safety data for safer care: from knowing to doing carolyn m. clancy, md director u.s. agency for...

Safety Data for Safer Care:Safety Data for Safer Care:From Knowing to DoingFrom Knowing to Doing

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

U.S. Agency for Healthcare Research and QualityU.S. Agency for Healthcare Research and Quality1st OECD Health Care Quality Indicators Seminar1st OECD Health Care Quality Indicators Seminar

On Improving Patient Safety Data SystemsOn Improving Patient Safety Data SystemsDublin, Ireland -- June 30, 2006Dublin, Ireland -- June 30, 2006

Safety in numbersSafety in numbers

AHRQ’s safety portfolioAHRQ’s safety portfolio

The growing role of The growing role of health information health information technologytechnology

Other safety initiativesOther safety initiatives

Future directionsFuture directions

Safety Data for Safer CareSafety Data for Safer Care

More Medical Errors in U.S.More Medical Errors in U.S.

50%50%

25%25%

0%0%UKUK GERGER NZNZ AUSAUS CANCAN USUS

2222%% 23%23%25%25% 27%27%

30%30%34%34%

Any medical mistake/error or test error in last 2 yearsAny medical mistake/error or test error in last 2 years

““Taking the Pulse of Health care Systems”Taking the Pulse of Health care Systems”Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05Commonwealth Fund International Health Policy Survey of Sicker Adults, 11/03/05

50%50%

25%25%

0%0%UKUKGERGER NZNZAUSAUS CANCAN USUS

1414%%23%23%

27%27% 28%28%31%31% 33%33%


Failure to Discuss MedicationsFailure to Discuss Medications

% of patients who said prior medications were not reviewed at discharge% of patients who said prior medications were not reviewed at discharge

Hospital/ER ReadmissionsHospital/ER Readmissions

50%50%

25%25%

0%0%UKUKGERGER NZNZ AUSAUSCANCANUSUS

1010%%14%14% 15%15% 16%16% 17%17%

20%20%

% of patients readmitted as a result of complications% of patients readmitted as a result of complications


18-month voluntary effort18-month voluntary effort Over 3,000 U.S. hospitals representing 75% of Over 3,000 U.S. hospitals representing 75% of

all U.S. hospital bedsall U.S. hospital beds 122,342122,342 lives saved – a HUGE milestone lives saved – a HUGE milestone Many millions more lives changed as we build Many millions more lives changed as we build

momentum for continuous improvement of momentum for continuous improvement of patient safetypatient safety


AHRQ’s safety AHRQ’s safety portfolioportfolio





AHRQ and Patient SafetyAHRQ and Patient Safety

Identify medical errors and other threats Identify medical errors and other threats to patient safety and understand why they to patient safety and understand why they occuroccur

Advance knowledge of practices that will Advance knowledge of practices that will reduce or eliminate the occurrence of reduce or eliminate the occurrence of medical errors and minimize risk of medical errors and minimize risk of patient harmpatient harm

Develop, assemble and disseminate Develop, assemble and disseminate information on how to implement best information on how to implement best practices for patient safetypractices for patient safety

Enable providers to monitor and evaluate Enable providers to monitor and evaluate threats to patient safety and the progress threats to patient safety and the progress being madebeing made

Patient Safety NetPatient Safety Net

““One-stop” portal of One-stop” portal of resources for resources for improving patient improving patient safety and preventing safety and preventing medical errorsmedical errors

Information on patient Information on patient safety resources, safety resources, tools, conferences, tools, conferences, and moreand more

Customize the site by Customize the site by creating “My PSNet” creating “My PSNet” pagepage

http://psnet.ahrq.govhttp://psnet.ahrq.gov

Web M&MWeb M&M

Morbidity and Morbidity and Mortality website Mortality website identifies problem identifies problem areas and potential areas and potential solutions solutions

Shares new cases Shares new cases and expert and expert commentariescommentaries

Monthly spotlight Monthly spotlight case with slide setcase with slide set

28,000 visitors/mo.28,000 visitors/mo.

http://webmm.ahrq.govhttp://webmm.ahrq.gov

Hospital Survey on Hospital Survey on Patient Safety CulturePatient Safety Culture

Helps hospitals and health Helps hospitals and health systems evaluate employee systems evaluate employee attitudes about patient safety attitudes about patient safety in their facilities or specific in their facilities or specific unitsunits

Includes survey guide, Includes survey guide, survey, and feedback report survey, and feedback report template to customize reportstemplate to customize reports

AHRQ partnership with AHRQ partnership with Premier, Inc., Department of Premier, Inc., Department of Defense, and American Defense, and American Hospital AssociationHospital Association

We’re Educating Patients, TooWe’re Educating Patients, Too

New Public Awareness AdsNew Public Awareness Ads

Maybe I should have told my doctor about all themedications I was taking...

HIT and Safety: Lessons HIT and Safety: Lessons

The “T” in HIT isn’t just for The “T” in HIT isn’t just for Technology -- it also needs Technology -- it also needs to include:to include: ToolsTools TeamworkTeamwork TrustTrust

Evidence is important, butEvidence is important, but Evidence isn’t everything – Evidence isn’t everything –

we also need VISION!we also need VISION!

Health IT OpportunitiesHealth IT Opportunities

Reengineer processes to Reengineer processes to improve patient safetyimprove patient safety As we migrate to a health IT As we migrate to a health IT

infrastructure, put effective processes in infrastructure, put effective processes in place as the same timeplace as the same time

Augment health IT applications for error Augment health IT applications for error reduction, CPOE and other decision reduction, CPOE and other decision support toolssupport tools

Build in the necessary disciplines Build in the necessary disciplines and team approachesand team approaches

How Do We Measure Success? How Do We Measure Success?

Long term goals of the Quality/ Long term goals of the Quality/ Safety/Health IT Portfolios Safety/Health IT Portfolios – Improve medication safetyImprove medication safety

– Improved decision-making for patients and Improved decision-making for patients and providersproviders

– Improve high-risk transitions in careImprove high-risk transitions in care

Health IT Research FundingHealth IT Research Funding

Over 100 grants to Over 100 grants to hospitals, providers, and hospitals, providers, and health care systems to health care systems to promote access to health promote access to health information technologyinformation technology

Projects in over 40 statesProjects in over 40 states Special attention to best Special attention to best

practices that can improve practices that can improve quality of care in rural, quality of care in rural, small community, safety small community, safety net and community health net and community health center care settingscenter care settings

AHRQ HIT AHRQ HIT Investment: Investment: $166 Million$166 Million

Meds Safety and Health ITMeds Safety and Health IT

Maximize the effectiveness of e- prescribing Maximize the effectiveness of e- prescribing between physicians and community pharmaciesbetween physicians and community pharmacies

Use patient-centered medication information Use patient-centered medication information systems for frail elderssystems for frail elders

Integrate prescribing tools with decision support Integrate prescribing tools with decision support (checking dosage, contraindications, and drug (checking dosage, contraindications, and drug interactions) into provider practiceinteractions) into provider practice

Implement decision support functions, including Implement decision support functions, including the influence of weight based dosing on the influence of weight based dosing on pediatric adverse drug events pediatric adverse drug events

Warfarin Interaction AlertWarfarin Interaction Alert

Blood thinner warfarin is Blood thinner warfarin is one of top 15 most one of top 15 most prescribed drugs in U.S.prescribed drugs in U.S.

In AHRQ-supported study, In AHRQ-supported study, doctors using computerized doctors using computerized alert system ordered 15 alert system ordered 15 percent fewer prescriptions percent fewer prescriptions for drugs that can interact for drugs that can interact with warfarinwith warfarin

Safety Safety alert!alert!

AC Feldstein et al, Archives of Internal Medicine, May 8, 2006AC Feldstein et al, Archives of Internal Medicine, May 8, 2006

AHRQ's Ambulatory Patient AHRQ's Ambulatory Patient Safety ProgramSafety Program

Five year goal: measurably improving the Five year goal: measurably improving the safety and quality of care for patients in safety and quality of care for patients in ambulatory environmentsambulatory environments

Develop, deploy and evaluate ambulatory Develop, deploy and evaluate ambulatory health IT systemshealth IT systems – focus on both technology – focus on both technology and system solutionsand system solutions

Rapid research in AHRQ’s Rapid research in AHRQ’s real-world real-world research networksresearch networks– What is the relationship between health IT, safety What is the relationship between health IT, safety

and quality (including efficiency)? and quality (including efficiency)? – How can we derive the greatest benefit - - clinical How can we derive the greatest benefit - - clinical

and financial – from health IT investments? and financial – from health IT investments? from from patient safety investments?patient safety investments?

– How can we move what we know works into wide-How can we move what we know works into wide-scale practice?scale practice?

What is the rationale for a What is the rationale for a focus on ambulatory care?focus on ambulatory care?

Health care services continue to shift into the Health care services continue to shift into the ambulatory arenaambulatory arena

Ambulatory care and transitions in care are Ambulatory care and transitions in care are high-risk for patient safetyhigh-risk for patient safety

Patient safety research and improvement has Patient safety research and improvement has focused on hospitalsfocused on hospitals

Ambulatory care requires:Ambulatory care requires:– Complex information managementComplex information management– Coordination of care for chronically ill and elderly Coordination of care for chronically ill and elderly

patientspatients

Patient Safety Act of 2005Patient Safety Act of 2005

• Creates “Patient Safety Creates “Patient Safety Organizations (PSOs)Organizations (PSOs)

• Establishes “Network of Patient Establishes “Network of Patient Safety Databases”Safety Databases”

• Mandates Comptroller General to Mandates Comptroller General to study effectiveness of Act (by study effectiveness of Act (by 2010)2010)

• Is completely voluntaryIs completely voluntary• Would be Would be impossibleimpossible without health without health

IT backboneIT backbone

PSO ObjectivesPSO Objectives

To generate information relevant to preventing harm to To generate information relevant to preventing harm to patients from health care (aggregate/analyze incident data; patients from health care (aggregate/analyze incident data; disseminate results)disseminate results)

To employ interoperable terms, definitions of patient safety To employ interoperable terms, definitions of patient safety incidentsincidents

To simplify task of reporting incidentsTo simplify task of reporting incidents To provide benchmarking & trend reportsTo provide benchmarking & trend reports To share de-identified data for use in improving patient safetyTo share de-identified data for use in improving patient safety

Solving a Safety Data ProblemSolving a Safety Data Problem

U.S.providers fear that patient safety analyses U.S.providers fear that patient safety analyses can be used against them in court or in can be used against them in court or in disciplinary proceedingsdisciplinary proceedings

State laws offer inadequate protection (e.g., State laws offer inadequate protection (e.g., large providers cannot share analyses large providers cannot share analyses system-wide without risk)system-wide without risk)

Patient safety improvement is hampered by Patient safety improvement is hampered by the inability to aggregate data; by analyzing the inability to aggregate data; by analyzing large numbers of events, patterns of failures large numbers of events, patterns of failures could be more rapidly identifiedcould be more rapidly identified

PSO ActivitiesPSO Activities

Conducts efforts to improve patient safety Conducts efforts to improve patient safety and qualityand quality

Collects & analyzes data, reports, records, Collects & analyzes data, reports, records, root cause analysesroot cause analyses

Develops/disseminates information to Develops/disseminates information to improve patient safetyimprove patient safety

Encourages culture of patient safetyEncourages culture of patient safety Maintains procedures to keep work product Maintains procedures to keep work product

confidentialconfidential

Network of Patient Safety Network of Patient Safety DatabasesDatabases

Interactive evidence-based management resourceInteractive evidence-based management resource Capacity to accept, aggregate, & analyze non-Capacity to accept, aggregate, & analyze non-

identifiable data voluntarily reported by PSOs, providers, identifiable data voluntarily reported by PSOs, providers, & others& others

Data to be used to analyze national & regional statistics, Data to be used to analyze national & regional statistics, including trends & patterns of health care errorsincluding trends & patterns of health care errors

Information to be made public & reported annually (in Information to be made public & reported annually (in AHRQ’s AHRQ’s National Healthcare Quality ReportNational Healthcare Quality Report))

Next StepsNext Steps

Develop & publish proposed rules governing operations Develop & publish proposed rules governing operations of PSOsof PSOs

Finish inventory of data elements, definitions & encoding Finish inventory of data elements, definitions & encoding schemesschemes

Consider options for fostering development of a network Consider options for fostering development of a network of patient safety databasesof patient safety databases

Plan for inclusion of patient safety information on Plan for inclusion of patient safety information on performance, trends AHRQ’s NHQR/DRperformance, trends AHRQ’s NHQR/DR

Targeted Injury Detection SystemTargeted Injury Detection System

AHRQ’s ACTION Network is supporting three AHRQ’s ACTION Network is supporting three studies to develop and implement targeted studies to develop and implement targeted injury detection systems to reduce inpatient injury detection systems to reduce inpatient injuriesinjuries

Addresses adverse drug events, hospital Addresses adverse drug events, hospital acquired infection and pressure ulcers/injuriesacquired infection and pressure ulcers/injuries

Systems will be designed for deployment Systems will be designed for deployment deploy in large urban hospitals and small rural deploy in large urban hospitals and small rural hospitals across U.S. hospitals across U.S.

Will be compatible with diverse electronic Will be compatible with diverse electronic health record systemshealth record systems

Systems-level Error-ProofingSystems-level Error-Proofing

Rapid-cycle learning from Rapid-cycle learning from lean manufacturing lean manufacturing systems, e.g. Toyota systems, e.g. Toyota production systemproduction system

High Reliability High Reliability Organization (HRO) Organization (HRO) systems can be adapted systems can be adapted into hospital settings, e.g. into hospital settings, e.g. airline safety systemsairline safety systems

Empowered employees Empowered employees and committed leadership and committed leadership are keys to successare keys to success

““Fail Safe” HospitalsFail Safe” Hospitals

Organizational infrastructure:Organizational infrastructure:- certified patient safety officer as part of line management;- certified patient safety officer as part of line management;

- Culture of Safety - Culture of Safety (organization-wide training; rewards for reporting; transparency; etc.)(organization-wide training; rewards for reporting; transparency; etc.)

Measurement infrastructure:Measurement infrastructure:- - AHRQ-standard concurrent and retrospective trigger systemsAHRQ-standard concurrent and retrospective trigger systems

- Culture of Safety-based voluntary reporting system- Culture of Safety-based voluntary reporting system

- certified pharmacist - certified pharmacist (or equivalent) (or equivalent) performing real-time ADE evaluationperforming real-time ADE evaluation

- certified chart reviewers - certified chart reviewers (random sample or full census)(random sample or full census)

- participates - participates (sends data) (sends data) to central (AHRQ) data repositoryto central (AHRQ) data repository

- external audits of injury detection data systems- external audits of injury detection data systems

Implemented safe practices:Implemented safe practices:- NQF / AHRQ evidence-based safe practices - NQF / AHRQ evidence-based safe practices (~30, at present)(~30, at present)

- IHI 100,000 Lives campaign- IHI 100,000 Lives campaign

Improving Patient Safety Improving Patient Safety Through Simulation ResearchThrough Simulation Research

New AHRQ RFA for New AHRQ RFA for research / evaluation of research / evaluation of simulation and the roles simulation and the roles it can play in improving it can play in improving safe delivery of caresafe delivery of care

Total amount of $2.4 Total amount of $2.4 million to fund 8-10 new million to fund 8-10 new grantsgrants

First projects to start First projects to start this fallthis fall

AHRQ RFA-HS-06-030AHRQ RFA-HS-06-030

Safer Hospitals by DesignSafer Hospitals by Design

U.S. hospital building U.S. hospital building boom - $23 billion boom - $23 billion spent in 2005 alone spent in 2005 alone

Creates opportunity to Creates opportunity to design safer hospitals design safer hospitals and incorporate and incorporate Health ITHealth IT

Small but growing Small but growing body of research can body of research can help inform planning help inform planning and construction and construction processprocess

P4P and Patient SafetyP4P and Patient Safety

Pay for ‘safety enhancing Pay for ‘safety enhancing activities’ (efforts to activities’ (efforts to promote safety culture; promote safety culture; effective implementation of effective implementation of HIT)HIT)

NO or decreased payments NO or decreased payments for harmful care for harmful care

Prerequisite: capacity for Prerequisite: capacity for seamless electronic seamless electronic reporting of performance reporting of performance measures and adverse measures and adverse eventsevents

Is health care getting safer?Is health care getting safer?

NoNo


NoNo

YesYes


NoNo

YesYes

Yes, but we need more Yes, but we need more and better data, and we and better data, and we need to build our need to build our partnerships as we build partnerships as we build the evidence basethe evidence base

XX

Your questionsYour questions??

safety data for safer care: from knowing to doing carolyn m. clancy, md director u.s. agency for...

Documents

patient safety resources

patient safety net

safer care safety data

numbers ahrqs safety

safer care slide

medical errors information

occurrence of medical

discharge slide