Organizations unveil patient safety road map
Consensus report endorses 30 specific practices
Some of the nation’s leading health care and consumer groups have endorsed 30 patient safety practices they describe as a road map for better patient safety.
These practices, they say, should be used universally in health care settings to reduce the risk of harm resulting from processes, systems, or environments of care.
The consensus report was released May 15, 2003, by the National Quality Forum (NQF), a Washington, DC-based private, nonprofit public benefit corporation created in 1999 in response to the need to develop and implement a national strategy for health care quality measurement and reporting.
The report was funded in part by the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD.
The practices are organized into five broad categories for improving patient safety:
- creating a culture of safety;
- matching health care needs with service delivery capabilities;
- facilitating information transfer and clear communication;
- adopting safe practices in specific clinical settings or for specific processes of care;
- increasing safe medication use.
More than 200 practices were considered, with evaluations focusing on those that:
- have strong evidence that they are effective in reducing the likelihood of harming a patient;
- are generalizable (i.e., they may be applied in multiple clinical care settings and/or for multiple types of patients);
- are likely to have a significant benefit to patient safety if truly implemented;
- have knowledge about them that is usable by consumers, purchasers, providers, and researchers.
In addition to the 30 recommended safe practices, the report identifies 27 practices that have great promise for reducing adverse events and should have high priority for further investigation.
Leaders applaud report
In a press briefing unveiling the report, health care leaders shared their thoughts on the findings and how health care facilities can best respond.
"This report is good news," said Kenneth W. Kizer, MD, MPH, president and chief executive officer of NQF.
"We know that modern health care is an exceedingly complex, high-risk, error-prone activity, and we know from the [1999 Institute of Medicine (IOM) report To Err Is Human] and others that medical errors are a major cause of death in this country, but there are ways we can prevent those errors from occurring. This is a road map to safety; it is clear that if these practices are implemented, we would make significant improvements in patient safety," he said.
"The only thing worse than one error is having the same error happen again and again," added Carolyn M. Clancy, MD, director of AHRQ.
"We need to continue to focus on systems and understand that what was released today is a road map for sustainable improvement. We still have a lot to learn," she said.
Thomas L. Garthwaite, MD, director and chief medical officer for the Los Angeles County Department of Health Services, said, "We think our system has done very well in learning from bad outcomes; in the future, we hope to learn from close calls. That’s why I’ve asked 45 of our practitioners to come here, to begin what is a long journey to a safer health care system."
"The Joint Commission welcomes and applauds this initiative," added Dennis J. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. "[More than] half of our current accreditation standards address patient safety directly."
What facilities should do
Coming up with a list of recommended practices is a good first step, but what do these health care leaders expect patient safety professionals to do once they receive the report to translate its findings into real-world improvement?
"One of the advantages of having this list of 30 practices is that each individual facility can systematically go through the list and see what they are currently doing and what opportunities for improvement exist," Kizer told Patient Safety Alert.
"This provides a structure that was not avail-able before for going through your processes and looking at what can be done. For example: Under the fourth cluster, clinical care, we know a great many practices are being followed to some extent — maybe 30% to 40% — but it’s not anywhere near where it should be," he continued. "Maybe your facility needs better protocols or needs to be more thorough, or whatever the case may be. In our membership, we’ve seen people go through that exercise as the list matured. I recommend that any system take this and put it in place as rapidly as they can."
"We’ve seen in the response to the IOM report and highly publicized adverse events that there’s no shortage of enthusiasm [for improving safety]," Clancy added. "This report will allow institutions to move from a reactive mode to a proactive mode."
"We’re looking at the report not only in terms of how it will affect policies and procedures, but we’re going to develop metrics to try to evaluate compliance," Garthwaite added.
Even the Joint Commission will be affected by the report, O’Leary said.
"The patient safety standards match up quite well with current Joint Commission initiatives," he noted. "For example, 15 of the 30 are currently reflected either in whole or part; an additional four are found in our patient safety goals, and four more are related to our standards."
Still, he conceded, "there are seven areas we are not involved in that we will certainly look very strongly at."
Momentum is building
Momentum is building in several areas to help support the implementation of the 30 safety practices. For example, Kizer said, "the Leapfrog Group has indicated its next leaps will involve these practices, and many coalitions are looking at these practices with an eye toward incorporating them in their contracts.
"I think over the next year or two you will see embedded elements that go to the heart of what we are asking. [The Centers for Medicare & Medicaid] has contributed to the support of this effort, too, but whether it ends up being a Condition of Participation is an option that is under their consideration," he added.
AHRQ has announced 10 patient safety grants for targeted research initiatives. These will be challenge grants, Clancy explained.
"We’re asking institutions to make some contributions, too. That will make it more likely the research will lead to sustainable improvement. We supported the evidence research, and NQF put it through the consensus development process; now, let’s see what we can do to accelerate things," she noted.
It’s clear that JCAHO will do its part. "The Joint Commission can serve as one of the effector arms to make this become a reality," O’Leary said. "We have a leg up [as an accrediting body], and we can create some friendly leverage. This is going to happen."
(For information about obtaining a copy of the report, go to: www.ahrq.gov or www.qualityforum.org/.)
PA state legislature puts patient safety in spotlight
New law requires patient safety committee, officer
The health care industry may have what amounts to a love-hate relationship with government involvement in health care practices, but patient safety advocates in Pennsylvania can, at the very least, take heart in the intent of a new law recently enacted by the state legislature.
The Medical Care Availability and Reduction of Error Act, or MCARE, more commonly referred to as Act 13, includes a patient safety subcategory that requires every hospital and ambulatory surgery facility licensed in the state to create a patient safety plan and submit it to the Department of Health.
The act, passed by the legislature in March 2002, is one of only a handful of similar state laws currently on the books, according to Connie Brady, RN, MSN, risk manager and patient safety officer for MMC Health Systems (MMCHS) in Meadville, PA.
"To my knowledge, there are only three or four," she says. Plans in Pennsylvania were to be in place by the summer of 2002, she adds, and the MMCHS plan now is beginning to drive quality improvement decisions.
"I think part of the reason the act came into being was the [1999 Institute of Medicine (IOM) report To Err is Human]," adds Marie Pears, RHIA, CPHQ, quality coordinator at Meadville. "It really shook a lot of people."
Components spelled out
The law has five major patient safety components, Brady says. They include the following:
- Each facility has to designate a patient safety officer.
- Each facility has to establish a patient safety committee.
- Each facility has to establish a system for health care workers to report serious events and incidents, and that system must be accessible "24/7."
- The act prohibits any retaliatory action against a health care worker for reporting a serious event or incident, in accordance with the Dec. 12, 1986, whistle-blower law.
- Facilities must provide written notification (disclosure of any serious medical error) to patients, in accordance with the act.
"The act was also very specific as to who the members of the committee should be," Brady adds.
"They had to include a patient safety officer, one board member, two residents of the community who were not agents, employees, or contractors of the facility; one active physician, and at least three health care workers — including one nurse." A given facility could have more people than that on the committee, she notes.
The real-world impact
Meadville’s response to the new law gives some insight into how patient safety legislation may affect the ongoing patient safety activities within specific health care facilities.
First, Meadville already had established a patient safety committee in November 2001, but even that existing committee was affected.
"In following the requirements of the act, the committee’s composition changed and I became chair of the patient safety committee as well as patient safety officer," Brady says. "We used some existing members of our committee, added community members and one active physician and a board member."
Pears, the quality coordinator, also is a member. "We decided we wanted the CFO to act as liaison between the board and QI [quality improvement], as well as having our quality coordinator as a member of the patient safety committee for peer review protection of very serious events that could be disclosed through the committee," Brady explains.
"It just made sense, since the committee would be talking about potential errors and harm to patients, that it be reported to the quality committee," Pears adds.
In essence, the reporting responsibility works like this: A member of the patient safety committee (Pears) reports directly to the quality assurance (QA)/QI committee, which reports to the facility executive committee, and then to the board. (See flowchart, below.)
FMEA required
One of the most significant requirements of the new law, Brady notes, is that the patient safety committee must conduct a failure mode and effect analysis (FMEA) on one system to be proactively examined for the prevention of errors. "We are to select one system to look at, and then one process [within that system]," she explains.
The committee’s decisions at MMCHS are informed by brainstorming sessions, current medical literature, reports, and publications such as the Sentinel Event Alert.
"The committee can get referrals from the overall QA committee, from other subcommittees, from the pharmacy, and so on," adds Pears.
However, Brady notes, "The committee has the last say in what we will look at."
"This is a totally different approach," Pears says, explaining that the system already has done one FMEA. "The first FMEA we did — and the only one we’ve done so far — was on epidural pumps," says Pears. "We had a near miss that could have been harmful to the patient."
In the current process, "we’ve put together the total of all the incidents that have been reported through risk management and took it through our patient safety committee," she explains. "The committee said we should look at some piece of the medication administration process."
The selection, in April 2003, was made after prioritizing all of the different error categories into high risk/high volume, high risk/low volume, and so on, Brady explains. "Now, we’ll do the FMEA, break the system down into which process has a greater chance of being a high-risk/high-volume problem, and what steps are related to human error."
A process improvement team can be created for any process identified by the FMEA, Pears says.
"For example, it could be the way a physician order is coming down to the pharmacy, it could be a dispensing problem, or it might be the absence of a dosage," she says.
When the FMEA is completed, the committee will come up with several recommendations for improvement. "These will go through the QA/QI committee to the board and will be evaluated through the board," Brady says.
Intent is positive
Having responded to the new law and set the organization’s revised patient safety committee in motion, how do the safety professionals at MMCHS feel about their state government’s patient safety initiative?
"I think the act was probably passed a little quickly, but I love the intent behind it," says Brady. One of the most positive aspects, she says, is the reporting process.
"Before the act — and at this point in time — we reported anything that compromised patient safety to the Department of Health," she notes.
"What Act 13 did was to establish a Patient Safety Authority, which in turn, established a reporting mechanism through which all hospitals and ambulatory surgery facilities in Pennsylvania could report all pertinent events, including near misses, anonymously," Brady points out.
"This is very similar to what was done in the airline industry; once they started to report all near misses, they were able to come up with solutions. To do that, you need a lot of data; this authority will have that, and it will then be able to make recommendations from the state level to all hospitals," she says.
"In the long run, I think it will be helpful," Pears adds. "It creates a way for us to trend the kinds of things that are happening — safety issues that can come back to the facilities so we can take a harder look at what’s going on. We may have had only one or two cases [of a specific error], but that same thing could be happening frequently across the state."
[For more information, contact:
• Marie Pears, RHIA, CPHQ, Quality Coordinator, Meadville Medical Center, 751 Liberty St., Meadville, PA 16335. Telephone: (814) 333-5583. E-mail: [email protected].]
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