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Leveraging serious reportable events to drive regulatory quality improvement initiatives at the

Leveraging serious reportable events to drive regulatory quality improvement initiatives at the Massachusetts Department of Public Health. Julian D’Achille , MD, MPH; Katherine Fillo , RN-BC, MPH; Kara Murray, MPH; Iyah Romm ; & Madeleine Biondolillo , MD. Background.

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Leveraging serious reportable events to drive regulatory quality improvement initiatives at the

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  1. Leveraging serious reportable events • to drive regulatory quality • improvement initiatives at the • Massachusetts Department of Public Health Julian D’Achille, MD, MPH; Katherine Fillo, RN-BC, MPH; Kara Murray, MPH; IyahRomm; & Madeleine Biondolillo, MD

  2. Background • The Hospital Complaint Unit of the Bureau of Health Care Safety and Quality (HCSQ) receives incidents reported by acute care hospitals and other state agencies as well as consumer complaints about hospitals in the Commonwealth, including Serious Reportable Events • The Hospital Complaint Unit is responsible for deciding the ultimate investigation of a hospital-based complaint/incident.

  3. Serious Reportable Events • Chapter 305 of the Acts of 2008, Section 9 authorizes DPH to collect adverse medical event data and publicly disseminate the information. • HCQS utilizes theNational Quality Forum (NQF) definitions of Serious Reportable Events (SRE). • Hospitals are required to report SREs within 7 days of the incident, and an updated report within 30 days including documentation of the incident review process and determination of preventability. • In June 2009, DPH implemented regulations prohibiting health care facilities from charging for services provided as a result of preventable SREs.

  4. Project Description Goals: • Appreciate the hospital complaint/incident process and work flow. • Identify, if applicable, patterns in decision making on incident/complaint outcomes. • Develop internal guideline/decision tree to provide consistent parameters for future decision making. • Develop performance measurement metrics and targets to track internal quality improvement.

  5. Methods • Review of current algorithms and processes. • Retrospective review of hospital incidents and complaints for period of 18 months. • Jan 2011 – June 2012 • Statistical analysis of incident/complaint outcomes. • Sensitivity and specificity analysis of serious reportable events.

  6. Results • 1490 incidents and complaints were reviewed from the time period between January 2011 through June 2012. • Total incidents for CY 2011 = 1118 • Total incidents for January – June 2012 = 372

  7. Summary Statistics • 230 on-site investigations generated (30.9%) • 177 (15.8%) incidents were investigated on-site in 2011 • 53 (14.2%) incidents were investigated on-site in 2012 • 71 onsite investigations conducted on SREs reported from January 2011-June 2012. • Only 4.3% of falls investigated as compared to 66.7% of wrong surgical procedures. • 25 (35.2%) of the SREs investigated on-site were found to have deficiencies. • 44.3% of the onsite investigations originated as consumer complaints.

  8. Proposals for Decision Tree/Guidance • Failure of Quality Improvement Activities • E.g. Quality of RCA and Corrective Measures • Duplicability – Potential for repeat harm even with RCA and corrective measures • Harm Potential/Degree of Harm • Incident Not Identified in Adequate/Timely Manner • Systems/Organizational Issues • Reporting Failures • Necessity – Events only made clear by investigation

  9. Future Directions • Complete development and implementation of decision tree. • Alignment with HCFRS online reporting system. • Ongoing analysis of incident reports to be able to follow trends. • Address process for reviewing Plans of Correction for hospitals that have deficiencies.

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