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Maryland Patient Safety Center

Creating a culture of safety

Michael Preston
MedChi Executive Director

ACP National Conference

Philadelphia, Pa.
April 5, 2006
 What it is
• Created by legislation, privately operated under
State designation
• Mission: To bring health care providers together
to understand the causes of unsafe practices,
and implement evidence-based improvements.
• Initiatives:
– Education/training
– Collaboratives
– Adverse event reporting
– Research
– Special projects
• John M. Eisenberg Pt. Safety & Quality Award
 Origins: industry and gov’t response to IoM

• IoM 1st report 1999, To Err is Human

• Md. Patient Safety Coalition, fall 2000
– MedChi, Md. Health Care Commission (MHCC),
Md. Hospital Assoc., QIO “Delmarva,” others

• Patient Safety Act, spring ’01

– Charged MHCC to study state-wide patient
safety system, incl. mandatory reporting of errors
– Physician, hospital support
– Final report to legislature due by 1.01.03
– MHCC study absorbs coalition
 3 years of study: influences
• Physicians: MedChi report fall ’01
– Medical society response to IoM and strategy
viz. media controversy over “bad doctors”
– Recommends:
• comprehensive, confidential errors reporting
• state-sponsored safety institute
• re-design of physician regulation

• Hospitals: Md. Hospital Assoc. (MHA)

– Quality Indicator Project, MedSafe program
– All hospitals already participating
 MHCC report: 3-part strategy
Objective
REGULATORY ACTION
Mandatory reporting of
adverse events resulting in
death or serious injury, use
of RCAs, JCAHO guides
CREATE MPSC
Provider education, voluntary
reporting of de-identified
information on adverse events
and near-misses
SYSTEMS IMPROVEMENT
Use of data systems and
advanced technologies to
improve care
Implementing entity
Md. Dept. Health and Mental
Hygiene (hospital regulator)
Md. Patient Safety Center
MHCC (via CON, State
Health Plan, Hospital &
Nursing Home report cards)
HSCRC (sets hospital rates:
set rate allowances for
technology improvement)
Affected entity
Hospitals, nursing homes,
and potentially other licensed
facilities
Initially: Hospitals, nursing
homes, and potentially other
licensed facilities
Eventually: Outpatient arena
(physician offices)
All facilities regulated by
CON and rate-regulated
hospitals
Implementation: Design meets reality
• Law authorized MPSC spring ’03
• Patient Safety Center
– Recognized in law, MHCC to create
– Medical review committee status
– Un-funded
– AHRQ grant application denied

• Regulations flew into effect

• Systems improvement
– Creative financing
 Pt. Safety Center “out to bid”

• Patient Safety Center designation put out to bid

• Md. Hospital Assoc + Delmarva (QIO) bid

– MedChi didn’t bid, supported approach, pledged
physician involvement in planning, oversight
– Hospital focus, resources
– Designation awarded jointly to MHA + Delmarva 6.04

• Structure & financing

– MHA, Delmarva resources: funds, management
– Donated expertise: medical advisory panels
– Hospital rate commission funding
MPSC Initiatives
 Education & Training: Goals
• Build awareness of need for patient safety and
potential for achieving it

• Promote cultural changes needed for improvement

– Example: leadership commitment from Board + CEO

• Ensure that institutional leaders and health

professionals have essential competencies,
– Example: Ability to perform root cause analysis (RCA)

• Offer proven safety solutions and better practices

 Education & Training: First year activities

Root cause analysis training

• >2,000 hospital, nursing home personnel trained

Human factors engineering

• 2-day program to reach all hospital dept. leaders
over 2 years

State-wide Patient Safety Conference

– 1st >700 attendees: some physicians, mostly
institutional (hosp, n/h) pharm.managers
– 2d (3.30.06) 1,200 attendees: still mostly institutional
 Safety Culture Collaborative Series

• Focused multi-site projects to produce

measurable improvements on key measures

• First-up: Intensive Care Units, based on:

– Institute for Healthcare Improvement (IHI)

Breakthrough Series
– AHRQ Keystone ICU Project

– VA-sponsored Transformation of ICU Collaborative

 ICU Collaborative

Participation by 82% of Maryland hospital

ICU’s addressing:
– Elimination of central line infections
– Elimination of Ventilator-associated pneumonia
– Deep vein thrombosis & peptic ulcer prevention
– Formation of rapid response teams
– Medication Reconciliation
 ICU Collaborative Results

36% decrease in blood stream infection rate

20% decrease in ventilator-associated

pneumonia

Emergency Care to be focus of second

collaborative
Adverse event and “close call” event reporting

• MPSC considering a vol. reporting system

– analyze data to identify trends and patterns

– Hospital reports, periodic patient safety

advisories, and education to be provided to
hospitals

– To begin 2006 (?)

 Other proposed opportunities

• Emergency Department Collaborative

• Telemedicine & Advanced Technology
Research Center (TATRC)
• AHRQ-ACTION Grant
• Research
• 1000,000 lives campaign
Prevention of Central Line-Associated Bloodstream Infection…
by implementing a series of interdependent, scientifically grounded
steps called the “Central Line Bundle”

Rapid Response Teams…at the first sign of patient decline

Improved Care for Acute Myocardial Infarction…to prevent
deaths from heart attacks

Prevention of Adverse Drug Events…by implementing medication

reconciliation

Prevention of Surgical Site Infection…by reliably delivering the

correct preoperative antibiotics at the proper time

Prevention of Ventilator-Associated Pneumonia…by

implementing a series of interdependent, scientifically grounded steps
called the “Ventilator Bundle
Challenge for physicians: ambulatory care

• Still totally developmental

• Growth of ambulatory care environment
• MedChi Quality Committee concepts:
– Target “hand-off” situations
– Link to electronic data collection capability
– Continue to build awareness
 References & contacts
1. See: Joshi, et al.,“Comprehensive Grassroots Model for Statewide
Safety Improvement”, JCAHO Journal on Quality & Patient Safety
(v31,n12, p. 671-677, Dec. 2005)

2. MHCC final report: http://mhcc.maryland.gov/patient_safety/finalrpt.pdf

3. Contacts:
Maryland Patient Safety Center
www.marylandpatientsafety.org
Director: William F. Minogue, MD
6820 Deerpath Rd.
Elkridge, MD 21075
wminogue@marylandpatientsafety.org
(410) 540-9210