In 2011, NQF’s work in the safety realm spanned updating of measures and serious reportable events (SREs), a recommended approach for further aligning public- and private-sector patient-safety measurement strategies, and development of implementation strategies in support of HHS’s Partnership for Patients Initiative.
Partnership for Patients is engaging stakeholders from the private and public sectors to reduce all-cause harm (i.e., all forms of harm that can affect patients) and hospital readmissions. More specifically, NPP partnered with the Partnership for Patients to host 11 webinars that attracted about 10,000 frontline clinicians, hospitals, and others across the country and provided education, tools, resources, and insight on key safety issues. These webinars ranged from big-picture interventions (e.g., how to get your Board on board when it comes to improving patient safety), to those with a more laser focus on clinical teams (e.g., reducing surgical-site infections [SSIs]). Nearly 90 percent of webinar participants, who came from every region of the country, reported that they would be able to implement something new in their institutions as a result of this novel public-private programming.
Moving forward in 2012, NPP is developing two action pathways, which its multiple partners can implement and spread. These pathways are focused on the health of mothers and babies by reducing elective deliveries before 39 weeks, and reducing avoidable admissions and re-admissions across all settings of care. These represent two of the 10 areas Partnership for Patients is pursuing to achieve its global safety and harm-reduction goals. Reaching these goals also will substantially reduce costs.
In addition, MAP released a report, Coordination Strategy for Healthcare-Acquired Conditions and Readmissions Across Public and Private Payers, in October 2011, detailing the ways in which public and private healthcare providers can align performance measurement to enhance patient safety. Specifically, the report makes three recommendations:
- There needs to be a national set of core safety measures applicable to all patients;
- Data need to be collected on all patients to inform these national core safety measures; and
- Public and private entities need to coordinate their efforts to make care safer.
MAP’s recent pre-rulemaking report further emphasizes the importance of safety measures by supporting their inclusion in federal public reporting and performance-based payment programs, and MAP will focus on alignment of core safety measures across programs in 2012. With respect to measure review, NQF endorsed numerous patient-safety measures, including healthcare-associated infections (HAIs), which now address long-term, acute-care and rehabilitation hospitals, and radiation-safety measures.
NQF also updated its list of SREs, a compilation of serious, harmful, and largely—if not entirely—preventable patient-safety events, designed to help the healthcare field assess, measure, and report performance in providing safe care. In the 2011 update, the events were broadened in focus to explicitly include hospitals, office-based practices, ambulatory surgery centers, and skilled nursing facilities to reflect the various settings in which patients receive care and could experience harm. Based on input from users, the implementation guidance for each event was expanded, and a glossary was added to facilitate uniformity in reporting of the events. The list includes wrong-site surgery; death or serious injury associated with medication errors or unsafe blood products; and failure to follow up on lab, pathology, or radiology test results. Public and private purchasers have drawn heavily from the SRE list in identifying healthcare-associated conditions for use in payment and reporting programs.
Finally, NQF launched a project in 2011 that will leverage health IT data to address patient safety and quality concerns associated with medical devices, such as pumps used to deliver intravenous medications at home. This project, which continues in 2012, will determine what data needs to be collected and shared to improve quality and safety related to devices. It also will focus on ways to identify and report adverse events associated with the use of such devices.