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MedChi Your Advocate Your Resource Your Profession Maryland Patient Safety Center

What it is. Created by legislation, privately operated under State designationMission: To bring health care providers together to understand the causes of unsafe practices, and implement evidence-based improvements.Initiatives: Education/trainingCollaborativesAdverse event reportingResearchSpecial projectsJohn M. Eisenberg Pt. Safety

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MedChi Your Advocate Your Resource Your Profession Maryland Patient Safety Center

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    1. MedChi Your Advocate Your Resource Your Profession Maryland Patient Safety Center Creating a culture of safety Michael Preston MedChi Executive Director ACP National Conference Philadelphia, Pa. April 5, 2006

    3. Origins: industry and gov’t response to IoM IoM 1st report 1999, To Err is Human Md. Patient Safety Coalition, fall 2000 MedChi, Md. Health Care Commission (MHCC), Md. Hospital Assoc., QIO “Delmarva,” others Patient Safety Act, spring ’01 Charged MHCC to study state-wide patient safety system, incl. mandatory reporting of errors Physician, hospital support Final report to legislature due by 1.01.03 MHCC study absorbs coalition

    4. 3 years of study: influences Physicians: MedChi report fall ’01 Medical society response to IoM and strategy viz. media controversy over “bad doctors” Recommends: comprehensive, confidential errors reporting state-sponsored safety institute re-design of physician regulation Hospitals: Md. Hospital Assoc. (MHA) Quality Indicator Project, MedSafe program All hospitals already participating

    5. MHCC report: 3-part strategy

    6. Implementation: Design meets reality Law authorized MPSC spring ’03 Patient Safety Center Recognized in law, MHCC to create Medical review committee status Un-funded AHRQ grant application denied Regulations flew into effect Systems improvement Creative financing

    7. Pt. Safety Center “out to bid” Patient Safety Center designation put out to bid Md. Hospital Assoc + Delmarva (QIO) bid MedChi didn’t bid, supported approach, pledged physician involvement in planning, oversight Hospital focus, resources Designation awarded jointly to MHA + Delmarva 6.04 Structure & financing MHA, Delmarva resources: funds, management Donated expertise: medical advisory panels Hospital rate commission funding

    8. MPSC Initiatives

    9. Education & Training: Goals Build awareness of need for patient safety and potential for achieving it Promote cultural changes needed for improvement Example: leadership commitment from Board + CEO Ensure that institutional leaders and health professionals have essential competencies, Example: Ability to perform root cause analysis (RCA) Offer proven safety solutions and better practices

    10. Education & Training: First year activities Root cause analysis training >2,000 hospital, nursing home personnel trained Human factors engineering 2-day program to reach all hospital dept. leaders over 2 years State-wide Patient Safety Conference 1st >700 attendees: some physicians, mostly institutional (hosp, n/h) pharm.managers 2d (3.30.06) 1,200 attendees: still mostly institutional

    11. Safety Culture Collaborative Series Focused multi-site projects to produce measurable improvements on key measures First-up: Intensive Care Units, based on: Institute for Healthcare Improvement (IHI) Breakthrough Series AHRQ Keystone ICU Project VA-sponsored Transformation of ICU Collaborative

    12. ICU Collaborative Participation by 82% of Maryland hospital ICU’s addressing: Elimination of central line infections Elimination of Ventilator-associated pneumonia Deep vein thrombosis & peptic ulcer prevention Formation of rapid response teams Medication Reconciliation

    13. ICU Collaborative Results 36% decrease in blood stream infection rate 20% decrease in ventilator-associated pneumonia Emergency Care to be focus of second collaborative

    14. Adverse event and “close call” event reporting MPSC considering a vol. reporting system analyze data to identify trends and patterns Hospital reports, periodic patient safety advisories, and education to be provided to hospitals To begin 2006 (?)

    15. Other proposed opportunities Emergency Department Collaborative Telemedicine & Advanced Technology Research Center (TATRC) AHRQ-ACTION Grant Research 1000,000 lives campaign

    17. Challenge for physicians: ambulatory care Still totally developmental Growth of ambulatory care environment MedChi Quality Committee concepts: Target “hand-off” situations Link to electronic data collection capability Continue to build awareness

    18. References & contacts 1. See: Joshi, et al.,“Comprehensive Grassroots Model for Statewide Safety Improvement”, JCAHO Journal on Quality & Patient Safety (v31,n12, p. 671-677, Dec. 2005) 2. MHCC final report: http://mhcc.maryland.gov/patient_safety/finalrpt.pdf 3. Contacts: Maryland Patient Safety Center www.marylandpatientsafety.org Director: William F. Minogue, MD 6820 Deerpath Rd. Elkridge, MD 21075 wminogue@marylandpatientsafety.org (410) 540-9210

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