Progress on the MPSC s Incident Reporting System

Transcription

1 Progress on the MPSC s Incident Reporting System Third Annual Maryland Patient Safety Center Conference March 23, 2007 Vahé A. Kazandjian, PhD, MPH President, LogicQual Research Institute Co-Chair, MPSC Advisory Board Vivian Miller, CPHQ, CPHRM, LHRM Research Project Manager Maryland Patient Safety Center Frank Pipesh Senior Director, Information Technology, Center for Performance Sciences The Maryland Patient Safety Center (MPSC) The MPSC is the organization where data play an important role, but only as a facilitator for services to health care organizations in Maryland. Indeed, the data are and will be used to identify areas of common need for improving safer practices and tailoring programs (services to assist hospitals and other care providing organizations). 1

2 Today s discussion is about a Maryland first! It is about the first initiative to collect, via a systematic, scientific, and field-tested tool key aspects of structures, processes, and outcomes of care that have direct implications to safety of care and eventually, to accountability. Although the use of the tool is voluntary, the data are not. Specifically, the MPSC strongly recommends that all hospitals report the data requested in the tool. More on this later in the presentation. First, a genesis of the Incident Reporting System and how the pilot phase is going. Please remember, we are from the Incident Reporting System (IRS) and we are here to help you! 2

3 Timeline 2004 Chose VECNA, located in College Park, MD as our vendor, after determining they could provide us with the best basic template/code to use as a starting point to develop the tool. MHA has had a successful partnership with VECNA on past ventures, most recently with the HSCRC Quality-based Reimbursement Initiative. Timeline 2005 Development of software continued for 1 year, with input from acute care facilities, and guidance from the MPSC Advisory Panel. Hospital representatives were included on an ad hoc basis for guidance and evaluation of specific questions pertaining to technology and the role of risk management. 3

4 Timeline 2006 Completed tool development Deployed pilot in June Timeline 2007 Complete preliminary data analysis from the pilot hospitals. By end of 2007, expand the database by adding the remaining hospital data that was submitted on paper or data files. 4

5 The Maryland Patient Safety Center s Web-based Incident Reporting System The Maryland Patient Safety Center s Reporting System is: Voluntary reporting of any/all adverse patient events. The Maryland State Department of Health and Mental Hygiene s Office of Health Care Quality requires: Mandatory reporting of all Level 1 Events to the OHCQ whenever it has been determined that the organization most likely contributed to the serious and/or permanent injury, illness or death of a patient. The Maryland Patient Safety Center s Web-based Incident Reporting System Designed to report all incidents, particularly those near miss events that seem to occur repeatedly Track and trend events based on: high cost high volume high risk Determine organizational priorities Focus efforts toward improving processes Promote safer practices 5

6 The Maryland Patient Safety Center s Web-based Incident Reporting System Per our contract with the Maryland Health Care Commission, the tool was to be tested in the 3 rd year of the MPSC s 3-year contract, but we are ahead of schedule and have been piloting since September Pilot will continue until year end Pilot Participants Total Number of Participating Hospitals/Healthcare Facilities 37/66 Number of Participating Facilities to use MPSC s Adverse Event Reporting Tool to Date 7 currently using tool Number of Participating Facilities to Submit Data to Date 24 6

7 Pilot Participants Chester River Hospital Center MedStar Health Harbor Hospital Center Good Samaritan Hospital Franklin Square Hospital Union Memorial Hospital Washington Hospital Center Georgetown Hospital Center National Rehabilitation Center Lifebridge Health System Sinai Hospital Center Northwest Hospital Center Anne Arundel Medical Center Upper Chesapeake Health System Fallston Memorial Hospital Harford Memorial Hospital Carroll Hospital Center Greater Baltimore Medical Center Garrett County Memorial Hospital Atlantic General Hospital Center Civista Medical Center Ft. Washington Medical Center Union Hospital of Cecil County St. Mary s Hospital Pilot Participants University of Maryland Health System University of Maryland Medical Center Maryland General Hospital Kernan Specialty Hospital Baltimore Washington Medical Center Mt. Washington Pediatric Center Shore Health System Easton Memorial Hospital Center Dorchester County Hospital Adventist Healthcare Potomac Ridge Behavioral Health Washington County Hospital Dimension Health System Prince George s County Hospital Laurel Regional Medical Center Gladys Spellman Specialty Hospital Peninsula Regional Medical Center Montgomery General Hospital 7

8 The Maryland Patient Safety Center s Web-based Incident Reporting System The tool is offered AT NO COST TO THE FACILITY. The tool was designed to satisfy more than one organizational need. In fact, as the tool continues to be piloted, improvements are made every day based on user suggestions and recommendations. The Maryland Patient Safety Center s Web-based Incident Reporting System Additionally, based on my past life as a risk manager, the MPSC s Incident Reporting System is very comparable to other web-based systems I have had the opportunity to review and assess. A reminder.use of the system is voluntary, but if your facility agreed to participate in the pilot, we need you to submit your data to the MPSC. 8

9 What are we seeing from the data collected? Data types: Systematic and defined for standard reporting purposes Free text for data mining opportunities What s Next? Pilot to be completed by December Formal implementation of tool begins January Benchmarking capabilities with other facilities to become more specific. Identification of possible patterns and trends among facilities. Maryland Patient Safety Center to work with hospital patient safety officers and the Institute for Safe Medication Practices (ISMP) to develop standardized best practice patient safety prevention processes, based on trended data. 9

10 What s Next? Make recommendations about better practice models to all facilities. Collect information about the implementation of new strategies for safer practices. Provide comparative analysis across facilities to demonstrate the extent and nature of improvements statewide. 10