CHPSO: Dedicated to Eliminating Preventable Harm and Improving the Quality of Health Care Delivery in California Hospitals

On September 27, 2010, Rory Jaffe, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (555 KB). Free PowerPoint® Viewer (Plugin Software Help).

Slide 1

CHPSO: Dedicated to Eliminating Preventable Harm and Improving the Quality of Health Care Delivery in California Hospitals

Rory Jaffe, MD MBA

Executive Director

California Hospital Patient Safety Organization

Slide 2

About CHPSO

• Created by California Hospital Association
• Not-for-profit
• Small (1.5 employees), planning to grow

Slide 3

To Err is Human

• PSOs are a direct response to report's recommendations:
  • Collect standardized information nationwide.
  • Develop voluntary reporting.
  • Extend peer review protections to data related to safety and quality improvement.
  • Develop a culture of safety.

Slide 4

Begin with the End in Mind

• What should our system look like?
  • Safety data is a "first class citizen" and ubiquitous.
    • Systems involved in the normal course of care produce most of the data (e.g., the EHR)
    • For each patient, we know whether they are getting the right care.
    • Compatible with HIE (health information exchange).
  • Information and knowledge is freely exchanged.
• How do we start?
  • Embrace standards whenever possible.
  • Avoid manual entry and rework whenever possible.
  • Encourage networking and sharing.

Slide 5

Reality Check

• No standard incident report system:
  • Vendor-specific systems.
  • Terminology varies, even within same vendor (for some vendors).
  • Work flow varies.
  • Scope varies:
    • Initial report, analysis, mitigation, outcome.
    • Types of events included.
    • Handling of legal issues.
• Change is expensive:
  • Integration of new system into infrastructure.
  • Personnel time for retraining

Slide 6

Baby Steps

• If providers don't participate, we cannot move towards our goal.
• Provide the lowest possible hurdle for participation:
  • No completeness standards.
  • Data collection and analysis is only one of our tools and may not be the most important.
    • We're not in the business of "counting stuff".
• Encourage providers to migrate to standards-compliant systems.

Slide 7

Current Status

Slide 8

Activities

• 160 member hospitals in CA, NV, AZ.
• Strong Web presence ~4,000 page views/month.
• Widely distributed newsletter and alerts 1,700 recipients.
• Group calls with specific case discussions.
• In-person discussions—shared challenges.
• Harvesting local expertise.

Slide 9

Alliances

• Specialized organizations/PSOs:
  • Brings specific expertise.
• Generalized PSOs:
  • Greater reach for rare issues.
  • Faster knowledge spread.
• Regulators:
  • Shared goals but different toolkits.
• Other provider types:
  • Shared problems.

Slide 10

Data Collection

• Starting up:
  • Waited for electronic standards from AHRQ.
  • Standards were for PSO-NPSD communication, not provider-PSO communication.
    • Develop standards provider-PSO.
  • Adapting provider systems to send in formatted data.
• Some providers are changing event reporting collection methods.

Slide 11

Challenges

• Legal uncertainty—interaction with other laws.
• Trust—preservation of confidentiality in the face of increased communication.
• Chaotic improvement environment:
  • Patient safety fatigue.
  • Measure reporting fatigue.
• Cost.
• Unproven value.
• Clients have widely varying needs and sophistication.

Slide 12

Contact Information

CHPSO
Dedicated to eliminating preventable harm and improving the quality of health care delivery in California hospitals

Rory Jaffe rjaffe@calhospital.org
Http://www.chpso.org/