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Quality of Care/Patient Safety

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Studies focus on systems for reporting medical errors and quality issues

In response to the alarming number of medical errors documented in the Institute of Medicine report, To Err Is Human, the Institute recommended creating a nationwide reporting system for serious care-related injuries. Such a reporting system could notify health officials about safety problems at individual institutions, increasing the likelihood that these issues would be addressed, and it might lead to a better understanding of their underlying causes.

A number of States currently have mandatory reporting systems, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has a voluntary reporting system for hospitals to report serious care-related injuries. Private-sector initiatives to improve quality of care have also begun.

A study supported by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00053) found that State reporting systems identified a greater number of care-related injuries than the JCAHO system. Participants in an AHRQ-supported workshop developed recommendations on the design and scope of a private-sector quality of care data monitoring system. Both projects are discussed here.

Williams, L.K., Pladevall, M., Fendrick, A.M., and others (2003, September). "Differences in the reporting of care-related patient injuries to existing reporting systems." (NRSA training grant T32 HS00053). Joint Commission Journal on Quality and Safety 29(9), pp. 460-467.

This study found that hospitals reported fewer care-related injuries to the voluntary system offered by JCAHO than they did to States mandating such reporting. The investigators compared the number of care-related injuries reported in 1999 by accredited hospitals to JCAHO with the number reported to 15 States requiring mandatory reporting of certain medical events. These included: an unanticipated death or major permanent loss of function not related to the patient's underlying condition; unanticipated death of a full-term infant, infant abduction or discharge to the wrong family; rape; hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities; surgery on the wrong patient or wrong site; and suicide of a patient in a setting where the patient receives around-the-clock care.

The number of reports submitted by JCAHO-accredited hospitals to States equaled or exceeded the number reported to JCAHO in all categories examined. Although JCAHO received fewer reports from accredited hospitals, its process requires a root cause analysis (RCA) of the event and a prevention plan. Also, it disseminates the lessons learned from reported events.

The researchers note that hospitals have many disincentives for reporting to JCAHO. The process of investigating an event and writing up an action plan can be time-consuming and expensive. If JCAHO determines that there is a continued threat to patient safety, it may conduct an on-site review of the event, and the cost is billed to the organization. When JCAHO is notified of an event, failure of the hospital to submit an acceptable RCA or action plan may affect the hospital's accreditation status, which may result in the loss of Medicare reimbursement. Furthermore, information reported to JCAHO may be subject to legal discovery, a process of obtaining evidence for trial.

Blewett, L.A., Parente, S.T., Peterson, E., and Finch, M.D. (2003, August). "The role of the private sector in monitoring health care quality and patient safety." (AHRQ grant HS10091). Joint Commission Journal on Quality and Safety 29(8), pp. 425-433.

Despite a number of public- and private-sector efforts, there is still no standard method for measuring and monitoring health care quality and safety across public and private payers. An AHRQ-sponsored workshop in fall 2000 examined the private sector's role in monitoring quality in the health care system. At the workshop, national experts outlined the design and scope of a private-sector data monitoring system, a longitudinal database that would use patient-level administrative data (with potential linkages) to produce real-time policy analysis and research applications.

They identified ten key attributes of the monitoring system, such as efficiency, timeliness, secured data storage that meets privacy requirements, and flexibility and adaptability. In addition, system data must be scalable, that is, collected in such a way that it can be used for comparisons across patient populations, geographic areas, or other categories. The system should allow for additional linkages with other data systems or primary data collection efforts.

A type of data repository eventually would be required to provide needed links to inpatient, outpatient, laboratory, and pharmacy claims with member and provider administrative data, clinical classifications, and member satisfaction information. Barriers and gaps to the development of such a system include the cost of data collection, the diversity of the units of data collection, data privacy, and limitations of administrative data elements.

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