AHRQ National Advisory Council Meeting July 13, 2012

1. AHRQ National Advisory Council MeetingJuly 13, 2012 Patient Safety in Ambulatory Health Care Jeffrey Brady, MD, MPH Center for Quality Improvement & Patient Safety (CQuIPS)

2. Agenda • Context for Patient Safety in Ambulatory Health Care Settings • Ongoing Projects, Current Research Activity, and Available Tools & Resources (Selected AHRQ Examples) • Future Directions • Discussion

3. Ambulatory Health Care Settings • Medical services provided in an outpatient environment (i.e., non-hospitalized). • Services may include diagnosis, treatment, surgery, and rehabilitation. • Applicable environments include: • medical offices (large and small) • outpatient clinics (hospital and free-standing) • community health centers • emergency departments & urgent care centers • out-patient surgery centers • renal dialysis centers • home health care

4. Uneven Progress in Patient Safety Across Health Care Settings • Patient safety research projects have more commonly addressed the hospital setting. • 2000: AHRQ conference: An Agenda for Research in Ambulatory Patient Safety • Recent analyses of patient safety research activity in ambulatory settings: • 2011: AMA – Research in Ambulatory Patient Safety 2000-2010: A 10-year Review • (ongoing - 2012): ASPE-funded environmental scan of patient safety and ambulatory care

5. AHRQ-funded Efforts: Patient Safety in Ambulatory Care (Examples) • 2005 to present: Funding Opportunity: Improving Patient Safety Through Simulation Research • 2007: Special Emphasis Notice: Interest in Research on Diagnostic Errors in Ambulatory Care Settings • 2007: Ambulatory Safety and Quality Program (HIT Portfolio) • 2008: Funding Opportunity: Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care • 2008: Medical Office Survey on Patient Safety Culture

6. Patient Safety Challenges in Ambulatory Care • Most ambulatory settings lack the human and financial resources to support robust safety and quality improvement operations. • Ambulatory care is less technologically complex, but often more logistically complex than inpatient care, which can create more challenging information exchange problems. • The dispersed nature of outpatient care can result in longer times to identify and document errors. • Greater reliance on patients and their roles both as a primary source for information and also understanding of and agreement with care protocols establish opportunities for patient safety events to occur.

7. Patient Safety Portfolio Goal To improve the quality of care delivered to patients by decreasing or eliminating health care risks and harms. • Continued investment in research • Increased emphasis on implementation All health care settings are within scope.

8. AHRQ PSNet • 7,699 resources are in the AHRQ PSNet collection. • Classifications by Setting of Care: • Hospitals (4,110) • Residential Facilities (123) • Psychiatric Facilities (33) • Ambulatory Care (650) • Outpatient Surgery (66) • Patient Transport (52)

9. AHRQ Web M&M • 260 cases & commentaries are in the Web M&M collection. • Classifications by Setting of Care: • Hospitals (221) • Psychiatric Facilities (6) • Residential Facilities (8) • Ambulatory Care (46) • Outpatient Surgery (5) • Patient Transport (3)

10. AHRQ Patient Safety Culture Surveys Survey Dimensions • Teamwork • Staffing • Training • Handoffs • Communication • Organizational learning • Management support for patient safety • Non-punitive response to mistakes • Overall perceptions of patient safety • Settings • Hospitals (2004) • Nursing homes (2008) • Medical offices (2009) • Retail pharmacies (Expected Summer 2012)

11. Medical Office Survey On Patient Safety Culture • Pilot tested in 200 offices • Free survey materials and technical assistance for survey administration • Designed for providers and staff in medical offices • Includes about 50 items in 12 areas (e.g., Teamwork, Staff Training) • Tracks changes in patient safety and evaluate interventions over time

12. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals Background: ED crowding – - compromises care quality - creates more opportunities for error - contributes to poor quality care, per recent evidence AHRQ/RWJ Partnered through ACTION to create new Guide for Hospitals – offers: • Step-by-step instructions for  planning and implementing patient flow improvement strategies to ease ED crowding   • Concrete strategies for anticipating and addressing implementation challenges drawn from actual experiences of Urgent Matters hospitals

13. HIV Research Network (HIVRN) and Medication Safety The HIVRN is comprised of 19 HIV providers that treated 27,737 patients (adult and pediatric) in 2010. • The HIVRN has identified specific methods and approaches by which sites have reduced medication errors. • For example, after receipt of the 2005 data the HIVRN alerted sites as to those patients who were on the non-preferred combination of truvada and unboostedatazanavir. Site PIs notified providers caring for these patients. • These interventions resulted in a sizable reduction in the proportion of patients on the non-preferred regimen. (34 percent reduction between 2005 and 2007).

14. MEADERS • Medication Error and Adverse Drug Event Reporting System (MEADERS) • Stand alone electronic system for improving medication error and adverse drug event reporting in primary care • Utilizes standardized taxonomy for reporting errors • Project initiated in 2006; first results of prototype published in 2010 • Software expanded and enhanced; second pilot testing competed spring 2012 • Next steps: Aligning taxonomy with common formats; exploration for use of the system within a Patient Safety Organization to overcome liability concerns around reporting

15. Common Formats (CF) for Patient Safety Event Reporting • Authorized by Patient Safety Act in 2005 • Developed with Federal work group comprising major health agencies (e.g., CDC, CMS, FDA, DOD, VA) • An important contribution to standardize patient safety measurement • Gaining acceptance (gov’t and private sector) • Ambulatory CF (Beta version) • Structure and significant amount of current content from the hospital CF will apply. • Some new conceptual work will be required.

16. AHRQ Simulation Grants • For research in 2007/2008 AHRQ sponsored 19 simulation grants for more than $10 million • 2-year cooperative agreements • Focused on practitioners and teams in a variety of clinical settings using a diverse range of simulation techniques • Intent was to inform researchers, providers, health educators, patients, policy makers, payers, and the public • Active Program Announcement and ongoing funding opportunities

17. High volume ambulatory surgical procedures Diagnosis of melanoma Obstetric emergency response drills in rural hospitals Improving teamwork & culture of safety in the ED Patient-tracking systems in the emergency department Acute coronary syndrome management in rural setting Rapid response emergency team training Standardized patients to improve patient education skills in the outpatient setting Training rapid response teams Emergent cesarean deliveries Three-dimensional virtual reality team training Patient care hand-offs Post-anesthesia care unit communication Pediatric emergency care (2) Assessing paramedic skill in endotracheal intubation Design and development of information systems for the ED (2) Improving physician–nurse communication with serious gaming AHRQ’s Grants - A Diverse Range of Simulated Clinical Applications

18. Questions are the Answer • Initiative stresses the importance of clinician-patient communication in ambulatory settings • Emphasizes the need for patients to prioritize questions • Products include: • Web site • Brochure • Waiting room video • Notepads • Outreach to clinician groups and professional journals

19. Blood Thinner Pills: Your Guide to Using Them Safely • Consumer publication and DVD explain what to expect and watch out for while taking blood thinner pills • Based on research originally conducted by one of AHRQ’s Partnership for Implementing Patient Safety grant projects • Educates patients about: • Medication therapy and potential side effects • How to communicate effectively with their health care providers • Tips for lifestyle modifications www.ahrq.gov/consumer/btpills.htm

20. Staying Active and Healthy with Blood Thinners DVD • Uses animations to simplify medical concepts • Offers practical lifestyle tips • Reinforces safe use via memorable mnemonic—BEST

21. Conclusions • Despite some patient safety improvements, progress in ambulatory care settings lags behind the pace of patient safety efforts in hospitals. • Remaining opportunities for improvements in patient safety ambulatory care are immense. • AHRQ is committed to making significant future investments in this enormously important area.

22. Discussion Points for the NAC Regarding research and implementation aimed at advancing patient safety in ambulatory care settings, please give us your: • General observations • Thoughts about high-priority topic areas • Ideas for strategic opportunities for AHRQ • Suggestions for AHRQ collaborations • Other recommendations