Over 400 health care leaders, professional staff and physicians attended the 2014 Virginia Patient Safety Summit at the Richmond Marriott held January 30-31. This year’s summit featured presentations from Joseph Hallinan, author of the book “Science of Human Error: Why We Make Mistakes”; Richard Kaine, Physician Director at Quality Management Resources; and David Maxfield from VITAL SMARTS and author of the book “Crucial Accountability.” The Summit concluded with a presentation from Tiffany Christensen, an author and patient advocate from Duke Medical Center. During the Summit John Fitzgerald, CEO of Inova Fair Oaks Hospital and Chairman of the VHHA Board of Directors, challenged all Virginia hospitals to embark upon a journey to achieve zero patient harm in Virginia hospitals by 2020 and to constantly improve the patient experience.
Also featured at the Summit were posters from hospitals across Virginia showcasing a variety of patient safety and quality improvement initiatives. From an effort to reduce hospital-acquired infections at Danville Regional Medical Center to a multidisciplinary project to increase efficiency and safety of chemotherapy at Bon Secours St. Francis Medical Center, Virginia hospitals are doing much work to improve patient safety. During the 2014 Patient Safety Summit hospitals had the opportunity to put their work on display to increase awareness of practices that work and to facilitate networking across the state. Click here to review a sample of the abstracts presented at the 2014 Patient Safety Summit.
In 2010, the VHHA Board of Directors chose as its top strategic priority for Virginia hospitals and health systems to demonstrate top-tier performance on quality and safety. And in Spring 2010 a Steering Committee was charged with defining the metrics, determining the precise goals and recommending a related action plan for Virginia to achieve top-tier (top 10%) performance in the United States.
We are pleased to report that at the Spring Conference in April 2011 the Committee’s recommendations were approved and the plan is underway. You will hear more in the coming weeks about how every VHHA member can participate in this collective endeavor. A summary of the metrics chosen, the goals and the action plan are provided below as is the overall Virginia performance scorecard. VHHA members received individual facility reports, which will be made available to the public in subsequent reporting cycles.
Before delving into the specifics, VHHA thanks its members from around the state who guided this work. The committee was chaired by Barry Gross, executive vice president/chief medical officer of Riverside Health System and a member of the VHHA Board. Its members included clinical and management leaders from hospitals and health systems from throughout Virginia. We are indebted to each of them for the energy, candor and spirit with which they tackled the work. It is clear that there is real passion in the field behind the quest for ever more reliable quality and safety; and there is great work underway already that we can all benefit from.
Three themes emerged in the course of the group’s work thatshaped the recommendations:
Moving the needle on safety takes leadership, persistence and creativity;
Safety improvement is a joint imperative for the field rather than a competitive differentiator; and
There is great opportunity for accelerating improvement through structured learning opportunities with each other.
Metrics and Targets
The VHHA quality and safety consensus measure selected were:
Healthcare-Associated Infections: Central Line-Associated Blood Stream Infections; (Currently in progress) Catheter Associated Urinary Tract Infections.; (Next phase);
Serious Reportable Adverse Events: Wrong Site Surgeries;
Readmission 30-Day (All) for Acute Myocardial Infarction, Heart Failure , and Pneumonia;
Mortality 30-Day for Acute Myocardial Infarction, Heart Failure, and Pneumonia;
Patient Satisfaction: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Overall Value Based Purchasing Pricing HCAHPS Score and the question “How do patients rate the hospital overall?” (9 or 10)
The improvement targets are reflected in the Virginia scorecard. They range from a 50 percent reduction from current CLABSI infection rates to no wrong site surgeries. For readmission, mortality and patient satisfaction, the target is for Virginia to be among the top five states in each measure. We recognize that this target will move over time as every hospital and state pursues improvement as well.
The Board of Directors approved making publicly available a Virginia report card that measures aggregate performance in the Commonwealth. For at least the first reporting period, individual hospital data will not be publicly released or shared with other organizations without permission from each member. Individual hospital reports identify a hospital’s rates, the rank among all Virginia hospitals and the top three performers on each measure.
Tracking progress is key, so we intend on reporting at least semi-annually. We will report trends in future iterations of the report and will likely include additional items with input from an ongoing Quality & Safety Steering Committee.
There is significant sentiment on the VHHA Board for publicly reporting soon all results at the organizational level, recognizing that nearly all of these measures are publicly available from one source or another.
Beyond the metrics, the plan approved by the Board involves a number of ways that we can collaborate with others and support improvement for all members. The key elements of this work plan are summarized below:
Establish a statewide Patient Safety Organization for collecting information on serious safety events and how to improve reliability.
Expand collaboratives supporting improvement on priority areas (e.g., current CUSP/CLABSI initiative).
Hold Statewide Patient Safety Summit on February 2, 2012 in conjunction with Patient Safety Day to share learning.
Establish a palliative care work group to develop a best practice white paper as it relates to mortality.
Coordinate with the VHHA Delivery System and Payment Reform Task Force to recommend a signature improvement initiative that has broad applicability and particular cost and quality benefit to Medicaid recipients (e.g., readmission for dually eligible, pressure ulcers).
All of these improvement initiatives will be pursued in a fashion that will complement the good work already underway in your organizations, coordinate with national efforts such as the Partnership for Patients and engage with other stakeholders. We look forward to our shared success in demonstrating superior hospital quality and safety in Virginia.