GHA PSO Patient Safety Advisory Committee

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GHA PSO Patient Safety Advisory Committee

• How can the GHA PSO Help You?
• Kathy McGowan, MPH
• Director Quality Patient Safety
• Georgia Hospital Association

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GHA PSO Vision

• A healthcare environment safe for all patients,
  in all processes, at all times.

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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.

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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.

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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.

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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).

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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.

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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.

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Federal Impact

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

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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.

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

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

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

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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

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Current GHA Initiatives

• Utilize information available from GHA
• Johns Hopkins Blood Stream Infection
  Collaborative
• TIPS Teams for Infection Prevention Success

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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

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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)

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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?