Maulik S. Joshi, Dr.P.H.President and CEO

Network for Regional Healthcare ImprovementEmail: mjoshi@nrhi.orgPhone: 410-829-6252

Patient Safety: Where Are We Now,

Regionally?

AcademyHealthJune 2008

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Patient Safety – The Regional Landscape

1. Reporting

A. Adverse events to a state agency

B. Healthcare Associated Infections

C. Leapfrog Leaps

D. Never events

2. Technical Assistance

A. Education

B. Collaboratives

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Patient Safety Reporting

As of October 2007, 26 states plus the District of Columbia had passed legislation or regulation related to hospital reporting of adverse events to a state agency. Many of these new laws and regulations are intended to hold health care facilities accountable for weaknesses in their systems. They also have the potential to improve patient safety through event report analysis and by dissemination of best practices and lessons learned. 

National Academy for State Health Policy (NASHP) Patient Safety Toolbox for States

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Patient Safety Reporting

12 states publicly report data on measures of patient safety

•Mandated and non-mandated

•Overlap of “quality” measures

NASHP: State Health Policies Aimed at Promoting Excellent Systems: A Report on States’ Roles in Health Systems Performance, April 2008

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Healthcare Associated Infections

• 20+ states have laws or bills for reporting healthcare acquired infections/MRSA

• Many Challenges:– What measures?

– Reflect what population?

– How collected?

– How reported?

– How interpreted?

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Leapfrog Leaps

• 37 Regional Roll-OutsStrong business coalition support

Main task is to encourage local hospitals to publicly

report their progress on the implementation of

Leapfrog’s four recommended quality and safety

practices or ‘leaps’: •implementation of computerized physician order entry

(CPOE) systems, •staffing ICUs with intensivists, •referring patients to hospitals with the best results for

treating certain high risk conditions, and •implementation of other safe practices endorsed by the

National Quality Forum.

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Never Events

Minnesota: Adverse Health Event Reporting System, through which hospitals, ambulatory surgical centers, and community behavioral health hospitals are required to report whenever one of 27 – now 28 - serious events takes place

Fourth Annual Public Report, Adverse Health Events in Minnesotawww.health.state.mn.us/patientsafety

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Technical Assistance

• Early models –

• Maryland Patient Safety Center

• Iowa Healthcare Collaborative

• Pittsburgh Regional Health Initiative

• HHS/AHRQ PSO Regulations

• More to come

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Technical Assistance

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Technical Assistance

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Technical Assistance

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Patient Safety Regionally

• There continues to be more public reporting on safety practices/measures

• Current focus on infections:

What’s next?

• Regionally based patient safety centers/PSOs:

Solely on reporting or branching to education and improvement?

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Patient Safety Regionally

• Evaluation: Regional impact is unknown

What is attribution?

Of local structure

Of local promotion

Of local standards

Of local implementation