BETTER HEALTHCARE THROUGH SAFE PRACTICES

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BETTER HEALTHCARE THROUGH SAFE PRACTICES
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Kenneth W. Kizer, MD, MPH
• President CEO
• The National Quality Forum
• November 1, 2002

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Medicine used to be simple, ineffective and
  relatively safe. Now it is complex, effective
  and potentially dangerous.

Sir Cyril Chantler, former Dean Guys, King and
St. Thomass Medical and Dental School Lancet
1999
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Presentation Overview
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• What is the National Quality Forum?
• What is the NQF doing to improve patient safety?
• Serious Reportable Events
• The Safe Practices Project
• Other activities

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WHAT IS THE NQF?
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• The National Quality Forum is a private,
  non-profit voluntary consensus standards setting
  organization.

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WHAT DOES THE NQF DO?
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• The NQF was established to improve the
  quality of U.S. health care by
• standardizing health care performance measurement
  and reporting
• designing an overall strategy and framework for a
  National Healthcare Quality Measurement and
  Reporting System and
• otherwise promoting, guiding and leading health
  care quality improvement.

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HISTORY
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Presidential Advisory Commission on Consumer
  Protection and Quality in the Health Care
  Industry established (1996)
• Commission recommended the creation of a private
  sector entity (Quality Forum) that would bring
  healthcare stakeholder sectors together to
  standardize health care performance measures and
  standards (1998)
• Quality Forum Planning Committee convened by
  White House (1998)
• NQF incorporated in District of Columbia (1999)
• NQF operational (2000)

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THE NQF-QI NEXUS
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Quality improvement requires a systematic
  approach
• A systematic approach requires a strategy, goals,
  performance measurement and reporting
• Performance measures must be standardized,
  reliable and meaningful
• Structure, process, goals and rewards must be
  aligned accountability has to be built in

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Member Councils
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Consumers
• Health care providers and health plans
• Purchasers
• Research and quality improvement organizations

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Board of Directors
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Board of Directors composed of 19 members
• The CEOs of 3 federal agencies (CMS, OPM and
  AHRQ)
• Representatives of 2 state agencies
• Private sector representatives
• Equitable status of member councils
• Consumers and purchasers constitute a majority
• 5 liaison members (JCAHO, NCQA, IOM, PCPI and
  FACCT)

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UNIQUE FEATURES

NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Broad and open membership (gt155 organizations as
  of Oct 2002)
• Public and private sector representation on
  governing board BOD includes JCAHO, NCQA, PCPI,
  IOM and FACCT equitable status of stakeholder
  sectors
• Attention to overall strategy for measuring and
  reporting healthcare quality, including
  establishing national goals
• Focus is on the entire continuum of healthcare
• Formal consensus process (voluntary consensus
  standards)

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National Technology and Transfer Advancement of
Act of 1995 (NTTAA)
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Defines the 5 key attributes of a voluntary
  consensus standards body (i.e., openness,
  balance of interest, due process, consensus, and
  an appeals process)
• Obligates federal government to adopt voluntary
  consensus standards (when the government is
  adopting standards)
• Encourages federal government to participate in
  setting voluntary consensus standards

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CORE BUSINESS LINES
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Endorse performance measure voluntary consensus
  standards
• 2. Convene stakeholders to address issues
  important to QI or PM
• 3. Identify QI/PM research needs

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SELECTED PROJECTS
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Hospital Performance Measures
• Diabetes Care Performance Measures
• Cancer Care Performance Measures
• Minority Healthcare Quality Measures
• Nursing Home Performance Measures

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• www.qualityforum.org

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Role of NQF in Patient Safety
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Endorsed Patient Safety Call to Action
• Endorsed list of Serious Reportable Events
  (Never Events) working with states on a
  national reporting system
• Developing a core list of safe practices
• Identifying national hospital care performance
  measures (which include patient safety measures)
• Developing consensus on a patient safety taxonomy
  

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• SERIOUS REPORTABLE EVENTS
• (NEVER EVENTS)

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SERIOUS REPORTABLE EVENTS IN HEALTHCARE PROJECT
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• The objective of the Serious Reportable
  Events Project was to reach agreement about a set
  of serious, preventable adverse events that might
  form the basis for a national state-based
  healthcare error reporting system and that could
  lead to substantial improvements in patient care.
  

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Healthcare Errors How Big is the Problem?
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• 3-38 of hospitalized patients affected by
  iatrogenic injury or illness
• 44,000-98,000 hospital deaths/year (IOM)
• 2-35 of hospitalized patients suffer adverse
  drug events (average 7)
• gt7,000 ADE deaths/year
• 2 million nosocomial infections/year

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING
Healthcare Errors Not a New Problem

• I would give great praise to the physician whose
  mistakes are small for perfect accuracy is seldom
  to be seen
• Hippocrates

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING
Healthcare Errors Not a New Problem

• . . . even admitting to the full extent the
  great value of the hospital improvements in
  recent years, a vast deal of the suffering, and
  some at least of the mortality, in these
  establishments is avoidable.
• 
  Florence
  Nightingale, 1863

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Code Words for Medical Errors
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Adverse event, adverse outcome
• Medical mishap unintended consequence
• Unplanned clinical occurrence unexpected
  occurrence untoward incident
• Therapeutic misadventure bad call
• Peri-therapeutic accident
• Sentinel event
• Iatrogenic complication/ injury
• Hospital acquired complication

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Patient Safety Data Problems
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Almost all data from acute care hospitals
• Adverse events grossly underreported
• No standardization of what is reported
• Overall, little reliable and consistent data

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SERIOUS REPORTABLE EVENTS IN HEALTHCARE PROJECT
Development Process
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Contract from CMS/AHRQ funding from
• Milbank
• Steering Committee/expert panels convened
• Literature/evidence reviewed
• Draft list developed
• List reviewed by member councils and public
  revised reviewed.
• Board review and endorsement

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LIST OF SERIOUS REPORTABLE EVENTS IN HEALTHCARE
Criteria
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Unambiguous, usually preventable, serious and any
  of
• Adverse and/or
• Indicative of a problem in a healthcare
  facilitys safety systems and/or
• Important for public credibility or public
  accountability

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SERIOUS REPORTABLE EVENTS Surgical Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a patient
• Retention of a foreign object in a patient after
  surgery or other procedure
• Intra-operative or immediately post-operative
  death in an ASA Class 1 patient

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SERIOUS REPORTABLE EVENTS Product or Device
Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient death or serious disability associated
  with the use of contaminated drugs, devices, or
  biologics provided by the healthcare facility
• Patient death or serious disability associated
  with the use or function of a device in patient
  care, in which the device is used or functions
  other than as intended
• Patient death or serious disability associated
  with intravascular air embolism that occurs while
  being cared for in a healthcare facility

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SERIOUS REPORTABLE EVENTS Patient Protection
Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Infant discharged to the wrong person
• Patient death or serious disability associated
  with patient elopement (disappearance)
• Patient suicide, or attempted suicide resulting
  in serious disability, while being cared for in a
  healthcare facility

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SERIOUS REPORTABLE EVENTS Care Management Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient death or serious disability associated
  with a medication error (e.g., errors involving
  the wrong drug, wrong dose, wrong patient, wrong
  time, wrong rate, wrong preparation or wrong
  route of administration)
• Patient death or serious disability associated
  with a hemolytic reaction due to the
  administration of ABO-incompatible blood or blood
  products
• Maternal death or serious disability associated
  with labor or delivery in a low-risk pregnancy
  while being cared for in a healthcare facility

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SERIOUS REPORTABLE EVENTS Care Management Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient death or serious disability associated
  with hypoglycemia, the onset of which occurs with
  the patient is being cared for in a healthcare
  facility
• Death or serious disability (kernicterus)
  associated with failure to identify and treat
  neonatal hyperbilirubinimia
• Stage 3 or 4 pressure ulcers acquired after
  admission to a healthcare facility
• Patient death or serious disability due to spinal
  manipulative therapy

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SERIOUS REPORTABLE EVENTS Environmental Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient death or serious disability associated
  with an electric shock while being cared for in a
  healthcare facility
• Any incident in which a line designated for
  oxygen or other gas to be delivered to a patient
  contains the wrong gas or is contaminated by
  toxic substances
• Patient death or serious disability associated
  with a burn incurred from any source while being
  cared for in a healthcare facility

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SERIOUS REPORTABLE EVENTS Environmental Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient death associated with a fall while being
  cared for in a healthcare facility
• Patient death or serious disability associated
  with the use of restraints or bedrails while
  being cared for in a healthcare facility

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SERIOUS REPORTABLE EVENTS Criminal Events
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Any instance of care ordered by or provided by
  someone impersonating a physician, nurse,
  pharmacist or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the
  grounds of the healthcare facility
• Death or significant injury of a patient or staff
  member resulting from a physical assault (i.e.,
  battery) that occurs within or on the grounds of
  the healthcare facility

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SERIOUS REPORTABLE EVENTS Some Unresolved Issues
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Will reporting be mandatory or voluntary?
• Will the reports be disclosed to the public and,
  if so, how, when, etc.?
• What is the mechanism of reporting and reporting
  format and who will collect the reports?
• How will the reports be used?
• Legal liability, peer review protections, and
  discoverability?

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• SAFE PRACTICES

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Safe Practices Project Purpose
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• To identify and promote greater awareness
  and utilization of healthcare practices that are
  known to improve patient safety (i.e.,safe
  practices)

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Safe Practices ProjectConsensus Process
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Contract with AHRQ/CMS
• Steering Committee/expert panels selected
• Candidate practices identified
• Steering Committee recommends core list to
  Members
• Member and public review of core list
• Member Council voting/revision of list as needed
• Board of Directors vote
• Dissemination and implementation

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Steering Committee Key Decisions
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Definitions
• Criteria for selection
• What is evidence
• How to identify candidate practices

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Definitions
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient safety freedom from injury or
  illness resulting from the processes of care
• Patient Safety Event an occurrence, or
  potential occurrence, that is directly linked to
  the delivery of healthcare that results, or could
  result, in injury, illness or death

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Definitions
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Practice a clearly recognizable process
  or manner of accomplishing a healthcare purpose
  or providing care. One or more similarly
  intended but different actions or sets of actions
  may constitute the process.

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Definitions
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Quality Improvement Practice a clearly
  recognizable process or manner of providing care
  that has an evidence base demonstrating that it
  improves outcomes of care

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Definitions
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient Safety Practice a clearly
  recognizable process or manner of providing care
  that has an evidence base demonstrating that it
  reduces the likelihood of harm due to the
  systems, processes or environments of care

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Identification of Candidate Practices
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• AHRQ contracted UCSF-Stanford Evidence-based
  Practice Center report
• The Leapfrog Groups safety leaps
• gt120 medical specialty, nursing, pharmacy and
  other allied health organizations
• NQF membership
• Safe Practices Steering Committee Advisory
  Panel

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Inclusion Criteria for Candidate Practices
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Specificity
• Effectiveness
• Benefit
• Generalizability
• Readiness

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Specificity
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• The process or manner of providing the
• service is clearly enough defined, and its
• essential components specified, that one
• could conduct an audit and readily
• determine whether the practice is in use.

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Effectiveness
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Clear evidence that the practice reduces
  patient safety events evidence may come from
• Research findings from healthcare
• Experiential or self-evident data
• Research findings or experiential data from
  non-healthcare industries

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Benefit
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Demonstrated evidence or reasonable promise
  that implementation (or intensified
  implementation) of the practice will
  significantly reduce morbidity or mortality or
  reduce the likelihood of a serious reportable
  event
• 
  as
  defined by NQF

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Generalizability
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Able to be implemented in multiple care settings
  and/or for multiple conditions

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Readiness
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• The technology, staff and/or other resources
  needed to implement the practice are reasonably
  available to most healthcare organizations

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Categories of Safe Practices
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Creating a culture of safety (1)
• Matching care needs with service capability (5)
• Facilitating information transfer and clear
  communication (11)
• Enhancing the safety of specific processes or
  settings of care (12)
• Increasing safe medication use (4)

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SAFE PRACTICES Creating a Culture of Safety
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• In a Culture of Safety there are standard
• methods to
• Prioritize events to be reported
• Analyze reported events
• Verify recommended actions taken
• Ensure leadership involvement
• 
  all predicated on having a
  nonpunitive environment

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SAFE PRACTICES Creating a Culture of Safety
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• In a Culture of Safety there are standard
• methods to
• Provide oversight and coordination
• Provide feedback to frontline
• Publicly disclose compliance
• Train staff in teamwork-based problem solving
• 
  all predicated on having a
  nonpunitive environment

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SAFE PRACTICES Matching Care Need With Service
Capability
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Refer elective high-risk procedures to high
  volume providers
• Use an explicit protocol for nurse staffing based
  on patient mix and staff skills
• Use intensivists to manage ICU patients
• Designate a health care advocate
• Use pharmacists in all stages of the medication
  use process

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Demonstrated Volume-Outcome Relationship
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Coronary artery bypass grafts
• Angioplasty
• Abdominal aortic aneurysm repair
• Carotid endarterectomy
• Esophageal cancer surgery
• Delivery of LBW baby lt1500 gms and/or lt32 wks
  gestation
• Delivery of baby with major congenital
  malformations

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SAFE PRACTICES Matching Care Need With Service
Capability
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Refer elective high-risk procedures to high
  volume providers
• Use an explicit protocol for nurse staffing based
  on patient mix and staff skills
• Use intensivists to manage ICU patients
• Designate a health care advocate
• Use pharmacists in all stages of the medication
  use process

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SAFE PRACTICES Facilitating Information
Transfer and Clear Communication
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Use repeat back for verbal orders
• Use only standardized abbreviations and dose
  designations
• Use original source documents when preparing
  records (do not rely on memory)
• Make complete record available whenever there is
  ahandoff (change of caregivers)

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SAFE PRACTICES Facilitating Information
Transfer and Clear Communication
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Ensure care information (esp change of orders,
  new dx data) is transmitted to all of the
  patients caregivers (including OP)
• Informed consent forms should be user friendly
• Prominently display in chart patients preference
  for life sustaining treatment
• Utilize computerized prescriber order entry

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CPOE Specifications
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Prescribers enter hospital medication
  orders via an automated information management
  system that is
• Linked to prescribing error prevention software
  
• Enables review of all new orders by a pharmacist
  before first dose
• Permits notation of allergies/reactions in one
  place
• Categorizes drugs into drug families to allow
  checking within classes
• Requires documentation of overrides
• Internal automatic performance checks of the
  information system

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SAFE PRACTICES Facilitating Information
Transfer and Clear Communication
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Patient should maintain a list of current
  medications and drug allergies/reactions
• Utilize a standard protocol for labeling
  radiographs
• Utilize a standard protocol to prevent wrong site
  or wrong person surgery

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Key Elements in Preventing Wrong Site Surgery
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Documentation of operative site in the patients
  record
• Patients record in OR
• OR team verifies operative site and document
  verification
• Whenever possible, patient also verifies
  operative site in OR, and this is documented

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SAFE PRACTICES Specific Settings or Processes
of Care
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Utilize a standard protocol to evaluate each
  patient for their risk of and that uses effective
  methods to prevent
• Intra-operative cardiac ischemia
• Pressure ulcers
• Venous thromboembolism
• Aspiration
• Central venous catheter-related infections

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SAFE PRACTICES Specific Settings or Processes
of Care
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Utilize a standard protocol to evaluate each
  patient for their risk of and that uses effective
  methods to prevent
• Surgical site infection
• Contrast media-induced nephropathy
• Malnutrition
• Pneumatic tourniquet-induced ischemia or
  thrombosis

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SAFE PRACTICES Specific Settings or Processes
of Care
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Decontaminate hands prior to and between each
  patient encounter
• Vaccinate all personnel against influenza
• Use dedicated anticoagulation services that
  facilitate coordinated care management

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SAFE PRACTICES Promoting Safe Medication Use
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Keep medication preparation areas orderly, well
  lit, and free of clutter, distraction and noise
• Standardize methods of labeling, packaging and
  storing medications
• Identify all high alert drugs in use and
  utilize standard procedures in their use
• Dispense medications in unit-of-use form whenever
  possible

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Dissemination and Implementation
NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Provide to CMS - ?COP
• Provide to purchasers (Leapfrog, etc) - ?contract
  terms
• Member organization use - ?benchmarking
• Use by consumers, states, others
• Provide to AHRQ to help shape the research agenda

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Conclusion

NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• HIGH QUALITY HEALTHCARE BEGINS WITH ENSURING
  PATIENT SAFETY

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NQF THE NATIONAL FORUM FOR HEALTH CARE QUALITY
MEASUREMENT AND REPORTING

• Grant me the courage to realize my daily
  mistakes so that tomorrow I shall be able to see
  and understand in a better light what I could not
  comprehend in the dim light of yesterday
• Maimonides (1135-1204)