Maulik S. Joshi, Dr.P.H. President and CEO Network for Regional Healthcare Improvement

1. Patient Safety: Where Are We Now, Regionally? AcademyHealth June 2008 Maulik S. Joshi, Dr.P.H. President and CEO Network for Regional Healthcare Improvement Email: mjoshi@nrhi.org Phone: 410-829-6252

2. Patient Safety – The Regional Landscape • Reporting • Adverse events to a state agency • Healthcare Associated Infections • Leapfrog Leaps • Never events • Technical Assistance • Education • Collaboratives

3. Patient Safety Reporting As of October 2007, 26 states plus the District of Columbia had passed legislation or regulation related to hospital reporting of adverse events to a state agency. Many of these new laws and regulations are intended to hold health care facilities accountable for weaknesses in their systems. They also have the potential to improve patient safety through event report analysis and by dissemination of best practices and lessons learned.  National Academy for State Health Policy (NASHP) Patient Safety Toolbox for States

4. Patient Safety Reporting 12 states publicly report data on measures of patient safety • Mandated and non-mandated • Overlap of “quality” measures NASHP: State Health Policies Aimed at Promoting Excellent Systems: A Report on States’ Roles in Health Systems Performance, April 2008

5. Healthcare Associated Infections • 20+ states have laws or bills for reporting healthcare acquired infections/MRSA • Many Challenges: • What measures? • Reflect what population? • How collected? • How reported? • How interpreted?

6. Leapfrog Leaps • 37 Regional Roll-Outs • Strong business coalition support • Main task is to encourage local hospitals to publicly report their progress on the implementation of Leapfrog’s four recommended quality and safety practices or ‘leaps’: • implementation of computerized physician order entry (CPOE) systems, • staffing ICUs with intensivists, • referring patients to hospitals with the best results for treating certain high risk conditions, and • implementation of other safe practices endorsed by the National Quality Forum.

7. Never Events • Minnesota: Adverse Health Event Reporting System, through which hospitals, ambulatory surgical centers, and community behavioral health hospitals are required to report whenever one of 27 – now 28 - serious events takes place Fourth Annual Public Report, Adverse Health Events in Minnesota www.health.state.mn.us/patientsafety

8. Technical Assistance • Early models – • Maryland Patient Safety Center • Iowa Healthcare Collaborative • Pittsburgh Regional Health Initiative • HHS/AHRQ PSO Regulations • More to come

9. Technical Assistance

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11. Technical Assistance

12. Patient Safety Regionally • There continues to be more public reporting on safety practices/measures • Current focus on infections: • What’s next? • Regionally based patient safety centers/PSOs: • Solely on reporting or branching to education and improvement?

13. Patient Safety Regionally • Evaluation: Regional impact is unknown • What is attribution? • Of local structure • Of local promotion • Of local standards • Of local implementation