9 th Annual Meeting of PSOs

Transcription

1 9 th Annual Meeting of PSOs April 26-27, 2017 The Patient Safety Organization Landscape Diane Cousins, RPh, Acting Director PSO Program Center for Quality Improvement and Patient Safety (CQuIPS)

2 9 th Annual Meeting of PSOs Attendance: 138 Total Registrants 105 PSO Workforce 55 PSOs Represented 39 First-timers from PSOs 2

3 9 th Annual Meeting of PSOs April 26-27, 2017 PSO Operations

4 PSO Program Status: (as of April 24, 2017) 1 newly-listed PSO thus far in 2017 with 85 listed PSOs 4

5 New PSO Listings since April 2016 Health Care Providers (6 PSOs) The Guthrie Clinic PSO, a component entity of the Guthrie Clinic; P0182 LifePoint PSO, LLC, a component entity of LifePoint Hospitals Holdings, LLC; P0180 HealthSouth Patient Safety Organization, LLC, a component entity of HealthSouth Corporation; P0187 AHS PSO, LLC, a component entity of AHS Legacy Operations, LLC; P0188 NCH Healthcare System, PSO, a component entity of NCH Healthcare System; P0191 Maine Primary Care Association Patient Safety Organization (MEPCA PSO) a component entity of the Maine Primary Care Association; P0192 5

6 New PSO Listings since April 2016 Hospital Associations & Regional Health Initiatives (1 PSO) Louisiana Alliance for Patient Safety PSO, a component entity of Louisiana Hospital Association; P0186 6

7 New PSO Listings since April 2016 Safety & Quality Consulting (2 PSOs) SimCore PSO, LLC, a component entity of SimCore Technologies, Inc.; P0189 HPI (Press Ganey), a component entity of Press Ganey; P0185 7

8 New PSO Listings since April 2016 Medical Group Practice Organizations (2 PSOs) Diagnostic Quality Assurance, a component entity of Quality Star, LLC; P0170 USAP PSO, a component entity of United States Anesthesia Partners; P0178 8

9 New PSO Listings since April 2016 University & Research Organizations (1 PSO) Kansas Clinical Improvement Collaborative, a component entity of University of Kansas Hospital; P0184 9

10 Listing & Technical Assistance Communications As of April 24 th, AHRQ staff has completed 256 listing and technical assistance communications in Over these nine years of the PSO program, there has been a grand total of 5,017 technical assistance communications. 10

11 9 th Annual Meeting of PSOs April 26-27, 2017 The 2016 PSO Profile

12 The 2016 Profile PSOs voluntarily submitted PSO and Provider Profile data by end of March 2017 regarding CY2016 activities Any PSO listed for any part of 2016 and still listed at year s end is eligible Most important is that this profile information is used to feed the PSO Selection Tool on the AHRQ PSO Web site 12

13 2016 PSOs Listed, Collecting, and Submitting Data Note: The number of PSOs submitting data is based on data actually received by the PSOPPC. 13

14 2016 Distribution of PSOs: By PSE Report Submission Mode and Format Distribution of PSOs by PSE Report Submission Mode and Format Note: A PSO may use more than one submission mode. Total Number of PSOs who responded (N=42) 14

15 Longitudinal Trend of PSOs: By Provider Type General Hospitals Specialty Hospitals Provider Type 2013 (N=4,464) 1,580 (35.4%) 349 (7.8%) 2014 (N=5,406) 1,850 (34.2%) 354 (6.5%) Critical Access Hospitals NA NA Licensed Practitioner Groups Specialized Treatment Facilities (e.g., Dialysis, Chemotherapy, Psychiatric) Long-Term Care (includes Skilled Nursing Facilities or Intermediate/Long-Term Care Facilities, and Assisted Living Facilities) Retail Pharmacy Other * 310 (6.9%) 1,937 (43.4%) 20 (0.4%) 3 (0.1%) 265 (5.9%) 335 (6.2%) 1,958 (36.2%) 35 (0.6%) 167 (3.1%) 707 (13.1%) *Other includes all categories not specifically identified above (e.g., Urgent Care/Emergency Medicine, etc.) Note: The orange highlighting indicates categories previously included in the Other category (N=5,065) 1,553 (30.7%) 359 (7.1%) 43 (0.8%) 169 (3.3%) 1,956 (38.6%) 31 (0.6%) 168 (3.3%) 786 (15.5%) 2016 (N=3,911) 2011 (51.4%) 386 (9.9%) 100 (2.6%) 493 (12.6%) 31 (0.8%) 166 (4.2%) 2 (0.1%) 722 (18.5%) 15

16 Distribution of General Hospitals: By Bed Size Note: In 2015, there were 14 hospitals that reported bed sizes of zero. In 2016, there were 23 hospitals that reported bed sizes of zero. Source: 2015 and 2016 PSO Profile data, 2015 and 2016 AHA Survey data for US hospital bed size. 16

17 9 th Annual Meeting of PSOs April 26-27, 2017 Common Formats

18 Common Formats News Common Formats for Community Pharmacy was released in December PSOPPC is currently able to receive data. Common Formats for Event Reporting Hospital Version 2.0 will be released on May 8 th. The Import Processor at the PSOPPC will be ready to accept data beginning in August/September. Core data set required for submission to the PSOPPC Supplemental data set for local use

19 Specific changes in Version 2.0 compared with Version 1.2 To reduce reporting burden, Version 2.0 event descriptions are condensed resulting in fewer data elements than Version 1.2; In Version 2.0, the Healthcare Event Reporting Form (HERF), Patient Information Form (PIF), and Summary of Initial Report (SIR) are consolidated into one module, called the Generic module; The event description for Healthcare-associated Infection (HAI) is now retired with Version 2.0, as occurrences of HAI can be reported using the Generic module instead of a separate HAI-specific module; Anesthesia and Surgery are split into two separate modules with separate event descriptions and flow charts; and Health Information Technology (HIT) is removed from the Device or Medical/Surgical Supply module but may be reintroduced later as a separate module.

20 PSOPPC Website Activity PSOPPC Website activity, over the past 4 years 6,832,929 page views and 73,441 visitors Common Formats Hospital Version 2.0 (Open for Public Comment) 4,453 total downloads since the release in Spring 2016 Common Formats Community Pharmacy Version total downloads since its release in December 2016 Alternate Data Submission downloads since its release in Summer

21 Longitudinal Distribution of Records Received by PSOPPC: By Event Date 21

22 PSE Event Type Distribution Received by the PSOPPC through 03/13/17 The PSOPPC received 310,386 patient safety reports through 03/13/17 39% of the reports received were submitted as Other : 58% for CF V1.1 23% for CF V1.2 Note: The Other category has been removed from the above analysis. VTE data are only contained in Common Formats Hospital V1.2 data. The total number of events, not including Other, (190,103) was used as the denominator in calculating the category rates in the pie chart. The total number of events (313,362) was used as a denominator in calculating the Other percentage. Percentages may not sum to 100% due to rounding. 22

23 Contracts for PSOPPC and NPSD AHRQ contracts for the work of the PSOPPC and the NPSD PSOPPC contract expires September 2017 NPSD contract expired September 2016 In December, AHRQ issued an RFP for a combined contract so that both functions will be performed by a single contractor with appropriate firewalls between the two functions. Award expected around September 23

24 9 th Annual Meeting of PSOs April 26-27, 2017 PSO Program Impact and Opportunities

25 AHRQ Communications and Outreach Through the PSO Web Site Resources: supporting the 2016 Guidance, video and diagram, Working With a PSO - One Approach Resources: NEW Guides Section: For PSOs and Providers Determining Parent Organizations and Affiliated Providers What is The Role of an Authorized Official? Educational Tools That Support Learning: PSO Policies and Procedures Topics to Address Common Terms and Acronyms 25

26 AHRQ Communications and Outreach Through Quarterly Calls PSO Quarterly Calls have been very well-attended! 26

27 AHRQ PSO Impact Case Studies Carolinas Rehabilitation PSO (P0094) Preparing to publish soon. PSO shared tools from AHRQ s Preventing Falls in Hospitals* guide with its facilities. From 2010 to 2015, the reported rate of unassisted falls per 1,000 patient days improved by 18.9%. In 2010, the reported rate was 5.39% unassisted falls per 1,000 patient days, and in 2015 the rate dropped to 4.37%. From 2010 to 2015, the reported rates of restraint use dropped to 40.6%; hospital-acquired venous thromboembolism, which fell 25.9%; catheterrelated urinary tract infections, which were reduced 70%; and urinary catheter use, which fell 41.7%. * 27

28 AHRQ Announces Advancing Patient Safety Implementation through Safe Medication Use Research (R18) (reissued 9/6/2016) This FOA will fund investigative research demonstration projects that examine the effective implementation of processes, policies, and behaviors that support safe use of medication as well as its sustainment and dissemination. It encourages the involvement of all members of the health care team, especially patients and families, nurses, pharmacists, technicians (pharmacy and medication administration technicians), health care administrators, risk managers, and physicians across all settings of care, including in the home. was reissued September 6, The expiration date is September 26,

29 Improving Diagnosis in Health Care The unique role that PSOs can play in the collection, analysis and dissemination of information about errors in diagnosis. AHRQ should evaluate the effectiveness of PSOs as a major mechanism for voluntary reporting and learning from these events Suggested citation: National Academies of Sciences, Engineering, and Medicine Improving diagnosis in health care. Washington, DC: The National Academies Press.

30 9 th Annual Meeting of PSOs April 26-27, 2017 Regulatory News and Updates

31 HHS Guidance Regarding Patient Safety Work Product and Providers External Obligations (May 2016) Clarify what information that a provider creates/assembles can become PSWP Help address conflicts between providers and CMS surveyors over PSWP Address concerns with how some providers may be using PSWP to meet their external obligations Address questions raised by the Tibbs case 31

32 Regulatory Update CMS/CCSQ Merit-Based Incentive Payment System & Alternative Payment Models (MIPS/APMS) Proposed Rule A Medicare program known as the Merit-Based Incentive Payment System (MIPS) - 1. Streamlines 3 previously separate payment programs: 2. And provides bonus payments for participation in eligible APMs. AHRQ s PSO program is listed as one of the Clinical Practice Inventory Activities. Eligible Professionals* contracting with a PSO can receive points for participation in the PSO program. The final rule was posted on the Federal Register website: Effective date: performance period begins in calendar year (CY) 2017 and applies to CY2019 Payment Year. 32

33 21 st Century Cures Act PL (December 13, 2016) SEC Leveraging Electronic Health Records To Improve Patient Care (c) Treatment Of Health Information Technology Developers With Respect To Patient Safety Organizations 33

34 21 st Century Cures Act (1) IN GENERAL. In applying part C of title IX of the Public Health Service Act (42 U.S.C. 299b 21 et seq.), a health information technology developer shall be treated as a provider (as defined in section 921 of such Act) for purposes of reporting and conducting patient safety activities concerning improving clinical care through the use of health information technology that could result in improved patient safety, health care quality, or health care outcomes. 34

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