Child Health PSO - Children's Hospital Association - Home · PDF fileChild Health PSO The Nation’s Only ... Cook Children's Health Care System, Fort Worth, TX 25. Dayton Children’s

Introduction to Child Health Patient Safety Organization November 2, 2016

[email protected]@childrenshospitals.org 1

© Child Health Patient Safety Organization, Inc. – a component organization of N.A.C.H.

Child Health PSOThe Nation’s Only PSO Dedicated to Preventing

Avoidable Harm in Children’s Hospitals

November 2, 2016 9:00 am PT / 10:00 am MT / 11:00 am CT / 12:00 pm ET

Event ID: 924 554 000


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Today’s Presenters

Kate ConradVice President

Delivery System Transformation

Barbara WeisManager

Patient Safety

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Agenda

1. Why a PSO?

2. About Child Health PSO

3. The Patient Safety Quality Improvement Act

4. How to Get Started

5. Wrap Up

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Leveraging a PSO to Improve Safety

• A public or private entity that is formally listed by the Department of Health and Human Services to carry out patient safety activities for providers under the PSQIA.

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Industry Top 5 Reasons

1. To Err is Human– Impact on harm

2. Patient Safety Quality Improvement Act– Federal protections available only for participants

3. The Joint Commission– Alternative to sentinel event reporting

4. Affordable Care Act – Satisfies health insurance exchange contractor

quality standards

5. Accountable Care– Further demonstrates commitment to learn and

improve and participate in industry warning systems7


Pediatric Top 5 Reasons

1. Pediatric affinity group– Harm in pediatric settings have unique issues

2. Track record in getting further faster together– Builds from other pediatric multi-center safety

initiatives

3. Children’s Hospital Association program– Connected with larger pediatric quality and safety

initiatives and communities

4. Supports High Reliability and Culture of Safety– Further supports national All Teach, All Learn

5. Leader led: Patient Safety Team– Prioritizes and directs pediatric value

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About Child Health PSO

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MISSION is to improve the safety and quality of child health care delivery by creating a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data that will enable the identification and reduction of risks and hazards associated with patient care.

Child Health PSO

Patient Safety Team, November 8, 2013

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TODAY’S VISION is to accelerate elimination of preventable harm. We will use strategic alliances with others to advance pediatric safety.

May 2009 Bylaws

SMART AIM is to eliminate preventable repeat pediatric harm events reported to the PSO by July 2017. Patient Safety Team, April 1, 2016




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Child Health PSO Journey

2009 2010 2011 2012 2013 2014 2015 2016 2017

Act Passed

CHA resolves that a PSO dedicated to pediatrics is essential to eliminate harm in children’s hospitals

Data collection begins10 mbr hospitals;371 eventsData partner: ECRI Institute PSO

Accelerate the elimination of pediatric harm

Focus on SSE/SSER with Children’s Hospitals Solutions for Patient Safety

Focus on elimination of repeat eventsPatient Safety

Team appointed

Results from expansion55 mbr hospitals1,987 eventsData partner: NextPlane Solutions

November 1999

...2005...

Child Health PSO listed with AHRQ

Final Regs 2007Final Rule 2008

Safe Tables launched

Safety Alerts launched

Safety Huddles launched

PSO Relisting

Note: from 2003 to 2009 the 19 hospitals participating in Children’s Hospitals Advancing Patient Safety (CHAPS) collected and analyzed 1,852 events and demonstrated the value of hospitals collaborating together to eliminate harm

PSO Relisting


Child Health PSO

Updated: 10/19/16

1. Akron Children's Hospital, Akron, OH2. Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL3. Arkansas Children's Hospital, Little Rock, AR4. Boston Children's Hospital, Boston, MA5. Brenner Children's Hospital, Winston-Salem, NC6. Children's Health Children's Medical Center Dallas, Dallas, TX7. Children's Healthcare of Atlanta, Atlanta, GA8. Children's Hospital, New Orleans, LA9. Children's Hospital & Medical Center, Omaha, NE10. Children's Hospital at Dartmouth, Lebanon, NH11. Children's Hospital Colorado, Denver, CO12. Children's Hospital Los Angeles, Los Angeles, CA13. Children’s Hospital of Orange County, Orange, CA14. Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA15. Children's Hospital of The King's Daughters, Norfolk, VA16. Children's Hospital of Wisconsin, Milwaukee, WI17. Children's Hospitals and Clinics of Minnesota, Minneapolis, MN18. Children's Mercy Kansas City, Kansas City, MO19. Children's National Medical Center, Washington, DC20. Children's of Alabama, Birmingham, AL21. Cincinnati Children's Hospital Medical Center, Cincinnati, OH22. Cohen Children's Medical Center, New Hyde Park, NY23. Connecticut Children's Medical Center, Hartford, CT

24. Cook Children's Health Care System, Fort Worth, TX25. Dayton Children’s Hospital, Dayton, OH26. Dwaine and Cynthia Willett Children’s Hospital of Savannah,

Savannah, GA27. East Tennessee Children's Hospital, Knoxville, TN28. Gillette Children’s Specialty Healthcare, St. Paul, MN29. Helen DeVos Children's Hospital, Grand Rapids, MI30. Johns Hopkins All Children’s Hospital, St. Petersburg, FL31. Kosair Children’s Hospital, Louisville, KY32. Kravis Children's Hospital at Mount Sinai, New York, NY33. Le Bonheur Children's Hospital, Memphis, TN34. Lucile Packard Children's Hospital at Stanford, Palo Alto, CA35. Mayo Clinic Children's Center, Rochester, MN36. Mercy Children's Hospital, Toledo, OH37. Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN38. MultiCare Mary Bridge Children's Hospital & Health Center, Tacoma,

WA39. Nationwide Children's Hospital, Columbus, OH40. Nicklaus Children's Hospital, Miami, FL41. Palmetto Health Children's Hospital, Columbia, SC42. Penn State Children's Hospital at The Milton S. Hershey Medical

Center, Hershey, PA43. Phoenix Children's Hospital, Phoenix, AZ44. Primary Children's Hospital, Salt Lake City, UT45. ProMedica Toledo Children's Hospital, Toledo, OH46. Riley Hospital for Children at Indiana University Health, Indianapolis,

IN47. Seattle Children's, Seattle, WA48. St. Joseph’s Children’s Hospital, Tampa, FL49. St. Jude Children's Research Hospital, Memphis, TN50. St. Louis Children's Hospital, St. Louis, MO51. Texas Children's Hospital, Houston, TX52. The Children's Hospital of Philadelphia, Philadelphia, PA53. UH Rainbow Babies & Children's Hospital, Cleveland, OH54. University of Michigan C.S. Mott Children's and Von Voigtlander

Women's Hospital, Ann Arbor, MI55. University of Minnesota Masonic Children’s Hospital, Minneapolis,

MN




Patient Safety: Eliminating Preventable Harm

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Children’s Hospitals’ Solutions for

Patient Safety (CHSPS)

Build a culture of safety and become a high reliability

organization

Child Health PSO(Children’s Hospital Association’s PSO)

Share openly with others, learn from high harm events and move

toward risk detection and mitigation


Current Focus is Learning from Highest Harm

• Learn definitions and methods to assign harm from CHSPS Cause Analysis Leaders

• Report SSEs and SSER to the PSO portals to drive the identification of themes, trends and alerts

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Serious Safe

Events

Serious Safe

EventRate



© Child Health Patient Safety Organization, Inc., a component of N.A.C.H

By July 2017 eliminate

preventable repeat pediatric harm

events reported to the PSO

e.g., reduce NG Tube events by x%

GLOBAL AIM: Elimination of Preventable Harm to Pediatric Patients

Consistent member reporting of events into the PSO Event Reporting System

KEY DRIVERS SECONDARY DRIVERS

Identification, analysis and prioritization of event types/themes

Credible and actionable local and national dissemination of event trends and discovery of event elimination strategies

Member adoption of PSO learning based recommended improvements

National influencer and partner with other safety leaders for patient safety

• User friendly secure portal• Leverage information systems at local

institutions

• Improved detection through− PSO Weekly Safety Huddles− Robust member data submission

into PSO portal/database• Consistent, timely PST analysis of

data and identification of event trends

• Robust systems for dissemination of event trends through multiple modalities

• Optimize multiple modalities for widespread dissemination of case-based findings of RCAs and interventions

• Build strong relationships with national agencies becoming a leader for pediatric patient safety

• Maximize CHA advocacy opportunities for pediatric patient safety

vrs 3/24/16

TBDCustomize to specific repeat events of focus: diabetes care, heating/ cooling devices, RFO

• Partnership with other PSOs• Contribute to national level knowledge of etiology of

pediatric adverse events• Identify and communicate national priorities to reduce

pediatric adverse events• Contribute to larger safety data sets• Provide forum for subspecialty groups• Collaborate with CHA on safety and measurement

priorities, policy comments and Amicus Brief opportunities

• Routinely assess member experience and satisfaction with portal

• Provide PSO training opportunities and coaching

• Data analytic framework• PST member coaching• Partnership with PSO vendor• Automated analysis and alerts

• Conduct Safe Tables• Webinars• Annual Meeting• PST Meeting driven summary/learning• Broaden huddle to include key interventions/ learning

• Release PSO annual data report• Broadly push out safety Alerts quarterly• Creation of alerts• Publications of work• Presentations at conferences• National and local electronic dashboards

INTERVENTIONSSMART AIM

TBD


How the PSO Helps you Improve Safety

Meaningful event learning. With a focus on Serious Safety Events, the PSO Safety Team conducts quarterly non-identifiable (blinded) data reviews to enable:

• Prioritized monthly virtual SSE learning opportunities from member presentations

• Prioritized safety alerts for spread

• Identification of participant coaching needs: classification, improvement resources

• Recommendations for quality improvement collaboratives based on trends

Weekly Safety Huddle. Modeled after daily safety calls, this safety huddle has been tested to support multicenter institutions to provide both a mechanism for early notification of events and a way to request help from other PSO participants.

Leverage national expertise to support participation in Child Health PSO• Alignment with the high reliability journey through CHSPS

• Regulatory interpretation and compliance to maintain protections

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Active Learning from Events – Safe Table

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• Activity coined by PSOs to express the application of protections when members convene to discuss patient safety work product

– Involves rules around allowable participation and discussion based on each PSO’s unique interpretation of the PSQIA and their unique policies and procedures

• Constitutes a PSO’s deliberations and direct feedback to members i.e., patient safety work product


An Example…Diagnostic Error

• One in 10 diagnosis are wrong. The 2015 IOM report Improving Diagnosis in Healthcare identified that diagnostic error contributes to 10% of patient deaths. However, diagnosis errors have received far less focused improvement efforts than other types of preventable harm events.

• Presentation:– Discuss a case where a diagnostic error occurred, resulting in

unnecessary clinical treatment and unidentified safety risk with further patient harm.

– The identified concerns and gaps in the processes that were identified in the root and proximate cause(s).

– Mitigation and action plans to prevent reoccurrence.

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Weekly Safety Huddle

• Modeled after daily safety calls

• Support multi-center shared learning

• Provide both a mechanism for early notification of events and a way to request help from other PSO participants – 15 minutes each week

225 355148Huddles

Asks for Help

FYIs

As of 10/31/16


Examples…

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“FYI, we had an SSE 4, Fentanyl overdose in NICU satellite facility related to miscalculation when using the hanging, infusing fentanyl drip to give a bolus dose.”

“This is an ask for help for best practices to communicate procedure and site/tissue marking on bilateral cases, relates to NME cutting wrong muscle during bilateral eye surgery”




Added Benefit from Safety Huddle and Discussion Thread

• Share pediatric approaches with national advisories and issues

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PSO Alerts Available to All CHA Members

https://childrenshospitals.org/Quality-and-Performance/Patient-Safety/Patient-Safety-Action-Alerts




Why PSO Reporting is Critical

Children‘s Hospital Patient Safety Organization Public

The PSO participant determines what to submit to the PSO in their Patient Safety Evaluation System

The PSO aggregates and reviews submissions (all PSO PSWP) and generates PSO patient safety work product. Direct feedback is provided to PSO members, both individually and collectively.

Non-identifiable PSWP is made available by the PSO to inform children’s hospitals external to the PSO and the public.

PSWP submission*

ALERTReports,

deliberations, and analyses

SAFE TABLESPSES

IN

OUT

Analysis

SSE Rate

Event details

Verbal report

* PSWP may be “functionally” reported with an amendment and respective policies implemented

Industry action


About the Patient Safety and Quality

Improvement Act

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Congress Passes Patient Safety and Quality Improvement Act (PSQIA)

• Creates “Patient Safety Organizations” (PSOs) for voluntary reporting and learning with federal privilege and confidentiality protections

• Establishes the “Network of Patient Safety Databases” (NPSD)

• Authorizes establishment of “Common Formats” for reporting patient safety events

• Department of Health and Human Services (HHS)

• Office of Civil Rights (OCR)

• Agency for Healthcare Research and Quality (AHRQ)

Slide 25

Adapted from AHRQ 2009 Annual Conference presentation

NOV 1999

JUL 2005


PSQIA Final Rule Establishes Ground Rules for the Playing Field - January 19, 2009

• Criteria for becoming and staying a “listed” PSO

• Outlines a host of requirements for participants and PSOs

• Explains how privilege and confidentiality is established and maintained within a PSO

• Identifies penalties for non-compliance

Slide 26

CFR 42 Part 3, Patient Safety and Quality Improvement Act Final Rule http://www.gpo.gov/fdsys/pkg/FR-2008-11-21/pdf/E8-27475.pdf




Patient Safety Organization (PSO) Requirements

PSOs must comply with a host of requirements and attestations, and are subject to AHRQ assessments

PSO members must report information to the PSO for the purpose of conducting patient safety activities

The information reported is protected by the PSO … and must be protected by the members (use of policies, training and documentation)

Additional information may be included in the PSO but without protection

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How to Get Started

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Next steps

Express intent to participate in Child Health PSO• Contact staff for

participation agreement or any questions

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Child Health PSO StaffKate Conrad, Vice [email protected](913) 981-4118

Barbara Weis, Manager, Patient [email protected](913) 981-4117

Emily Tooley, Patient Safety [email protected](913) 981-4130

Cindy DuMortier, [email protected](913) 981-4146

Child Health PSO StaffKate Conrad, Vice [email protected](913) 981-4118

Barbara Weis, Manager, Patient [email protected](913) 981-4117

Emily Tooley, Patient Safety [email protected](913) 981-4130

Cindy DuMortier, [email protected](913) 981-4146


Maximizing PSO Network Participation

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Understand

Refine

DefineImplement

Manage

1 Identify business goals/value

2 Assign an executive champion

3 Assemble multidisciplinary stakeholders

4 Reaffirm purpose and goals

5 Develop PSES

6 Develop PSO structure

7 Enter data

8 Actively learn




• Identify your organization’s commitment to patient safety

• Identify an objective with the PSO to support that vision

• Note: the quicker you engage with reporting, the quicker value can be obtained and communicated

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1 Identify business goals/value

To improve patient safety and prevent harm through the sharing of information and lessons learned with other children’s hospitals under the federal protections of

confidentiality and legal privilege


2 Assign an executive champion

• Crystalizes the vision for preventable harm and how this is supported by the PSO

• May or may not be contract’s Authorized Agent

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“We want to end the era where each of our hospitals need to experience an SSE in order to improve the root causes. Our goal

is to reduce the SSER by 25% and then keep going.”

-- Stephen Muething, MD 4/16/2014




3 Assemble multidisciplinary stakeholders

• Learn together about the regulations and your hospital’s objectives

• Join PSO training together – AHRQ and Child Health PSO• https://www.pso.ahrq.gov/legislation

(see video “Working with a PSO” under educational tools that support learning

• Schedule joint call with PSO staff

• Note: PSO program offers additional tools and resources, such as – Shared policies

– Training webinars and materials

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4 Reaffirm purpose and goals

• Reflect back on business goals and value to proceed

• Note: Changes to people, structure, regulatory interpretations occur over time– When these happen, or annually

Refresh policies

Refresh structure

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Wrap Up

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Our Opportunity

• Maximize our combined efforts/size

• Better data for analysis

• Accelerated journey to eliminate harm

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Children’s Hospital Association

600 13th St., NW | Suite 500 | Washington, DC 20005 | 202-753-5500

16011 College Blvd. | Suite 250 | Lenexa, KS 66219 | 913-262-1436

www.childrenshospitals.org

Remember Every Child Behind the Number

Documents

Child Health PSO - Children's Hospital Association - Home · PDF fileChild Health PSO The Nation’s Only ... Cook Children's Health Care System, Fort Worth, TX 25. Dayton Children’s