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Pennsylvania Patient Safety Authority Issues Annual Report for 2008

The Authority attempts to measure the level of adoption of select process and safety practices by Pennsylvania's healthcare facilities and enhances its educational mission through its Patient Safety Liaison program

HARRISBURG, Pa., April 30 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority issued its 2008 Annual Report with survey information containing the level of adoption of some process and safety practices related to guidance published in Patient Safety Advisories and objectives established by national patient safety organizations.

"While experts agree it's difficult to measure patient safety, the Authority has attempted to establish a baseline through a survey after five years of collecting reports from Pennsylvania's healthcare facilities," Dr. Ana Pujols-McKee, chair of the Pennsylvania Patient Safety Authority said. "The results show facilities have adopted some practices to help improve patient safety, but in some other areas improvements can be made."

Pujols-McKee said the methodology behind the survey included input from Patient Safety Officers (PSOs) and patient safety practices defined by national organizations including: the Centers for Medicare and Medicaid Services Hospital-Acquired Conditions, the Joint Commission's 2009 National Patient Safety Goals and the National Quality Forum's Serious Reportable Events and Safe Practices for Better Healthcare. The survey included practices relevant to hospitals, ambulatory surgical facilities (ASFs), birthing centers and abortion facilities.

The safe practices surveyed were organized into five domains: Safety Leadership; Medication Safety; Safe Surgery; Infection Prevention; and Device Safety.

"In regard to safety leadership, our results show hospitals are doing pretty well in implementing cultures of safety that allow individuals within those facilities to voice their concerns if they don't like how an adverse event was handled, but there are still one-third of the hospitals that responded that have not adopted principles that provide a just culture," Pujols-McKee said. "Similar results were found for ASFs and other facilities."

Pujols-McKee explained that a "just culture" is one that does not punish individuals for honest mistakes or for reporting safety concerns and injuries. It also does not go to the opposite extreme by permitting repeated, intentional rule violations. A just culture seeks a middle ground that tries to find system or engineering solutions to reduce inevitable human errors, while holding individuals accountable for intentionally violating safety policies or procedures.

The majority of responding hospitals (70%) report some level of implementation of Just Culture principles, with 59% reporting full implementation hospital-wide. One-third of hospitals (30%) report that they have not yet implemented these principles. The Authority found similar results for ASFs and other facilities, with 72% reporting some level of implementation, while 28% have not adopted this approach.

Pujols-McKee said an important component of instituting a just culture is to ensure leadership in a facility shares the responsibility of providing the safest environment possible for patients. Senior leaders can demonstrate their leadership on safety by inviting PSOs to address their Board of Trustees and to make patient safety a standing item on a board agenda.

"Nearly half [47%] of participating hospital PSOs reported that they had attended four or more Board of Trustees meetings, while in one-third the PSO did not attend any," Pujols-McKee said. "ASFs had similar responses with forty-four percent reporting PSO participation in four or more board meetings and twenty-four percent reporting none. I think we can work with facilities to improve these numbers by educating leadership on safety and its relevance to their facilities."

All 525 Pennsylvania facility PSOs received the survey. A total of 200 facilities statewide completed the survey, including 118 hospitals (59%), 80 ambulatory surgical facilities (40%), one birthing center (0.5%) and one abortion facility (0.5%). For confidentiality reasons, the birthing centers and abortion facilities responses were combined with ASFs.

For the complete methodology behind the survey and results for all patient safety domains go to Page 11 of the 2008 Annual Report on the Authority's website at

Pujols-McKee said the Authority has begun educating Boards of Trustees and other senior leadership on patient safety through a program in conjunction with the Hospital and Healthsystem Association of Pennsylvania (HAP) and the American Hospital Association (AHA). The program was designed for senior leadership and board members to engage them in patient safety issues. Four pilot sessions have been funded by the Authority with the expectation that the program will be delivered statewide once feedback from the pilot sessions is obtained.

"The boards of trustees education program is a top priority of the Authority's mission to ensure all individuals from the top on down participate in making their facilities safer for patients," Pujols-McKee said. Our first pilot session was successful and we anticipate the next three will garner the same positive response and action needed to make real changes to improve patient safety."

Pujols-McKee said another educational component begun in 2008 by the Authority is the Patient Safety Liaison (PSL) program. Led by the Director of Educational Programs, the PSL program gives facilities a consultant with whom they can discuss patient safety issues and receive educational materials based upon Pennsylvania data. A PSL was hired in the northeastern part of the state August 2008 with two others on board for the northwest and south central regions by July 2009. The full complement of six PSLs is projected for FY 09-10.

"We know from our annual user survey that facilities find the information in our Patient Safety Advisories useful [98%], relevant [97%], readable [99%], high in scientific quality [97%] and high in educational value [99%]," Pujols-McKee said. "We also know that over sixty-two percent of PSOs surveyed have made or plan to make changes based upon the guidance. What our PSL program is here to do is help more facilities implement that guidance and find out what else the Authority can provide to help them make process changes in their facilities."

Pujols-McKee added that so far facilities in the northeast have given feedback that has provided two new educational sessions for facilities on methicillin-resistant Staphylococcus aureus (MRSA) and basic patient safety principles behind Act 13 of 2002. These sessions will be available to facilities statewide once all PSLs are in their regions.

For more information on the Patient Safety Liaison program and other Authority educational activities go to Page 80 of the 2008 Annual Report.

Another important component of the Authority's mission is to help facilities define what should or should not be reported. In the 2007 Annual Report, the Authority discussed at length variations in reporting by facilities. Potential explanations for the disparity include differences in Act 13 interpretations, facility case mix, varying levels of facility cultures of safety and potential over-reporting and under-reporting.

Pujols-McKee said the Authority's board of directors has been working with the Department of Health to improve reporting standardization through a guiding principals document. The document has been published in the Pennsylvania Bulletin for public comment. The Authority's board is taking the comments into account while modifying the guiding principals document. The Authority will forward the document to the Department of Health that will need to approve and implement the guidance as the regulating agency. The Authority, in turn, will provide education and training to healthcare facilities based upon the guidance.

For more information on the standardization reporting project go to Page 55 of the 2008 Annual Report.

Providing education and training for Act 52 of 2007 (healthcare-associated infection law) to Pennsylvania's healthcare facilities and nursing homes is also a priority for the Authority, according to Pujols-McKee. Hospitals began reporting healthcare-associated infections through the Centers for Disease Control and Prevention's National Health Surveillance Network (NHSN) in February 2008. By law, the Authority, Department of Health and Pennsylvania's Healthcare Cost Containment Council (PHC4) receive the data to fulfill each agency's mission.

By law, Pennsylvania nursing homes must also report healthcare-associated infections to the Authority for analysis.

"The Authority has been working with its HAI Advisory Panel made up of infection experts from across the state to develop the reporting requirements for nursing homes," Pujols-McKee said. "We recently began a pilot reporting program for nursing homes and we expect all nursing homes to be reporting healthcare-associated infections in June."

The Authority also unveiled a new website recently with a tagline representing its mission "Analyzing, Educating and Collaborating for Patient Safety."

"Throughout last year, the Authority has made significant progress on the priorities outlined in its strategic plan," Pujols-McKee said. "Through the measurement survey and the PSL program we should be able to gauge how much progress facilities are making in implementing real change in their institutions. Feedback gathered during these facility visits will also help the Authority tailor its educational activities to best support the ongoing patient safety efforts made by facilities."

The complete Annual Report for 2008, as well as additional information about the Patient Safety Authority is accessible on the Authority's website,

SOURCE Pennsylvania Patient Safety Authority
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