DoD Patient Safety Initiatives

1. 0 DoD Patient Safety Initiatives CAPT Frances Stewart, MC, USN OASD(HA)/Clinical & Program Policy Col Virginia Connelly, USAF, NC TMA/O&I/Clinical Operations

2. 1 Overview Background Requirements DoD Patient Safety Program Challenges Next Steps Background Requirements National Defense Authorization Act FY2001 New JCAHO Safety Standards DoD Patient Safety Program Challenges Next Steps Background Requirements National Defense Authorization Act FY2001 New JCAHO Safety Standards DoD Patient Safety Program Challenges Next Steps

3. 2 Background Patient Safety in DoD before the IOM report Facility and Service efforts National Patient Safety Partnership Quality Interagency Coordination Task Force (QuIC) National Quality Forum Nov 1999 IOM report �To Err is Human� Executive Order Dec 7, 1999 QuIC report Feb 2000

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5. 4 NDAA 01 Centralized error tracking process Report, compile, analyze errors Emulate VA system Information sharing between DoD and VA System designs and protocols for reducing errors Error Tracking Process SecDef shall implement a centralized process for reporting, compilation, and analysis of errors in the Provision of health care under the defense health program that endanger patients beyond the normal risks associated with the care and treatment of such patients. To the extent practicable, that process shall emulate the system established by the Secretary of Veterans Affairs for reporting, compilation, and analysis of errors in the Provision of health care under the Department of Veterans Affairs health care system that endanger patients beyond such risks. Sharing of Information The Secretary of Defense and the Secretary of Veterans Affairs-- (1) shall share information regarding the designs of systems or protocols established to reduce errors in the Provision of health care described in subsection (a); and (2) shall develop such protocols as the Secretaries consider necessary for the establishment and administration of effective processes for the reporting, compilation, and analysis of such errorsError Tracking Process SecDef shall implement a centralized process for reporting, compilation, and analysis of errors in the Provision of health care under the defense health program that endanger patients beyond the normal risks associated with the care and treatment of such patients. To the extent practicable, that process shall emulate the system established by the Secretary of Veterans Affairs for reporting, compilation, and analysis of errors in the Provision of health care under the Department of Veterans Affairs health care system that endanger patients beyond such risks. Sharing of Information The Secretary of Defense and the Secretary of Veterans Affairs-- (1) shall share information regarding the designs of systems or protocols established to reduce errors in the Provision of health care described in subsection (a); and (2) shall develop such protocols as the Secretaries consider necessary for the establishment and administration of effective processes for the reporting, compilation, and analysis of such errors

6. 5 NDAA 01 Patient care reporting and management system Purposes Study occurrence of errors in patient care provided under Chapter 55 of Title 10, U.S.C. Identify systemic factors associated with errors Correct systemic factors Requirements Hospital-level patient safety center within QA Dept of each DoD health care organization Collect, assess, report nature/frequency of errors Patient safety standards throughout DHP Purposes of System (1) To study the occurrences of errors in the patient care provided under chapter 55 of title 10, United States Code. Chapter 55 is entitled Medical and Dental Care, and applies to both the direct care and purchased care side (2) To identify the systemic factors that are associated with such occurrences. (3) To provide for action to be taken to correct the identified systemic factors. Requirements for System (1) hospital-level patient safety center, in QA Dept of each DoD health care organization, to collect, assess, and report on nature and frequency of errors related to patient care. (2) For each health care organization of the Department of Defense and for the entire Defense health program, patient safety standards that are necessary for the development of a full understanding of patient safety issues in each such organization and the entire program, including the nature and types of errors and the systemic causes of the errors. Purposes of System (1) To study the occurrences of errors in the patient care provided under chapter 55 of title 10, United States Code. Chapter 55 is entitled Medical and Dental Care, and applies to both the direct care and purchased care side (2) To identify the systemic factors that are associated with such occurrences. (3) To provide for action to be taken to correct the identified systemic factors. Requirements for System (1) hospital-level patient safety center, in QA Dept of each DoD health care organization, to collect, assess, and report on nature and frequency of errors related to patient care. (2) For each health care organization of the Department of Defense and for the entire Defense health program, patient safety standards that are necessary for the development of a full understanding of patient safety issues in each such organization and the entire program, including the nature and types of errors and the systemic causes of the errors.

7. 6 NDAA 01 DoD Patient Safety Center within AFIP Analyze information Develop action plans for patterns of errors Execute action plans to control errors Report to Agency for Healthcare Research & Quality (AHRQ) as appropriate Integrate processes to reduce errors, enhance safety Contract with external organization to manage DoD National Patient Safety Database (3) Establishment of a Department of Defense Patient Safety Center within the Armed Forces Institute of Pathology, which shall have the following missions: (A) To analyze information on patient care errors that is submitted to the Center by each military health care organization. (B) To develop action plans for addressing patterns of patient care errors. (C) To execute those action plans to mitigate and control errors in patient care with a goal of ensuring that the health care organizations of the Department of Defense provide highly reliable patient care with virtually no error. (D) To provide, through the Assistant Secretary of Defense for Health Affairs, to the Agency for Healthcare Research and Quality of the Department of Health and Human Services any reports that the Assistant Secretary determines appropriate. (E) To review and integrate processes for reducing errors associated with patient care and for enhancing patient safety. (F) To contract with a qualified and objective external organization to manage the national patient safety database of the Department of Defense. (3) Establishment of a Department of Defense Patient Safety Center within the Armed Forces Institute of Pathology, which shall have the following missions: (A) To analyze information on patient care errors that is submitted to the Center by each military health care organization. (B) To develop action plans for addressing patterns of patient care errors. (C) To execute those action plans to mitigate and control errors in patient care with a goal of ensuring that the health care organizations of the Department of Defense provide highly reliable patient care with virtually no error. (D) To provide, through the Assistant Secretary of Defense for Health Affairs, to the Agency for Healthcare Research and Quality of the Department of Health and Human Services any reports that the Assistant Secretary determines appropriate. (E) To review and integrate processes for reducing errors associated with patient care and for enhancing patient safety. (F) To contract with a qualified and objective external organization to manage the national patient safety database of the Department of Defense.

8. 7 NDAA 01 Healthcare Team Coordination Program Expand to all DoD health care operations Establish two Centers of Excellence One to support fixed facilities; one to support combat care Deploy to all fixed and combat casualty care organizations (10 per year) Expand from focus on ED to all major medical specialties (one per year) (d) MedTeams Program.--The Secretary shall expand the health care team coordination program to integrate that program into all Department of Defense health care operations. In carrying out this subsection, the Secretary shall take the following actions: (1) Establish not less than two Centers of Excellence for the development, validation, proliferation, and sustainment of the health care team coordination program, one of which shall support all fixed military health care organizations, the other of which shall support all combat casualty care organizations. (2) Deploy the program to all fixed and combat casualty care organizations of each of the Armed Forces, at the rate of not less than 10 organizations in each fiscal year. (3) Expand the scope of the health care team coordination program from a focus on emergency department care to a coverage that includes care in all major medical specialties, at the rate of not less than one specialty in each fiscal year. (4) Continue research and development investments to improve communication, coordination, and team work in the Provision of health care. (d) MedTeams Program.--The Secretary shall expand the health care team coordination program to integrate that program into all Department of Defense health care operations. In carrying out this subsection, the Secretary shall take the following actions: (1) Establish not less than two Centers of Excellence for the development, validation, proliferation, and sustainment of the health care team coordination program, one of which shall support all fixed military health care organizations, the other of which shall support all combat casualty care organizations. (2) Deploy the program to all fixed and combat casualty care organizations of each of the Armed Forces, at the rate of not less than 10 organizations in each fiscal year. (3) Expand the scope of the health care team coordination program from a focus on emergency department care to a coverage that includes care in all major medical specialties, at the rate of not less than one specialty in each fiscal year. (4) Continue research and development investments to improve communication, coordination, and team work in the Provision of health care.

9. 8 JCAHO Patient Safety and Error Reduction Standards: Jan 2001 Reduction of errors/other factors that contribute to adverse outcomes requires an environment that encourages: Recognition and acknowledgement of risks Initiation of actions to reduce risks Internal reporting of what was found and actions taken Focus on processes and systems Minimization of individual blame/retribution Organizational learning about errors �The leaders of the organization are responsible for fostering such an environment.� �Patient Safety and Medical/Health Health Care Errors Reduction Standards� January 2001 Standards: Leadership Chapter -- LEADERS ENSURE: L.D. 5 Implementation of an integrated patient safety program throughout the organization Designation of one or more individuals or an interdisciplinary group to manage the program Procedures for immediate response to errors Clear systems for internal and external reporting Annual report to governing body on occurrence of errors and actions taken to improve patient safety, both in response to actual occurrences and proactively. L.D. 5.1 Processes for identifying and managing sentinel events are defined and implemented. LD.5.2 Ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors is defined and implemented. LD.5.3 That patient safety issues are given a high priority and addressed when processes, functions, or services are designed or redesigned. Other standards related to Patient Safety and Medical/Health Care Error Reduction occur in the Leadership Chapter and in other chapters: Management of Information Chapter; Education Chapter; Continuum of Care Chapter; Management of Human Resources Chapter Web site provided later in presentation�Patient Safety and Medical/Health Health Care Errors Reduction Standards� January 2001 Standards: Leadership Chapter -- LEADERS ENSURE: L.D. 5 Implementation of an integrated patient safety program throughout the organization Designation of one or more individuals or an interdisciplinary group to manage the program Procedures for immediate response to errors Clear systems for internal and external reporting Annual report to governing body on occurrence of errors and actions taken to improve patient safety, both in response to actual occurrences and proactively. L.D. 5.1 Processes for identifying and managing sentinel events are defined and implemented. LD.5.2 Ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors is defined and implemented. LD.5.3 That patient safety issues are given a high priority and addressed when processes, functions, or services are designed or redesigned. Other standards related to Patient Safety and Medical/Health Care Error Reduction occur in the Leadership Chapter and in other chapters: Management of Information Chapter; Education Chapter; Continuum of Care Chapter; Management of Human Resources Chapter Web site provided later in presentation

10. 9 JCAHO Safety Standards Leadership Integrated Patient Safety Program Designation of one or more qualified individuals or an interdisciplinary group to manage the program Procedures for immediate response to errors Clear systems for internal and external reporting Annual report to governing body �Patient Safety and Medical/Health Health Care Errors Reduction Standards� January 2001 Annual report to governing body on occurrence of errors and actions taken to improve patient safety, both in response to actual occurrences and proactively �Patient Safety and Medical/Health Health Care Errors Reduction Standards� January 2001 Annual report to governing body on occurrence of errors and actions taken to improve patient safety, both in response to actual occurrences and proactively

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12. 11 Purpose Establish a uniform system to prevent or minimize the occurrence of untoward outcomes consequent to medical care and ultimately improve patient safety and health care quality

13. 12 Goals Provide a safe environment for patients, visitors and staff Prevent injury; manage injury that does occur so as to minimize negative consequences Enhance performance through comprehensive monitoring standardized reporting thorough analysis of untoward events Establish a �culture of safety� throughout MHS

14. 13 Key Building Blocks Integrated system throughout organization Identify and report all adverse events, Sentinel Events, and close calls Identify root causes and system factors Focus on system and processes vs. individual blame and punishment Disseminate safety alerts and lessons learned Prospective analysis of systems and environment to reduce occurrence of errors The key building blocks for accomplishing these goals are: 1. Comprehensive identification and reporting of all adverse events, Sentinel Events, and close calls 2. Review and analysis of adverse events, Sentinel Events, and close calls in order to identify underlying causes and system changes that can reduce the potential for recurrence 3. Determination of cause aimed at system and process issues rather than individual blame and punishment. 4. Effective dissemination of patient safety alerts and lessons learned throughout the organization. 5. Prospective analysis of service delivery systems before an adverse event occurs to identify system redesigns that will reduce the likelihood of error. The key building blocks for accomplishing these goals are: 1. Comprehensive identification and reporting of all adverse events, Sentinel Events, and close calls 2. Review and analysis of adverse events, Sentinel Events, and close calls in order to identify underlying causes and system changes that can reduce the potential for recurrence 3. Determination of cause aimed at system and process issues rather than individual blame and punishment. 4. Effective dissemination of patient safety alerts and lessons learned throughout the organization. 5. Prospective analysis of service delivery systems before an adverse event occurs to identify system redesigns that will reduce the likelihood of error.

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16. 15 Building a Foundation Patient Safety Working Group HA, TMA, Services, VA, AFIP Collaboration with VHA, AHRQ and other Federal Agencies Six-month Pilot Program WRAMC, NNMC Bethesda, Fort Belvoir, Fort Meade, Nellis AF Launched Oct 2000 PILOT Bi-weekly teleconferences and feedback from sites Use lessons learned to enhance training PILOT Bi-weekly teleconferences and feedback from sites Use lessons learned to enhance training

17. 16 DoD Patient Safety Center (AFIP) Form partnership between AFIP & USUHS Piggyback on VHA use of NASA database MHS Patient Safety Registry Request management analysis of AFIP by Army Plan: Partnership between AFIP and USUHS: AFIP has minimal resources related to research, education, public healthPlan: Partnership between AFIP and USUHS: AFIP has minimal resources related to research, education, public health

18. 17 MedMARx Computerized medication error reporting system from the US Pharmacopeia In use on a pilot basis in many MTFs, including the five Patient Safety Program pilot sites Allows anonymous comparisons with other facilities across the country and analysis of pooled data

19. 18 Educational Tools for Beneficiaries Five Steps for Safer Health Care Developed by the QuIC and the Health Benefits Education Campaign Evidence based Goal is to make patients and their families more informed and active participants in their care Useful for public education and �just in time� reminders Five Steps to Safer Health Care 1. Speak up if you have questions or concerns. Choose a doctor who you feel comfortable talking to. Take a relative or friend if this will help you ask questions and understand answers. It's okay to ask questions and expect answers you can understand. 2. Keep a list of all the medicines you take. Tell your doctor and pharmacist about the medicines that you take, including over-the-counter and about drug allergies. Ask pharmacist about side effects and things to avoid while taking medicine. Read label, including warnings. Make sure it is what your doctor ordered, and you know how to use it. If the medicine looks different than you expected, ask pharmacist. 3. Make sure you get the results of any test or procedure. Ask your doctor or nurse when and how you will get the results. If you do not get them when expected -- Call your doctor and ask for them. Ask what the results mean for your care. 4.Talk with your doctor and health care team about your options if you need hospital care. If you have more than one hospital to choose from, ask your doctor which one has best care and results for condition. Research shows results often are better at hospitals doing a lot of these procedures. Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you understand the instructions. 5. .Make sure you understand what will happen if you need surgery. Ask your doctor and surgeon: Who will take charge of my care while in hospital? Exactly what will you be doing? How long will it take? What will happen after the surgery? How can I expect to feel during recovery? Tell if you have allergies or have ever had a bad reaction to anesthesia. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.Five Steps to Safer Health Care 1. Speak up if you have questions or concerns. Choose a doctor who you feel comfortable talking to. Take a relative or friend if this will help you ask questions and understand answers. It's okay to ask questions and expect answers you can understand. 2. Keep a list of all the medicines you take. Tell your doctor and pharmacist about the medicines that you take, including over-the-counter and about drug allergies. Ask pharmacist about side effects and things to avoid while taking medicine. Read label, including warnings. Make sure it is what your doctor ordered, and you know how to use it. If the medicine looks different than you expected, ask pharmacist. 3. Make sure you get the results of any test or procedure. Ask your doctor or nurse when and how you will get the results. If you do not get them when expected -- Call your doctor and ask for them. Ask what the results mean for your care. 4.Talk with your doctor and health care team about your options if you need hospital care. If you have more than one hospital to choose from, ask your doctor which one has best care and results for condition. Research shows results often are better at hospitals doing a lot of these procedures. Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you understand the instructions. 5. .Make sure you understand what will happen if you need surgery. Ask your doctor and surgeon: Who will take charge of my care while in hospital? Exactly what will you be doing? How long will it take? What will happen after the surgery? How can I expect to feel during recovery? Tell if you have allergies or have ever had a bad reaction to anesthesia. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.

20. 19 Reducing Errors in High Hazard Environments Collaborative effort of the QuIC and the Institute for Healthcare Improvement (IHI) 47 teams from VA, DoD, AHRQ, and HCFA 19 teams from Army, Navy, Air Force and OSD Four Clinical Areas ICU, ER, OR and L&D Rapid cycle quality improvement Spread of innovation

21. 20 Collaborative Teams ICU - NMC San Diego, Travis AFB, Tripler AMC, WRAMC, WHMC ED - NH Camp Lejeune, NMC Portsmouth OR - NNMC Bethesda, NH Bremerton, NH Jacksonville L&D - Landstuhl, NH Camp Pendleton, NH Pensacola, Andrews AFB, Womack AMC Administrative - DoD (HA, TMA, Dept of Navy, US Army MEDCOM); HCFA; AHRQ

22. 21 Value Based Purchasing Using the power of public and private purchasers to improve the quality of care Many mechanisms available Public education, technical assistance, awards, incentives, contract modifications, etc. Need to target specific changes HHS Value Based Purchasing Group Leapfrog Group

23. 22 Leapfrog Group Organized by large corporate purchasers such as General Motors, General Electric, 3M and the Pacific Business Group on Health HCFA and OPM are liaison members Goal is a breakthrough improvement in safety Three �leaps� as a starting point Computerized physician order entry Evidence based referrals ICU staffing

24. 23 Healthcare Team Coordination Program MedTeams Developed by Dynamics Research Corporation with funding from Army Research Labs Currently only the emergency medicine training has been tested Labor and delivery program being planned Medical Team Management Developed by Eglin Air Force Base hospital staff Facility wide

25. 24 �To Do� List Disseminate Patient Safety DODI Finalize Regional Implementation Plan Develop standardized educational tools for beneficiaries and staff Complete and evaluate Pilot Program Evaluate Leapfrog proposals

26. 25 Challenges Resources Coordination Combat care settings Purchased care system Converting data to information Surveillance and Prevention and the ultimate challenge�.. Resources Coordination between system components Expanding to combat care settings Exporting to purchased care system Research and Data Prevention/Surveillance Resources Coordination between system components Expanding to combat care settings Exporting to purchased care system Research and Data Prevention/Surveillance

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28. 27 Next Steps Charter Patient Safety Council Launch DoD Patient Safety Website Refine training program based on Pilot Integrate new JCAHO Patient Safety Standards into MHS and Service policies http://www.jcaho.org/standard/fr_ptsafety.html

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30. 29 So What Is Different? Integrated program throughout MTF and MHS Not just one person�s job Include combat care and purchased care settings Centralized reporting, analysis, dissemination Compare and benchmark Identify unrecognized patterns, problems Centralized guidance Identify solutions so you don�t have to Centralized training

31. 30 So What Is Different? New Tools to Help Reduce Errors Healthcare Team Coordination Patient Safety Web site DoD Patient Safety Handbook Spread lessons and information throughout MHS Learn from �isolated incidents� and each other Focus on prevention vs. just counting events Assess environment for what could go wrong Collaboration with other Federal Agencies

32. 31 Implications for MTFs Designated Patient Safety Officer at each MTF Begin cultural shift -- attitude change precedes behavioral change Leadership must create the right environment to decrease resistance, fear, blame, and punishment Significance must permeate organization Start now! Review old reports for issues that still need attention Start routine environmental assessments now Learn from Collaborative Teams

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34. 33 HA: CAPT Frances Stewart 703-681-1703; Frances.Stewart@tma.osd.mil TMA: Col Virginia Connelly 703-681-0064; Virginia.Connelly@tma.osd.mil Army: COL Judy Powers 210-221-6622; Judith.powers@amedd.army.mil Navy: Carmen Birk 202-762-3081; Ccbirk@us.med.navy.mil Air Force: Major Meghan Pilger 202-767-4359; Meghan.pilger@usafsg.bolling.af.mil

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