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Stephen Pavkovic, RN, MPH, JDDirector, Patient SafetyUHC
The UHC PSO Experience
AHRQ Annual Conference
Bethesda, MD
September 11, 2012
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About UHC
UHC is Chicago-based alliance of 116 academic medical centers and 258 of their affiliated hospitals UHC provides clinical, operational and financial comparative
data and informatics UHC Performance Improvement Solutions
Imperatives for Quality UHC/AANC Nurse Registry Program™ UHC-AAMC Faculty Practice Solutions Center™ National Initiatives Support Patient Safety Program
Patient Safety Net®
Integrated Claims, Complaints and Incidents Modules
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AMC Members Across the Nation
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Representing the Nation’s Leading AMCs
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Presentation Overview
Foundation What is a PSO? Why Common Formats?
UHC Patient Safety Program UHC PSN, Powered by Datix
UHC Performance Improvement PSOCommon Formats facilitated research and findings
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What is a PSO?
Created by Patient Safety and Quality Improvement Act – 2005
The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients
Regulations provide Federal legal privilege and confidentiality protections to information that is assembled and reported by providers to a PSO or developed by a PSO for the conduct of patient safety activities.
PSWP - patient safety work product The Act also significantly limits the use of this
information in criminal, civil, and administrative proceedings.
The Act includes provisions for monetary penalties for violations of confidentiality or privilege protections.
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What is a PSO?
Patient Safety and Quality Improvement Act defines how patient safety event information is collected, developed, analyzed and maintained. The Act regulates PSOs membership:
PSOs are required to work with more than one provider Excludes insurance companies
Establishes a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for providers, PSOs, and other entities. For analyzing national and regional statistics, including trends and
patterns of patient safety events. The NPSD utilizes common formats and will promote interoperability
among reporting systems. The Department of Health and Human Services will provide technical assistance to PSOs.
76 PSO listed – 2012.
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Common Formats
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Common Formats
Common Formats are a set of common definitions and reporting formats, used to specify the clinical definitions and technical requirements that allow health care providers to exchange data with PSOs and the NPSD in an interoperable and standardized manner.
Ensure consistency in reporting patient safety event information
Provide analysis of patient safety event information and give feedback to health care providers
Facilitate a learning environment that reduces future risk to patients
Inpatient Hospital based Ambulatory care in development
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Common Formats
Leveling the field for comparative data reporting permitting “apples to apples” comparisons Contents: Definition of Event Scope of Reporting Risk Assessments and Preventative Actions Circumstances of Events
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UHC Patient Safety Program
UHC-Datix PSN® Suite
PSN® Incident Reporting Tool
Claims Management
Module
Complaints Module
Reports and Research
Managers have access to
dashboard reports
Rich source of data for research with 2.2 million patient
safety events
Aggregate Data Provides
Comparisons Among
Organizations
UHC PI Patient Safety
Organization
PSN® serves as the data
collection tool for UHC PI PSO
AHRQ-Listed PSO since 2008
Common Format (v 1.1)
compliant
Federal Confidentiality
& Privilege Protection
Community of Learners
Education and Member
Success Sharing Opportunities
Safety Stories
Data mining and Aggregate
Analysis Reports & Collaboratives
Project Collaboratives
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Overview of Patient Safety Net®
Internet-based incident reporting system with point of care for adverse events and near misses (unsafe conditions)
Real time triage, routing and analysis of patient safety events by location, event type or harm score
AHRQ Common Format (v1.1) compliant
Shared UHC taxonomy with customizable questions
Integrated Patient Complaint and Claims modules to identify prevention opportunities
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PSN® Front Line Event Report Components
Reporter Information Event Detail
Patient Information Event Basics
Harm ScoreOrganization
Specific Information
Each organization may customize the properties of selected questions in the event report.
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PSN® Manager Workflow
FLR submits event report
Consultant
E-mail/Event Report goes to appropriate managers
Managers can: • View and edit the event report • Read and audit other manager reviews • Consult with managers• Enter and ‘submit’ their own reviews commenting on contributing
factors, corrective actions, and costs incurred• Attach documents
Quality/Risk (Q/R) Managers also:• ‘Submit’ a report to PSN – which changes the status to ‘closed’• Unsubmit a report• Delete a report• Submit a report to UHC PSO, if applicable
The Q/R manager actively ‘closes’ the report to submit to PSN data
repository – report auto submits after 45 days
Q/R MgrPhysician
Mgr Ancillary
MgrPharmacist
MgrLocation
Mgr
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PSN® - How to submit to PSO
PSO Specific Legal Disclaimer Individual file management Batch file management
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UHC Patient Safety Net® (PSN®) by the NumbersSince 2004, over 2.2 million events
1.5 million AHRQ Common Format (v1.1) reports 103 sites representing:
20,500 Assigned passwords 19,000 staffed beds 138 Obstetrics and Obstetric Inpatient Units 119 Operating Room Departments 114 Emergency Departments 82 Radiation Departments and Radiation Oncology Units 61 Blood Banks 33 Pediatrics ICUs 23 Burn Units
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UHC Patient Safety Net® (PSN®) Research Overview
Common Formats facilitate aggregate research and shared user experience
“Found in the NET” and PSN-based research: Epidural medication misadministration 2009, N= 31 Transfusion related events, 2011, N= 29,506 Medication CPOE events, 2012 Annual falls survey
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ADD Harmscore
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UHC Patient Safety Net® (PSN®) Harm Score Survey
Shared user experience promotes applied learning
2011 Survey of 921 managers at 89 PSN users sites Review of 9 clinical scenarios with AHRQ (v1.1)
harm score assignment 2012 Survey of 13,000 managers at 102 PSN user sites
Review of 9 clinical scenarios with AHRQ (v1.2) harm score assignment
Inter-rater agreement demonstrated “moderate” agreement v1.1 – Fleiss’ kappa value = 0.51 V1.2 – Fleiss’ kappa value = 0.47
Submitted for publication – September 2012
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PPC submission
Preparing for UHC PI PSO event submission via PPC to NPSD
FallsTransfusionsMedications
Currently Testing Internal goal to be first PSO to successfully submit to
NPSD
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UHC Performance Improvement PSO
First PSO member submission: September 2009 Total UHC PSN reports: 1,032,981 through June 2012 103 PSN Sites - Program Participants - eligible for PSO
membership 47 PSO members in 21 States 19 Submitting members
Total PSO Submissions, from all event types: 66,976
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PSN® User Groups for Analysis Organization
PSN Program Participants “Non PSO” N = 56 (of 103)
PSO Members N = 47
PSO SubmittersN = 19 (of 47)
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Top Event Type and Distribution by PSN® User Group
Medication related
Skin Integrity
Fall
Laboratory test
0% 5% 10% 15% 20% 25% 30% 35% 40%
Non-PSO Member PSO Member PSO Submitter
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Harm Score Distribution for 1,032,981 PSN® Events
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
10% 54% 36%
Harm Reached the Patient Unsafe Conditions
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Harm Score Distribution by PSN® User Group
PSO Submitter (N = 225,265)
PSO Member (N = 263,348)
Non-PSO Member (N = 544,368)
0%10%
20%30%
40%50%
60%70%
80%90%
100%
Harm Reached the Patient Unsafe Conditions
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“PSO Submitter” RatesOrg ID Submit to PSN PSO Submission Rate
1 18,691 95.99%2 3,357 93.09%3 6,577 86.03%4 6,081 56.50%5 15,772 47.76%6 43,999 45.69%7 15,354 30.62%8 16,273 20.84%9 27,530 3.21%
10 344 2.33%11 16,874 .95%12 3,845 .34%13 3,365 .06%14 16,658 .05%15 5,339 .02%16 19,437 .01%17 31,440 .01%18 11,760 .01%19 12,666 .01%
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PSO Submitted Event Distribution by Harm Scores (v 1.1)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
14% 61% 24%
Overall PSO Submitted Harm Score Distribution
Harm Reached the Patient Unsafe Condition
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PSO Submitted Event Distribution by Harm Scores (v 1.1)
123456789
10111213141516171819
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Harm Reached the Patient Unsafe Condition
PERCENTAGE OF SUBMITTED EVENTS
PS
N S
UB
MIT
TIN
G O
RG
AN
IZA
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Findings
Distribution of harm scores assignment is similar for all of PSN®
Top submitted event types is similar for all of PSN®
No physical barriers to PSO submission
Percentage of total events submitted to PSO varies widely among PSO members
Distribution of harm score for events submitted to PSO varies widely
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Contributing Factors to PSO Submission Variation
Member FactorsSafety cultureLitigation postureLegislative climate in venue
11 States represented in 19 submitting organizations
Submission guidelines
Other factors…
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Take Home Messages
Common Formats facilitate the collection and evaluation of patient safety data
PSOs provide a method to collect and share patient safety information
UHC PSO members’ submission practices vary widely
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Thank you.Julie Cerese, UHC Vice PresidentSteve Thomas, UHC Data Analyst
Questions?
Stephen Pavkovic, RN, MPH, JDDirector Patient Safety
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