all patients, in all processes, at all times.

3. GHA PSO Mission • The GHA PSO is dedicated to maximizing patient safety, reducing medical errors and improving the quality of healthcare by providing systems of data reporting, collection, analysis and dissemination of information. • To provide GHA member hospitals a unique opportunity to engage in patient safety improvement activities through aggregation of common cause data and identifying trigger points for potential emerging issues.

4. GHA PSO Guiding Principles • The GHA PSO will offer healthcare providers a secure environment to conduct patient safety activities so that healthcare providers can analyze quality and safety issues to improve care, reduce risk to patients, and share findings and lessons learned. • The GHA PSO will encourage healthcare providers to voluntarily submit and share information, which will be de-identified and used to track patient safety trends statewide. • The GHA PSO will give feedback to healthcare providers on ways to reduce risk and improve patient safety and quality.

5. What will the GHA PSO do? • The rule allows the GHA PSO to receive and analyze patient safety work product (which includes information about adverse events, near misses and quality related data), as well as provide feedback to providers about the events; all in a protected legal environment.

6. How can the GHA PSO help me? • GHA PSO Benefits: • GHA PSO can collect and analyze patient safety data – employs common formats (definitions, data elements, etc.). • GHA PSO can aggregate similar data from many organizations and identify underlying patterns and develop tools to mitigate the risk of adverse events (common cause analysis).

7. continued • GHA PSO Benefits continued: • GHA PSO activities encourage and reinforce a culture of safety to minimize patient risk. • GHA PSO can provides benchmarking and trend reports. • GHA PSO can provide timely feedback and support to participants.

8. continued • GHA PSO Benefits: • GHA PSO can assist providers to improve quality and patient safety by sharing lessons learned and best practices – generates de-identified information relevant to preventing harm to patients. • GHA PSO can develop and disseminate patient safety information that will be beneficial to all providers to improve bottom line costs.

9. Federal Impact • CMS has implemented non-reimbursement of select Never Events/HACs. • Adverse events cost $$$$$$$ to make it right.

10. Where do we begin? • Review crosswalks to target common cause events • HAC – no pay events (Hospital Acquired Conditions) • HAI events – Hospital Acquired Infections (transparency) • NPSG (National Patient Safety Goals) • Review AHRQ common formats – tools designed to collect common elements (definitions and formulas) and causal factors to then allow aggregation and evaluation of preventive measures and early trigger events. • Evaluate hospital trend reports/surveillance activities/incident reports.

11. Crosswalk of Patient Safety Initiatives 2009-2010 AHRQ Common Format CMS HAC/Never Events “NO Pay”

12. Crosswalk of Patient Safety Initiatives 2009-2010 AHRQ Common Format CMS HAC/ Never Events “NO Pay” HAI

13. Crosswalk of Patient Safety Initiatives 2009-2010 CMS HAC/Never Events “NO Pay” AHRQ Common Format HAI NPSG

14. GHA initial focus • Focus on infection prevention/HAIs • CMS no pay events • Joint Commission National Patient Safety Goals • AHRQ common formats available • Georgia Hospitals are already involved in infection prevention initiatives • Patient Safety Network Survey identified infections as a top priority • Georgia is one of the few states in the nation without a mandatory infection reporting law • Ongoing legislative battle • Will probably be introduced again this year

15. AHRQ Common Formats • Refer to sample common formats handouts • Healthcare Associated Infection • This common format addresses the presence of an infectious agent that was not evident or incubating at the time of admission • The format covers: • BSI (Blood Stream Infections) • PN (Pneumonia) • SSI (Surgical Site) • UTI (Urinary Tract) • Unknown and Other

16. Current GHA Initiatives • Utilize information available from GHA • Johns Hopkins Blood Stream Infection Collaborative • TIPS: Teams for Infection Prevention Success

17. Bottom Line – National Average for Hospital Acquired Infections and related costs to the Hospitals • Catheter related blood stream infections • 25K – 56K per case • 100K for antibiotic resistant bloodstream infection • Surgical Site infections • 57K per case for deep organ SSI • Urinary catheter infections • 10K per case

18. Other AHRQ common formats available • Anesthesia • Blood, Tissue, Organ Transplantation or Gene Therapy • Device and Medical or Surgical Supply • Falls • Medication and Other Substances • Perinatal • Pressure Ulcers • Surgical and Other Invasive Procedure (except perinatal)

19. Next Steps • Pursue grant funding for establishment of web-based reporting tool • Create GHA PSO Toolkit (Patient Safety Act Executive Summary, Commonly used Definitions, FAQs, Best Practices for Partnering with the GHA PSO, Model PSES policy) • Create GHA PSO Registration Packet (Participation Agreement, BA and Data Use Agreement, Primary Contact Form) • Other Action Items?