Richard G. Koss

Towards an international classification for patient safety : the conceptual framework

Global advances in patient safety have been hampered by the lack of a uniform classification of patient safety concepts. This is a significant barrier to developing strategies to reduce risk, performing evidence-based research and evaluating existing healthcare policies relevant to patient safety. Since 2005, the World Health Organizations World Alliance for Patient Safety has undertaken the Project to Develop an International Classification for Patient Safety (ICPS) to devise a classification which transforms patient safety information collected from disparate systems into a common format to facilitate aggregation, analysis and learning across disciplines, borders and time. A drafting group, comprised of experts from the fields of patient safety, classification theory, health informatics, consumer/patient advocacy, law and medicine, identified and defined key patient safety concepts and developed an internationally agreed conceptual framework for the ICPS based upon existing patient safety classifications. The conceptual framework was iteratively improved through technical expert meetings and a two-stage web-based modified Delphi survey of over 250 international experts. This work culminated in a conceptual framework consisting of ten high level classes: incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors/hazards, organizational outcomes, detection, mitigating factors, ameliorating actions and actions taken to reduce risk. While the framework for the ICPS is in place, several challenges remain. Concepts need to be defined, guidance for using the classification needs to be provided, and further real-world testing needs to occur to progressively refine the ICPS to ensure it is fit for purpose.

Performance of Top-Ranked Heart Care Hospitals on Evidence-Based Process Measures

Background— Despite the increasing availability of evidence-based clinical performance measure data that compares the performances of US hospitals, the general public continues to rely on more popular resources such as the US News & World Report annual publication of “America’s Best Hospitals” for information on hospital quality. This study evaluated how well hospitals ranked on the US News & World Report list of top heart and heart surgery hospitals performed on acute myocardial infarction and heart failure measures derived from American College of Cardiology and American Heart Association clinical treatment guidelines. Methods and Results— This study identified 774 hospitals, including 41 of the US News & World Report top 50 heart and heart surgery hospitals. To compare hospitals, 10 rate-based performance measures (6 addressing processes of acute myocardial infarction care and 4 addressing heart failure care), were aggregated into a cardiovascular composite measure. As a group, the US News & World Report hospitals performed statistically better than their peers (mean, 86% versus 83%; P<0.05). Individually, however, only 23 of the US News & World Report hospitals achieved statistically better-than-average performance compared with the population average, whereas 9 performed significantly worse (P<0.05). One hundred sixty-seven hospitals in this study routinely implemented evidenced-based heart care ≥90% of the time. Conclusions— A number of the US News & World Report top hospitals fell short in regularly applying evidenced-based care for their heart patients. At the same time, many lesser known hospitals routinely provided cardiovascular care that was consistent with nationally established guidelines.

The adoption of smoke-free hospital campuses in the United States

Background: The adoption of a smoke-free hospital campus policy is often a highly publicised local event. National media coverage suggests that the trend towards adopting these policies is growing, and this publicity can frequently lead hospital administrators to consider the adoption of such policies within their own institutions. Little is actually known, however, about the prevalence of these policies or their impact. Objectives: To determine the national prevalence of smoke-free hospital campus policies and the relation between these policies and performance on nationally standardised measures for smoking cessation counselling in US hospitals. Methods: 4494 Joint Commission-accredited hospitals were invited to complete a web-based questionnaire assessing current smoking policies and future plans. Smoking cessation counselling rates were assessed through nationally standardised measures. Results: The 1916 hospitals responding to the survey (43%) were statistically similar to non-responders with respect to performance measure rates, smoking policies and demographic characteristics. Approximately 45% of responders reported an existing smoke-free hospital campus policy. With respect to demographics, higher proportions of smoke-free campus policies were reported in non-teaching and non-profit hospitals. Smoke-free campus hospitals were also more likely to provide smoking cessation counselling to patients with acute myocardial infarction, heart failure and pneumonia who smoke (p<0.001). Conclusions: By February 2008, 45% of US hospitals (up from approximately 3% in 1992) had adopted a smoke-free campus policy; another 15% reported actively pursuing the adoption of such a policy. By the end of 2009, it is likely that the majority of US hospitals will have a smoke-free campus.

Integrating performance measure data into the Joint Commission accreditation process

This article describes the Joint Commission’s implementation plans, experience, and results to date of incorporating performance measurement data into the accreditation process. These plans have evolved in response to changes in the health care environment, feedback from accredited organizations, and both technical and political obstacles encountered. During the late 1980s, the Joint Commission developed a national performance measurement system, the IMSystem, to incorporate information about the process and outcomes of care into the accreditation process. In 1995, the ORYX initiative was introduced to offer health care organizations significant flexibility in selecting a measurement system and measures while promoting organizational self-improvement and accountability. Recently, the plans have evolved to incorporate standardized core measures that are known to be valid and reliable. These initiatives have moved the field much closer to the day when quality assessment will reflect a comprehensive view of organizational performance, based, in part, on performance measurement data.

Case volume and hospital compliance with evidence-based processes of care

BACKGROUND For many complex cardiovascular procedures the well-established link between volume and outcome has rested on the underlying assumption that experience leads to more reliable implementation of the processes of care which have been associated with better clinical outcomes. This study tested that assumption by examining the relationship between cardiovascular case volumes and the implementation of twelve basic evidence-based processes of cardiovascular care. METHOD AND RESULTS Observational analysis of over 3000 US hospitals submitting cardiovascular performance indicator data to The Joint Commission on during 2005. Hospitals were grouped together based upon their annual case volumes and indicator rates were calculated for twelve standardized indicators of evidence-based processes of cardiovascular care (eight of which assessed evidenced-based processes for patients with acute myocardial infarction and four of which evaluated evidenced-based processes for heart failure patients). As case volume increased so did indicator rates, up to a statistical cut-point that was unique to each indicator (ranging from 12 to 287 annual cases). t-Test analyses and generalized linear mixed effects logistic regression were used to compare the performance of hospitals with case volumes above or below the statistical cut-point. Hospitals with case volumes that were above the cut-point had indicator rates that were, on an average, 10 percentage points higher than hospitals with case volumes below the cut-point (P < 0.05). CONCLUSION Hospitals treating fewer cardiovascular cases were significantly less likely to apply evidence-based processes of care than hospitals with larger case volumes, but only up to a statistically identifiable cut-point unique to each indicator.

Integrating Healthcare Standards and Performance Measurement

Over the past 50 years the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has relied primarily on an assessment of standards compliance to make judgments about the capability of a healthcare organization to provide good quality care. Over the last decade, the focus has shifted from paying exclusive attention to capabilities and routine processes of care, to an assessment of the actual results of care by monitoring and measuring clinical outcomes. This transition requires exploration and understanding of the complex interrelationships between healthcare standards and performance measures.Adding performance measurement to a standards-based assessment means that the JCAHO can implement a more continuous accreditation process. Continuous accreditation allows an organization to regularly evaluate and improve its processes to maintain performance that constantly meets or exceeds expectations. Establishing a valid, complementary relationship between healthcare standards and performance measures is a complex and challenging undertaking, and fertile ground for extensive research. Success will result in a more complete, thorough and continuous assessment of the care provided by healthcare organizations.