Working to reduce medical errors and improve safety for people receiving health care in Washington.

Work Group Summaries

Washington Patient Safety Conference
June 2002

Group 1

Concentrated on structural issues to support the two selected clinical topics—prevention of surgical site infection, and prevention of venous thromboembolism—what do we need to go forward? There is lack of coordination of topics at the state level—how do we take this work (of the Coalition) into the future, coordinate efforts, keep topics from fading from interest?

  • Continue the core planning group, form Steering Committee and add other members (business community, consumer, etc.)
  • Have a conference at least annually
  • Steering Committee should take the recommendations and flesh them out within Washington, e.g., address geographic issues

Topic 1: Surgical Site Infection

  • Link with the work of the national surgical infection collaborative work—perhaps Steering Committee can endorse
  • Identify a return on investment (ROI) for preventing surgical infection
  • Collaborative work will be the basis for ongoing measurement around this recommendation

Topic 2: Thromboembolism

  • Interest group to meet in the summer, focus on continuum of care from inpatient to outpatient care; get Medicare Part A and B talking about it.
  • Identify ROI for the recommendation.

Group 2

1. Consumer Education

  • Reference JCAHO Speak Up and National Patient Safety Foundation (NPSF) documents for basic information to share.
  • Share the above groups (JCAHO & NPSF) information with table members and get consensus then send the participants at the meeting for group input and consensus.
  • Utilizing the numerous educational avenues listed on our flip chart information begin to spread the use of the new tool for Patient Safety In Washington State
  • Engage physicians by educating at State-Wide meetings, as well as taking this to the medical schools to incorporate into their education process
  • Engage nursing and other professionals through their educational offerings
  • Continually reinforce the message like “Speak Up” on an ongoing basis utilizing the various tools for education – flyers/brochures in offices, DMV, Post Office, etc. Utilize TV, radio, and newspapers for Public Service Announcements (PSA’s), posters in hospitals and physician offices
  • Teach physicians and staff to encourage the dialogue with patients and families – can utilize scripting as appropriate (i.e. can I answer any other questions for you?, here is a notepad to write down any questions you may have and when the doctor comes to see you I will help you get those questions answered).

Goals/timeframes:

1 – 3 months: get table 2 group consensus on the information
3 – 6 months: get whole coalition consensus on the information
6 – 12 months: have available materials for hospitals, physician offices/clinics, health plans, etc. to begin usage
12 – 24 months: get more difficult places to begin campaign ie. Medical schools, PSA’s, etc.

Overall goal is to accomplish the information blitz within next two years.

2. Informed Consent

  • With a more educated and engaged patient/family population the roll out of improving informed consent would be a natural flow
  • Provide a source for evidence-based information to assist in the explanation of procedures and surgeries.
  • Create education materials keeping in mind literacy issues and cultural diversities

Goals/timeframes:
Natural flow after initial first 12 months of above project

Group 3

The Foundation for Health Care Quality was volunteered by Dorothy Teeter, FHCQ CEO, for continued organizational and staff support.

Topic 1: Prevention of surgical site infection

  • Goal: 95% of all patients get the right antibiotic
  • How to achieve?
    • Within 6 months: establish a way for all hospitals to commit to participate
      • Identify the educational tool(s) and uniform data collection tool for hospitals
      • Establish the statewide baseline
      • Help hospitals improve performance
      • Establish data repository
    • Within 18 months: remeasuare

Topic 2: Improve consumer involvement in their care and safety

  • Focus on polypharmacy
    • The State Coalition will support this effort
    • Target those over 50 years old
    • Use statewide information blitz

At 12 months: survey patients > 50 years – has anything changed? Plan followup activities

Group 4

Improve the capture of errors and events

  • Non-alignment emerged around the potential use and misuse of data
  • What are we doing to share our improvements: hospitals want to talk about the good things, and insurers and the State want to hear about the good things.
  • Improve partnerships between insurers and hospitals
  • Identify neutral third-party forum to share
  • Use an existing user group - add consumer and payer perspectives; put out a newsletter so everyone can benefit.
  • Hospitals/providers want some protection in the marketplace.
  • Others want assurance that providers/hospitals are working aggressively to make improvements
  • Payers would focus on evidence-based measures and support anonymous reporting.
  • Summary: a voluntary collaborative to share information; collaborative would include providers, consumers, payers, et al.

Group 5

Patient safety relies on information, and need to get consumers involved: focus is on information to the consumer.

Develop Patient Safety Coalition

  • Address the top three LeapFrog initiatives first, then broader issues.
  • How?
    • Identify the Coalition
    • Align knowledge and constituencies
    • Want a common goal and focused goals
      • Who needs to be there? Who are the stakeholders?
      • Convene a neutral and time-sensitive body
      • Develop a single set of measures and priorities for the Coalition
      • Need 'gain-gain'
    • Individual commitment
      • How to communicate better with hospitals
      • Share best practices & measures
      • Talk to hospital leadership, get buy-in
  • In two years:
    • The LeapFrog initiative will have 'gained traction.'
    • Physician leaders around patient safety
    • Patient-to-patient safety meetings?
    • Financial commitment
    • CEO commitment
    • Need steering committee and quarterly meetings

Group 6

1. Intensivists in Intensive Care Units

  • The wording in the recommendation is overly-specific.
  • Standard should be the "percent of hospitals who apply this to their ICU patients".
  • The Coalition needs to make itself known as an entity, then get a group to own the language around this standard, articulate it and its rationale.
  • Talk to all of the interested parties about it, e.g, LeapFrog and the professional organizations that define 'intensivists' - take a 'Walk in the Woods' by February 200

2. Patients involved in their care and documentation

  • The Coalition must be in existence and serve as champion: identify the groups that would be partners in this, e.g., consumers, AMA, WSMA, and facilitate that discussion; there is already some alignment of interests among the parties. Target date is Fall 2002.
  • The role of the Coalition is to make sure this all happens.
  • The measure will be defined by that group.

Group 7

1. Antibiotics and surgical site infections

  • Each hospital adopts the CDC standard for defining what a surgical site infection is. (Possible resistance from hospitals that use their own definition of infection.) Target: 1 year
    • Evaluate which hospitals are using it
    • Determine why, if not using
    • Help hospitals adopt its use
    • Report who has adopted
  • Eventual expansion of use of definition to other settings, e.g., outpatient surgery
  • Develop best practices using hospital stakeholders using consensus process
  • Implement best practice using various methods, e.g., statewide collaborative
  • Consider peer-reporting of adherence to best practice (2 years) or public reporting (3 years)

2. CPOE

  • So many stakeholders agree on it but big issue is funding - ultimately need to seek funding for acquisition.
  • Six month goal: increase shared understanding among the stakeholders about barriers (a Walk in the Woods approach), then seek funding together.

Responses From Panel

Troy Hutson, Washington State Hospital Association:

  • Great work; impressed with effort and the quality of the recommendations
  • Leadership: how do we get leadership to continue?
  • Need to be inclusive - get all stakeholders involved
  • Voluntary collaboration - let's build on what we know how to do, our willingness to work together, and use existing models for improvement, e.g. collaboratives, COAP
  • Need to take that Walk in the Woods together with LeapFrog
  • JCAHO, National Public Safety Foundation - how do all the efforts fit together?
  • Strategic vision: let's figure out how to use this structure to look at patient safety comprehensively, which will eliminate need to respond to multiple requests

Maxine Hayes, Department of Health:

  • Very good use of her time
  • DOH could provide leadership and use its voice in Olympia for advocacy
  • Need to legitimatize the Coalition, then can assign work. All of the sponsors should commit to ongoing support.
  • Part of the DOH's mission is to assure patient safety, but can't do it alone. All of our efforts are very interdependent.
  • Will contribute their credibility to the formation of the Coalition.
  • All sponsors want to be very supportive
  • Recognized Mary Selecky's presence today.
  • DOH is not a purchaser but does have, for example, the Diabetes Collaborative expertise

Steven Seitz, Agency for Healthcare Research & Quality, User Liaison Program:

  • AHRQ has been to five states dealing with state policymakers, and is working with LeapFrog is help some of the states get started
  • Most states did 'talking head' events, but one had a pre-determined political agenda it wanted to advance: outcome of the event was "here's what we are not going to do."
  • Other states' work compared to Washington?
    • We have the better chance of getting something to actually happen
    • We started by dealing with the internal processes of the stakeholders - where do we disagree?
    • Many of our reports ended up pretty specific - they have 'stickiness.'
    • Can consolidate all into an action plan