Patient Safety Achieving a New Standard for Care (2004) / Chapter Skim
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8 Patient Safety Reporting Systems and Applications
8 Patient Safety Reporting Systems and Applications
Pages 250-278
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From page 250... ...
If safety is to be a core feature of health care delivery systems, clinicians, administrators, and patients will need tools, based on reliable clinical data, to build and assure a safe care environment. Health professionals 250
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From page 251... ...
An ideal clinical performance reporting system should be able to function simultaneously along the entire continuum of applications, but such broad use requires careful data system design, automated systems that link directly to care delivery, and explicit data standards. There are many legitimate applications of clinical performance data, each having its own historical underpinnings and approaches.
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From page 252... ...
The feedback of performance data to clinicians for continuing education purposes falls into this category, as does the redesign of care processes by health care organizations based on analysis of data collected in near-miss and adverse event reporting systems. Falling between these two extremes are applications intended to encourage health care providers to strive for excellence by rewarding those who achieve the highest levels of performance with higher payments and greater demand for their services.
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From page 253... ...
operation and – Hypothesis sanctions – Licensing report cards management generation and – Malpractice – Credentialing/ – Contracting – Identification of testing – Tort actions privileging "best in class" – Certification and accreditation FIGURE 8-1 A continuum of possible uses and mechanisms of action for patient safety data.
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From page 254... ...
. The vast majority of providers are not negligent, incompetent, or impaired, yet the services they provide are clearly inadequate, suggesting that minimum performance standards alone cannot achieve generally excellent care delivery (James, 1992)
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From page 255... ...
. These types of applications require certain data and information to be "transparent," a term denoting the situation in which those involved in health care choices at any level -- including patients, health professionals, and purchasers -- have sufficiently complete, understandable information about clinical performance to make wise decisions (Institute of Medicine, 2001)
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From page 256... ...
In a transparent world, all participants would have access to hospital- and surgeon-specific performance datasets including a rich set of process and outcome measures, satisfaction reports, and other information. To date, public reporting of performance data has been limited, but experience is growing (Agency for Healthcare Research and Quality, 2001; Baumgarten, 2002; California HealthCare Foundation, 2003; Centers for Medicare and Medicaid Services, 2003; Department of Health and Human Services, 2002a, b; Dudley et al., 2002; McCormick et al., 2002; National Committee for Quality Assurance, 2002a, b)
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From page 257... ...
Health care delivery organizations and professionals have a great deal to gain from a balanced system of public reporting. To the extent that safer care produces fewer injuries, it can significantly reduce legal exposure, as evidenced by the malpractice experience of surgical anesthesiologists following successful profession-wide improvement efforts (Joint Commission on Accreditation of Healthcare Organizations, 1998; Chassin, 1998; Cohen et al., 1986; Cooper et al., 2002; Duncan and Cohen, 1987; Gaba, 1989; Pierce, 1996)
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From page 258... ...
Explicit external expectations, implemented through public reporting balanced across institutions by independent auditing of underlying data systems, can establish shared priorities and parallel investment in the necessary data infrastructure. Many efforts now under way are aimed at providing financial rewards to providers based on either their relative performance ranking compared with their peers or improvements in their individual performance over time (Bailit Health Purchasing, 2002a; Bailit Health Purchasing, 2002b; Kaye, 2001; Kaye and Bailit, 1999; National Health Care Purchasing Institute, 2002; White, 2002)
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From page 259... ...
. Historically, many learning approaches have relied extensively on comparative performance data, often using the same types of data included in public report cards or provided to purchasers in payment-for-quality programs.
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From page 260... ...
260 Before After Accountability focus change activities on the lower tail of the distribution mean performance mean performance after change before change 0.15 0.15 quality assurance threshold (performance "standard") 0.10 0.10 Frequency 0.05 0.05 0.00 0.00 (# of providers attaining a particular quality level)
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From page 261... ...
quality FIGURE 8-4 Use of patient safety data: Accountability versus system redesign.
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From page 262... ...
This section presents a case study involving the use of mortality reports for accountability purposes and then uses this case study to illustrate key points related to issues surrounding the use of patient safety data, including the selection of measures, the risk that the use of performance data will instill fear and provoke defensive behavior on the part of providers, and the concept of preventability. The section ends with a discussion of the implications of the range of applications for patient safety data systems.
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From page 263... ...
The Medicare mortality reports, updated by parallel consideration of similar, more recent efforts, can serve as a useful case study for understanding issues surrounding data standards for patient safety. Selection of Measures Outcome measures, although of keen interest to regulators, purchasers, and individuals, are particularly difficult to use for accountability purposes since they do not necessarily measure competence (Trunkey and Botney, 2001)
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From page 264... ...
For example, Eddy estimates that all major factors proven to explain infant mortality rates (race, maternal alcohol consumption, maternal tobacco smoke exposure, altitude, and differences in prenatal care delivery performance) account for only about 25 percent of documented variation in patient outcomes (Eddy, 2002)
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From page 265... ...
Standardized clinical data are not captured as part of the care delivery process. The HCFA mortality reports were produced from Medicare claims data, which lack important clinical detail.
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From page 266... ...
It is also an important consideration in deciding how much emphasis to place on accountability versus learning applications because the former applications run a much higher risk of instilling fear than do the latter. Reaction 1: Kill the Messenger Accountability data inherently focus on individual health professionals or care delivery organizations.
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From page 267... ...
. Such experience suggests that, whenever possible, accountability for patient safety should focus at the level of an organization rather than the level of individual health professionals working within the organization.
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From page 268... ...
Patients and their caregivers are sometimes forced to knowingly accept adverse secondary consequences to achieve a more important primary treatment goal. The concept of preventability separates care delivery errors from such recognized but unavoidable treatment consequences.
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From page 269... ...
Patient safety data systems should cast a wide net, focusing on all types of adverse events, not just those that are preventable based on current understanding and current systems of care delivery. Achieving this broad focus will require careful use of the term "error," with clear recognition of its linkage to system-level solutions and attention to its pejorative connotations for health professionals.
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From page 270... ...
. In the absence of careful planning, a health care delivery organization with limited resources may find that all of its measurement resources are consumed by special data collection to comply with external reporting requirements, with none remaining for learning and system redesign (Casalino, 1999)
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From page 271... ...
Patient Safety Data Audits When patient safety data are used for external performance reporting, it is important that the data be audited. When performance data are used for licensure or payment purposes or to support purchaser or consumer decisions, providers have an incentive to "look their best." Audits are necessary to assure all stakeholders that the reporting system is fair.
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From page 272... ...
The National Committee for Quality Assurance (NCQA) , a private-sector accrediting and performance reporting organization, oversees an auditing process to assure the integrity of aggregate-level performance data reported by about 460 health plans on 60 performance measures in the Health Plan Employer Data and Information Set (National Committee for Quality Assurance, 2003)
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From page 273... ...
2002a. Ensuring Quality Health Plans: A Purchaser's Toolkit for Using Incentives.
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2002b. Secretary Thompson Welcomes New Effort to Provide Hospital Quality of Care Information.
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1998. When employers choose health plans do NCQA accreditation and HEDIS data count?
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2000. The public release of performance data: What do we expect to gain?
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From page 277... ...
Washington, DC: National Committee for Quality Assurance. National Health Care Purchasing Institute.
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From page 278... ...
2003. Health plan quality data: The importance of public reporting.
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