A new tool helps individual practices evaluate the safety and quality of their care.
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| Mary A. Pittman |
“We will not achieve even close to the level of quality and safety we need in the United States,” said health policy analyst Lucian Leape, M.D., in a BusinessWeek article (“The Best Medical Care in the U.S.,” July 17, 2006), “as long as we have individual practitioners and hospitals doing individual things.”
Much effort has gone into improving safety in hospitals as a result of the 1999 report by the Institute of Medicine, To Err Is Human, a call to reduce the incidence of errors in medicine. Although the report focused on acute care, it also addressed patient safety in the ambulatory environment.
The Health Research and Educational Trust (HRET), along with the Institute for Safe Medication Practices (ISMP) and the Medical Group Management Association (MGMA) Center for Research, received funding from the Commonwealth Fund in 2005 to examine patient safety issues in physician offices.
Errors in Ambulatory Care
In the past seven years, improvement efforts have focused on the inpatient environment because of the high costs associated with that level of care. It is also easier to employ efforts in a contained setting where the patient is present for multiple days and the caregivers are more easily identified. But the bulk of health care is delivered in physician practice settings, where less is known about error rates and potential safety and quality challenges.
Documented evidence shows that adverse events in primary care occur frequently and can be avoided. For example, of every 1,000 outpatients taking a prescription medication, 90 will seek medical attention because of a drug complication. And a study by MGMA and COPIC, a large physician liability insurer in Colorado, found that lost test results create a risk to patient safety and quality of care, even more so than drug interactions or office-based surgery.
In ambulatory care, many medical errors are due to complex logistics: A number of sites and players are involved in the care process, and insufficient infrastructure exists to adequately support communications, information retrieval and sharing, and decision-making. This lack of infrastructure and decision support is particularly acute in the smaller physician practices that make up the majority of care providers in the United States.
A New Safety Assessment Tool
To help individual physician practices measure safety and quality processes, HRET, ISMP and MGMA joined to create an assessment instrument, the Physician Practice Patient Safety Assessment (PPPSA). A similar tool was developed for the acute care setting by HRET and ISMP in 2001 and revised in 2004. The PPPSA was designed with input from a national panel of patient safety experts from all health care disciplines, along with a working group of advisory members from academia, clinical practice, quality and safety organizations, and other fields. It can be accessed free at www.physiciansafetytool.org.
The PPPSA has been distributed to a representative group of medical practices, and preliminary analyses are being used to construct a baseline of the current state of patient safety in medical group practices. It is well positioned to further raise awareness of several best practices for patient safety and provides anonymous benchmarking for organizations and the physician practice community.
Features and Uses of the PPPSA
The PPPSA, the first comprehensive assessment of the ambulatory setting, was designed for use by a multidisciplinary team of administrators, physicians, nurses and technicians within individual practices to assess six domains related to care:
- medications;
- handoffs and transitions between providers or settings;
- surgery, anesthesia and invasive procedures;
- personnel qualifications and competencies;
- practice management and culture; and
- patient education and communication.
The self-assessment includes 80 individual items under these six domains. The multidisciplinary team discusses the items and evaluates the practice’s success in implementing them. The team checks one of five boxes on the assessment to indicate the level of implementation for each item: responses range from “no activity to implement” to “partially implemented in the practice for some areas” to “fully implemented in the practice for all areas.” Once the self-assessment is completed, a score is developed for each domain, and an overall score is compiled.
Data collected from the PPPSA will be used to identify the highest priority areas for training materials and other tools. Preliminary data indicate that there is ample opportunity for improvement in all of the six domains. Only two domains--surgery and invasive procedures, and management and culture--had more than 50 percent of the respondents reporting that the assessment items were fully implemented.
From the experience of HRET and ISMP in developing these and other safety tools, we have identified four kinds of materials and tools that improve safety systems:
- documented practices that improve reliability, safety and quality;
- turnkey programs demonstrated to change clinical practice and reduce errors;
- assessment guides to evaluate information system solutions; and
- effective ways to inform and educate patients about their role in the care process.
Information Technology in Physician Practices
As in acute care, information technology will contribute to higher quality and safety in ambulatory settings, but it will take more time. According to the National Ambulatory Medical Care Survey, only an average of 17.6 percent of physicians reported using electronic medical records in their office-based practices, and that percentage has not increased significantly between 2001 and 2003. Larger and more affluent practices and those affiliated with health maintenance organizations were more likely to use the technology.
The PPPSA may prove a useful tool to examine the systems changes that are necessary to effectively implement information technology in physician practices. In addition, a workbook to compare practices against a national database as well as fee-based customized reports will be available at www.physiciansafetytool.org.
Better Access
Consumers have become more engaged and educated about their decision-making in health care. With greater transparency and access to comparative data on hospital quality available, it is just a matter of time before they demand the same or greater levels of information about their physician practices.
With the PPPSA and subsequent work, efforts will continue to improve care in the physician office practice, ensuring the delivery of safe health care to all patients in all settings.
Mary A. Pittman, Dr.P.H., is president of the Health Research and Educational Trust.
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This article 1st appeared on October 31, 2006 in HHN Magazine online site.
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