Copyright 2010 Health Data Solutions, Inc. Risk management software project started by the Pioneer Health Network Risk Managers wanted a better way.

Copyright 2010 Health Data Solutions, Inc.

Risk management software project started by the Pioneer Health Network

Risk Managers wanted a better way to identify trends and issues needing attention.

Final product improved entire risk management process

Mistakes Cost Money

$$ Musician losses arm due to mishandled injection: $6.7 million verdict$$ Neglect leads to gangrene, death: $10.7 million verdict$$ Errors at girl’s birth: $3.7 million verdict$$ Negligent post-op monitoring cost $1.5 million$$ Dementia patient wanders, killed by car: $850,000$$ Delayed diagnosis yields $2 million$$ Unlocked wheelchair wheels lead to $250,000 fall$$ Miscommunication costs $1.65 million$$ Failure to respond to elevated Troponin results in heart attack, anoxic brain damage: $4.75 million settlement$$ Aspiration death: $2.06 million verdict$$ Hypoglycemic event leads to brain damage and $4 million settlement$$ Death from infection: $13.5 million settlement

Ways to Make it All Work

Honesty

Patient safety first

Public relations

Team work

Good documentation system*

The Problem and Tracking Quality

“The problem is not bad people; the problem is that the system needs to be made safer . . .”

“More people die from medical errors than motor vehicle accidents. . .”

Estimated as high as 98,000 deaths a year attributed to medical errors.

IOM (2000). To Err is Human: Building a Safer Health System

“Without ongoing tracking of quality to assess…progress in meeting the six aims for improvement (Safe, Effective, Patient-centered, Timely, Efficient, Equitable), patients, healthcare practitioners, policy makers, educators and purchasers cannot identify progress or understand where improvement efforts are most needed.”

IOM (2001). Crossing the Quality Chasm: A New Health System for the 21st Century, p. 40

National Patient Safety

and Clinical Quality Efforts

AHRQ

ISMPIHI

Ambulatory & Hospital

Quality Alliances

CMS

Leapfrog Group

Partnership for Pt. Safety

NCQA

Nat’l Quality Forum

JCNat’l Pt. Safety

Foundation

NPSF

QUALITY CHOIR

Attribution: Jerod Loeb, Joint Commission

5M Campaign

HCUPPSO’s Sentinel Event

Reporting

Data collection

Safety Goals

Hospital Core

Nursing Sensitive

Serious Reportable Events

Cancer CareThoracic

Surgery

Safe PracticesRewards Program Safe Practices

ACE

9th Scope of Work

SCIP HCAHPS

Collaboratives

100K Campaign

Hospital Compare

“In God we trust; all others must bring data"

-- W. Edwards Deming

Quote at the bottom of an email signature of a Director Quality/Patient Safety & Dietary Services at a CAH in Ohio

Patient Safety Performance Measurement

Data EvolutionData Evolution

Data Collection

Data Reporting

Data Analysis

Inform Strategy

Typical Effort

Desired Effort

• Healthcare Providers make significant investments in collecting data for regulatory or accreditation purposes

• The goal is to push the Effort Curve to the right through increased staff competency, use of tools and automation of data collection1fr Hill, Terry, Rural Hospital Performance Improvement and Balanced Scorecard

Quality Data Check

Electronic incident management software

program.

Allows for electronic entry, investigation and

trending of incidents.

Uploads data to web based application

(webQDC) to provide aggregate reporting. Copyright 2010 Health Data Solutions, Inc.


The application and data reside on your own hospital network


Data input screens are simple to use and navigate


A paper reporting form is

also available


The investigation form is built into

the system.

The investigation can be assigned to a ‘reviewer’ electronically which adds to

efficiency

Assign SOC’s to all individuals

involved in incident


Final Review CommitteeForm

Record any comments or

recommendations made by the

review committee

Report Capabilities



Personnel Report

Report sorted by

department and

personnel

Identify Trends

Use the information for

evaluations

Identify individual

education and training

needs




CAH-Aggregate Data Report


Trending information can be uploaded to our website and

reports generated for a

region.

Uploading is voluntary and

no incident specific or PHI

is collected.

Regional data can be analyzed to support regional quality improvement projects. Trending reports can then determine

effectiveness of project.


Procedure/Test

Occurrences by Severity

CAH- Aggregate

For more information or to request a demonstration:

Jason Friesen, PresidentHealth Data Solutions

620 [email protected]

www.healthdatasolutions.org

Copyright 2010 Health Data Solutions, Inc. Risk management software project started by the Pioneer Health Network Risk Managers wanted a better way.

Documents

settlement slide

health data solutions

tracking quality

automation of data collection

quality chasm

ohio slide

national patient safety

work honesty patient