Quality & Patient Safety

Overview

Quality & Patient Safety

December 8, 2008

CHA is committed to helping hospitals improve quality, reduce medical errors and adverse events, and maximize patient safety.

CHA’s vision is an “optimally healthy society.” CHA’s goal is for “every Californian to have equitable access to affordable, high-quality, medically necessary health care.”

California Hospital Engagement Network

Overview

California Hospital Engagement Network
Working to reduce patient harm by 40 percent and readmissions by 20 percent by the end of 2013

February 11, 2012

The U.S. Department of Health and Human Services has provided $218 million to 26 state, regional, national, or hospital system organizations to form hospital engagement networks and further advance the Partnership for Patients initiative. CHA is a subcontractor to Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association. Each hospital engagement network is focused on 10 clinical areas, as well as leadership and culture, to accelerate the quality improvement and patient safety initiatives already under way in hospitals. Hospitals will collaborate both locally and nationally across the various hospital engagement networks to adopt new practices that have the potential to reduce inpatient harm by 40 percent and preventable readmissions by 20 percent by the end of 2013. It is an important undertaking that, when achieved together, promises greater benefit to patients and communities.

California Hospital Patient Safety Organization

Overview

California Hospital Patient Safety Organization
Trusted leadership in patient safety

December 8, 2008

One of the first and largest PSOs in the nation, the California Hospital Patient Safety Organization (CHPSO) is a trusted leader in the analysis, dissemination and archiving of patient safety information. CHPSO offers unmatched access to the emerging best practices of hundreds of hospitals.

Complimentary membership is available to California Hospital Association and regional hospital association members.

CHA News Article

CHA Members Receive Free PSO Membership with CHPSO

June 6, 2013 Rory Jaffe

Next year, hospitals with more than 50 beds will be required, under a provision of the Affordable Care Act (ACA), to contract with a patient safety organization (PSO) in order to participate in a health insurance exchange plan. While the law mandates compliance by Jan. 1, 2015, health plan contracts begin Jan. 1, 2014, meaning hospitals effectively need to have a contract with a PSO in place by the beginning of 2014. An article in today’s HealthLeaders Media highlights the need for early action.

For members of CHA and the regional hospital associations, the California Hospital Patient Safety Organization (CHPSO) meets the ACA-mandated requirement and is free. CHPSO membership offers hospitals extensive legal protections, data collection and analysis, pooled expertise, education programs and in-depth patient safety resources. CHPSO also offers the formal agreement required by law to meet hospitals’ security and confidentiality requirements, so it is important that hospitals join CHPSO if they haven’t already. For more information about CHPSO, contact Executive Director Rory Jaffe at rjaffe@chpso.org; visit the CHPSO website at www.chpso.org; or view CHPSO’s membership list www.chpso.org/member-listing.

CHA News Article

CHPSO Continues Monthly Causal Analysis Learning Series

May 28, 2013 Rory Jaffe

Most hospitals are acquainted with root cause analysis (RCA) and have conducted the process many times in the 17 years since the Joint Commission first required its use to investigate sentinel events. Improper use of RCA — a type of event investigation used to identify why adverse events occur and how to prevent them — can render the process not only useless but harmful if the underlying issues are not correctly identified and addressed. Too often quality and safety professionals are given little guidance or training on conducting an effective causal analysis. To help members implement their own RCA process, CHPSO is offering a complimentary, five-part webinar learning series.

CHA News Article

CHPSO Offers Insight to Affordable Care Act PSO Mandate

May 9, 2013 Rory Jaffe

The California Hospital Patient Safety Organization (CHPSO) invites CHA members and non-members to join Executive Director Rory Jaffe, MD, MBA, as he helps demystify one of the Affordable Care Act’s (ACA’s) least-understood mandates during a free webinar May 21, 11 a.m. – noon (PT). Health insurance exchanges, a key component of the ACA, will require most participating hospitals to:

Report to a patient safety organization (PSO);
Utilize a patient safety evaluation system (PSES); and
Implement a comprehensive discharge program.

CHA News Article

Vanguard Awards Presented at CHPSO’s Second Annual Meeting

April 19, 2013 Rory Jaffe

Patient safety organizations (PSOs) were created to facilitate the protected collection and analysis of incident data to identify and create safer delivery of quality care to patients. PSOs will only be successful in this mission if they have active engagement and submission of incident reports from their member hospitals. During the California Hospital Patient Safety Organization (CHPSO) Second Annual Meeting held April 8 and 9, Executive Director Dr. Rory Jaffe presented CHPSO’s Vanguard Awards to members who exemplify the necessary follow-through by submitting incident data and consistently participating in patient safety initiatives and learning opportunities. The four recipients of the 2012 Vanguard Award are:

John Muir Health – Accepted by Dr. Roy Kaplan, executive medical director, quality and safety
NorthBay Healthcare Group – Accepted by Mary Dickey, director, accreditation and licensure, patient safety & privacy
St. Joseph Health – Accepted by Machelle Theel, director of clinical excellence
Sutter Health – Accepted by Teresa L. Wallace, MSW, CPHRM, CPHQ, director of healthcare risk

CHPSO extends its appreciation to these organizations for their commitment to helping eliminate preventable patient harm.

CHA News Article

CHPSO Annual Meeting to Feature Hospital Engagement Network Facilitators

March 21, 2013 Rory Jaffe

The California Hospital Engagement Network (CalHEN) will present a breakout session at the California Hospital Patient Safety Organization’s (CHPSO) Second Annual Meeting, April 8-9 in Sacramento. As part of the session, CalHEN facilitators, who work one-on-one with individual hospitals, and representatives from hospitals across the state will discuss their success in reducing patient harm in various clinical areas. Areas covered will include adverse drug events, catheter-associated urinary tract infections, central line-associated blood stream infections, injuries from falls and immobility, obstetrical adverse events, pressure ulcers, preventable readmissions, surgical site infections, venous thromboembolism, and ventilator-associated pneumonia.

Infection Control

Overview

Infection Prevention

August 21, 2009

Health care-associated infections (HAIs) constitute a risk to patients and health care facilities. Estimates indicate that 240,000 patients admitted to California hospitals annually develop HAIs, contributing to the suffering associated with illness and increasing costs to the health care system by approximately $3.1 billion. Literature suggests that a significant proportion of HAIs can be eliminated with intensive surveillance and prevention programs. CHA supports decreasing the number of HAIs through a deliberate and systematic approach that addresses infection-control program infrastructure and oversight. CHA also supports the public reporting of meaningful, scientifically valid information related to HAIs. The most prevalent HAIs (approximately 80 percent) are urinary tract infections, surgical-site infections, ventilator-associated pneumonia and central-line blood stream infections.

The HAI Advisory Committee – created by SB 739 (Chapter 526, Statutes of 2006) — recommends methods for preventing and reporting HAIs to the California Department of Public Health.

CHA News Article

CDC Updates Guidelines for Evaluating Illness Related to MERS-CoV

June 17, 2013 BJ Bartleson

The Centers for Disease Control and Prevention (CDC) has issued a notice to health care providers updating guidelines for evaluating the severe respiratory illness associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). To date, all cases have a direct or indirect link to one of four countries: Saudi Arabia, Qatar, Jordan and the United Arab Emirates. No cases have been reported in the United States. Recommendations and guidance on MERS-CoV are available at the CDC MERS website.

CHA News Article

CDPH Issues AFL on Novel Coronavirus Alert
Middle East Respiratory Syndrome Coronavirus confirmed in several countries

June 7, 2013 BJ Bartleson

The California Department of Public Health (CDPH) has issued an All Facility Letter (AFL) informing health facilities of recent reports of health care associated transmission of a novel coronavirus, known as Middle East Respiratory Syndrome Coronavirus (MERS-CoV). In addition, the U.S. Department of Health and Human Services has determined the virus is potentially a significant public health emergency justifying an emergency use authorization by the FDA for in vitro diagnostics to detect it. Person-to-person transmissions have been identified in multiple countries. Since May, a total of 21 cases have been confirmed, nine of which were fatal. To date, no cases of MERS-CoV have been identified in the United States. See the attached AFL for patient evaluation, infection control guidance and laboratory biosafety precautions. More information is also available from the Centers for Disease Control and Prevention.

CHA News Article

Multistate Outbreak of Hepatitis A Linked to Frozen Berry Blend Product
Public health alert issued by CAHAN

June 5, 2013 BJ Bartleson

The California Department of Public Health (CDPH), in collaboration with the Centers for Disease Control and Prevention, is investigating a multistate outbreak of hepatitis A. The outbreak, which has been linked to consumption of Townsend Farms’ organic antioxidant blend of frozen berries sold by Costco, has reportedly infected 34 people in five western states with acute hepatitis A; almost half have been hospitalized. Costco is notifying its members who have purchased the product since late February. Individuals who have consumed the product and aren’t already immune due to prior illness or vaccination may benefit from post-exposure prophylaxis if it can be provided within two weeks of exposure. CDPH has published the attached hepatitis A post-exposure prophylaxis guidance for health providers. Also attached are front and back images of the packaging labels.

CHA News Article

FDA Allows Importing of Parenteral Nutrition Drugs

June 5, 2013 BJ Bartleson

The U.S. Food and Drug Administration (FDA) announced late last week that injectable drugs used in total parenteral nutrition (TPN) and currently in critical shortage will be imported into the U.S. and available to patients immediately. The shortage of parenteral nutrition drugs experienced in the U.S. since late 2012 is largely the result of the voluntary shutdown of American Regent/Luitpold, a major manufacturer of injectable nutrition drugs. The company decided to cease operations temporarily to address quality issues that included particulate matter in its products. Other U.S. manufacturers of TPN components are now working to increase supplies to further offset the supply shortage. More information is available at the FDA’s website.

CHA News Article

CDPH Issues Call for Cases: Candidemia Among Injection Drug Users

May 23, 2013 BJ Bartleson

The California Department of Public Health (CDPH) requests reports of any isolation of Candida among injection drug users from blood cultures since March 1. The Oregon Public Health Division is investigating a cluster of Candidemia (defined as any Candida species isolated from blood) cases in Lane County, Oregon, among injection drug users between October 2012 and April 2013, with one case including endocarditis. Three of the Candidemia cases have occurred since March 6.

While the investigation is ongoing, interim data show that patients were intravenously injecting “black tar” heroin as well as methamphetamine. The Candida species identified to date are C. albicans and C. pelliculosa. CDPH acknowledges concerns about additional cases, specifically along the I-5 drug traffic route from Mexico. Reports and questions about the issue can be directed to Allison.Stone@cdph.ca.gov.

Pay for Quality Reporting/Performance

Overview

Pay for Quality Reporting/Performance

December 8, 2008

Pay for performance is an emerging movement — in which providers are rewarded for the quality of their health care services — among health plans and insurers (the Centers for Medicare & Medicaid Services and others). Some programs are initially providing financial incentives to participate in quality reporting. However, the overall movement focuses on financially rewarding high quality patient care or financially penalizing poor quality of care. The CHA Board has adopted a partial payment or non-payment policy related to billing for preventable adverse events that are under the control of the hospital.

CHA News Article

IRF, LTCH Quality Program Recordings Available

July 27, 2012 Patricia Blaisdell Alyssa Keefe

Recordings of recent conference calls held by the Centers for Medicare & Medicaid Services on the quality reporting programs for inpatient rehabilitation facilities (IRFs) and long-term-care hospitals (LTCHs) will be available July 30 through Aug. 1. Facilities may access the calls by dialing (855) 859-2056, and using conference IDs 13189170 for IRFs and 13198135 for LTCHs. As mandated by the Affordable Care Act, IRF and LTCH quality reporting programs will begin Oct. 1.

Public Reporting of Quality Data

Overview

Public Reporting of Quality Data

December 8, 2008

CHA supports a single, meaningful reporting system of quality data that allows transparency and enhances accuracy. Consumer groups, health plans and payers continue to push for more public disclosure of hospital quality. CHA remains supportive of transparency if the measures are scientifically based, valid and accurate.

CHA News Article

CHA Provides Support for Hospitals to Improve HCAHPS
2013 Webinar Series

January 15, 2013

Hospitals are invited to participate in a series of complementary webinars on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which accounts for 30 percent of each hospital’s score in the Medicare Value-Based Purchasing program. The webinars are scheduled monthly, January through August 2013. In addition, hospitals will be able to participate in one in-person workshop to receive and share tools as well as promising practices and strategies to measure patients’ experience of care, compare and report on performance and improve quality of care. Two workshops are planned — one in Northern California and one in Southern California. However, exact dates and locations are not yet finalized. CHA is able to provide all California hospitals with this support due to a grant from AHRQ/HRET Patient Safety Learning Network. For details on the webinar series and how to participate, see attached flyer.

Recording

CDPH’s Website on HAI Reporting Webinar CD
Improved website, fresh data on HAI, validation process update

October 9, 2012

Webinar Recorded Live October 9, 2012

In mid-August, CDPH released their most recent data on HAI reporting through an improved website. This website presents the material in a more user-friendly format and groups the reporting hospitals into like categories for a more balanced analysis and comparison. Learn about changes to the website, recent release and analysis of HAI data, and what it says about the performance of California hospitals to date.

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Quality & Patient Safety