Online Performance Appendix: Patient Safety (continued)

Patient Safety Research

The FY 2010 President's Budget Request level for Patient Safety Research is $48,889,000, the same level as the FY 2009 Omnibus Level. The Patient Safety program is comprised of two research components: Patient Safety Threats and Medical Errors (including HAIs) and Patient Safety Organizations.

Patient Safety Threats and Medical Errors

The FY 2010 President's Budget Request level provides $41,889,000 million for patient safety threats and medical errors, including $17,304,000 for funds related to reducing Healthcare-Associated Infections (HAIs). This level will enable us to provide continued support for a number of ongoing research contracts, IAAs, and research grants including:

• The AHRQ PSNet and the AHRQ WebM&M, both of which have a growing user base and high levels of customer satisfaction based on annual customer satisfaction surveys.
• Patient safety grants focused on diagnostic error, ambulatory care patient safety intervention tool kit development, CERTS pediatric patient safety.
• A follow-on effort to the PSIC "graduates" fellowship training.
• Patient safety evaluation activities.
• Patient safety implementation projects conducted through our ACTION program.
• TeamSTEPPS™ technical assistance.
• Patient safety knowledge transfer projects.

In terms of performance measures, in FY 2007 the patient safety portfolio was able to provide a baseline for the number of U.S. health care organizations using AHRQ-supported tools to improve patient safety—382 hospitals. The FY 2008 target for this measure is 439 hospitals, increasing to 504 hospitals in FY 2009. In addition, AHRQ intends to increase the number of tools that will be available in AHRQ's inventory of evidence-based tools to improve patient safety and reduce the risk of patient harm. FY 2007 efforts focused on developing a baseline measure. The FY 2007 baseline for the inventory of evidence-based tools is 61. AHRQ's goal is to develop an additional 7 tools in 2008 (for a total of 68), 8 additional tools in FY 2009 (for a total of 76), and 10 additional tools in 2010 (for a total of 86).

As part of ongoing efforts aimed at reducing and eliminating HAIs, AHRQ has helped to coordinate and execute the Department of Health and Human Services National Action Plan related to HAIs. In FY 2009, $17,304,000 in additional funds were made available for work in this important area. A portion of the additional funds will expand a multistate project (from 10 States to approximately 30 States) to apply the approach that proved to be successful in the Michigan Keystone project to prevent central line-associated blood stream infections (CLABSI). Significant reductions in these infections were achieved through a comprehensive unit-based surveillance program (CUSP) in intensive care units. AHRQ will continue funding HAIs at $17,304,000 at the FY 2010 President's Budget Request level. Possible topics to be addressed as part of the HAI initiative include projects that focus on other infection sites (e.g., the urinary tract, lungs, surgical sites), hospital locations outside the ICU, and other health care settings (e.g., nursing homes, outpatient clinics, etc.), as well as the prevention of additional types of infections (e.g., Clostridium difficile) and contributing factors such as antibiotic overuse.

Patient Safety Organizations (PSOs)

The Patient Safety and Quality Improvement Act of 2005 amended the Public Health Service Act to foster a culture of safety in health care organizations. To encourage health care providers to work with PSOs, the Act (and implementing regulations) provides Federal confidentiality and privilege protections to deliberations carried out under the aegis of PSOs. This legal protection of information voluntarily reported to PSOs will promote increased reporting and analysis of patient safety events and subsequent improvements in care. The Act prohibits the use of these analyses in civil, administrative, or disciplinary proceedings and limits their use in criminal proceedings. AHRQ is coordinating implementation of the Act as a science partner to PSOs and health care providers. The Agency's goals are to help advance the methodologies that identify the most important causes of threats to patient safety, identify best practices for addressing those threats, and share the lessons learned as widely as possible. Specific work to carry out the Act includes:

1. Promulgating regulations to implement the Act.
2. Developing systems to allow application by organizations to become PSOs.
3. Listing successful applicant organizations as PSOs.
4. Where appropriate, re-listing and de-listing PSOs.
5. Maintaining a database of PSO administrative information.
6. Providing technical assistance to PSOs; and
7. Holding an annual meeting of PSOs.

Work related to patient safety event information includes:

• Specifying common definitions and reporting formats and disseminating it through notification in the Federal Register.
• Establishing systems to help PSOs de-identify information (data on an individual patient, reporter, provider, or institution).
• Developing a network of patient safety databases that will allow exchange of de-identified information among PSOs and reporting to AHRQ.
• Publication annually in AHRQ's National Healthcare Quality Reports information on national and regional statistics, including trends and patterns of health care errors.

Funding for this important Act will continue at the FY 2010 President's Budget Request at $7,000,000. This level of support will enable AHRQ, working with the Secretary, to support PSO operations in FY 2009, including publishing the list of operational PSOs. (Measure 1.3.40.)

Long Term Objective: Within 5 years, providers that implement evidence-based tools, interventions, and best practices will progressively improve their patient safety scores on standard measures (e.g., Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Hospital Survey of Patient Safety (HSOPS), Patient Safety Indicators (PSIs), and the Medical Office Survey on Patient Safety Culture).

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