Enhancing Patient Safety in California Hospitals: CHPSO Initiative

1. Dedicated to eliminating preventable harm and improving the quality of health care delivery in California hospitals CHPSO Rory Jaffe, MD MBA Executive Director California Hospital Patient Safety Organization

2. About CHPSO • Created by California Hospital Association • Not-for-profit • Small (1.5 employees), planning to grow

3. To Err is Human • PSOs are a direct response to report’s recommendations • Collect standardized information nationwide • Develop voluntary reporting • Extend peer review protections to data related to safety and quality improvement • Develop a culture of safety

4. Begin with the End in Mind • What should our system look like? • Safety data is a “first class citizen” and ubiquitous • Systems involved in the normal course of care produce most of the data (e.g., the EHR) • For each patient, we know whether they are getting the right care • Compatible with HIE (health information exchange) • Information and knowledge is freely exchanged • How do we start? • Embrace standards whenever possible • Avoid manual entry and rework whenever possible • Encourage networking and sharing

5. Reality Check • No standard incident report system • Vendor-specific systems • Terminology varies, even within same vendor (for some vendors) • Work flow varies • Scope varies • Initial report, analysis, mitigation, outcome • Types of events included • Handling of legal issues • Change is expensive • Integration of new system into infrastructure • Personnel time for retraining

6. Baby Steps • If providers don’t participate, we cannot move towards our goal • Provide the lowest possible hurdle for participation • No completeness standards • Data collection and analysis is only one of our tools and may not be the most important • We’re not in the business of “counting stuff” • Encourage providers to migrate to standards-compliant systems

7. Current Status

8. Activities • 160 member hospitals in CA, NV, AZ • Strong web presence ~4,000 page views/month • Widely distributed newsletter and alerts 1,700 recipients • Group calls with specific case discussions • In-person discussions — shared challenges • Harvesting local expertise

9. Alliances • Specialized organizations/PSOs • Brings specific expertise • Generalized PSOs • Greater reach for rare issues • Faster knowledge spread • Regulators • Shared goals but different toolkits • Other provider types • Shared problems

10. Data Collection • Starting up • Waited for electronic standards from AHRQ • Standards were for PSO — NPSD communication, not provider — PSO communication • Develop standards provider — PSO • Adapting provider systems to send in formatted data • Some providers are changing event reporting collection methods

11. Challenges • Legal uncertainty — interaction with other laws • Trust — preservation of confidentiality in the face of increased communication • Chaotic improvement environment • Patient safety fatigue • Measure reporting fatigue • Cost • Unproven value • Clients have widely varying needs and sophistication

12. CHPSODedicated to eliminating preventableharm and improving the quality ofhealth care delivery in CaliforniahospitalsContact Information Rory Jaffe rjaffe@calhospital.org http://www.chpso.org/