Pennsylvania Patient Safety Authority Issues Annual Report for 2012

HARRISBURG, Pa., April 30, 2013 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority issued its 2012 Annual Report highlighting increases in its educational programs where attendance grew 70 percent since last year with nearly twice the number of individuals participating in its free educational sessions offered by its Patient Safety Liaison (PSL) program. 

"One of the Authority's main objectives is to educate Pennsylvania's healthcare providers so they can prevent adverse events from happening to patients," John Bulger, D.O., MBA, chair of the Pennsylvania Patient Safety Authority said. "Through the PSL program Pennsylvania healthcare facilities have taken advantage of the educational sessions and guidance in Pennsylvania Patient Safety Advisories."

"In an annual survey of Patient Safety Officers, PSO's responding said they made over twelve hundred process changes based upon these educational programs and Advisory guidance. That's twice as many process changes than in previous years," Bulger added. 

The PSL program began in August 2008. Overseen by the Authority's Director of Educational Programs, each PSL has between 60-80 healthcare facilities that they meet with regularly to ensure the PSOs are aware of the valuable resources available to them from the Authority and other patient safety leaders.

"Due to the increased demand for the Authority's educational sessions and materials, the Authority hired two additional Patient Safety Liaisons last year," Bulger said. "The PSLs develop their educational programs through feedback received from the facilities.

"Educational programs offered last year include a full-day conference where facilities can select from four different curriculums such as root cause analysis and just culture for a deeper dive into those topics," Bulger added. 

For more information on the Authority's educational programs go to Addendum D in the 2012 Annual Report at www.patientsafetyauthority.org. To view more results of the 2012 Annual User Survey, go to Addendum G.

Bulger said the Annual Report also highlights the Authority's new strategic plan which enhances the projects and programs begun by the Authority in the last several years.

"In developing the next strategic plan, the Authority took several steps to ensure over seventy stakeholders were involved in the process for determining what the Authority's objectives would be for the next several years," Bulger said. "From the various discussions, critical issues surfaced. Some are issues the Authority has confronted before and others are new issues that have arisen in recent years."

Five critical issues identified by the Pennsylvania Patient Safety Authority Board of Directors are:

• How can we best measure the Authority's effectiveness in improving patient safety?
• How do we bring consistency to reporting among the Authority, the Pennsylvania Department of Health and healthcare facilities?
• How do we mutually engage patients and providers in patient safety?
• How do we strategically align ourselves with healthcare providers and trends critical to patient safety?
• How do we learn to effectively influence facilities and providers to implement our recommendations?

Bulger said that with each critical issue are several directives the Authority has developed through discussions with stakeholders to determine the most efficient path for effectively achieving the Authority's mission of improving patient safety within Pennsylvania healthcare facilities.

"This next strategic plan requires more collaboration and outreach with others within the healthcare community to make progress on issues like how to engage patients and families more in their healthcare," Bulger said. "Also, in order to have more consistency to reporting among the Authority, the Department of Health and Pennsylvania healthcare facilities, a common ground will need to be established through further discussions with all parties involved."

Bulger said some of the meetings have already begun, but success in achieving these initiatives will be varied and depend greatly on the willingness of all stakeholders involved to come up with a resolution.

For more detailed information on the Authority's new strategic plan, go to Addendum F in the 2012 Annual Report at www.patientsafetyauthority.org.

Bulger said the Authority's collaborative efforts with Pennsylvania healthcare facilities are also highlighted in the 2012 Annual Report.

Through a U.S. federal program called "Partnership for Patients," the Authority has joined with the Hospital and Healthsystem Association of Pennsylvania and has received approximately $1.6 million for a two-year program to focus on initiatives to decrease falls, wrong-site surgery and adverse drug events statewide. Other healthcare organizations collaborating in the Pennsylvania Hospital Engagement Network (HEN) include the Healthcare Improvement Foundation, Quality Insights of Pennsylvania and the Pennsylvania Health Care Quality Alliance.

"Approximately one hundred and thirty Pennsylvania hospitals are participating in the HEN project," Bulger said. "Goals of the project are to help hospitals achieve a forty percent reduction in preventable harm and a twenty percent reduction in preventable readmissions."

Another Authority collaboration involves 11 ambulatory surgical facilities working to improve the preoperative screening and assessment of patients in ASFs.

"The Authority used a statewide needs assessment of ASFs completed in 2011 to identify potential contributing factors to same-day cancellations of procedures and transfers to acute care," Bulger said. "This information was used to develop a screening and assessment process based on best practices in the northeast region of Pennsylvania."

"The ASF collaboration is expected to conclude this year," Bulger added.

For more information about the Authority's collaboration efforts in hospitals and ASFs go to Addendum E of the 2012 Annual Report at www.patientsafetyauthority.org.  

Other Highlights of the Authority's 2012 Annual Report include:

2012 Detailed Overview of Data Reported Through PA-PSRS

Between January 1 and December 31, 2012, Pennsylvania acute care facilities submitted 235,249 reports through the Pennsylvania Patient Safety Reporting System (PA-PSRS). To date, over 1.8 million reports have been submitted through PA-PSRS. Approximately, 3.4 percent were Serious Events (events that caused harm), while 96.6 percent were Incidents or near-misses (events that did not cause harm).

"Overall, facilities increased reporting by almost three percent in 2012," Bulger said. "ASF reports increased over seven percent from last year. The Authority attributes the increase to the PSL program educating ASFs on the importance of reporting."

For more details about the Authority data and breakdowns by event type, gender and age groups go to Addendum B of the 2012 Annual Report at www.patientsafetyauthority.org.

Nursing Home Healthcare Associated Infection Data

Nursing homes in Pennsylvania submitted a total of 32,257 infection reports through PA-PSRS in 2012; a 1.5 percent decrease from the 32,761 submitted in 2011.

In 2010, the Authority began its "Long-Term Care Best Practice Assessment Project" to identify best practices in nursing homes demonstrating successful infection prevention efforts; to collaborate with facilities with high infection rates to remove barriers to implementation of evidence-based practices; to provide education and best practice strategies to nursing homes reporting high infection rates; to study the impact and correlation of various levels of implementation of infection control best practices on nursing homes' infection rates; and to assess patterns of care that could be targeted for improved quality.

"Last year, the Authority published Advisory articles showing the results of their study," Bulger said. "Follow up interviews of the nursing home facilities were conducted to determine if the facilities used the Long-Term Care Best Practice Assessment Tool developed by the Authority."  

"This three-year project is expected to conclude this year with another Advisory article," Bulger added.

For more information about the nursing home data and prevention efforts go to Addendum H of the 2012 Annual Report at www.patientsafetyauthority.org.

Summaries of Selected 2012 Advisory Articles

The Pennsylvania Patient Safety Authority distributes its Pennsylvania Patient Safety Advisory to more than 5,700 program affiliates (i.e., acute healthcare facilities, nursing homes, board and panel members in Pennsylvania) as of December 31, 2012.

As part of an ongoing effort in conjunction with the Authority, the Pennsylvania Medical Society provides web-based continuing medical education (CME) credit to physicians who complete its Studies in Patient Safety: Online CME Cases. The articles included in this online publication are first published in the Advisory. The Authority selects articles for submission to the society based on the frequency and severity of the patient safety issue, the availability of known solutions to the problem, and the topic's relevance to a physician audience. The Authority develops the CME questions that accompany the articles as posttests.  

"In 2012, fourteen Advisory-based CME activities were available from the society," Bulger said. "Physicians passed over twenty-four hundred posttests associated with the fourteen activities and obtained over twenty-one hundred credits.

"The number of posttests passed by physicians and resulting credits in 2012 are the greatest, respectively, in a calendar year since the Authority's efforts with the society began in 2006," Bulger added.

In 2012, the Authority published four quarterly issues and one supplement, containing 35 articles. Topics of articles include: The Role of the Electronic Health Record in Patient Safety Events, Patients Taking Their Own Medications While in the Hospital, The Breadth of Hospital-Acquired Pneumonia: Nonventilated vs. Ventilated Patients in Pennsylvania, Survey of Ambulatory Surgical Facility Preoperative Screening Processes in Pennsylvania, Falls Risk Assessment: A Foundational Element of Falls Prevention Programs and Responses to the Authority's Potential Recommendations to Prevent Wrong-Site Surgery.

For more information about the Pennsylvania Patient Safety Advisory, go to Addendum C of the 2012 Annual Report.

The complete Annual Report for 2012, as well as additional information about the Patient Safety Authority, is accessible on the Authority's website www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority