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Patient safety Patient safety indicatorsindicators

Patient safety Patient safety indicatorsindicators

Yolanda Agra Varela. MD; Ph.D

Sennior Adviser

National Quality Agency. Ministry of Health

Dublin 29 June 2006

Patient Safety. A national priority Patient Safety. A national priority for the Spanish Health Systemfor the Spanish Health System

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STRATEGY Nº 8: STRATEGY Nº 8: To improve patient safety in the NHSTo improve patient safety in the NHS

• To improve awareness and culture To improve awareness and culture

• To develop an information system on PSTo develop an information system on PS

• To perform best practices in all Health Regions To perform best practices in all Health Regions

STRATEGY Nº 8: STRATEGY Nº 8: To improve patient safety in the NHSTo improve patient safety in the NHS

• To improve awareness and culture To improve awareness and culture

• To develop an information system on PSTo develop an information system on PS

• To perform best practices in all Health Regions To perform best practices in all Health Regions

PATIENT SAFETY: A PRIORITY FOR THE PATIENT SAFETY: A PRIORITY FOR THE SPANISH NHSSPANISH NHS

3

AWARENESS AND CULTUREAWARENESS AND CULTURE

INFORMATION-Communication campaign-National Conference: ENEAS-International Conference: November 2006

RESEARCH

-Sponsoring National RP-Review Group on PS (agreement with IberoamericanCochrane Collaboration)

PROFESSIONAL PERCEPTION Validated questionnaire“Hospital Survey on Patient Safety Culture”

TRAINING-Basic training in all Regions-Risk Management Tool Kit: on-line -Training for managers and directors-Advanced Qualification on PS-Medication and safety-Material for University training

4

Incidence of Patients with AEIncidence of Patients with AE

9,75

7,39

10,5

5,7

11,7

9

7,5

9,3

13,7

10,9

12,2

9,3

2,63,5

16

10,1

8,6

3,72,9

16,6

10,611,3

3,9

3,2

17,2

11,1

10,1

1

3

5

7

9

11

13

15

17

N Y U C A A-adjusted

UK D NZ CA Spain30.121 14.700 14.179 1.014 1.097 3.74514.179 6.579 5.624

INTERNATIONAL ADVERSE EVENTS INCIDENCE STUDIES

SPAIN 2005

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INFORMATION SYSTEMSINFORMATION SYSTEMS

ADVERSE EVENTSADVERSE EVENTS

Comparative Analysis of the International Comparative Analysis of the International Information Systems of AEInformation Systems of AE

Design a notification system of Adverse Events Design a notification system of Adverse Events for the NHS, taking into consideration legal for the NHS, taking into consideration legal aspectsaspects

INDICATORSINDICATORS

Agreement on national indicators on PS (AHRQ, Agreement on national indicators on PS (AHRQ, OCDE)OCDE)

ADVERSE EVENTSADVERSE EVENTS

Comparative Analysis of the International Comparative Analysis of the International Information Systems of AEInformation Systems of AE

Design a notification system of Adverse Events Design a notification system of Adverse Events for the NHS, taking into consideration legal for the NHS, taking into consideration legal aspectsaspects

INDICATORSINDICATORS

Agreement on national indicators on PS (AHRQ, Agreement on national indicators on PS (AHRQ, OCDE)OCDE)

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TO IMPROVE BEST PRACTICES IN ALL REGIONSTO IMPROVE BEST PRACTICES IN ALL REGIONS

To improve patient identificationTo implement PS UnitsTo prevent nosocomial infectionsTo promote good practices in clinical settings to prevent:To promote good practices in clinical settings to prevent:

-Anaesthesia-Related -Anaesthesia-Related ComplicationsComplications

-Hip Fractures in Surgical Patients-Hip Fractures in Surgical Patients-Pressure ulcers in Hospital -Pressure ulcers in Hospital

PatientsPatients-Pulmonary Thromboembolism -Pulmonary Thromboembolism

(PTE) and Deep (PTE) and Deep Venous Venous Thrombosis Thrombosis (DVT) in Surgical (DVT) in Surgical PatientsPatients

-Infection in Surgical Wounds-Infection in Surgical Wounds-Wrong-Site Surgery-Wrong-Site Surgery-Medication Errors and-Medication Errors and-Ensure Last Wishes of patients-Ensure Last Wishes of patients

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escudo msc-agencia.jpg

NATIONAL HEALTH SYSTEM

99

779 HOSPITALS

157,926 BEDS

4 Beds per 1,000 inhabitants

326 (42%)

103,736 (66%)

574 Acute Care Hospitals

92 Mental Health Hospitals

113 Long-Term Care Centres

69,000 Physicians

103,000 Nurses

65%

85%

PUBLIC FUNDED CENTRES

IN-PATIENT HEALTH CARE - 2005IN-PATIENT HEALTH CARE - 2005

256 (40 %)

1111

MINIMUM BASIC DATA SET MINIMUM BASIC DATA SET Mandatory Administrative dataMandatory Administrative data

Hospital

Data Base Quarterly(MBDS)

Health Region

Data Basevalidation

Regional Data Base

NationalData Base

Hospital activity

+

Discharge records (ICD9-CM)

1212

SURGERY-RELATED COMPLICATIONSSURGERY-RELATED COMPLICATIONSOBSERVATIONS INDICATOR

CODECASES PER YEAR

Total (%) and discharges

2000 2001 2002 2003

D: All surgical discharges

Underreporting

OECD: all hospitalized patients

Underreporting: other sources are needed

Wound Infection998.5, 998.51,

998.59

23,960

(2.14)

1,117,478

25,537

(2.15)

1,186,381

26,573

(2.20)

1,203,129

27,888

(2.26)

1,230,378

D: All surgical discharges. Excl. obstetrics and newborn

OECD adn AHRQ: also exlclude vena cava procedures

Underreporting: other clinical records needed

PTE-DVT415.1, 11,19

45111,4519,4511,4512,4518

20,010

(1.96)

1,018,443

20,957(1.94)

1,078,437

21,268

(1.95)

1,088,100

22,978

(2.07)

1,109,453

D: All surgical discharges > 18

OECD: some diseases excluded

Should we excluded them?

Hip fracture820

1,479

(0.14)

1,025,416

1,411

(0.13)

1,093,463

1,474

(0.13)

1,113,593

1,586

(0.14)

1,140,475

D: All surgical discharges

OECD: all medical and surgical discharges

Underreporting: surgical record should be reported

Foreign body998.4

173

(0.015)

1,117,478

201

(0.017)

1,186,381

202

(0.016)

1,203,129

193

(0.016)

1,230,378

Wrong site E876.5

3 10 3 -

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OBSTETRIC-RELATED COMPLICATIONSOBSTETRIC-RELATED COMPLICATIONS

OBSERVATIONS INDICATORCODE

CASES PER YEAR Total (%) and discharges

2000 2001 2002 2003

 D: all newbornOCDE and AHRQ: live birth excluding subdural or cerebral hemorrage, injury skeleton, (767.3, 767.4) preterm and osteogenesis imprefecta (756.51)Not all Hospitals have clinical records for the newborn

Birth trauma767.0, 7673, 7674,

7677-9

3,332(1.22)

272,470

3,423(1.17)

291,558

3,379(1.11)

303,918

3,202(0.98)

320,903

D: 650, 651-659. Not all included

OECD: vaginal delivery

Vaginal664-665

DRGs: 372-375

24,646(9.07)

271,527

27,534(9.8)

279,561

29,740(11.36)

261,622

35,518(12.75)

278,483

D: procedures 74.0, 74.99

OECD: cesarean delivery

CesareaDRGs: 370-371

265(0.47)

56,086

272(0.43)

63,375

314(0.46)

67,993

372(0.50)

73,644

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OTHER MEDICAL CARE COMPLICATIONSOTHER MEDICAL CARE COMPLICATIONSOBSERVATIONS INDICATOR

CODECASES PER YEAR

Total (%) and discharges

2000 2001 2002 2003

D:All discharges> 5 days.Excl: neonates and obstetrics

Hemiplegia, paraplegia, quadriplegia Should be excluded?Underreporting: Nurse records should be included

Pressure ulcers707.0

11362

(0.75)

1,516,545

12971

(0.83)

1,552,007

13589

(0.86)

1,572,436

15254

(0.95)

1,610,410

D: All discharges. Excl: neonates and neoplasm

Underreporting

OECD: also exclude immunocompromised (codes?)

Underreporting: other sources are needed

Infections999.3, 996,62

6901

(0.24)

2,859,960

6887

(0.23)

2,932,521

7617

(0.25)

2,979,440

8541

(0.28)

3,073,553

D: All discharges. Excl: neonates

Underreporting: other data base needed

Transfusional reactions

999.6, 999.7, not: E8760

(%0 )

14

(0.004)

3,148,050

17

(0.005)

3,237,692

21

(0.006)

3,287,200

19

(0.006)

3,386,013

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ADVANTAGES OF MBDSADVANTAGES OF MBDS

Agreement at Agreement at NationalNational level for a level for a Minimum Minimum Basic Data SetBasic Data Set

Common standardsCommon standards for codification at national level (ICD-9-CM) for codification at national level (ICD-9-CM)

Resources existsResources exists in the Hospitals (clinical documentation units) in the Hospitals (clinical documentation units)

High CoverageHigh Coverage: Almost 100% discharges are codified in public : Almost 100% discharges are codified in public Hospitals and >25% in private (depending on the Region)Hospitals and >25% in private (depending on the Region)

High qualificationHigh qualification of the experts in codification in public hospitals of the experts in codification in public hospitals

Exhaustive codification:Exhaustive codification: adverse events could be detected through adverse events could be detected through MBDSMBDS

Useful Useful for identifying problemsfor identifying problems for further analysis for further analysis

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LIMITATIONS OF THE DATALIMITATIONS OF THE DATA

Clinical records: incomplete diagnosis information Clinical records: incomplete diagnosis information (comorbidity and elderly patients)(comorbidity and elderly patients)

Discharge records are the usual source of Discharge records are the usual source of codification codification (not all diagnoses and procedures are (not all diagnoses and procedures are included e.g.surgery discharges)included e.g.surgery discharges)

Private acute care Hospitals (60%) not included in Private acute care Hospitals (60%) not included in the MBDSthe MBDS

Variability in codification related with qualification Variability in codification related with qualification and DRG,s use of the data for reimbursementand DRG,s use of the data for reimbursement

Second diagnosis: Prehospitalization vs in-patient Second diagnosis: Prehospitalization vs in-patient complicationcomplication

Variability among Regions Variability among Regions

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CONSEQUENCESCONSEQUENCESDifferences in the quality of codifications among Differences in the quality of codifications among HospitalsHospitals

Lower rates of complications in comparison with Lower rates of complications in comparison with specific studies: Underreportingspecific studies: Underreporting

Unknown variability among Regions Unknown variability among Regions

National Specific software in development : delay in National Specific software in development : delay in data reportingdata reporting

Oriented to assess cost and not quality of careOriented to assess cost and not quality of care

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ACTIONS FOR IMPROVEMENTACTIONS FOR IMPROVEMENTTo increase the number of private Hospitals with codificationTo increase the number of private Hospitals with codification

To improve professional awareness (managers and clinicians) To improve professional awareness (managers and clinicians)

Feed-back : Give to them to improve the quality of care, not as Feed-back : Give to them to improve the quality of care, not as punishmentpunishment

To improve expert skills in codification in all HospitalsTo improve expert skills in codification in all Hospitals

Systematic quality control for clinical records and MBDSSystematic quality control for clinical records and MBDS

Review all clinical records (not only discharge records) should be a Review all clinical records (not only discharge records) should be a requirement to perform the MBDSrequirement to perform the MBDS

For a real picture we would need: review other data bases and clinical For a real picture we would need: review other data bases and clinical records and develop specific adhoc audits and studiesrecords and develop specific adhoc audits and studies

1919

The challenge:Comparing these

Indicators among the OECD countries