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Copyright 2010 Health Data Solutions, Inc.
Risk management software project started by the Pioneer Health Network
Risk Managers wanted a better way to identify trends and issues needing attention.
Final product improved entire risk management process
Mistakes Cost Money
$$ Musician losses arm due to mishandled injection: $6.7 million verdict$$ Neglect leads to gangrene, death: $10.7 million verdict$$ Errors at girl’s birth: $3.7 million verdict$$ Negligent post-op monitoring cost $1.5 million$$ Dementia patient wanders, killed by car: $850,000$$ Delayed diagnosis yields $2 million$$ Unlocked wheelchair wheels lead to $250,000 fall$$ Miscommunication costs $1.65 million$$ Failure to respond to elevated Troponin results in heart attack, anoxic brain damage: $4.75 million settlement$$ Aspiration death: $2.06 million verdict$$ Hypoglycemic event leads to brain damage and $4 million settlement$$ Death from infection: $13.5 million settlement
Ways to Make it All Work
Honesty
Patient safety first
Public relations
Team work
Good documentation system*
The Problem and Tracking Quality
“The problem is not bad people; the problem is that the system needs to be made safer . . .”
“More people die from medical errors than motor vehicle accidents. . .”
Estimated as high as 98,000 deaths a year attributed to medical errors.
IOM (2000). To Err is Human: Building a Safer Health System
“Without ongoing tracking of quality to assess…progress in meeting the six aims for improvement (Safe, Effective, Patient-centered, Timely, Efficient, Equitable), patients, healthcare practitioners, policy makers, educators and purchasers cannot identify progress or understand where improvement efforts are most needed.”
IOM (2001). Crossing the Quality Chasm: A New Health System for the 21st Century, p. 40
National Patient Safety
and Clinical Quality Efforts
AHRQ
ISMPIHI
Ambulatory & Hospital
Quality Alliances
CMS
Leapfrog Group
Partnership for Pt. Safety
NCQA
Nat’l Quality Forum
JCNat’l Pt. Safety
Foundation
NPSF
QUALITY CHOIR
Attribution: Jerod Loeb, Joint Commission
5M Campaign
HCUPPSO’s Sentinel Event
Reporting
Data collection
Safety Goals
Hospital Core
Nursing Sensitive
Serious Reportable Events
Cancer CareThoracic
Surgery
Safe PracticesRewards Program Safe Practices
ACE
9th Scope of Work
SCIP HCAHPS
Collaboratives
100K Campaign
Hospital Compare
“In God we trust; all others must bring data"
-- W. Edwards Deming
Quote at the bottom of an email signature of a Director Quality/Patient Safety & Dietary Services at a CAH in Ohio
Patient Safety Performance Measurement
Data EvolutionData Evolution
Data Collection
Data Reporting
Data Analysis
Inform Strategy
Typical Effort
Desired Effort
• Healthcare Providers make significant investments in collecting data for regulatory or accreditation purposes
• The goal is to push the Effort Curve to the right through increased staff competency, use of tools and automation of data collection1fr Hill, Terry, Rural Hospital Performance Improvement and Balanced Scorecard
Quality Data Check
Electronic incident management software
program.
Allows for electronic entry, investigation and
trending of incidents.
Uploads data to web based application
(webQDC) to provide aggregate reporting. Copyright 2010 Health Data Solutions, Inc.
Copyright 2010 Health Data Solutions, Inc.
The application and data reside on your own hospital network
Copyright 2010 Health Data Solutions, Inc.
Data input screens are simple to use and navigate
Copyright 2010 Health Data Solutions, Inc.
A paper reporting form is
also available
Copyright 2010 Health Data Solutions, Inc.
The investigation form is built into
the system.
The investigation can be assigned to a ‘reviewer’ electronically which adds to
efficiency
Assign SOC’s to all individuals
involved in incident
Copyright 2010 Health Data Solutions, Inc.
Final Review CommitteeForm
Record any comments or
recommendations made by the
review committee
Report Capabilities
Copyright 2010 Health Data Solutions, Inc.
Copyright 2010 Health Data Solutions, Inc.
Personnel Report
Report sorted by
department and
personnel
Identify Trends
Use the information for
evaluations
Identify individual
education and training
needs
Copyright 2010 Health Data Solutions, Inc.
Copyright 2010 Health Data Solutions, Inc.
Copyright 2010 Health Data Solutions, Inc.
CAH-Aggregate Data Report
Copyright 2010 Health Data Solutions, Inc.
Trending information can be uploaded to our website and
reports generated for a
region.
Uploading is voluntary and
no incident specific or PHI
is collected.
Regional data can be analyzed to support regional quality improvement projects. Trending reports can then determine
effectiveness of project.
Copyright 2010 Health Data Solutions, Inc.
Procedure/Test
Occurrences by Severity
CAH- Aggregate
For more information or to request a demonstration:
Jason Friesen, PresidentHealth Data Solutions
www.healthdatasolutions.org