Safety Data for Safer Care: From Knowing to Doing

1. Safety Data for Safer Care:From Knowing to Doing Carolyn M. Clancy, MD Director U.S. Agency for Healthcare Research and Quality 1st OECD Health Care Quality Indicators Seminar On Improving Patient Safety Data Systems Dublin, Ireland -- June 30, 2006

2. Safety Data for Safer Care • Safety in numbers • AHRQ’s safety portfolio • The growing role of health information technology • Other safety initiatives • Future directions

3. 34% 30% 27% 25% 23% 22% UK GER NZ AUS CAN US More Medical Errors in U.S. Any medical mistake/error or test error in last 2 years 50% 25% 0% “Taking the Pulse of Health care Systems” Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05

4. Failure to Discuss Medications % of patients who said prior medications were not reviewed at discharge 50% 33% 31% 28% 27% 23% 25% 14% GER AUS UK CAN NZ US 0% “Taking the Pulse of Health care Systems” Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05

5. Hospital/ER Readmissions % of patients readmitted as a result of complications 50% 20% 25% 17% 16% 15% 14% 10% GER US NZ CAN UK AUS 0% “Taking the Pulse of Health care Systems” Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05

6. 18-month voluntary effort • Over 3,000 U.S. hospitals representing 75% of all U.S. hospital beds • 122,342 lives saved – a HUGE milestone • Many millions more lives changed as we build momentum for continuous improvement of patient safety

7. Safety Data for Safer Care • Safety in numbers • AHRQ’s safety portfolio • The growing role of health information technology • Other safety initiatives • Future directions

8. AHRQ and Patient Safety • Identify medical errors and other threats to patient safety and understand why they occur • Advance knowledge of practices that will reduce or eliminate the occurrence of medical errors and minimize risk of patient harm • Develop, assemble and disseminate information on how to implement best practices for patient safety • Enable providers to monitor and evaluate threats to patient safety and the progress being made

9. “One-stop” portal of resources for improving patient safety and preventing medical errors Information on patient safety resources, tools, conferences, and more Customize the site by creating “My PSNet” page Patient Safety Net http://psnet.ahrq.gov

10. Morbidity and Mortality website identifies problem areas and potential solutions Shares new cases and expert commentaries Monthly spotlight case with slide set 28,000 visitors/mo. Web M&M http://webmm.ahrq.gov

11. Hospital Survey on Patient Safety Culture • Helps hospitals and health systems evaluate employee attitudes about patient safety in their facilities or specific units • Includes survey guide, survey, and feedback report template to customize reports • AHRQ partnership with Premier, Inc., Department of Defense, and American Hospital Association

12. We’re Educating Patients, Too

13. New Public Awareness Ads Maybe I should have told my doctor about all the medications I was taking...

14. Safety Data for Safer Care • Safety in numbers • AHRQ’s safety portfolio • The growing role of health information technology • Other safety initiatives • Future directions

15. HIT and Safety: Lessons • The “T” in HIT isn’t just for Technology -- it also needs to include: • Tools • Teamwork • Trust • Evidence is important, but • Evidence isn’t everything – we also need VISION!

16. Health IT Opportunities Reengineer processes to improve patient safety • As we migrate to a health IT infrastructure, put effective processes in place as the same time • Augment health IT applications for error reduction, CPOE and other decision support tools • Build in the necessary disciplines and team approaches

17. How Do We Measure Success? • Long term goals of the Quality/ Safety/Health IT Portfolios • Improve medication safety • Improved decision-making for patients and providers • Improve high-risk transitions in care

18. Health IT Research Funding • Over 100 grants to hospitals, providers, and health care systems to promote access to health information technology • Projects in over 40 states • Special attention to best practices that can improve quality of care in rural, small community, safety net and community health center care settings AHRQ HIT Investment: $166 Million

19. Meds Safety and Health IT • Maximize the effectiveness of e- prescribing between physicians and community pharmacies • Use patient-centered medication information systems for frail elders • Integrate prescribing tools with decision support (checking dosage, contraindications, and drug interactions) into provider practice • Implement decision support functions, including the influence of weight based dosing on pediatric adverse drug events

20. Safety alert! Warfarin Interaction Alert • Blood thinner warfarin is one of top 15 most prescribed drugs in U.S. • In AHRQ-supported study, doctors using computerized alert system ordered 15 percent fewer prescriptions for drugs that can interact with warfarin AC Feldstein et al, Archives of Internal Medicine, May 8, 2006

21. AHRQ's Ambulatory Patient Safety Program • Five year goal: measurably improving the safety and quality of care for patients in ambulatory environments • Develop, deploy and evaluate ambulatory health IT systems – focus on both technology and system solutions • Rapid research in AHRQ’s real-world research networks • What is the relationship between health IT, safety and quality (including efficiency)? • How can we derive the greatest benefit - - clinical and financial – from health IT investments? from patient safety investments? • How can we move what we know works into wide-scale practice?

22. What is the rationale for a focus on ambulatory care? • Health care services continue to shift into the ambulatory arena • Ambulatory care and transitions in care are high-risk for patient safety • Patient safety research and improvement has focused on hospitals • Ambulatory care requires: • Complex information management • Coordination of care for chronically ill and elderly patients

23. Safety Data for Safer Care • Safety in numbers • AHRQ’s safety portfolio • The growing role of health information technology • Other safety initiatives • Future directions

24. Patient Safety Act of 2005 • Creates “Patient Safety Organizations (PSOs) • Establishes “Network of Patient Safety Databases” • Mandates Comptroller General to study effectiveness of Act (by 2010) • Is completely voluntary • Would be impossible without health IT backbone

25. PSO Objectives • To generate information relevant to preventing harm to patients from health care (aggregate/analyze incident data; disseminate results) • To employ interoperable terms, definitions of patient safety incidents • To simplify task of reporting incidents • To provide benchmarking & trend reports • To share de-identified data for use in improving patient safety

26. Solving a Safety Data Problem • U.S.providers fear that patient safety analyses can be used against them in court or in disciplinary proceedings • State laws offer inadequate protection (e.g., large providers cannot share analyses system-wide without risk) • Patient safety improvement is hampered by the inability to aggregate data; by analyzing large numbers of events, patterns of failures could be more rapidly identified

27. PSO Activities • Conducts efforts to improve patient safety and quality • Collects & analyzes data, reports, records, root cause analyses • Develops/disseminates information to improve patient safety • Encourages culture of patient safety • Maintains procedures to keep work product confidential

28. Network of Patient Safety Databases • Interactive evidence-based management resource • Capacity to accept, aggregate, & analyze non-identifiable data voluntarily reported by PSOs, providers, & others • Data to be used to analyze national & regional statistics, including trends & patterns of health care errors • Information to be made public & reported annually (in AHRQ’s National Healthcare Quality Report)

29. Next Steps • Develop & publish proposed rules governing operations of PSOs • Finish inventory of data elements, definitions & encoding schemes • Consider options for fostering development of a network of patient safety databases • Plan for inclusion of patient safety information on performance, trends AHRQ’s NHQR/DR

30. Targeted Injury Detection System • AHRQ’s ACTION Network is supporting three studies to develop and implement targeted injury detection systems to reduce inpatient injuries • Addresses adverse drug events, hospital acquired infection and pressure ulcers/injuries • Systems will be designed for deployment deploy in large urban hospitals and small rural hospitals across U.S. • Will be compatible with diverse electronic health record systems

31. Systems-level Error-Proofing • Rapid-cycle learning from lean manufacturing systems, e.g. Toyota production system • High Reliability Organization (HRO) systems can be adapted into hospital settings, e.g. airline safety systems • Empowered employees and committed leadership are keys to success

32. “Fail Safe” Hospitals • Organizational infrastructure: - certified patient safety officer as part of line management; - Culture of Safety (organization-wide training; rewards for reporting; transparency; etc.) • Measurement infrastructure: - AHRQ-standard concurrent and retrospective trigger systems - Culture of Safety-based voluntary reporting system - certified pharmacist (or equivalent) performing real-time ADE evaluation - certified chart reviewers (random sample or full census) - participates (sends data) to central (AHRQ) data repository - external audits of injury detection data systems • Implemented safe practices: - NQF / AHRQ evidence-based safe practices (~30, at present) - IHI 100,000 Lives campaign

33. Improving Patient Safety Through Simulation Research • New AHRQ RFA for research / evaluation of simulation and the roles it can play in improving safe delivery of care • Total amount of $2.4 million to fund 8-10 new grants • First projects to start this fall AHRQ RFA-HS-06-030

34. U.S. hospital building boom - $23 billion spent in 2005 alone Creates opportunity to design safer hospitals and incorporate Health IT Small but growing body of research can help inform planning and construction process Safer Hospitals by Design

35. P4P and Patient Safety • Pay for ‘safety enhancing activities’ (efforts to promote safety culture; effective implementation of HIT) • NO or decreased payments for harmful care • Prerequisite: capacity for seamless electronic reporting of performance measures and adverse events

36. Is health care getting safer? No

37. Is health care getting safer? No Yes

38. No Yes X Yes, but we need more and better data, and we need to build our partnerships as we build the evidence base Is health care getting safer?

39. Your questions?