Chapter 24 Patient safety and quality initiatives in health informatics

Patient safety

"freedom from accidental injury due to medical care, or medical errors," where error is defined as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."- IOM Safety: "the reduction of risk and unnecessary harm to an acceptable minimum" and patient safety as "the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum."- ICPS The ICPS defines error as "failure to carry out a planned action as intended or application of an incorrect plan" and healthcare-associated harm as "harm arising from or associated with plans or actions taken during the provision of healthcare, rather than an underlying disease or injury."

Quality of care

"the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."- IOM

What does quality care look like?

*Safe*. Prevents injury or other adverse outcomes *Effective*. Ensures that evidence-based interventions are used, with patients always receiving the treatments most likely to be beneficial *Patient-centered*. Ensures that patient preferences, needs, and values are front and center in the process of clinical decision making *Timely*. Delivered when needed and without harmful delays *Efficient*. Prevents the waste of valuable human and material resources *Equitable*. Provided to all individuals without regard for ethnic, racial, socioeconomic, or other personal characteristics

Quality data standards

-Establishing and adopting standards at multiple levels to support semantic interoperability -Semantic interoperability: data are exchanged without a loss of context or meaning and therefore can be reused without special effort on the part of the user -Only possible when all organizations adopt the same standards for quality measurement and reporting and using those standards in their electronic systems

Patient Falls & pressure ulcers: specifically for nurses

-Falls and pressure ulcers are preventable and are sensitive to nursing care -Using health IT to prevent these occurrences are key to quality nursing care and positive patient outcomes -CDS critical to falls and pressure ulcers

Medication safety

-Health IT is proven to improve the quality and safety of care in relation to medication safety -CPOE and CDS systems implemented in clinical practice have reduced errors in the process of ordering medications -Bar Code Medication Administration and eMAR systems have been implemented to streamline clinical workflow, focusing on improving medication administration at the point of care. Ensure that providers adhere to the "5 Rights" of medication administration WHEN used properly- NO WORKAROUNDS!! Smart infusion pumps -Med error reduction by having pre-programmed drug libraries with dose limit alerts IOM reports, TJC standards and National Patient Safety Goals (NPSG) represent structural incentives for use of health IT to improve medication safety

Characteristics of successful health IT implementation projects for quality and safety

-Leadership support -Comprehensive health IT implementation and adoptation -Health IT as a "tool" -patient engagement -end user involvement -peer champion support

The ultimate goal

Capture data for quality reporting in the context of existing documentation workflows -This requires that standard clinical content is adopted and used in electronic systems, standard vocabulary is used to encode that content and messaging standards are used to transfer information from one healthcare organization to another Standard quality measures are needed to ensure that all organizations are using consistent metrics for benchmarking Organizations are using the same types of data to populate the quality metrics

What determines improvement?

Evidence shows that successful implementation of BCMA and eMAR systems that improve patient safety depend on: 1. Workplace culture (leadership, teamwork, and clinician ownership) 2. Training and support 3. Acceptance of the major impact of work practices by all staff 4. A usable system with adequate decision support

Health IT as a "tool"

Health IT applications considered a tool or a single component of a multifaceted intervention to improve the underlying clinical process and, ultimately, patient outcomes.

Leadership support

Leaders support adoption and use of health IT to improve patient care and facilitate practice changes

patient engagement

Patients engaged in clinical process changes to deliver evidenced-based care, to improve safe practices, and to improve patient outcomes. Health IT is one tool to support process changes.

Evaluating quality and patient safety

Structure -Buildings, equipment, staffing ratios, budget -All factors may not be under the control of the local facility (e.g., Joint Commission standards or MU requirements) Process -Clinical and managerial processes that support the provision of care Outcomes -The end result of the structures and processes in place (clinical outcomes and throughput)

PSQRD Framework

Supports understanding where the health IT intervention is most likely to have an effect Pertinent for evaluating the effect of health IT interventions on quality and patient safety- provides a means to explain why a health IT interventions was successful (or not)

What we learned from the IOM reports on quality...

The U.S. needs a systematic redesign of established clinical processes Health IT is needed to support and maintain the transition to best practices Recent U.S. policy is aligning incentives with the goal of adoption and widespread use of health IT to ensure quality and safety Federal Health Information Technology Strategic Plan: 2011-2015: The ONC's plan for working with public and private sectors to achieve the nation's health IT goals ONC released Federal Health Information Technology Strategic Plan: 2015-2020- to highlight achievements of Meaningful Use and where IT infrastructure is lacking (e.g., interoperability & patient-centeredness)

Federal Health Information Technology Strategic Plan: 2015-2020

Two objectives: 1. To use health IT to make care safer 2. To improve the safety of health IT Key areas of focus : -Improving the quality of care -Preventing adverse events -Adverse events: an undesirable experience associated with the use of a medical product in a patient.

Improving quality outcomes

Use health IT interventions that target patients to improve : -Access to treatment -Adherence with medication, diet & exercise regimens -Adherence to recommended screening guidelines -Engagement in symptom management

Chronic illness screening & management

Using health IT to improve clinical processes includes: -Clinical decision support based on clinical practice guidelines -Pay-for-performance measures -CMS core measures

Comprehensive health IT implementation and adoptation

attention to both management and clinical process to promote fidelity with intervention

end user involvement

end users involved in iterative development and implementation of health IT interventions to improve quality and safety

peer champion support

the use of peer support to facilitate adoption and proper use of health IT applications within clinical workflow