2005-06 National (USA) Patient Safety Goals from the new Patient Safety Centre

In March 2005, the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission Resources (JCR) announced the establishment of the Joint Commission International Center for Patient Safety, a virtual entity that draws upon the patient safety expertise, resources and knowledge of both the Joint Commission and JCR. The center will provide patient safety solutions to healthcare organizations worldwide. The mission of the center is to continuously improve patient safety in all healthcare settings.

The Joint Commission on Accreditation of Healthcare Organizations' Board of Commissioners approved the 2006 National Patient Safety Goals this spring. The Joint Commission promotes and provides for the delivery of safe, high-quality care through ambulatory care and office-based surgery, assisted living, behavioural healthcare, critical access hospital, disease-specific care, home care, laboratory, long term care, networks and hospital.

The website of the Patient Safety Center (www.jcipatientsafety.org), launched April 15, 2005, is designed as a major repository of resources and information about all aspects of patient safety for patients, their families, healthcare institutions and allied healthcare professionals, including physicians, nurses and pharmacists.

Reference: www.jcaho.org/about+us/facts_jcicps.htm)

Leavitt: Katrina demonstrates need for e-health records

The majority of the one million people displaced by Hurricane Katrina have no medical records, making it difficult for clinicians working in disaster medical centers to treat them, Mike Leavitt, secretary of the Department of Health and Human Services, told the eHealth Initiative conference today. With paper records destroyed or unavailable, Leavitt said doctors have no idea what drugs Katrina refugees are taking.

Medical personnel working at makeshift hospitals in the hurricane-battered Gulf Coast and at facilities in cities caring for Katrina refugees are handicapped by the lack of medical records, including medications prescribed to former Gulf Coast residents now scattered at shelters nationwide, Leavitt said.

Although some medical experts have warned of catastrophic medical events following Katrina, such as an outbreak of West Nile Virus, Dr. Frederick Cerise, secretary of the Louisiana Department of Health and Hospitals, said he was more concerned about refuges with chronic medical conditions such as cancer not getting the treatment they need because of a lack of medical records.

Cerise, who spoke to the conference via speakerphone from his office in Baton Rouge, La., said he is working with members of the eHealth Initiative, insurers, the Centers for Medicare and Medicaid Services (CMS) and Dr. David Brailer, national coordinator for health information technology at HHS, to electronically re-create patient records.

For example, payment information held by insurers and CMS could help zero in on prescribed medications and lab tests ordered, though not the results of those tests, Cerise said.

Francois de Brantes, the health care initiatives program leader for General Electric's Corporate Health Care and Medical Services, said the difference between electronic and paper health records after Katrina was best illustrated by the time it took to transfer records for patients in Veterans Affairs Department hospitals in the Gulf Coast compared with the records of patients in private hospitals.

It took the VA about 100 hours to transfer electronic health records for its all patients in the South, while it will take thousands of hours for the private sector to reconstitute paper medical records, de Brantes said.

Reference: https://govhealthint.com/article90691-09-08-05-Web

The Campaign is One of the Largest Healthcare Quality Improvement Efforts Ever Undertaken in the U.S.

The Institute for Healthcare Improvement (IHI) announced today that over 2,500 acute care hospitals in the United States have now joined its Campaign to save 100,000 lives. The Campaign encourages hospitals to adopt proven practices and procedures that can dramatically improve patient care and is the first-ever national campaign to promote saving a specified number of lives by a certain date (June 2006). At current enrollment numbers, the Campaign has become one of the largest healthcare quality improvement efforts ever undertaken in the U.S. Hospitals that choose to participate in the Campaign commit to implementing some or all of the following six quality improvement changes:

• Deploy Rapid Response Teams
  
• Deliver Reliable Evidence-Based Care for Acute Myocardial Infarction
  
• Prevent Adverse Drug Events
  
• Prevent Central Line Infections
  
• Prevent Surgical Site Infections
  
• Prevent Ventilator-Associated Pneumonia

Reference: www.ihi.org

Clinical Quality Improvement and Patient Safety

American Medical Association Celebrates Healthcare Safety Win for America's Patients

President George W. Bush signed the Patient Safety legislation in July 2005. This legislation was one of the American Medical Association's top legislative priorities for 2005 and passage represents the culmination of an almost two year effort by the AMA.

"The healthcare community has long been committed to improving patient safety, and significant progress has been made through new technology, research and education. This patient safety law is the catalyst we need to transform the current culture of blame and punishment into one of open communication and prevention," said AMA President J. Edward Hill, M.D.

By establishing a system of voluntary, confidential reporting and analyzing of healthcare errors, this law will implement broad patient safety reforms and improvements in the quality of care for patients across the US. The AMA hopes this new legislation will begin to transform the current culture of blame and punishment into one of open communication and prevention.

Reference: www.ama-assn.org

National Patient Safety Agency Board Reporting and Learning System Update

Early in 2004 Health Minister Lord Norman Warner launched the National Patient Safety Agency's (NPSA) work to put into place a National Reporting and Learning System (NRLS) for patient safety problems - the first of its kind worldwide. The system is designed to draw together reports of patient safety errors and systems failures from health professionals across England and Wales to help the National Health Service (NHS) to learn from things that go wrong.

By the end of that year the NPSA put a system into place to allow all 607 NHS organizations the capability to report patient safety incidents to the NRLS. The next step was to work with these organizations to further tailor their reporting route to best suit their needs. The NPSA is delighted to announce that 90% of NHS organizations are now reporting through their chosen route.

Most problems affecting patient safety occur as a result of weaknesses in systems and processes, rather than the acts of individuals. It is essential that incidents are reported locally and that they are investigated and analyzed so that suitable learning and actions can follow. At the national level, the NRLS enables the NPSA to take an unprecedented overview, identify recurring patterns and develop practical national solutions.

Reference: www.npsa.nhs.uk/npsa/display?contentId=4215

Building stronger health systems key to reaching the health Millennium Development Goals

Building up and strengthening health systems is vital if more progress is to be made towards the Millennium Development Goals (MDGs), the World Health Organization (WHO) said in a new report. Unless urgent investments are made in health systems, current rates of progress will not be sufficient to meet most of the goals.

The report, Health and the Millennium Development Goals, presents data on progress on the health goals and targets and looks beyond the numbers to analyze why improvements in health have been slow and to suggest what must be done to change this. The report points to weak and inequitable health systems as a key obstacle, including particularly a crisis in health personnel and the urgent need for sustainable health financing.

Health systems require not only urgent investment, but also commitments from developing countries to increase accountability and prioritize health in national and poverty reduction plans, and from donors to better coordinate aid. One example of lack of coordination given in the report is that of Viet Nam, where 400 donor missions visited in one year. Lack of coordination renders already fragile health systems even weaker. In an effort to tackle this problem in relation to health statistics, a wide range of partners has come together to form the Health Metrics Network, a global partnership designed to improve the availability and quality of health data and thus enhance accountability.

Reference: www.who.int/mediacentre/news/releases/2005/pr35/en/index.html

Final Report of the Review of Future Governance Arrangements for Safety and Quality in Healthcare

In July 2005, the Review of the Future Governance Arrangements for Safety and Quality in Healthcare reported to the Australian Health Ministers' Conference. The purpose was to advise Ministers on the future governance arrangements for leadership and national coordination of safety and quality in healthcare prior to the completion of the current term of the Australian Council for Safety and Quality in Healthcare, which finishes in June 2006.

Recommendations include: a new national safety and quality body should be established to succeed the current Australian Council for Safety and Quality in Healthcare; the work of the national body should have a safety and quality improvement focus across the continuum of healthcare; public reporting on the safety and quality of care should be used as a key driver for change; health ministers should determine the appropriate legal form/structure and agree that the new body be established as soon as practicable and transition arrangements should ensure a seamless changeover from the current Council.

The Review Team urges that priority number one be to establish new national governance arrangements for safety and quality improvement as a matter of urgency. For more information and to see the complete report: www.health.gov.au/internet/wcms/publishing.nsf/
Content/2D1487CB9BBD7217CA256F18005043D8
/$File/Safety and Quality.pdf

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