Pennsylvania Patient Safety Authority Focuses on Data, Standardization of Reports, the Patient Safety Advisory, Education and its Collaboration Efforts in its 2015 Annual Report

Monday, May 2, 2016 Education News J E 4
Highlights include implementation of 28 principles to standardize reporting, an increase in facility engagement and a reduction in catheter-associated urinary tract infection rates

HARRISBURG, Pa., May 2, 2016 /PRNewswire-USNewswire/ -- Implementing 28 principles to help standardize reports due to requests from Pennsylvania healthcare facilities plays a part in five areas the Pennsylvania Patient Safety Authority focused on in its 2015 Annual Report released today.

"The standardization project took several months with a multi-stakeholder workgroup to help develop a consensus on twenty-eight guiding principles as well as make technical changes to the Authority's reporting system to improve consistency in event reporting, Rachel Levine, M.D. chair of the Pennsylvania Patient Safety Authority said. "It is a work in progress in terms of analyzing the reports, but early signs indicate the implementation is working."

Levine added the guiding principles were implemented April 1, 2015, with an online educational program developed to ensure that all Authority, Department of Health and healthcare facility staff had a common understanding of the principles.

"Outreach to educate healthcare staff about the new reporting standards was extensive, so much so that by the end of the year over seventy percent of users [1000 healthcare workers] had completed the required modules," Levine said. "The Authority also provided on-site standardization education to four hundred and twenty-three Patient Safety Officers, physicians, quality managers, nurse leaders and other clinical staff."

The guidance was developed to help provide consistent standards to acute healthcare facilities in Pennsylvania in determining whether occurrences within facilities meet the statutory definitions of Serious Events, Incidents, Infrastructure Failures and Other as defined in the Medical Care Availability and Reduction of Error (MCARE) Act. The reporting guidelines were identified based on frequently asked questions (FAQs), controversies and inconsistencies that were evident in the data collected. The guidelines were adopted after a public comment period and published in the Pennsylvania Bulletin September 27, 2014.

"New and revised event types and subtypes were created in the Pennsylvania Patient Safety Reporting System [PA-PSRS] to help in the standardization effort," Levine said. "The number of reports submitted under the new event types nearly doubled between the second and third quarter of the year; and between the second and fourth quarters, the number of events submitted increased over one hundred percent."

Levine added that although for this Annual Report it had been less than a year of data analysis since implementation of the new standards and any conclusions would be preliminary, the Authority is encouraged that for all indicators it felt were important, changes seem to be moving in the desired direction.

Some examples include: 1) there was a noticeable increase in Serious Event reports starting in April 2015, the month the new standards went into effect; 2) the use of new and revised event types and subtypes promotes more consistency in reporting, which is evident with the number of reports submitted under the new event types nearly doubling since implementation; and 3) healthcare facilities have enthusiastically embraced education for the standardization principles.

"The principles have found good acceptance among healthcare providers, as evidenced by the nature of the help desk calls received during implementation, the tenor of conversations among facilities and the Authority's Patient Safety Liaisons (PSLs) and an increase in Serious Event reporting," Levine added.

Healthcare providers continued to report robustly to the Authority, submitting 238,890 reports in 2015 with 7, 732 Serious Events (up 9%), while Incident reports averaged 19,263 per month, a decrease of 1.1 percent compared to 2014. The total number of reports submitted by Pennsylvania acute care facilities since the program's inception in 2004 is 2.5 million.

For a detailed overview of PA-PSRS data and the standardization implementation project that includes breakdowns of reports by event type, region and gender go to the "Detailed Overview of Data Reported through PA-PSRS" and "Reporting Standardization: Guidance for Acute Healthcare Reporting" sections of the 2015 Annual Report.

Levine said in 2015 the flagship publication of the Authority, the Pennsylvania Patient Safety Advisory, continued to provide clinicians of Pennsylvania's healthcare facilities with data analysis and improvement strategies to help them improve system processes within their institutions.

"The Advisory has provided more than five hundred patient safety focused articles to date and forty-eight Advisory-based educational toolkits to Pennsylvania healthcare facilities since it was first published in 2004," Levine said. "The Advisory has been credited by facilities with contributing to nearly 4,500 structure and process improvements."

Levine added that the information provided by Advisory articles garnered more than 784,000 website hits in 2015, with more than 12,180 Advisory-based continuing education credits earned by healthcare professionals  reading the Advisory from 2006 through 2015.  The Advisory has 4,622 subscribers in the United States with subscribers in all 50 states, plus DC, the Virgin Islands, Puerto Rico, other US territories and in 44 countries worldwide.

"Through the Advisories, Authority analysts continued to expand the coverage and scope of strategies designed to address patient safety issues," Levine said. "In the articles, analysis of problems and challenges is followed by information on possible solutions; many articles include or reference toolkits that facilities can adapt and implement themselves.

"It's free to subscribe to the Advisory, which is published quarterly," Levine added.

Some of the Advisory article topics addressed in 2015 include: Pregnancy Complications, Insulin Pens, Antibiotic Stewardship, Hospital-acquired Pressure Ulcers, Patient Aggression, Wrong-Site Orthopedic Procedures, Oral Anticoagulants and Standardized Emergency Codes.

For more details about the Pennsylvania Patient Safety Advisory go to "The Pennsylvania Patient Safety Advisory" section of the 2015 Annual Report.

Levine said educational programs through the Authority's unique Patient Safety Liaison (PSL) program continued in 2015.

"The PSL program provides Pennsylvania healthcare facilities with a personal link to the Authority and continues to provide a unique resource to Pennsylvania hospitals, ambulatory surgical facilities, birthing centers and abortion facilities," Levine said. "PSL program staff are located regionally throughout the state provide education, consultation and awareness of all available resources to facilities."

In 2015, the Authority hired three new PSL program staff mid-year, which led to some restructuring. Educational programs, such as regional events and webinars, are scheduled regularly throughout the Commonwealth.

"PSLs provide educational programs at the request of individual healthcare facilities, health systems, institutions of higher learning, professional organizations and accountable care organizations," Levine added. "Reporting facilities that either hosted Authority events or attended regional events increased thirteen percent in 2015."

In all, 192 educational programs were offered by the Authority and 6,946 healthcare workers were educated in 2015. Some of the education topics offered include: Alarm Management, Autism, Falls, Hand Hygiene, Pressure Ulcers, Wrong-Site Surgery, Medication Reconciliation, Norovirus, Failure Modes and Effects Analysis, Operating Room Fire Safety, Health Literacy and Simulation.

For more details about the PSL program and education programs offered by the Authority go to the "Educational Programs: Providing a Strong Foundation for Improvement" section of the 2015 Annual Report.

Last year, the Authority continued to partner with and educate Pennsylvania healthcare workers across the state in healthcare-associated infection (HAI) prevention. Two infection prevention analysts joined the Authority in 2015, and the Authority infection prevention analysts provided a statewide ambulatory surgical facility symposium for healthcare workers to learn strategies to prevent infections in healthcare settings.

A collaboration with the Health Research and Educational Trust (HRET) successfully reduced catheter-associated urinary tract infection rates (CAUTI) by 54%.

"Through the collaboration, facilities reduced unnecessary catheter use, improved the safety culture and used tools provided by the Authority and HRET that enable them to sustain their results," Levine said. "The fourteen-month collaboration began in late 2014 and the Authority infection prevention analysts continue to provide long-term care facilities with the support they need to prevent CAUTIs."

The Authority began additional work with the Hospital and Healthsystem Association of Pennsylvania (HAP) late in 2015 on Hospital Engagement Network (HEN) 2.0. Other collaborative partnerships occurred with: the Pennsylvania Department of Health, the National Patient Safety Foundation, the Pennsylvania Society of Anesthesiologists, the Quality Insights Quality Innovation Network and the Association for Professionals in Infection Control and Epidemiology.

"The Authority took another step forward by partnering with the University of Pittsburgh Medical Center to offer continuing medical education credits for its hand hygiene webinar, 'How to Implement a Systems and Behavior Approach to Improve Hand Hygiene,'" Levine added.

Pennsylvania nursing homes submitted 31,672 infection reports through PA-PSRS in 2015, a 9.9% increase from 2014. The first full year of data from long-term care (LTC) was reported in 2015 using the McGeer criteria. The year 2015 serves as the new benchmark for LTC-HAI data for Pennsylvania.

For more details about the Authority's HAI program and collaborations including the results of its Infection Control Annual Survey go to the "Healthcare-Associated Infections" and "Building Improvement in Patient Safety through Collaborations and Partnerships" sections of the 2015 Annual Report.

Levine said the Authority also recognized 21 healthcare workers from 12 healthcare facilities throughout Pennsylvania for its annual "I Am Patient Safety" poster campaign. The contest promotes individuals and groups within Pennsylvania's healthcare facilities who have demonstrated an exceptional commitment to patient safety. The recognized winners are featured on this year's cover and their patient safety efforts are detailed in the "Authority-Recognized Healthcare Providers are Committed to Patient Safety" section of the 2015 Annual Report.

"In its third year, the Authority's I Am Patient Safety poster contest has received more nominations than ever before, doubling its number from last year," Levine said. "Through the campaign, Pennsylvania healthcare workers from all areas and departments are recognized for their patient safety efforts.

"The Authority board members and I applaud the efforts made by this year's recognized winners and commend them for a job well done," Levine added.

The complete 2015 Annual Report, as well as additional information about the Pennsylvania Patient Safety Authority, is accessible on the Authority's website

Find the Authority on Facebook and Twitter


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SOURCE Pennsylvania Patient Safety Authority



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