Quality Improvement Organization
Patient Safety Initiatives

Funded by Medicare to help seniors, QIOs have a major impact on care for the general public, which relies on the same institutions and practitioners that serve Medicare beneficiaries. QIOs encourage systematic primary efforts to prevent the onset of disease, secondary efforts to detect and prevent recurrence or progression of disease, and efforts to eliminate medical errors.

A study recently published in JAMA on quality of care for Medicare beneficiaries shows these efforts are paying off. The study showed improvement on 20 out of 22 measures of quality of care, such as administration of aspirin and/or beta blockers after heart attack, regular blood sugar testing for diabetes, mammogram screening for breast cancer, and immunizations for flu and pneumonia. QIOs are playing a leading role in a number of key areas of patient safety, including:

• Working with doctors and hospitals to improve systems of care to reduce death and disability from heart attack, heart failure, diabetes, pneumonia, breast cancer, and influenza.

• Training hospital teams to reduce postoperative infections by better selection and more timely use of antibiotics.

• Conducting outreach to improve patient safety and quality of care among the medically disadvantaged and in rural areas across the nation.

• Serving as the driving force in a federal initiative to improve patient safety in nursing homes, focusing on better pain management, prevention of pressure sores, prevention of falls, prevention of pneumonia, and treatment of delirium and infections.

• Conducting extensive programs to educate the public about preventive health measures.

• Helping consumers interpret Medicare data on care provided by nursing homes and home health agencies. QIOs are also developing methodology to inform consumers about quality of care provided by hospitals and in physicians’ offices.

• Training home health providers in rapid cycle clinical process improvement as part of a major federal initiative.

QIOs across the nation are also in the forefront of developing state-wide collaborative partnerships to advance patient safety. Some examples:

• The Carolinas Center for Medical Excellence is actively involved in the work of the Patient Safety Committee of the South Carolina Hospital Association. This committee, which has extensive multidisciplinary representation from the hospital community, produces materials on patient safety for distribution to hospitals. In conjunction with the SC Hospital Association, CMR developed a brochure that focuses on medication safety for patients based on similar materials from the federal Agency for Healthcare Research and Quality and the Massachusetts Coalition for the Prevention of Medical Errors. The brochure has been endorsed by the SC Medical Association and the SC Society of Health System Pharmacists and shared by these groups with their contacts throughout the state. For more information, contact: Diana Zona at 803-731-8225.

• Delmarva Foundation of the District of Columbia (DFDC) founded and facilitates the two-year old DC Patient Safety Coalition. DFDC created a steering committee for the coalition, bringing together major stakeholders such as the DC hospital association, DC medical society, department of health, and providers such as the VA hospital and the National Rehabilitation Hospital. The coalition began by sponsoring a series of public events to raise awareness of patient safety issues. The coalition has identified health literacy as an important factor in patient safety, and is creating a formal initiative to address this issue in the District (perhaps concentrating on its impact on medication errors). For more information, contact: Robin Wolfgang at 410-822-0697.

• Delmarva Foundation of Maryland was instrumental in initiating the Maryland Patient Safety Coalition in 2001 by bringing relevant stakeholders together to begin discussions and collaboration. A subgroup of the Coalition became the steering committee for the Maryland Healthcare Commission's effort to study the status of patient safety programs statewide. Delmarva hosted a statewide Patient Safety conference in April 2001 in Baltimore and subsequently presented a summary report to the state legislature. Delmarva is currently working with the Steering Committee on developing targeted projects for improving patient safety. For more information, contact: Robin Wolfgang at 410-822-0697.

• HealthInsight, the QIO for Utah and Nevada, worked with the Utah Health Department and the state hospital association to develop and launch a groundbreaking hospital reported sentinel event system. In Nevada, HealthInsight is working with the state medical association, hospitals, and the patient safety institute, which recently recommended the elimination of abbreviations in orders. HealthInsight is also working with the Missouri QIO on a special project to prevent medical errors. For more information, contact:

• Health Services Advisory Group (HSAG), the Arizona QIO, has joined with the Arizona Hospital and Healthcare Association (AzHHA) to address patient safety issues proactively. Working with AzHHA and the Arizona Medical Association, Health Services Advisory Group was instrumental in initiating Arizona’s Patient Safety Task Force, comprised of quality improvement leaders, insurance industry representatives, and physician champions. The task force recently released Practice Guidelines for Patient Safety: Correct Identification of Patients, Their Surgical Sites and Procedures , which can be viewed at www.azhha.org. In addition to citing causative factors for surgical errors, the guidelines feature practices and a template for a corrective action plan. For more information, contact: Patricia Dubick at 602-665-6168.

• MetaStar, the Wisconsin QIO, helped found the Wisconsin Patient Safety Institute, Inc., and serves on the Institute’s executive committee along with the state medical society, hospital association, pharmacy association, nursing association, chamber of commerce, a business alliance, and a consumer representative. MetaStar has played a major role in all aspects of the Institute's work, including an annual forum devoted to patient safety and the endorsement and promotion of recommendations for improving patient safety. For more information, contact: Kay Simmons at 608-274-5008.

• MPRO, the Michigan QIO, is an active member of the Michigan Health and Safety Coalition, comprised of health care plans such as Blue Cross Blue Shield of Michigan (BCBSM), health care providers, medical associations, state agencies such as the Michigan Department of Community Health, as well as the three major auto companies and auto unions. MPRO has facilitated discussions among expert clinical review panels and achieved consensus on "hospital volume guidelines," created as a statewide response to the national referral guides published by the Leapfrog Group. Using the most recent evidence-based medical literature, the panels created guidelines for abdominal aortic aneurysm repair, carotid endarterectomy surgery, esophagectomy for cancer, care of infants with congenital anomalies in neonatal intensive care units, intensive care unit physician staffing, care for low birth weight infants in neonatal intensive care units, open-heart surgery, and percutaneous coronary interventions. MPRO is also currently working with BCBSM to develop a patient safety improvement model based on the successful experience of anesthesiologists and the aviation industry. For more information, contact: Tom Leyden at 734-454-7272.

• Primaris (in collaboration with HealthInsight of Utah) is conducting a Patient Safety Demonstration Project under contract to the Missouri Department of Health and Senior Service. The project focuses on inpatient safety and use of adverse events coding to predict medical errors. Primaris also works directly with hospitals and providers to promote a culture of patient safety, using guidelines and practices recommended by AHRQ, JCAHO, and NQF. Primaris is active in education, holding statewide conferences featuring prominent patient safety advocates to discuss and share best practices. The Missouri QIO also conducted statewide training sessions on the use of Failure Modes and Effects Analysis (FMEA), medical coding of adverse events and efforts to promote a blameless culture in reporting errors and near misses, and JCAHO patient safety goals. Primaris’s two medical directors represent the states’s chapter of the American College of Physicians/American Society of Internal Medicine (ACP/ASIM) in a federally funded project to educate physicians about patient safety. For more information, contact: Deborah Finley at 800-735-6776.

• Ohio KePRO is a founding member of the Ohio Patient Safety Discussion Forum. This group was convened by the Ohio Department of Health to explore joint efforts to promote safer care in Ohio. Other members of the Forum include the Ohio Hospital Association, the Ohio Nurses Association, the Ohio Osteopathic Association, the Ohio Patient Safety Institute, the Ohio Pharmacists Association, and the Ohio State Medical Association. In February 2003, the Forum launched the Ohioans First campaign with an initial goal of eliminating the use of dangerous medication abbreviations in Ohio. Ohio KePRO staff are also active in the Ohio Patient Safety Institute (OPSI) that brings together all the stakeholders in patient safety to share data, resources, and expertise. OPSI sponsors educational initiatives directed at patients and providers on topics ranging from medication safety to disclosure of errors. For more information, contact: Suzana Iveljic at 216-447-9604.

• Stratis Health is active in the Minnesota Alliance for Patient Safety (MAPS), a partnership among the Minnesota Hospital Association, Minnesota Medical Association, Minnesota Department of Health and more than 50 other public and private health care organizations working together to improve patient safety. Stratis Health recently co-sponsored a MAPS statewide conference on successful patient safety efforts in Minnesota. Stratis Health also serves on the MAPS Best Practices committee, which has proposed and is in the process of developing the Patients As Partners Initiative. Additional information on MAPS is at www.mnpatientsafety.org. For more information, contact: Jennifer Lundblad at 952-853-8523.

• The Virginia Health Quality Center (VHQC) is a leading member of Virginia's patient safety coalition, Virginians Improving Patient Care and Safety (VIPCS), founded in 2000. VIPCS members include the Virginia Hospital and Healthcare Association, Virginia Association of Health Plans, Virginia Pharmacists Association, and the Medical Society of Virginia. VIPCS has actively promoted systematic efforts to continuously improve quality of care and safety through annual statewide educational programs (and other educational activities as well). The coalition also supported state legislation which passed the Virginia General Assembly in the 2002, defining patient safety organizations (PSOs) and confidentiality protections afforded PSOs when handling handling patient safety data. Additional information about VIPCS is at: www.vipcs.org. For more information, contact: Melissa Jones at 804-289-5320.

• West Virginia Medical Institute created an electronic reporting system for medical errors, which is currently available to all hospitals in the state. This system promotes the reporting of incidents as well as "near misses," believed to outnumber actual medical errors 30:1, and creates a wealth of data useful for improving patient safety. The system uses a commercial data-reporting tool developed by DoctorQuality, a Philadelphia company. To date, five hospitals have joined the project, with several others considering participation. WMVI also co-sponsored the First Annual Patient Safety Conference in West Virginia with Charleston Area Medical Center, featuring nationally-known patient safety experts, and is planning a follow-up conference in late 2003. For more information, contact: Marc McCombs at 304-346-9864.