How Can States and Institutions Work Together to Create a Culture of Safety? Concrete Actions to Improve Patient Safety Marge Keyes, M.A. Health Scientist Administrator, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ) Rockville, MD

Building the Business Case for Patient Safety– an AHRQ-JCAHO Invitational Conference Architecture: more than just a financial argument Architecture: more than just a financial argument Foundation Foundation – Defining and measuring ROI – Examining the impact of reimbursement and purchasing policies Roughing in the structure Roughing in the structure Raising the roof Raising the roof Customizing the options Customizing the options Passing inspection Passing inspection

Evidence-based Practices to Improve Patient Safety Making Health Care Safer: A Critical Analysis of Patient Safety Practices (July 2001) Making Health Care Safer: A Critical Analysis of Patient Safety Practices (July 2001) – Patient safety practices: those that reduce the risk of AE related to exposure to medical care across a range of diagnoses or conditions – 40 researchers (expertise in patient safety, EBM, and clinical medicine, nursing, and pharmacy) – Primarily hospital care but included some nursing home and ambulatory care practices – Selection of practices relied on Inclusion criteria Inclusion criteria Structured evaluation of the evidence Structured evaluation of the evidence

Top Evidence-based Safety Practices 11 of 79 practices rated highest 11 of 79 practices rated highest – Appropriate prophylaxis to prevent thromboembolism – Perioperative beta-blockers – Maximum sterile barriers when placing central IV catheters – Antibiotic prophylaxis in surgical patients to prevent perioperative infection – Antibiotic-impregnated central venous catheters to prevent catheter-related infections – Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia

Top Evidence-based Safety Practices – Pressure relieving bedding to prevent pressure ulcers – Real-time ultrasound guidance during central line insertion – Appropriate provision of nutrition (emphasis on early enteral nutrition for critically ill or surgical patients) – Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications – Patients to recall and restate informed consent information

Response to the EPC Report on Patient Safety Practices JAMA – July 24/31, 2002 Leape, Berwick, Bates JAMA – July 24/31, 2002 Leape, Berwick, Bates – Acceptance of a practice does not always rely on evidence from a randomized trial – Reasonable judgment based on best “available” evidence may be acceptable approach

Response to the EPC Report on Patient Safety Practices JAMA – July 24/31, 2002 Shojania, Duncan, McDonald, Wachter JAMA – July 24/31, 2002 Shojania, Duncan, McDonald, Wachter – Charge was to identify evidence-based safety practices – General insistence on evidence should not prevent implementation of practical, low-risk, understudied interventions that seem likely to work

Response to the EPC Report on Patient Safety Practices Gap between standards considered acceptable by academics and standards of evidence considered acceptable by those in business Gap between standards considered acceptable by academics and standards of evidence considered acceptable by those in business NQF consensus development process NQF consensus development process

Patient Safety Improvement Corps Goal: develop and maintain “front line” capacity for patient safety improvement at the community, regional, and state level Goal: develop and maintain “front line” capacity for patient safety improvement at the community, regional, and state level Objective: By 2004 have on-site experts and technical assistance in 10 states/health care organizations to improve patient safety Objective: By 2004 have on-site experts and technical assistance in 10 states/health care organizations to improve patient safety

Patient Safety Improvement Corps Initially considered two models Initially considered two models – CDC’s EIS model – Department of Agriculture cooperative state research, education, and extension service model Feasibility study Feasibility study – Diverse needs and opinions

Patient Safety Improvement Corps Future users/participants Future users/participants – AHA representative conference calls – NASHP state representative conference calls Common needs Common needs – Leadership buy-in – Core content with short, practical courses – Train together

Criteria Used to Evaluate Evidence- Based Practices If I wanted to improve patient safety at my institution over next 3 years and resources were not a significant factor, how would I grade this practice? If I wanted to improve patient safety at my institution over next 3 years and resources were not a significant factor, how would I grade this practice? 4-person editorial board independently rated each of the 79 practices 4-person editorial board independently rated each of the 79 practices – Find the best available evidence – 3 major categories for rating

Clear Opportunities for Research Preventing infections Preventing infections – Perioperative glucose control – Use of supplemental perioperative oxygen – Silver alloy coated urinary catheters – Prophylactic antibiotics to prevent perioperative infection Limited antibiotic use to prevent antibiotic resistance Limited antibiotic use to prevent antibiotic resistance Use of analgesics in patients w/acute abdomen (w/o compromising diagnostic accuracy Use of analgesics in patients w/acute abdomen (w/o compromising diagnostic accuracy Localizing surgery/procedures to high volume centers Localizing surgery/procedures to high volume centers Hand washing compliance Hand washing compliance

Clear Opportunities for Research (cont’d) Appropriate enteral nutrition Appropriate enteral nutrition – Post-surgical – Critically ill Appropriate use of prophylaxis to prevent venous thromboembolism in at-risk patients Appropriate use of prophylaxis to prevent venous thromboembolism in at-risk patients Nurse staffing Nurse staffing Technology/Informatics Technology/Informatics – CPOE with DSS to decrease medication errors and AE related to the drug ordering process