Two Models of Medical Error Reduction Programs in Radiation Oncology
by
Ed Kline
RadPhysics Services LLC
Albuquerque, NM, © RPS
Introduction
* This presentation describes the design, implementation, and results of two QA/medical error reduction programs
* Both programs are designed for
o Reducing preventable systems-related medical errors (i.e., sentinel events, “near misses”)
o Preventing violations of regulatory requirements (i.e., State/NRC)
o Ensuring compliance with recommended standards (i.e., JCAHO, ACR, ACRO, etc.)
History
* Institute of Medicine (IOM) report5
o Focused a great deal of attention on the issue of medical errors and patient safety
o 44,000 to 98,000 deaths per year in U.S. hospitals each year as the result of medical errors
o 10,000 deaths per year in Canadian hospitals
o Exceeds annual death rates from road accidents, breast cancer, and AIDS combined in U.S.
To Err is Human: Building a Safer Health System.
* Key legislation
o Patient Safety Quality Improvement Act9
+ Certifies patient safety organizations in each State to collect data and report on medical errors
o State Patient Safety Centers
+ In past 5 years, 6 states have enacted legislation supporting creation of state patient safety centers
+ 5 of the 6 states now operate patient safety centers
+ Separate mandatory reporting systems for serious adverse events
+ Centers are housed within state regulatory agencies
Reducing Medical Errors, Issue Module, Kaiser EDU.org, Accessed through www.kaiseredu.org.
* Patient safety centers include10
o The Florida Patient Safety Corporation
o The Maryland Patient Safety Center
o The Betsy Lehman Center for Patient Safety and Medical Error Reduction (Massachusetts)
o The New York Center for Patient Safety
o The Oregon Patient Safety Commission
o The Pennsylvania Patient Safety Authority
State Patient Safety Centers: A New Approach to Promote Patient Safety, The Flood Tide Forum, National Academy for State Health Policy, 10/04, Accessed through www.nashp.org.
* State reporting: mandatory vs voluntary11
o Mandatory reporting: Colorado, Florida, Kansas, Nebraska, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Washington
o Voluntary reporting: District of Columbia, Georgia, New Mexico, North Carolina, Oregon, Wyoming
o Considering new legislation: Arizona, California, Maine
o Mandatory reporting but considering new legislation: Massachusetts, New Jersey
National Conference of State Legislatures, National Academy for State Health Policy, 12/03, Accessed through www.nashp.org.
* JCAHO revises standards
o Patient safety standards effective 7/1/01
o Requires all JCAHO hospitals (5,000) to implement ongoing medical error reduction programs
o Almost 50 percent of JCAHO standards are directly related to safety
Patient Safety - Essentials for Health Care, 2nd edition, Joint Commission on Accreditation of
Healthcare Organizations. Oakbrooke Terrace, IL: Department of Publications, 2004.
* JCAHO’s sentinel event policy13
o Implemented in 1996
o Identify sentinel events
o Take action to prevent their recurrence
o Complete a thorough and credible root cause analysis
o Implement improvements to reduce risk
o Monitor the effectiveness of those improvements
o Root cause analysis must focus on process and system factors
o Improvements must include documentation of a risk-reduction strategy and internal corrective action plan
o Action plan must include measurements of the effectiveness of process and system improvements to reduce risk
Sentinel Event Policies and Procedures - Revised: July 2002, Joint Commission on Accreditation of Healthcare Organizations, Accessed through www.jcaho.org/accredited+organizations/long+term+care/sentinel+events/index.htm.
* JCAHO’s Office of Quality Monitoring
o Receives, evaluates and tracks complaints and reports of concerns about health care organizations relating to quality of care issues
o Conducts unannounced on-site evaluations
* JCAHO and CMS agreement14
o Effective 9/16/04
o Working together to align Hospital Quality Measures (JC’s ORYX Core Measures and CMS’7th Scope of Work Quality of Core Measures)
Joint Commission, CMS to Make Common Performance Measures, Joint Commission on Accreditation of Healthcare Organizations, Accessed through www.jcaho.org/accredited+organizations/long+term+care/sentinel+events.
* CMS quality incentives15
o Quality Improvement Organizations (QIOs)
+ Contracted by CMS to operate in every State
+ 67% of QIOs perform independent quality audits
o Premier Hospital Quality Initiative
+ 3-year demonstration project recognizes and provides financial reward
+ CMS partnership with Premier Inc., nationwide purchasing alliance
+ Hospitals in top 20% of quality for specific diagnosis get financial reward
# Top decile gets 2% Diagnosis Related Group (DRG) bonus
# 2nd decile get 1% DRG bonus
+ Hospitals performing below 9th and 10th decile baseline levels, DRG payments reduced 1% and 2%, respectively
Medicare Looks for Ways to Boost Quality Care Comments Sought on New Plan for Quality Improvement Organizations, Centers for Medicare & Medicare Services (CMS), Accessed through www.cms.hhs.gov.
* CMS quality incentives
o CMS consumer website
+ Beginning in 4/05, hospital quality data available at www.HospitalCompare.hhs.gov or 1-800-MEDICARE
o Data indicators16
+ In 2006, hospitals reporting quality data to Medicare receive 3.7% increase in inpatient payments
+ Non-reporters receive 3.3% increase
+ Data covers 10 quality indicators for cardiology
+ Plans are to expand into other disciplines
and more in this presentation
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