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Stephen Pavkovic, RN, MPH, JDDirector, Patient SafetyUHC

The UHC PSO Experience

AHRQ Annual Conference

Bethesda, MD

September 11, 2012

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About UHC

UHC is Chicago-based alliance of 116 academic medical centers and 258 of their affiliated hospitals UHC provides clinical, operational and financial comparative

data and informatics UHC Performance Improvement Solutions

Imperatives for Quality UHC/AANC Nurse Registry Program™ UHC-AAMC Faculty Practice Solutions Center™ National Initiatives Support Patient Safety Program

Patient Safety Net®

Integrated Claims, Complaints and Incidents Modules

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AMC Members Across the Nation

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Representing the Nation’s Leading AMCs

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Presentation Overview

Foundation What is a PSO? Why Common Formats?

UHC Patient Safety Program UHC PSN, Powered by Datix

UHC Performance Improvement PSOCommon Formats facilitated research and findings

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What is a PSO?

Created by Patient Safety and Quality Improvement Act – 2005

The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients

Regulations provide Federal legal privilege and confidentiality protections to information that is assembled and reported by providers to a PSO or developed by a PSO for the conduct of patient safety activities.

PSWP - patient safety work product The Act also significantly limits the use of this

information in criminal, civil, and administrative proceedings.

The Act includes provisions for monetary penalties for violations of confidentiality or privilege protections.

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What is a PSO?

Patient Safety and Quality Improvement Act defines how patient safety event information is collected, developed, analyzed and maintained. The Act regulates PSOs membership:

PSOs are required to work with more than one provider Excludes insurance companies

Establishes a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for providers, PSOs, and other entities. For analyzing national and regional statistics, including trends and

patterns of patient safety events. The NPSD utilizes common formats and will promote interoperability

among reporting systems. The Department of Health and Human Services will provide technical assistance to PSOs.

76 PSO listed – 2012.

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Common Formats

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Common Formats

Common Formats are a set of common definitions and reporting formats, used to specify the clinical definitions and technical requirements that allow health care providers to exchange data with PSOs and the NPSD in an interoperable and standardized manner.

Ensure consistency in reporting patient safety event information

Provide analysis of patient safety event information and give feedback to health care providers

Facilitate a learning environment that reduces future risk to patients

Inpatient Hospital based Ambulatory care in development

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Common Formats

Leveling the field for comparative data reporting permitting “apples to apples” comparisons Contents: Definition of Event Scope of Reporting Risk Assessments and Preventative Actions Circumstances of Events

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UHC Patient Safety Program

UHC-Datix PSN® Suite

PSN® Incident Reporting Tool

Claims Management

Module

Complaints Module

Reports and Research

Managers have access to

dashboard reports

Rich source of data for research with 2.2 million patient

safety events

Aggregate Data Provides

Comparisons Among

Organizations

UHC PI Patient Safety

Organization

PSN® serves as the data

collection tool for UHC PI PSO

AHRQ-Listed PSO since 2008

Common Format (v 1.1)

compliant

Federal Confidentiality

& Privilege Protection

Community of Learners

Education and Member

Success Sharing Opportunities

Safety Stories

Data mining and Aggregate

Analysis Reports & Collaboratives

Project Collaboratives

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Overview of Patient Safety Net®

Internet-based incident reporting system with point of care for adverse events and near misses (unsafe conditions)

Real time triage, routing and analysis of patient safety events by location, event type or harm score

AHRQ Common Format (v1.1) compliant

Shared UHC taxonomy with customizable questions

Integrated Patient Complaint and Claims modules to identify prevention opportunities

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PSN® Front Line Event Report Components

Reporter Information Event Detail

Patient Information Event Basics

Harm ScoreOrganization

Specific Information

Each organization may customize the properties of selected questions in the event report.

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PSN® Manager Workflow

FLR submits event report

Consultant

E-mail/Event Report goes to appropriate managers

Managers can: • View and edit the event report • Read and audit other manager reviews • Consult with managers• Enter and ‘submit’ their own reviews commenting on contributing

factors, corrective actions, and costs incurred• Attach documents

Quality/Risk (Q/R) Managers also:• ‘Submit’ a report to PSN – which changes the status to ‘closed’• Unsubmit a report• Delete a report• Submit a report to UHC PSO, if applicable

The Q/R manager actively ‘closes’ the report to submit to PSN data

repository – report auto submits after 45 days

Q/R MgrPhysician

Mgr Ancillary

MgrPharmacist

MgrLocation

Mgr

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PSN® - How to submit to PSO

PSO Specific Legal Disclaimer Individual file management Batch file management

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UHC Patient Safety Net® (PSN®) by the NumbersSince 2004, over 2.2 million events

1.5 million AHRQ Common Format (v1.1) reports 103 sites representing:

20,500 Assigned passwords 19,000 staffed beds 138 Obstetrics and Obstetric Inpatient Units 119 Operating Room Departments 114 Emergency Departments 82 Radiation Departments and Radiation Oncology Units 61 Blood Banks 33 Pediatrics ICUs 23 Burn Units

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UHC Patient Safety Net® (PSN®) Research Overview

Common Formats facilitate aggregate research and shared user experience

“Found in the NET” and PSN-based research: Epidural medication misadministration 2009, N= 31 Transfusion related events, 2011, N= 29,506 Medication CPOE events, 2012 Annual falls survey

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ADD Harmscore

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UHC Patient Safety Net® (PSN®) Harm Score Survey

Shared user experience promotes applied learning

2011 Survey of 921 managers at 89 PSN users sites Review of 9 clinical scenarios with AHRQ (v1.1)

harm score assignment 2012 Survey of 13,000 managers at 102 PSN user sites

Review of 9 clinical scenarios with AHRQ (v1.2) harm score assignment

Inter-rater agreement demonstrated “moderate” agreement v1.1 – Fleiss’ kappa value = 0.51 V1.2 – Fleiss’ kappa value = 0.47

Submitted for publication – September 2012

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PPC submission

Preparing for UHC PI PSO event submission via PPC to NPSD

FallsTransfusionsMedications

Currently Testing Internal goal to be first PSO to successfully submit to

NPSD

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UHC Performance Improvement PSO

First PSO member submission: September 2009 Total UHC PSN reports: 1,032,981 through June 2012 103 PSN Sites - Program Participants - eligible for PSO

membership 47 PSO members in 21 States 19 Submitting members

Total PSO Submissions, from all event types: 66,976

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PSN® User Groups for Analysis Organization

PSN Program Participants “Non PSO” N = 56 (of 103)

PSO Members N = 47

PSO SubmittersN = 19 (of 47)

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Top Event Type and Distribution by PSN® User Group

Medication related

Skin Integrity

Fall

Laboratory test

0% 5% 10% 15% 20% 25% 30% 35% 40%

Non-PSO Member PSO Member PSO Submitter

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Harm Score Distribution for 1,032,981 PSN® Events

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

10% 54% 36%

Harm Reached the Patient Unsafe Conditions

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Harm Score Distribution by PSN® User Group

PSO Submitter (N = 225,265)

PSO Member (N = 263,348)

Non-PSO Member (N = 544,368)

0%10%

20%30%

40%50%

60%70%

80%90%

100%

Harm Reached the Patient Unsafe Conditions

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“PSO Submitter” RatesOrg ID Submit to PSN PSO Submission Rate

1 18,691 95.99%2 3,357 93.09%3 6,577 86.03%4 6,081 56.50%5 15,772 47.76%6 43,999 45.69%7 15,354 30.62%8 16,273 20.84%9 27,530 3.21%

10 344 2.33%11 16,874 .95%12 3,845 .34%13 3,365 .06%14 16,658 .05%15 5,339 .02%16 19,437 .01%17 31,440 .01%18 11,760 .01%19 12,666 .01%

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PSO Submitted Event Distribution by Harm Scores (v 1.1)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

14% 61% 24%

Overall PSO Submitted Harm Score Distribution

Harm Reached the Patient Unsafe Condition

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PSO Submitted Event Distribution by Harm Scores (v 1.1)

123456789

10111213141516171819

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Harm Reached the Patient Unsafe Condition

PERCENTAGE OF SUBMITTED EVENTS

PS

N S

UB

MIT

TIN

G O

RG

AN

IZA

TIO

N

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Findings

Distribution of harm scores assignment is similar for all of PSN®

Top submitted event types is similar for all of PSN®

No physical barriers to PSO submission

Percentage of total events submitted to PSO varies widely among PSO members

Distribution of harm score for events submitted to PSO varies widely

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Contributing Factors to PSO Submission Variation

Member FactorsSafety cultureLitigation postureLegislative climate in venue

11 States represented in 19 submitting organizations

Submission guidelines

Other factors…

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Take Home Messages

Common Formats facilitate the collection and evaluation of patient safety data

PSOs provide a method to collect and share patient safety information

UHC PSO members’ submission practices vary widely

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Thank you.Julie Cerese, UHC Vice PresidentSteve Thomas, UHC Data Analyst

Questions?

Stephen Pavkovic, RN, MPH, JDDirector Patient Safety

UHCpavkovic@uhc.edu

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