Influencing Health Care:Influencing Health Care:Safety & MeasurementSafety & Measurement

Peter Angood MD FACS FCCMPeter Angood MD FACS FCCM

Vice President & Chief Patient Safety OfficerVice President & Chief Patient Safety OfficerJoint Commission (JCAHO)Joint Commission (JCAHO)

Chief Patient Safety Officer & Co-DirectorChief Patient Safety Officer & Co-DirectorJoint Commission International Center for Joint Commission International Center for

Patient SafetyPatient Safety

Chicago, USAChicago, USA

> 5 Years After The IOM Report:> 5 Years After The IOM Report:“To Err Is Human”“To Err Is Human”

Regulation/Accreditation: A-Regulation/Accreditation: A- Workforce Training Issues: BWorkforce Training Issues: B Information Technology: B-Information Technology: B- Error Reporting Systems: CError Reporting Systems: C Malpractice System: D+Malpractice System: D+

Wachter, RM; Health Affairs; 11/2004Wachter, RM; Health Affairs; 11/2004

Mission:Mission: To continuously improve the safety and To continuously improve the safety and

quality of care provided to the public quality of care provided to the public through the provision of health care through the provision of health care accreditation and related services that accreditation and related services that support performance improvement in health support performance improvement in health care organizations.care organizations.

Free-standing not-for-profit organization Free-standing not-for-profit organization with deemed status by federal Center for with deemed status by federal Center for Medicare and Medicaid Services (CMS)Medicare and Medicaid Services (CMS)

Joint Commission on Accreditation of Joint Commission on Accreditation of Healthcare Organizations (JCAHO)Healthcare Organizations (JCAHO)

““To continuously improve the To continuously improve the safety and quality of care”safety and quality of care”

The Joint Commission on Accreditation of Healthcare Organizations

~ Overlapping Strategies ~~ Overlapping Strategies ~

Committed to continually Committed to continually enhance the value of its enhance the value of its accreditation and certification accreditation and certification programs.programs. • The Joint Commission will strive to The Joint Commission will strive to

ensure that they are patient-centered, ensure that they are patient-centered, data-driven, relevant, and integral to the data-driven, relevant, and integral to the performance improvement activities of performance improvement activities of health care organizations.health care organizations.

Commitment:Commitment: To continually enhance the value of Joint Commission To continually enhance the value of Joint Commission accreditation and certification programs to ensure that they are patient-accreditation and certification programs to ensure that they are patient-centered, data-driven, relevant and integral to the performance centered, data-driven, relevant and integral to the performance improvement activities of health care organizations.improvement activities of health care organizations.

As of December 30, 2005.

Ambulatory Care 1,234Assisted Living 72Behavioral Health Care 1,821Critical Access Hospitals 268Home Care 3,422Hospitals 4,342Laboratory 1,947Long Term Care 1,364 Networks 21Office Based Surgery 221Total 14,712

Accredited ProgramsAccredited ProgramsAccredited ProgramsAccredited Programs

Disease-Specific Care 229Health Care Staffing 70Total 299

Certified ProgramsCertified ProgramsCertified ProgramsCertified Programs

This is the core competency of the Joint CommissionThis is the core competency of the Joint Commission

Safety and Regulatory IssuesSafety and Regulatory Issues

Persistent Accreditation Issues:Persistent Accreditation Issues: Precision of standardsPrecision of standards Consistency of surveyorsConsistency of surveyors Perceptions of relevancePerceptions of relevance Intermittent nature of processIntermittent nature of process

Shared Visions, New PathwaysShared Visions, New Pathways

~ Overlapping Strategies ~~ Overlapping Strategies ~

Committed to developing, Committed to developing, utilizing, and maintaining valid utilizing, and maintaining valid and reliable performance and reliable performance measures.measures. • These measures are needed to support These measures are needed to support

a credible, data-driven accreditation a credible, data-driven accreditation process and the publication of process and the publication of meaningful comparative performance meaningful comparative performance information for the public. information for the public.

Requirements that define performance Requirements that define performance expectations with respect to structure, expectations with respect to structure, process, and outcomes that must be process, and outcomes that must be substantially in place in an substantially in place in an organization to enhance the safety and organization to enhance the safety and quality for patient carequality for patient care

Performance Measurement DataPerformance Measurement Data Adverse Event ReportingAdverse Event Reporting

StandardsStandards

Core Measure Identification Process Core Measure Identification Process Library of hospital priority measurement areasLibrary of hospital priority measurement areas• Acute myocardial infarction (implemented Acute myocardial infarction (implemented

2002)2002)• Heart failure (implemented 2002)Heart failure (implemented 2002)• Community acquired pneumonia (implemented Community acquired pneumonia (implemented

2002)2002)• Pregnancy and related conditions Pregnancy and related conditions

(implemented 2002)(implemented 2002)• Surgical infection prevention (Implemented Surgical infection prevention (Implemented

July 2004)July 2004)• Intensive care (Scheduled July 2005)Intensive care (Scheduled July 2005)• Pain management (In development)Pain management (In development)• Children’s asthma (In development)Children’s asthma (In development)• Hospital Based Inpatient Psychiatric Services Hospital Based Inpatient Psychiatric Services

(In development)(In development)• DVT (In development)DVT (In development)• Sepsis (In development)Sepsis (In development)

Performance MeasurementPerformance Measurement Environment is rapidly evolvingEnvironment is rapidly evolving US Federal Gov’t – accelerating changeUS Federal Gov’t – accelerating change Link between performance measurement and Link between performance measurement and

accreditationaccreditation Alignment with Hospital Quality Alliance Alignment with Hospital Quality Alliance

(HQA-2003) & National Quality Forum (NQF-(HQA-2003) & National Quality Forum (NQF-1999) important1999) important

Accreditation: Accreditation: • contractual agreement to collect on 3 contractual agreement to collect on 3

measure setsmeasure sets• AMI, CHF, Pneumonia, SIP or Pregnancy & AMI, CHF, Pneumonia, SIP or Pregnancy &

Related ConditionsRelated Conditions

~ Overlapping Strategies ~~ Overlapping Strategies ~

Committed to making patient Committed to making patient safety an imperative in all safety an imperative in all accredited organizations.accredited organizations. • This will be accomplished through the This will be accomplished through the

standards and policies of the Joint standards and policies of the Joint Commission and through collaboration Commission and through collaboration with other patient safety leadership with other patient safety leadership organizations. organizations.

Sentinel Event PolicySentinel Event Policy

Established in January 1996:Established in January 1996:

• To have a positive impact in improving To have a positive impact in improving carecare

• To focus attention on underlying To focus attention on underlying causes and risk reductioncauses and risk reduction

• To increase the general knowledge To increase the general knowledge about sentinel events, their causes and about sentinel events, their causes and preventionprevention

• To maintain public confidence in the To maintain public confidence in the accreditation processaccreditation process

Percent of 3231 events

Sentinel Event AlertsSentinel Event Alerts1.1. Potassium chloridePotassium chloride2.2. Policy issuesPolicy issues3.3. Policy issuesPolicy issues4.4. Policy issuesPolicy issues5.5. Policy issuesPolicy issues6.6. Wrong site surgeryWrong site surgery7.7. SuicideSuicide8.8. Restraint deathsRestraint deaths9.9. Infant abductionsInfant abductions10.10. Transfusion errorsTransfusion errors11.11. High Alert MedicationsHigh Alert Medications12.12. Op/post-op Op/post-op

complicationscomplications13.13. Impact of Impact of SE AlertSE Alert14.14. Fatal fallsFatal falls15.15. Infusion pumpsInfusion pumps16.16. Proactive risk reductionProactive risk reduction17.17. Home fires (O2 therapy)Home fires (O2 therapy)18.18. KernicterusKernicterus

19.19. Look-alike, sound-alike Look-alike, sound-alike drugsdrugs

20.20. Kreutzfeldt-Jakob diseaseKreutzfeldt-Jakob disease21.21. Medical gas mix-upsMedical gas mix-ups22.22. Needles & sharps injuriesNeedles & sharps injuries23.23. Dangerous abbreviationsDangerous abbreviations24.24. Wrong-site surgery #2Wrong-site surgery #225.25. Ventilator-related eventsVentilator-related events26.26. Delays in treatmentDelays in treatment27.27. Bed rail deaths & injuriesBed rail deaths & injuries28.28. Nosocomial infectionsNosocomial infections29.29. Surgical firesSurgical fires30.30. Perinatal deathsPerinatal deaths31.31. Anesthesia awarenessAnesthesia awareness32.32. Kernicterus #2Kernicterus #233.33. PCA by proxyPCA by proxy34.34. Intrathecal vincristineIntrathecal vincristine35.35. Wrong route / wrong tubeWrong route / wrong tube36.36. Medication reconciliationMedication reconciliation37.37. Device ConnectionsDevice Connections

National Patient Safety GoalsNational Patient Safety Goals Selection of the Goals and Selection of the Goals and

requirements is guided by a panel of requirements is guided by a panel of experts: experts:

Sentinel Event Advisory GroupSentinel Event Advisory Group

Each year, a set of Goals & their Each year, a set of Goals & their Requirements are identified from a Requirements are identified from a variety of sourcesvariety of sources

The Goals and their Requirements are The Goals and their Requirements are field reviewed & published by mid-year field reviewed & published by mid-year for the coming calendar yearfor the coming calendar year

NPSG Compliance Data for 2003—2006NPSG Compliance Data for 2003—2006NPSG requirementNPSG requirement 20032003 20042004 20052005 20062006

1a: Two identifiers1a: Two identifiers 3.8%3.8% 4.1%4.1% 3.9%3.9% 3.8%3.8%

1b: Time out before surgery1b: Time out before surgery 8.9%8.9% 8.0%8.0% 17.1%17.1% 7.7%7.7%

2a: Read-back verbal orders2a: Read-back verbal orders 7.4%7.4% 8.2%8.2% 11.6%11.6% 9.6%9.6%

2b: Standardize abbreviations2b: Standardize abbreviations 23.5%23.5% 24.8%24.8% 39.5%39.5% 11.5%11.5%

2c: Improve timeliness of reporting2c: Improve timeliness of reporting ------ ------ 7.6%7.6% 17.3%17.3%

2e: Hand-off communications2e: Hand-off communications ------ ------ ------ 5.8%5.8%

3a: Concentrated electrolytes3a: Concentrated electrolytes 3.0%3.0% 1.9%1.9% 1.3%1.3% ------

3b: Limit concentrations3b: Limit concentrations 0.6%0.6% 0.9%0.9% 1.5%1.5% 0.0%0.0%

3c: Manage look-alike/sound-alike 3c: Manage look-alike/sound-alike drugsdrugs ------ ------ 1.9%1.9% 5.8%5.8%

3d: Label medications & solutions3d: Label medications & solutions ------ ------ ------ 7.7%7.7%

4a: Preoperative verification4a: Preoperative verification 1.5%1.5% 5.4%5.4% 5.5%5.5% 1.9%1.9%

4b: Surgical site marking4b: Surgical site marking 6.2%6.2% 4.6%4.6% 3.8%3.8% 3.8%3.8%

7a: CDC hand hygiene guidelines7a: CDC hand hygiene guidelines ------ 1.2%1.2% 3.6%3.6% 7.7%7.7%

7b: HC-associated infection & RCA7b: HC-associated infection & RCA ------ 0.1%0.1% 0.0%0.0% 0.0%0.0%

8a: Medication reconciliation – list8a: Medication reconciliation – list ------ ------ 0.0%0.0% 3.8%3.8%

8b: Medication reconciliation – 8b: Medication reconciliation – reconcilereconcile ------ ------ 0.3%0.3% 7.7%7.7%

9a: Fall risk assessment9a: Fall risk assessment ------ ------ 3.03.0 ------

9b: Fall prevention program9b: Fall prevention program ------ ------ ------ 7.7%7.7%

Alternatives Approaches to the NPSGsAlternatives Approaches to the NPSGsNPSG requirementNPSG requirement 2004 Requests2004 Requests 2005 Requests2005 Requests

1a: Two identifiers1a: Two identifiers 33 11

1b: Time out before surgery1b: Time out before surgery 11 11

2a: Read-back verbal orders2a: Read-back verbal orders 66 00

2b: Standardize abbreviations2b: Standardize abbreviations 1515 1717

2c: Timeliness of reporting2c: Timeliness of reporting ---------------- 11

3a: Concentrated electrolytes3a: Concentrated electrolytes 9090 11

3b: Limit concentrations3b: Limit concentrations 1010 3535

3c: Look-alike/sound-alike drugs3c: Look-alike/sound-alike drugs ---------------- 1414

4a: Preoperative verification4a: Preoperative verification 66 11

4b: Surgical site marking4b: Surgical site marking 5454 00

5a: Free-flow protection5a: Free-flow protection 4242 44

6a: Alarm maintenance & testing6a: Alarm maintenance & testing 11 00

6b: Alarm settings & audibility6b: Alarm settings & audibility 44 00

7a: CDC hand hygiene guidelines7a: CDC hand hygiene guidelines ---------------- 7878

7b: Infection-related sentinel events7b: Infection-related sentinel events ---------------- 00

8a: Medication reconciliation8a: Medication reconciliation ---------------- 1010

8b: Medication information to next 8b: Medication information to next providerprovider ---------------- 00

9a: Fall risk assessment9a: Fall risk assessment ---------------- 33

2005 National Patient Safety Goals2005 National Patient Safety Goals1.1. Patient identificationPatient identification

2.2. Communication among caregiversCommunication among caregivers

3.3. Medication safetyMedication safety

4.4. Wrong-site surgeryWrong-site surgery

5.5. Infusion pumpsInfusion pumps

6.6. Clinical alarm systemsClinical alarm systems

7.7. Health care-associated infectionsHealth care-associated infections

8.8. Reconciliation of medicationsReconciliation of medications

9.9. Patient fallsPatient falls

10.10. Flu & pneumonia immunizationFlu & pneumonia immunization

11.11. Surgical firesSurgical fires

12.12. NPSG implementation by network NPSG implementation by network componentscomponents

1.1. Patient identificationPatient identification

2.2. Communication among caregiversCommunication among caregivers

3.3. Medication safetyMedication safety

4.4. Wrong-site surgery Universal ProtocolWrong-site surgery Universal Protocol

5.5. Infusion pumpsInfusion pumps

6.6. Clinical alarm systemsClinical alarm systems

7.7. Health care-associated infectionsHealth care-associated infections

8.8. Reconciliation of medicationsReconciliation of medications

9.9. Patient fallsPatient falls

10.10. Flu & pneumonia immunizationFlu & pneumonia immunization

11.11. Surgical firesSurgical fires

12.12. NPSG implementation by network NPSG implementation by network componentscomponents

13.13. Patient involvementPatient involvement

14.14. Pressure ulcersPressure ulcers

2006 National Patient Safety Goals2006 National Patient Safety Goals

Provisions of the Universal ProtocolProvisions of the Universal Protocol Preoperative verification processPreoperative verification process

• Relevant pre-op tasks completed and Relevant pre-op tasks completed and information is available and correctinformation is available and correct

Surgical site markingSurgical site marking• Unambiguous mark, visible after prep & Unambiguous mark, visible after prep &

drapedrape• Right/left, multiple structures or levelsRight/left, multiple structures or levels

““Time out” immediately before startingTime out” immediately before starting• Involves entire team; active communicationInvolves entire team; active communication• Fail-safe model: “No go” unless all agreeFail-safe model: “No go” unless all agree

Applicable to invasive procedures in all settingsApplicable to invasive procedures in all settings

Wrong-site SurgeriesWrong-site Surgeries

Surveying and Scoring theSurveying and Scoring theNational Patient Safety GoalsNational Patient Safety Goals

Must implement Must implement allall applicable Goals & applicable Goals & Requirements or implement an acceptable Requirements or implement an acceptable alternative(s)alternative(s)

Evaluated in the PPR and during all full Evaluated in the PPR and during all full accreditation surveys and for-cause surveysaccreditation surveys and for-cause surveys

Surveyors evaluate actual performance, not Surveyors evaluate actual performance, not just intentjust intent

Failure to comply with one or more Failure to comply with one or more requirements of a Goal will result in a requirements of a Goal will result in a “Requirement for Improvement”“Requirement for Improvement”

NPSG requirements that are also in the NPSG requirements that are also in the standards will only be scored once (no standards will only be scored once (no “double jeopardy”)“double jeopardy”)

Aggregate dataAggregate data

• Data from 2003 - 2005 surveys posted Data from 2003 - 2005 surveys posted on Joint Commission web siteon Joint Commission web site

Individual health care organizationsIndividual health care organizations::

• Compliance with specific requirementsCompliance with specific requirements

• Quality Reports Quality Reports - on web site since - on web site since 20042004

Public Disclosure of Compliance Public Disclosure of Compliance with National Patient Safety Goalswith National Patient Safety Goals

~ Overlapping Strategies ~~ Overlapping Strategies ~

Committed to ensure that the Committed to ensure that the accreditation process is publicly accreditation process is publicly accountable.accountable. • The Joint Commission will provide The Joint Commission will provide

meaningful and useful information about meaningful and useful information about the performance of accredited the performance of accredited organizations to the public.organizations to the public.

WWW.QualityCheck.orgWWW.QualityCheck.org

SIP Measure ReportingSIP Measure Reporting

Strategic Surveillance System - Release 1.0Strategic Surveillance System - Release 1.0(Corporate Summary & Comparison of Organization Level PFP Points)(Corporate Summary & Comparison of Organization Level PFP Points)

System ABC’s PFP Point Total Average = (3282.50/11) = 299

System ABC compared to other groups of hospitals from PFP Studies:

PFP Means Across Various Groups of Hospitals - 2004 Studies

299

163190

206243

348 348

0

50

100

150

200

250

300

350

400

NYCHHC SolucientBenchmark

Group

US New sBenchmark

Group

RandomControl Group

For CauseGroup

ConditionalAccreditation

Status

PreliminaryDenial of

AccreditationStatus

Group Name

PF

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Strategic Surveillance System - Release 1.0Strategic Surveillance System - Release 1.0 (Corporate Dashboard View by Measure Set) (Corporate Dashboard View by Measure Set)

Hospital Quality AllianceHospital Quality Alliance 2003 - Voluntary reporting of 10 selected 2003 - Voluntary reporting of 10 selected

measures from JCAHO & CMS focused measures from JCAHO & CMS focused towards AMI, CHF & Pneumoniatowards AMI, CHF & Pneumonia

2004 - Medicare Modernization Act created 2004 - Medicare Modernization Act created formal link to measures and hospital formal link to measures and hospital reimbursementreimbursement

2005 – expanded to all measures and 2005 – expanded to all measures and included SIP measures setincluded SIP measures set

2007 – reported patient experience of care 2007 – reported patient experience of care survey (H-CAPS) & risk-adjusted measures survey (H-CAPS) & risk-adjusted measures for 30-day mortality of AMI & CHF to be for 30-day mortality of AMI & CHF to be gathered by CMSgathered by CMS

Institute of Medicine 2005Institute of Medicine 2005

Performance Measurement Performance Measurement recommendations includes IOM’s recommendations includes IOM’s starter set of measures for hospital starter set of measures for hospital performance that is > HQA measuresperformance that is > HQA measures

2006 - Deficit Reduction Omnibus Act 2006 - Deficit Reduction Omnibus Act adopts IOM recommendations for adopts IOM recommendations for inclusion in a new “value-based inclusion in a new “value-based purchasing” (P4P) framework to be purchasing” (P4P) framework to be implemented by 2009implemented by 2009

State-based initiatives increasingState-based initiatives increasing

HQA & NQF ChangesHQA & NQF Changes Joint Commission remains committed Joint Commission remains committed

& flexible to evolving performance & flexible to evolving performance measurement environmentmeasurement environment

Deficit Reduction Act creates impetus Deficit Reduction Act creates impetus for HQA & NQF to accelerate for HQA & NQF to accelerate expansion of the array of measures in expansion of the array of measures in the production process:the production process:• SCIPSCIP• ICU Measure SetICU Measure Set• Pediatric AsthmaPediatric Asthma• Nursing-SensitiveNursing-Sensitive• AHRQ Quality IndicatorsAHRQ Quality Indicators

~ Overlapping Strategies ~~ Overlapping Strategies ~

Committed to addressing Committed to addressing pressing public policy issues that pressing public policy issues that impact the quality and safety of impact the quality and safety of health care.health care. • The Joint Commission will convene The Joint Commission will convene

thought leaders and subject-matter thought leaders and subject-matter experts and will issue public policy experts and will issue public policy recommendations.recommendations.

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TopicsTopics # of # of DownloadsDownloads

Nursing Shortage– white paperNursing Shortage– white paper 967,308967,308

Emergency Preparedness – white paperEmergency Preparedness – white paper 113,359113,359

Organ Donation – white paperOrgan Donation – white paper 92,64792,647

Medical Liability – white paperMedical Liability – white paper 292,033292,033

Improving the Quality of Pain Management Improving the Quality of Pain Management Through Measurement and ActionThrough Measurement and Action

638,938638,938

Universal ProtocolUniversal Protocol 157,880157,880

Universal Protocol Implementation GuidelinesUniversal Protocol Implementation Guidelines 127,798127,798

““Do Not Use” ListDo Not Use” List 104,860104,860

Standing Together Emergency Planning GuideStanding Together Emergency Planning Guide 587,554587,554

Speak Up BrochureSpeak Up Brochure 154,535154,535

Universal Protocol Brochure (Wrong Site Surgery)Universal Protocol Brochure (Wrong Site Surgery) 95,79895,798

Organ Donation BrochureOrgan Donation Brochure 46,93746,937

Infection Control BrochureInfection Control Brochure 150,934150,934

Medication Management BrochureMedication Management Brochure 50,44650,446

Joint Commission Joint Commission InternationalInternational

Center for Patient SafetyCenter for Patient Safety

Partnering for Solutions in Systems ImprovementPartnering for Solutions in Systems Improvement

Collaboration & PartneringCollaboration & Partnering

Patient Safety “Solutions”Patient Safety “Solutions”

Information DistributionInformation Distribution

Educational ProgramsEducational Programs

Patient Safety ResearchPatient Safety Research

Public Policy-AdvocacyPublic Policy-Advocacy

Patient Safety Legislation & Patient Safety Legislation & Patient Safety OrganizationsPatient Safety Organizations

DefinitionDefinition: : A Safety Solution is any system A Safety Solution is any system

design or intervention that has design or intervention that has demonstrated the ability to prevent demonstrated the ability to prevent or mitigate patient harm stemming or mitigate patient harm stemming from the processes of health care from the processes of health care

Measurement IssuesMeasurement Issues Are outcomes & performance Are outcomes & performance

measurement feasible?measurement feasible? Can reliable risk adjustment be Can reliable risk adjustment be

performed for patient & providers?performed for patient & providers? How to overcome cultural variability & How to overcome cultural variability &

resistance to reporting?resistance to reporting?

Cult of the RCT phenomenon…Cult of the RCT phenomenon… Development of measures is not Development of measures is not

enough for systems change!enough for systems change!

Measurement IssuesMeasurement Issues Infection-Related Issues:Infection-Related Issues:

• VAPVAP• Central Line InfectionCentral Line Infection• Blood Stream InfectionBlood Stream Infection• SepsisSepsis• Surgical Wound InfectionSurgical Wound Infection

WHO Alliance: Global ChallengeWHO Alliance: Global Challenge Taxonomy/Classification SystemsTaxonomy/Classification Systems Professional Society & OrganizationsProfessional Society & Organizations

Barriers & Solutions…Barriers & Solutions…

What Is On The Radar Screen?What Is On The Radar Screen?

Physician Engagement in SafetyPhysician Engagement in Safety