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

2. Acknowledgement This project was funded under a cooperative agreement with the Agency for Healthcare Research and Quality (AHRQ) UC1 HS01 4920-02. This project was funded under a cooperative agreement with the Agency for Healthcare Research and Quality (AHRQ) UC1 HS01 4920-02.

3. 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

4. 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

5. 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

6. Quarterly Number and Rate of Adverse Event Reports, WV Patient Safety Project 2005-2007

7. Rates of Reported Events, By Type and Quarter WV Patient Safety Project, 2005-7

8. 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

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

10. 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

11. 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

12. Hospital Survey on Patient Safety Culture Baseline - Remeasurement Comparisons

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

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

15. 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*

16. Example Report

18. Unobserved Falls Acute Care

19. Median Event Rates over 9 Quarters Critical Access and non Critical Access Hospitals WV Patient Safety Project 2005-7

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

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

23. Falls collaborative results

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

26. 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.

27. Further Information Gail Bellamy Gail Bellamygbellamy@wvmi.org Patricia Ruddick Patricia RuddickPruddick@wvmi.org Karen L. Hannah Karen L. Hannahkhannah@wvmi.org Charles Schade, MD cschade@wvmi.org David Lomely dlomely@wvmi.org