Stephen Pavkovic, RN, MPH, JD Director, Patient Safety UHC The UHC PSO Experience Stephen Pavkovic, RN, MPH, JD Director, Patient Safety UHC AHRQ Annual Conference Bethesda, MD September 11, 2012

About UHC UHC is Chicago-based alliance of 116 academic medical centers and 258 of their affiliated hospitals UHC provides clinical, operational and financial comparative data and informatics UHC Performance Improvement Solutions Imperatives for Quality UHC/AANC Nurse Registry Program™ UHC-AAMC Faculty Practice Solutions Center™ National Initiatives Support Patient Safety Program Patient Safety Net® Integrated Claims, Complaints and Incidents Modules

AMC Members Across the Nation This map represents the impressive roster of Member organizations throughout the U.S.

Representing the Nation’s Leading AMCs Note: Customized to include the member audience for the presentation as well as other selected peers.

Presentation Overview Foundation What is a PSO? Why Common Formats? UHC Patient Safety Program UHC PSN, Powered by Datix UHC Performance Improvement PSO Common Formats facilitated research and findings

Created by Patient Safety and Quality Improvement Act – 2005 What is a PSO? Created by Patient Safety and Quality Improvement Act – 2005 The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients Regulations provide Federal legal privilege and confidentiality protections to information that is assembled and reported by providers to a PSO or developed by a PSO for the conduct of patient safety activities. PSWP - patient safety work product The Act also significantly limits the use of this information in criminal, civil, and administrative proceedings. The Act includes provisions for monetary penalties for violations of confidentiality or privilege protections.

The Act regulates PSOs membership: What is a PSO? Patient Safety and Quality Improvement Act defines how patient safety event information is collected, developed, analyzed and maintained. The Act regulates PSOs membership: PSOs are required to work with more than one provider Excludes insurance companies Establishes a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for providers, PSOs, and other entities. For analyzing national and regional statistics, including trends and patterns of patient safety events. The NPSD utilizes common formats and will promote interoperability among reporting systems. The Department of Health and Human Services will provide technical assistance to PSOs. 76 PSO listed – 2012.

Common Formats

Common Formats Common Formats are a set of common definitions and reporting formats, used to specify the clinical definitions and technical requirements that allow health care providers to exchange data with PSOs and the NPSD in an interoperable and standardized manner. Ensure consistency in reporting patient safety event information Provide analysis of patient safety event information and give feedback to health care providers Facilitate a learning environment that reduces future risk to patients Inpatient Hospital based Ambulatory care in development

Common Formats Leveling the field for comparative data reporting permitting “apples to apples” comparisons Contents: Definition of Event Scope of Reporting Risk Assessments and Preventative Actions Circumstances of Events

UHC Patient Safety Program UHC-Datix PSN® Suite PSN® Incident Reporting Tool Claims Management Module Complaints Module Reports and Research Managers have access to dashboard reports Rich source of data for research with 2.2 million patient safety events Aggregate Data Provides Comparisons Among Organizations UHC PI Patient Safety Organization PSN® serves as the data collection tool for UHC PI PSO AHRQ-Listed PSO since 2008 Common Format (v 1.1) compliant Federal Confidentiality & Privilege Protection Community of Learners Education and Member Success Sharing Opportunities Safety Stories Data mining and Aggregate Analysis Reports & Collaboratives Project Collaboratives

Overview of Patient Safety Net® Internet-based incident reporting system with point of care for adverse events and near misses (unsafe conditions) Real time triage, routing and analysis of patient safety events by location, event type or harm score AHRQ Common Format (v1.1) compliant Shared UHC taxonomy with customizable questions Integrated Patient Complaint and Claims modules to identify prevention opportunities

PSN® Front Line Event Report Components Patient Information Event Basics Reporter Information Event Detail Organization Specific Information Harm Score Each organization may customize the properties of selected questions in the event report.

FLR submits event report PSN® Manager Workflow FLR submits event report E-mail/Event Report goes to appropriate managers Location Mgr Pharmacist Mgr Ancillary Mgr Physician Mgr Q/R Mgr Managers can: View and edit the event report Read and audit other manager reviews Consult with managers Enter and ‘submit’ their own reviews commenting on contributing factors, corrective actions, and costs incurred Attach documents Quality/Risk (Q/R) Managers also: ‘Submit’ a report to PSN – which changes the status to ‘closed’ Unsubmit a report Delete a report Submit a report to UHC PSO, if applicable Consultant The Q/R manager actively ‘closes’ the report to submit to PSN data repository – report auto submits after 45 days

PSN® - How to submit to PSO PSO Specific Legal Disclaimer Individual file management Batch file management

UHC Patient Safety Net® (PSN®) by the Numbers Since 2004, over 2.2 million events 1.5 million AHRQ Common Format (v1.1) reports 103 sites representing: 20,500 Assigned passwords 19,000 staffed beds 138 Obstetrics and Obstetric Inpatient Units 119 Operating Room Departments 114 Emergency Departments 82 Radiation Departments and Radiation Oncology Units 61 Blood Banks 33 Pediatrics ICUs 23 Burn Units

UHC Patient Safety Net® (PSN®) Research Overview Common Formats facilitate aggregate research and shared user experience “Found in the NET” and PSN-based research: Epidural medication misadministration 2009, N= 31 Transfusion related events, 2011, N= 29,506 Medication CPOE events, 2012 Annual falls survey

ADD Harmscore

UHC Patient Safety Net® (PSN®) Harm Score Survey Shared user experience promotes applied learning 2011 Survey of 921 managers at 89 PSN users sites Review of 9 clinical scenarios with AHRQ (v1.1) harm score assignment 2012 Survey of 13,000 managers at 102 PSN user sites Review of 9 clinical scenarios with AHRQ (v1.2) Inter-rater agreement demonstrated “moderate” agreement v1.1 – Fleiss’ kappa value = 0.51 V1.2 – Fleiss’ kappa value = 0.47 Submitted for publication – September 2012

PPC submission Preparing for UHC PI PSO event submission via PPC to NPSD Falls Transfusions Medications Currently Testing Internal goal to be first PSO to successfully submit to NPSD

UHC Performance Improvement PSO First PSO member submission: September 2009 Total UHC PSN reports: 1,032,981 through June 2012 103 PSN Sites - Program Participants - eligible for PSO membership 47 PSO members in 21 States 19 Submitting members Total PSO Submissions, from all event types: 66,976

PSN® User Groups for Analysis Organization PSN Program Participants “Non PSO” N = 56 (of 103) PSO Members N = 47 Total 101 Members 47 PSO Members 19 PSO Submitters PSO Submitters N = 19 (of 47)

Top Event Type and Distribution by PSN® User Group

Harm Score Distribution for 1,032,981 PSN® Events

Harm Score Distribution by PSN® User Group Steve: For this slide can you flip the listing Non-PSO first at top of page PSO middle. PSO Submitter at bottom.

“PSO Submitter” Rates Org ID Submit to PSN PSO Submission Rate 1 18,691 95.99% 2 3,357 93.09% 3 6,577 86.03% 4 6,081 56.50% 5 15,772 47.76% 6 43,999 45.69% 7 15,354 30.62% 8 16,273 20.84% 9 27,530 3.21% 10 344 2.33% 11 16,874 .95% 12 3,845 .34% 13 3,365 .06% 14 16,658 .05% 15 5,339 .02% 16 19,437 .01% 17 31,440 18 11,760 19 12,666

PSO Submitted Event Distribution by Harm Scores (v 1.1)

PSO Submitted Event Distribution by Harm Scores (v 1.1)

Findings Distribution of harm scores assignment is similar for all of PSN® Top submitted event types is similar for all of PSN® No physical barriers to PSO submission Percentage of total events submitted to PSO varies widely among PSO members Distribution of harm score for events submitted to PSO varies widely

Contributing Factors to PSO Submission Variation Member Factors Safety culture Litigation posture Legislative climate in venue 11 States represented in 19 submitting organizations Submission guidelines Other factors…

Take Home Messages Common Formats facilitate the collection and evaluation of patient safety data PSOs provide a method to collect and share patient safety information UHC PSO members’ submission practices vary widely

Thank you. Julie Cerese, UHC Vice President Steve Thomas, UHC Data Analyst Questions? Stephen Pavkovic, RN, MPH, JD Director Patient Safety UHC pavkovic@uhc.edu