National Perspectives on Patient Safety William B' Munier, MD

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National Perspectives on Patient SafetyWilliam
B. Munier, MD

• Annual Betsy Lehman Center
• Patient Safety Symposium
• December 5, 2005

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Todays Agenda

• Patient safety today
• The Patient Safety and Quality Improvement Act of
  2005
• AHRQs plans to implement the law
• Discussion

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Patient Safety Today

• Five Years After To Err Is Human
• Advances in patient safety
• Obstacles to progress

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Five Years After To Err Is Human ( two years
after Patient Safety)

• Changing environment
• Active involvement of many stakeholders
• Increased national focus
• AHRQ
• IHI
• JCAHO
• NQF
• Many other organizations

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Advances in Patient Safety

• Wide scale adoption of patient safety programs in
  hospitals
• Initiation or expansion of large-scale patient
  safety efforts, e.g.,
• MERS-TH/TM
• Pennsylvania state-wide reporting initiative
• Development of measures (e.g., JCAHO, NQF)
• Early efforts at tying payment to safety

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Obstacles to Progress

• Patient safety information
• Medical records and event reporting systems
• Surveillance/detection efforts
• Definitions measures
• Baselines
• Complexity of the delivery system/process
• Training experience
• Cost
• Monitoring
• Making structural process improvements

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Patient Safety and QualityImprovement Act of 2005

• Purpose
• Major provisions
• Goals
• Implementation
• Issues for resolution

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Purpose of Act

• To provide for the improvement of patient safety
• To reduce the incidence of events that adversely
  affect patient safety

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Major Provisions of Act

• Creates Patient Safety Organizations (PSOs)
• Establishes Network of Patient Safety Databases
  (NPSD)
• Mandates Comptroller General to study
  effectiveness of Act (by 2010)
• Is a completely voluntary system

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Goals of Act

• To encourage providers to identify correct
  medical errors threats to patient safety by
  ensuring that their work with PSOs cannot be used
  against them in court or in disciplinary
  proceedings
• To encourage aggregation of cases by among
  PSOs, creating a network of patient safety
  databases
• To permit PSOs to identify patient safety
  improvement strategies

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Implementation

• Implementation strategies
• Structural support
• Patient Safety Organizations
• Network of Patient Safety Databases

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Implementation Strategies

• Build on existing work
• Sharp end infrastructure
• Private sector resources
• Previous conceptual work (IOM JCAHO NQF)
• Coordinate DHHS/Federal efforts
• Use IT to maximum extent practical
• Keep it simple

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Structural Support

• Create system for inventorying patient safety
  reporting activities, program inquiries
• Patient safety reporting systems
• Patient safety event definitions (data element
  level)
• Suggestions/inquiries tracking system
• Develop infrastructure at AHRQ/DHHS to manage the
  program in two basic tracks
• Foster/support PSOs
• Create maintain an operational NPSD

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PSO Program

• PSO certification processing system (AHRQ)
• Reviewing accepting initial subsequent PSO
  certifications
• Handling complaints
• Revoking acceptance of certification, when
  necessary
• Safety improvement (PSOs)
• Collecting, analyzing reports
• Disseminating information on strategies to
  improve patient safety
• Annual meeting

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PSO Next Steps

• Publish RFI to
• Gauge interest in becoming a PSO
• Provide reaction to draft criteria for
  certification
• Generate questions that need answers
• Host meeting of potential PSOs
• Review certification process
• Explain NPSD modus operandi, etc.
• Create dedicated Website

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NPSD Objectives

• To define terms, definitions of patient safety
  events encourage wide-spread adoption
• To generate information relevant to preventing
  harm to patients from health care
  (aggregate/analyze event data disseminate
  results)
• To simplify task of reporting events, consistent
  with achieving above objectives
• To provide benchmarking reports
• To share de-identified data for use in improving
  patient safety

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NPSD Next Steps

• Finish inventory of data elements, definitions
  encoding schemes used currently to
• Inform development of common formats
• Provide technical assistance to PSOs
• Develop system to accept data from PSOs
• Analyze/report patient safety trends
• Publish alerts, good practices, etc.
• Plan revisions to NHQR/DR report

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Issues for Resolution (examples)

• Who may become a PSO?
• Conflicts of interest
• Definition of component organizations
• Safeguards for protecting use of patient safety
  work product
• What are the criteria for re-certification
  revocation of certification?
• How should data be handled?
• Duplicate reporting
• Integrated analysis of events actions over time

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Discussion