Healthcare Quality & Provider

Advisory Committee

AGENDA

April 15, 2010

Provider Advisory Committee

Sustinet Board of Directors

Review of minutes

Review of next meetings and potential external speakers

Review of agenda

Key topic area:  Safety

Discussion

Transparency and Accountability needed:  Bad things happen in the dark.  Sunlight is the best disinfectant.

Do all the changes with Sustinet contribute to a culture of safety and quality with the patient at the center?

The modern patient safety movement began in 1994 when Dr, Leape began to address patient safety challenges and then in 1999 IOM report To Err is Human energized advocates across the country.

Adverse events are injuries resulting from medical care as opposed to adverse outcomes arising from underlying disease

Errors are acts of commission – doing something wrong or acts of omissions – failure to do the right thing.

General Principles of patient safety

Prevention of errors – systems thinking such as the check list

Simplification and standardization

Improving communication

Transitions and handoffs – the most common in health care

Teamwork and communication strategies

Look to aviation to finds ways to dampen down hierarchies

Look to military – crew resource management – he who knows can make the decision – not who has rank

Patient empowerment and education

Language barriers and health literacy

What patients need to be responsible for

Access to data and hospital and physician information

Independent patient advocate at each hospital

Addressing billing fraud

Access to usable information for decision making

Reporting systems of errors

Anyone can report

Just culture

Reporting made easy

Narratives used to talk about incident – personalize

Feedback that is immediate and relevant

Sustained leadership

Hospital Board involvements

Culture of safety

Possible use of AHRQ’s Patient Safety Indicators so that we will KNOW if we are making a difference?

Auditing of information submitted by hospitals and physicians

Adverse Events in Hospitals

Frequency of adverse events

Just a few

100,000 deaths

IOM – one medication error per patient per hospital day

100,000 healthcare acquired infection deaths annually

93 % not reported

In CT probably 4600 adverse events and about 267 reported

Public needs access to easy to use data on hospitals

Over Use

Overtreatment – Brownlee

The Treatment Trap – Rosemary Gibson

Steve Smith – Newsweek article

Regulatory oversight – need to be independent transparent with stiff penalties.

FDA

Joint Commission

DPH’s failures

Accreditation should be mandatory

Audit audit audit

Institute for Healthcare Improvement – whatever they say!

Trigger tools

Hospital Board Involvement

Education

Dr. Leape’s – patient safety needs to be taught in medical schools

Implementation of science based medicine

Academic detailing/not pharma detailing

Continuing update of knowledge and skills;  no mechanism to insure competence

Is CME working? – no one thinks it is

Physician practices

Conflicts of interests – financial ownership or technology

Cottage industries

Errors of omission as well as errors of commission.

How do private practices assure patient safety

Marketing

Conflicts of Interests

Electronic documentation for patient

Patient safety indicators

Consider bringing in guests:  Dr. Steve Smith (unnecessary care); Dr. James Conway (IHI) safety; possible expert guests from New Jersey, which has done good work in this area.

Plan for next meeting

Call information:                  888-831-2982 

                                                General public Passcode 2391203

 Prov_Adv_Agenda_4_15_10.pdf