The UHC PSO Experience

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Slide 0

The UHC PSO Experience

Stephen Pavkovic, R.N., M.P.H., J.D.
Director, Patient Safety
UHC

AHRQ Annual Conference
Bethesda, MD
September 11, 2012

Slide 1

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.

Slide 2

AMC Members Across the Nation 

Image: A map of the United States beneath the UNC logo shows the locations of AMC member organizations.

Slide 3

Representing the Nation's Leading AMCs

Slide 4

Presentation Overview

Foundation:

• What is a PSO?
• Why Common Formats?

UHC Patient Safety Program:

• UHC PSN, Powered by Datix.

UHC Performance Improvement PSO.

Common Formats facilitated research and findings.

Slide 5

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.

Slide 6

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.

Slide 7

Common Formats

Image: A photograph shows an orange and an apple.

Slide 8

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.

Slide 9

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.

Slide 10

Fall Event Description

Image: Example—an event description of a fall.

Slide 11

UHC Patient Safety Program

Image: A chart shows the structure of the 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.

Slide 12

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.

Slide 13

PSN® Front Line Event Report Components

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

Image: The following components appear on six colored fragments that form an ovoid shape:

• Patient Information.
• Event Basics.
• Reporter Information.
• Event Detail.
• Organization Specific Information.
• Harm Score.

Slide 14

PSN® Manager Workflow

Image: A flowchart depicts the following process:

FLR submits event report (E-mail/Event Report goes to appropriate managers) →

• Location Manager.
• Pharmacist Manager.
• Ancillary Manager.
• Physician Manager.
• Q/R Manager.

All managers forward the report to the Consultant.
The Q/R manager actively "closes" the report  to submit to PSN data repository—report auto submits after 45 days.
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.

Slide 15

PSN®—How to submit to PSO

• PSO Specific Legal Disclaimer.
• Individual file management.
• Batch file management.

Image: A screenshot shows the fields of the online form through which PSOs can be submitted.

Slide 16

UHC Patient Safety Net® (PSN®) by the Numbers

Since 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.

Slide 17

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.

Slide 18

Figure 1. AHRQ Common Format Harm Scale v.1.1

Image: A figure shows the AHRQ Common Format Harm Scale: Death, Severe permanent harm, Permanent harm, Temporary harm, Additional treatment, Emotional distress or inconvenience, No harm, Unknown.

Slide 19

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.

Slide 20

PPC submission

• Preparing for UHC PI PSO event submission via PPC to NPSD.
  Falls.
  Transfusions.
  Medications.
• Currently Testing.
  Internal goal to be first PSO to successfully submit to NPSD.

Slide 21

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.

Slide 22

PSN® User Groups for Analysis Organization

Image: A series of concentric circles shows the following data:

• PSN Program Participants "Non-PSO", N = 56 (of 103).
• PSO Members, N = 47.
• PSO Submitters, N = 19 (of 47).

Slide 23

Top Event Type and Distribution by PSN® User Group

Image: A bar graph shows percentage of laboratory test, fall, skin integrity, and medication-related event submitted by Non-PSO Members, PSO Members, and PSO Submitters.

Slide 24

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

Image: A bar graph shows the following data:

• Harm - 10%.
• Reached the Patient - 54%.
• Unsafe Condition - 36%.

Slide 25

Harm Score Distribution by PSN® User Group

Image: A bar graph shows Harm Score distribution by PSN User Group:
Non-PSO Member (N = 544,368):

• Harm - 10%.
• Reached the Patient - 52%.
• Unsafe Condition - 38%.

PSO Member (N = 263,348):

• Harm - 8%.
• Reached the Patient - 56%.
• Unsafe Condition - 36%.

PSO Submitter (N = 225,265):

• Harm - 10%.
• Reached the Patient - 57%.
• Unsafe Condition - 33%.

Slide 26

"PSO Submitter" Rates

Slide 27

PSO Submitted Event Distribution by Harm Scores (v 1.1)

Image: A bar graph shows the following overall PSO-submitted Harm Score distribution:

• Harm - 14%.
• Reached the Patient - 61%.
• Unsafe Condition - 24%.

Slide 28

PSO Submitted Event Distribution by Harm Scores (v 1.1)

Image: A bar graph shows percentage of submitted events by submitting organizations. The organizations are identified by number.

Slide 29

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.

Slide 30

Contributing Factors to PSO Submission Variation

Member Factors.

• Safety culture.
• Litigation posture.
• Legislative climate in venue.
  • 11 States represented in 19 submitting organizations.

Submission guidelines.

Other factors...

Slide 31

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.

Slide 32

Thank you.
Julie Cerese, UHC Vice President.
Steve Thomas, UHC Data Analyst.

Questions?

Stephen Pavkovic, R.N., M.P.H., J.D.
Director Patient Safety
UHC
pavkovic@uhc.edu