1. The State of Patient Safety in Minnesota Jennifer P. Lundblad, PhD, MBA for the BHCAG Community Forum November 11, 2010

2. Critical Juncture: The Institute of Medicine Reports Our collective attention has been raised: To Err is Human (1999) Crossing the Quality Chasm (2000)  Six overarching "Aims" for 21st Century health care: Six overarching "Aims" for 21st Century health care Safe Timely Effective Efficient Equitable Patient-centered

3. Goals of Session Assess the qualitative state of patient safety, ten years after the IOM reports Share Hospital Compare and Adverse Events data the quantify the progress Encourage a dialogue about where we go next as a community

4. Who is Stratis Health? Independent, nonprofit, community-based Minnesota organization founded in 1971 –Mission: Lead collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities Working at the intersection of research, policy, and practice –With Medicare and Hospital Compare –With MDH on Adverse Health Events

5. Qualitatively, What is the State of Patient Safety?

6. Actions resulting from the IOM reports National –Joint Commission established National Patient Safety Goals (2002 and ongoing) –IHI launched100K Lives Campaign (2005-2006) and 5 Million Lives Campaign (2007-2009) –National Patient Safety Foundation established National Patient Safety Week in March each year –Medicare re-focused QIO program on patient safety –Employers launched Leapfrog Group

7. Actions resulting from the IOM reports (cont.) Minnesota –MN Alliance for Patient Safety (MAPS) multi- stakeholder coalition launched (2000) –MN Adverse Health Events law passed (2003) –Safest In America initiative implemented –MN Executive Session on Patient Safety held (2001-2003, 2007-2008)

8. What have we learned from these efforts? Clinical and technical changes are needed, but so are improved teamwork, leadership, communication, and organizational culture. Learning, networking, and best practices must be hard-wired into patient safety programs. Transparency and accountability, along with a fair and just culture, are drivers to achieve safety.

9. Observations and Issues in Transparency MN has gone from a laggard to a leader in publicly reporting health care performance data Many good efforts in place, but they still reflect the silos of health care delivery –Can future measurement go beyond setting-based measures to reflect care across the continuum as a patient experiences health care? A multitude of data reporting Web sites –Confusion? Comparability of data?

10. Observations and Issues in Transparency (cont.) How we are doing on the big picture goals for transparency? –Effective at bringing the attention of health care leaders to quality and patient safety, and driving improvement? Yes! –Helping consumers be more informed decision makers and activated patients? Not yet, and much more to be done to understand how data can be meaningful to consumers and patients. –Effectively helping get us where we want to be as a system (i.e., 6 IOM aims)? Slow progress? Too early to tell?

11. Quantitatively, What is the State of Patient Safety?

12. What is the current state of quality and safety in Minnesota? Generally good compared to other states: AHRQ dashboard on health care quality puts Minnesota at a “Strong” rating compared to other states, but just better than the cut-off for “Average” (“Very Strong” is the best) Minnesota ranks # 6 among all states in the most recent “America’s Health” ranking by United Health Foundation (down from #3) –But how good are we?

13. Hospital Compare Hospital measures began to be publicly reported in March 2006 (with data from July 2004 through June 2005) –Most recent data was reported in September 2010 (with data from January through December 2009) Conditions reported include heart attack, heart failure, pneumonia, and surgical care A total of 6 reporting periods since 2006 Nearly 30 total measures

14. Hospital Compare (cont.) Analysis of 2006-current Hospital Compare: # of measures where Minnesota average is higher than national average has been decreasing (50% in 2006, 20% in 2010) –MN heart attack care measures were better (7 of 8) than nat’l average in 2006, now mixed –MN heart failure measures were all worse (4 of 4) than nat’l average in 2006, still worse –MN pneumonia measures were mixed in 2006, now all worse (6 of 6)

15. Hospital Compare (cont.) Analysis of 2006-current Hospital Compare: –Of all measures, 23 showed improvement in Minnesota between 2006 and now, and only 2 decreased (and only slightly) –But only 13% of the measures improved more in Minnesota than in the nation –Only 2 measures in MN were 90% or better in 2006, 11 measures are 90% or better today

16. Minnesota’s Hospital Adverse Events Report MN legislature passed first-in-the-nation adverse events law in 2003, implemented by MN Department of Health –Mandated hospital reporting of NQF’s 28 “never events” (including root cause analyses and corrective action plans) for learning purposes –www.health.state.mn.us/patientsafetywww.health.state.mn.us/patientsafety

19. MN Adverse Events Progress has been made in reducing harm to patients and in addressing some of the most common system breakdowns that lead to adverse events. Opportunities for learning remain, along with challenges to consistent, robust implementation of evidence-based best practices.

20. In Summary… Noteworthy improvement in provider and patient awareness of patient safety Unprecedented move toward transparency Significantly better understanding of how and why medical errors occur and what we can do to prevent them Mixed results in terms of quantitative data, with ongoing opportunities to improve

21. Jennifer Lundblad, President and CEO  952-853-8523 jlundblad@stratishealth.org www.stratishealth.org

22. Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.