Title: Patient Safety Priorities
1- Patient Safety Priorities
- Patient Safety Committee
- September 8, 2008
- Paula Griswold, Executive Director,
MA Coalition for the Prevention
of Medical Errors - Alice Bonner, PhD, RN, Executive Director,
Massachusetts Long Term Care Foundation
2Next Steps for the HCQCCs Patient Safety
Committee
- Develop a comprehensive map of the landscape of
Patient Safety efforts in all healthcare settings
- Identify overlaps and gaps in current Patient
Safety efforts - Develop and prioritize criteria that will allow
the Council to make an impact by focusing on the
gaps and allowing the Council to build on
current Patient Safety efforts
3Council Reaching Out for Input Where to Focus
Attention/How It Can Be Most Effective
- The Council is asking
- What are you doing for Patient Safety? Why are
you doing it? - Where do you see the gaps in Patient Safety
efforts? - What priorities do you see for HCQCC? Based on
what criteria?
4Overview
- Current Landscape of Patient Safety Activities
- Potential Priorities for Future Patient Safety
Goals - Criteria for Selecting Priorities
- Recommendations
5Current Landscape Patient Safety Activities
6Current Landscape - Patient Safety Activities
Within Settings
- Still getting responses from members and others
- Seems to be a fair description more
expectations, infrastructure, and activities in
larger settings - Hospitals, nursing homes CMS, DPH, Joint
Commission, private payers - Cf. Small physician groups, for example
- might respond to complaints/problems
- might have malpractice insurer office review
- If not affiliated with hospital, may have no peer
review or PCA review - Board/Payer/PCA maintenance of certification
ABMS Patient Safety Training module - QIO/Payers outpatient quality measures show
reliability of care - Consider Ask all health care providers, with
support from their professional association, to
have some patient safety program ( safety as
systems design/reliability of care)
7Current Landscape Patient Safety Activities
8Current Landscape - Patient Safety Activities
Across Settings - Transitions
- MA Care Transitions Task Force
- Why focus on transitions in care?
- What are opportunities to improve quality and
reduce cost? - Examples of current programs
8
9MA Care Transitions Task Force
- Purpose
- To bring together people from various
organizations across the state who are working on
care transitions - Membership to date
- MA LTC Foundation (co-chair), MA Health Data
Consortium (co-chair), MA Coalition for the
Prevention of Medical Errors, Evercare, Dovetail
Health, Umass-Memorial Health Care, Winchester
Hospital, Partners Healthcare, Brockton Hospital,
Boston Medical Center,, Masspro, Hebrew Senior
Life, MONE, MHA, Home Care Alliance, DPH, CMS
10MA Care Transitions Task ForceGoals
- To improve the quality of care coordination and
communication when patients are transferred from
one level of care (or location) to another - Transitions include a patient moving from primary
care to specialty physicians anywhere within the
hospital patients moving from the ED to various
departments patients discharged from the
hospital or SNF to home, assisted living or
other arrangements - (adapted from NTOCC)
11Care Transitions
- Definition a handoff between practitioners,
often when the patient moves from one setting to
another - Why are transitions perilous?
- Patients are especially vulnerable to medication
errors and post-discharge adverse events
(Forster, 2003) - Factors that contribute can be related to 3
categories the hospital care system, the
patients characteristics or the clinicians
characteristics - How big a problem is this?
- 38 million U.S. hospital discharges in 2003
- Patients with recurrent hospitalizations
accounted for 13 of hospitalized patients, but
60 of resources - 843,167 hospital discharges annually in
Massachusetts - 11.6 to SNF
- 16 home with services (2006 data)
12Care Transitions
- In a study by Forster et al, 20-25 of patients
experienced an adverse event during the
transition from hospital to home - One third of adverse events are associated with
disability - Half of adverse events are associated with use of
additional health services - One third of the adverse events were deemed
preventable (Forster, Ann Int Med, 2003)
13Care Transitions
- What can go wrong?
- Treatments not received
- Medications duplicated or omitted
- Follow up appointments missed
- Unknown advanced directives with subsequent
episode of care - Medication errors (commission, omission)
- Adverse events lead to ED or hospital readmission
14Care Transitions
- Where are the cost savings?
- Acute care readmissions
- In HF patients, potential savings of 5,000 per
patient over one year (Naylor, JAGS, 2004) - Delayed long term care placement
- Fewer caregiver missed days of work and fewer
caregiver episodes of illness - Where are costs increased?
- Upfront costs of program implementation
- Home health and home support services
15Current MA Care Transitions Initiatives (selected
examples)
- RED (Re-Engineered Discharge) at Boston Medical
Center - Transitioning Care at Partners
- Evercare of New England implementing Transition
Coaching model - Dovetail Health discharge support initiatives
- MA LTC Foundation Improving Care Transitions
Initiative - POLST Transitions pilot project, HCQCC EOL
subcommittee
16Care Transitions Relationship to Other MA
Quality Initiatives
- Masspro and RIQP are examining care transitions
in 9th SOW - IHI/ Commonwealth planning grant to develop
prototypes of transition tools with 5 healthcare
systems/regions, including Berkshire Health
System - Office of Healthy Aging, Office on Health and
Disability, DPH has a grant on chronic disease
self-management and healthy aging - Eric Coleman and NTOCC willing to lend support to
local initiatives - BOOST project, involving Society of Hospital
Medicine on AHRQ website - Mt Auburn Hospital, other systems have
transitions initiatives
17Identifying Priorities for Future Patient Safety
Goals
- Consulted Coalition members held four small
group discussions to identify priorities - All four groups identified
- Communication - inter-professional,
inter-personal between patient and caregiver,
inter-organizational including shared learning,
and inter-facility including transitions of care - Transitions - including within hospitals and
between settings, especially hospital discharge
in age of hospitalists, focus on infections
during transitions - Medication Safety - including anticoagulation
management, medication errors at outpatient
pharmacies, and after hospital discharge to home
or to long term care
18Identifying Priorities for Future Patient Safety
Goals
- Additional areas identified by some groups
include - Focus, focus, focus the importance of setting
priorities, so that providers can succeed with
improvement efforts. - Having a safe place for sharing and collaborative
learning across institutions - Primary care practitioner availability is
becoming a patient safety issue threatening
coordination and continuity of care - Use of multidisciplinary teams for patient care
(including in facilities and medical home model) - Payment reform continue changing the way health
care is paid to support these changes
19Criteria Recommended for Selecting Priority Goals
- Greatest opportunity to reduce harm to patients
- Build on existing requirements and existing
priorities for greatest likelihood of success - Add value consider helping create cooperation
and synergy among different sectors that are
otherwise working in silos/independently - Look for win wins for significant improvement
potential for safety/quality and cost reductions
20Recommendations for Future Patient Safety
Priorities
- Retain focus on current goals
- - Infections in hospitals
- - Serious Reportable Events in hospitals,
- including preventing harm from falls and
pressure ulcers - Expand care sites for elimination of Serious
Reportable Events Falls and Pressure Ulcers - - work already underway in skilled nursing
facilities, home health around falls - - include SNF and home health as well as
hospitals in goal (e.g., falls) - - work with Massachusetts Falls Prevention
Coalition - Expand sites of care for Preventing
Infections/Harm from Infections - - Dialysis centers
- - Long term care facilities work already
underway - - Coordination across sites of care
- - Task small group to clarify elements of goal
- - infection prevention, antibiotic
stewardship/prescribing, nursing assessment
21Recommendations for Future Patient Safety
Priorities
- Set goal that all health care providers, with
support from their professional association,
create a basic Patient Safety Program - someone responsible for patient safety
- internal reporting of adverse events
- correct problems and measure effectiveness
- proactively think about where there is the
greatest potential for harm and design systems to
prevent harm - promote safety culture
22Recommendations for Future Patient Safety
Priorities
- Improve Transitions of Care, including
communication - Safety is not a silo related to several other
areas of quality - A. Generic elements for all transitions,
including at least - information transfer
- explicit handoff of care responsibility from
provider to provider - ensure follow-up of pending results
- meet patient/family needs
- focus on the process, not just the forms
- B. Specific focus on hospital discharge
transition - To home, with or without home health/hospice
- To skilled nursing facility
23Recommendations for Future Patient Safety
Priorities
- Improve Transitions of Care, including
communication ( contd) - C. Coordinates with other requirements/
incentives Joint Commission, NQF, Leapfrog, DPH,
Masshealth P4P (future), payers - D. Coordinates with other improvement efforts
- Interface with all related HCQCC Committees
- fit with HCQCC chronic care model
- fit with HQCC - End of Life work POLST
- Fit with Massachusetts State Quality Institute
Chronic Care Model - Fit other projects mentioned
- E. Consider Care Transitions Task Force as
Clinical Advisory Committee for this work
24Recommendations for Future Patient Safety
Priorities
- Next steps recommended, if these priorities
chosen - Small task forces to define explicit wording of
goal - Basic patient safety program
- Aim/Scope for infection prevention