Performance Data: From Both Sides Now Gail R. Bellamy, Ph.D. AHRQ 2007 Annual Conference “Improving Health Care, Improving Lives

Acknowledgement This project was funded under a cooperative agreement with the Agency for Healthcare Research and Quality (AHRQ) UC1 HS This project was funded under a cooperative agreement with the Agency for Healthcare Research and Quality (AHRQ) UC1 HS

Background Transforming Health Care Quality through Information Technology Implementation Grant Transforming Health Care Quality through Information Technology Implementation Grant “Partnering to Improve Patient Safety in Rural West Virginia Hospitals” “Partnering to Improve Patient Safety in Rural West Virginia Hospitals” Expansion of 8 hospital patient safety pilot project Expansion of 8 hospital patient safety pilot project

Goals of AHRQ Grant Focus on rural hospitals, including critical access hospitals Focus on rural hospitals, including critical access hospitals Provide a free, confidential event reporting system to any interested rural hospital Provide a free, confidential event reporting system to any interested rural hospital Develop a collaborative network among hospitals to share information and best practices Develop a collaborative network among hospitals to share information and best practices

Performance Data: From the Side of the Project Number of hospitals enrolled Number of hospitals enrolled Utilization of IT Utilization of IT Numbers of reports: 43,000 to date Numbers of reports: 43,000 to date Nature of reports: Catastrophic/fatal rarely reported Nature of reports: Catastrophic/fatal rarely reported

Quarterly Number and Rate of Adverse Event Reports, WV Patient Safety Project

Rates of Reported Events, By Type and Quarter WV Patient Safety Project,

Performance Data: From the Side of the Project Value Value Interviews with key informants Interviews with key informants CEOs CEOs Risk Managers Risk Managers Floor Nurses Floor Nurses

Performance Data: From the Side of the Hospital Benchmarking Benchmarking Patient Safety Culture Survey Patient Safety Culture Survey

Patient Safety Culture: Survey methodology Baseline survey completed in conjunction with in-house training on software (Jan- Oct 2005) Baseline survey completed in conjunction with in-house training on software (Jan- Oct 2005) Midpoint (Jul-Sep 2006) and final (Jul-Sep 2007) surveys mailed to hospitals to administer to staff Midpoint (Jul-Sep 2006) and final (Jul-Sep 2007) surveys mailed to hospitals to administer to staff Convenience sample Convenience sample

R 1.Staff feel like their mistakes are held against them. (A8) R 2. When an event is reported, it feels like the person is being written up, not the problem. (A12) R 3.Staff worry that mistakes they make are kept in their personnel file. (A16) R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree Survey report example: Nonpunitive Response to Error

Hospital Survey on Patient Safety Culture Baseline - Remeasurement Comparisons

Midpoint survey report example: Nurse vs admin. Positive scores by dimension

Performance Data: From the Side of the Hospital Benchmarking Benchmarking Event Rates Event Rates

Event Categories Unobserved Falls Unobserved Falls Observed Falls Observed Falls Elopement Elopement Delay In Tests or Treatments Delay In Tests or Treatments All Laboratory Specimen Related Occurrences Except Delays All Laboratory Specimen Related Occurrences Except Delays Injury or Exposure to Hospital Staff Injury or Exposure to Hospital Staff Omitted Medication Doses* Omitted Medication Doses* Wrong Medication Administered* Wrong Medication Administered* Wrong Dose of Drug* Wrong Dose of Drug* Adverse Drug Reactions Adverse Drug Reactions Patient Misidentification* Patient Misidentification*

Example Report

Unobserved Falls Acute Care

Median Event Rates over 9 Quarters Critical Access and non Critical Access Hospitals WV Patient Safety Project

Performance Data: From the Side of the Hospital Benchmarking Benchmarking Patient Safety Indicators Patient Safety Indicators

Performance Data: From the Side of the Hospital Measuring improvement Measuring improvement Falls collaborative Falls collaborative

Falls collaborative results

Performance Data: From both sides now  Sustainability  Return-on-Investment  WV Center on Patient Safety

Conclusions From the perspective of the WV AHRQ Project Team the implementation project was a success. From the perspective of the majority of participating hospitals the ORM IT product helped them to improve patient safety by providing timely, detailed data.

Further Information Gail Bellamy Gail Patricia Ruddick Patricia Karen L. Hannah Karen L. Charles Schade, MD David Lomely