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Patient Safety
Patient Safety
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Quality
Improvement Organization
Patient
Safety Initiatives
QIOs
work in thousands of
hospitals and doctors’
offices around the
country to improve
patient safety by helping
physicians and institutions
analyze the way they
provide care, measure
outcomes, and adopt
proven best practices.
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:
- Carolina
Medical Review 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.
- 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).
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
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