Patient Safety Awareness Week highlights the crucial role of all healthcare professionals in ensuring patient safety, addressing significant public health issues such as healthcare-associated infections and medical errors. Statistics reveal alarming rates of patient harm, with thousands of deaths and adverse events occurring annually, stressing the necessity for collaborative efforts in safety improvement. Ongoing initiatives like the Partnership for Patients have shown promising results in reducing hospital-acquired conditions and promoting a culture of safety within the healthcare system.

1. Patient Safety Awareness Week
Patient Safety Is a Public Health Issue
Jeff Brady, MD, MPH, Director, Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality (AHRQ), Rear Admiral, U.S. Public Health Service
Patrick Conway, MD, Deputy Administrator for Innovation & Quality, Chief Medical Officer,
Centers for Medicare and Medicaid Services
CAPT Arjun Srinivasan, MD, Associate Director for Healthcare Associated Infection Prevention
Programs, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
Tejal K. Gandhi, MD, MPH, CPPS, President and CEO, National Patient Safety Foundation
President and CEO, NPSF Lucian Leape Institute
Thursday, March 17, 2017

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Patient Safety Awareness Week Is Here
Thank you for the work that
you do!
Everyone in the health care
process plays a role in
delivering safe care
We are all united in the goal of
keeping patients and those
who care for them free from
harm

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Patient Safety Is a Public Health Issue
Learn more.
Download the
full PDF report
for free at:
www.npsf.org/
free-from-harm

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Patient Safety Is a Public Health Issue
 Harms caused during care involve
– Significant mortality and morbidity
– Quality of life implications
– Adversely affect patients in every care setting
 Not unlike obesity, airplane motor vehicle
crashes, breast cancer and other public health
imperatives

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Magnitude of Harm is Significant
 As many as 440,000 patient deaths annually
(James 2013).
 ~1 in 10 patients develops an adverse event
during hospitalization (AHRQ).
 ~1 in 2 surgeries had a medication error and/or
an adverse drug event (Nanji et al. 2015).
 >12 million patients each year experience a
diagnostic error in outpatient care (Singh et al.
2014).

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Solution Requires United Effort
 Work underway at the federal, state and local
levels
 Some important progress has been made
– Partnership for Patients initiative resulted in
~1.3 million reduction in hospital-acquired
conditions from 2011-2013
 More work to be done
– Everyone has a role to play in keeping patients safe
and free from harm

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We Are All Patients
Spread
the Word
Don a gown; snap
a pic; and share.
Add hashtags
#unitedforpatient
safety
#PSAW2016
Don’t forget to link
to NPSF!

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CAPT Arjun Srinivasan, MD
Associate Director for Healthcare Associated Infection Prevention
Programs
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention

10. What Is“Public Health?”
• Public health promotes and protects the health of
people and the communities where they live,
learn, work and play.
– While a doctor treats people who are sick,those of us
working in public health try to prevent people from
getting sick or injured in the first place.
• We work in close partnership with all stakeholders
to get this done.
• We work at the federal,state and local levels.
Source:Trust for America’s Health
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11. Approaching Healthcare-associated
Infections from the Public Health
Perspective
• We do NOT view healthcare-associated
infections as“someone’s fault”
• Nor do we view them as“an inevitable price of
medical care”
• We view healthcare-associated infections as
failures of a system.
– By making strategic improvements to healthcare
delivery processes,we can prevent infections
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12. Healthcare-associated Infections
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13. Michigan (103 ICUs)
Prevention of Central Line Associated
Blood Stream Infections
0
2
4
6
8
10
0 18
103 ICUs at 67
Michigan
hospitals, 18
months
BSIs/1000catheterdays
Pronovost et al,NEJM 2006
~ 70% prevented
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14. Prevention Happening; More Needed
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15. HAI Prevention Strategy
 Data
 NHSN
 Emerging Infections Program
 Partnerships
 Research
 Prevention Epicenters
 SHEPheRD
Prevented
Preventable
Prevention
approach
unknown
HAIs
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16. A National Program for Preventing
Healthcare-associated Infections
 Identifying best practices
 Education and training
 To implement those practices
 Measurement
 Research
 To expand implementation and develop new
interventions
 National goals
 National policies
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17. Healthcare Infection Control Practices
Advisory Committee (HICPAC)
Federal advisory
committee that provides
guidance regarding:
• Infection Control
• Strategies for
Surveillance
• Prevention
• Control of
healthcare-
associated
infections
• Antimicrobial
Resistance
• Any related events
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18. • Nation’s leading system to
track healthcare-
associated infections (HAI),
including antibiotic
resistance and antibiotic
use
• Vital for local,state, and
national HAI prevention
• Over 17,000 healthcare
facilities enrolled in all 50
states
• Allows targeted
prevention
National Healthcare Safety Network (NHSN)
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19. Prevention Epicenters
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20. The Next Critical Frontier in Healthcare-
associated Infections: Antibiotic Resistance
 Many healthcare-associated
infections are caused by bacteria
that are resistant to the antibiotics
we would like to use to treat them
 Antibiotic resistance has a major
impact on the health of the US
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21. Combating Antibiotic Resistance
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22. What Will it Take to Combat Antibiotic
Resistance?
 Ongoing efforts to prevent
infections and the spread of
resistant bacteria
 Better use of antibiotics
 Better tracking of resistance and
antibiotic use
 Better coordination and
collaboration
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23. A Coordinated Approach
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Jeff Brady, MD, MPH
Director, Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality (AHRQ)
Rear Admiral, U.S. Public Health Service

25. Unprecedented Reductions in Harm
and the Impact of this Improvement
Between 2010 and 2014:
• 17% reduction in rates of hospital-acquired conditions
• Over 2.1 million adverse events and infections averted in
hospitals
• 87,000 deaths averted due to reduced adverse hospital events.
► ~50,000 lives saved for 2011, 2012, and 2013 combined
► ~37,000 lives saved for 2014
• $19.8 billion in health spending savings
* National patient safety efforts save 87,000 lives and nearly $20 billion in 12/1/15 HHS press release: http://www.hhs.gov/about/news/2015/12/01/national-patient-safety-efforts-
save-lives-and-costs.html.
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26. Patient Safety in the United States:
National Progress, but Harm Persists
2010: 145 Harms/1000 Discharges
2011: 142 Harms/1000 Discharges
2012: 132 Harms/1000 Discharges
2013: 121 Harms/1000 Discharges
2014: 121 Harms/1000 Discharges
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27. Why is it so hard
to make health care safer?
• COMPLEXITY
► Health care delivery is complex (technical, organizational,
administrative, etc.)
• FLAWED SYSTEMS
► Health care systems (at all levels) are not designed to
optimize safety or to address systems-based problems
• INEFFECTIVE COMMUNICATION
► Poor Communication is a common contributor to patient
harm
• WEAK INCENTIVES
► The business case for patient safety is inadequate (but
improving)
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28. How AHRQ Makes a Difference
• AHRQ invests in research and evidence to
understand how to make health care safer and
improve quality
• AHRQ creates materials to teach and train
health care systems and professionals to
catalyze improvements in care
• AHRQ generates measures and data used to
track and improve performance and evaluate
progress of the U.S. health system
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29. AHRQ’s Patient Safety Priorities
• Causes of harm associated with health care
and understanding why it occurs and how to
prevent it
• Apply knowledge to accelerate patient safety
improvement in all health care settings
• Prevent HAIs, reduce antibiotic resistance
• Improve communication and engagement
among providers and between clinicians and
patients
• Build capacity in the health care system to
address safety issues 33

30. The Research Continuum:
Discovery to Implementation
Research
Testing &
Demonstration
Implementation
Measurement
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31. Patient Safety Tools and Training
• Patient Safety Culture
Surveys
• TeamSTEPPS® team
training materials
• Comprehensive Unit-
based Safety Program
(CUSP) toolkits to reduce
CLABSI, CAUTI, etc.
• Re-Engineered
Discharge (RED) tools to
reduce avoidable hospital
readmissions
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32. Three Domains of AHRQ’s
CARB*- Related Efforts
• AHRQ maintains a robust program of
research and implementation projects
aimed to:
o Improve the use of antibiotics through
antibiotic stewardship
o Interrupt the transmission of antibiotic-
resistant bacteria
o Prevent healthcare-associated infections
(HAIs) in the first place
* Combating Antibiotic-Resistant Bacteria
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33. What’s on the Horizon
• Diagnostic error
o IOM report, September 2015
o Area of growing concern in patient safety field
• Increased funding for ambulatory care patient
safety projects
• Continued focus on HAIs, including antibiotic
resistance through support of CARB effort
• Patient/provider communication and
engagement
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34. Funding Opportunities
• AHRQ supports investigator-initiated research
that addresses patient safety issues.
• Two recent opportunities focus on diagnostic
safety in all settings:
► Incidence and factors that contribute to diagnostic
failure
► Strategies and interventions to improve diagnostic
safety
• Other opportunities include: safe medication
use, health care simulation, and HAI
prevention.
www.ahrq.gov/funding
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35. AHRQ Patient Safety Network
(AHRQ PSNet)
• PSNet is a national “one-stop” portal of resources
for improving patient safety and preventing medical
errors
• Offers wide variety of information on patient safety
resources, tools, conferences, and more
http://psnet.ahrq.gov
http://webmm.ahrq.gov
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36. Looking Ahead: 2015 NPSF Report
• Free from Harm: Accelerating Patient Safety
Improvement Fifteen Years after To Err Is
Human
• Calls for total systems approach and
establishment of a culture of safety
• Recommendations build on current state of
health care, moving the field forward
• Aligns with AHRQ’s approach, understanding
how to make the system a safer place for
clinicians to practice and patients to seek
care
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37. Visit Our Web Site
www.ahrq.gov
www.ahrq.gov/professionals/quality-patient-safety/index.html 41

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Patrick Conway, MD
Deputy Administrator for Innovation & Quality
Chief Medical Officer
Centers for Medicare and Medicaid Services

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CMS support of health care Delivery System Reform will result in
better care, smarter spending, and healthier people
Key characteristics
 Producer-centered
 Incentives for volume
 Unsustainable
 Fragmented Care
Systems and Policies
 Fee-For-Service Payment
Systems
Key characteristics
 Patient-centered
 Incentives for outcomes
 Sustainable
 Coordinated care
Systems and Policies
 Value-based purchasing
 Accountable Care Organizations
 Episode-based payments
 Medical Homes
 Quality/cost transparency
Public and Private sectors
Evolving future stateHistorical state

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Improving the way providers are incentivized, the
way care is delivered, and the way information is
distributed will help provide better care at lower
cost across the health care system.
Delivery System Reform requires focusing on the way we pay
providers, deliver care, and distribute information
Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
}
“ {
Pay
Providers
Deliver
Care
Distribute
Information
FOCUS AREAS
“

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During January 2015, HHS announced goals for value-based
payments within the Medicare FFS system

42. 'Jaw-dropping': Medicare deaths, hospitalizations AND costs
reduced
1999 2013 Difference
All-cause mortality 5.30% 4.45% -0.85% (approx. 300,000
deaths per year)
Total Hospitalizations/
100,000 beneficiaries
35,274 26,930 -8,344 (approx. 3 million
hospitalizations per year)
In-patient Expenditures/
Medicare fee-for-service
beneficiary
$3,290 $2,801 -$489
End of Life Hospitalization (last
6 months)/100 deaths
131.1 102.9 -28.2
Sample consisted of 68,374,904 unique Medicare beneficiaries (FFS and Medicare Advantage).
Findings were consistent across geographic and demographic groups.
Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013; Harlan M. Krumholz, MD, SM;
Sudhakar V. Nuti, BA; Nicholas S. Downing, MD; Sharon-Lise T. Normand, PhD; Yun Wang, PhD; JAMA. 2015;314(4):355-365.; doi:10.1001/jama.2015.8035
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43. •Bold goal to dramatically improve patient
safety across the country
•Over $500 million investment
•Working with over 3700 hospitals
representing 80+% of patient admissions
across the country
•Measuring results, testing improvements, and
sharing of best practices
•Significant national improvements in patient
safety
Partnership for Patients (PfP)
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Partnership for Patients contributes to safety improvements
Ventilator-
Associated
Pneumonia
Early
Elective
Delivery
Central Line-
Associated
Blood Stream
Infections
Venous
thromboembolic
complications
Re-
admissions
Leading Indicators, change from 2010 to 2013
62.4% ↓ 70.4% ↓ 12.3% ↓ 14.2% ↓ 7.3% ↓
Data shows from 2010 to 2014…
87,000
2.1 million
PATIENT HARM
EVENTS AVOIDED
$20 billion
IN SAVINGS

45. 2010 to Interim 2014: 145 to 120 HACs
49
145 142
132 121 121 120
2.1 million fewer HACs $19.8 billion in costs averted
87,000 fewer HAC-related deaths

46. • Severe Sepsis and Septic Shock (mandatory)
• Clostridium Difficile, including antimicrobial stewardship
• Hospital-Acquired Acute Renal Failure
• Airway Safety
• Iatrogenic Delirium
• Procedural Harm (pneumothorax, bleed, etc.)
• Undue Exposure to Radiation
• Failure to Rescue
• Results Beyond the 40/20 Aims on HACs and readmissions
• Hospital Culture of Safety – Including Worker Safety
Partnership for Patients (PfP)
Leading Edge Advanced Practice Topics (LEAPT), 2013 - 2014
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48. HEN “1.0” (2011-2014) HEN “2.0” (2015-2016)
Awards 26 organizations 17 organizations
Geographic Coverage 50 states & Puerto Rico 50 states & Puerto Rico
Period of Performance 3 years 1 year (12 months)
An extension of the PfP model test is underway
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49. The innovative work of LEAPT has
continued to spread under PfP 2.0
HENs have proposed to work on
former LEAPT topics, including:
• Sepsis & Septic
Shock
• Clostridium difficile
(C. diff)
• Antibiotic
Stewardship
• Culture of Safety
including worker
safety
• Undue Exposure to
Radiation
• Failure to Rescue
HENs have proposed to add new
emerging topics to their repertoire:
• Pediatric Safety
• Early intervention for
mental health
• Safe diabetes
management
• Multi-drug resistant
organisms
• Expanded ADE sub-
topics (e.g. anti-
epileptics)
• Peripheral Intravenous
Infiltrations/Extravasati
ons
• Unplanned Extubations
• Pain Management
• …And more!
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53. Percentage of Hospitals Meeting Each Person and Family
Engagement Metric, July 2013 and November 2014
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54. Hospital Compare - Focus on Patient Safety
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55. • Patient safety is an essential component of CMS’s work. We
must prevent harm. We need your help.
• CMS is encouraging networks and their participants to seek
out opportunities for synergy, alignment, and collaboration
across the health care system in order to achieve impact for
patients and their families.
• Alignment of powerful forces is central to our proven ability
to generate breakthrough results.
• CMS is committed to collaboration and sustaining the work
on patient safety.
Moving Forward in Active Partnership
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Transforming Clinical Practice Initiative is designed to help
clinicians achieve large-scale health transformation
• The model will support over 140,000 clinician practices over the next four
years to improve on quality and enter alternative payment models
Phases of Transformation
• Two network systems will be
created
1) Practice Transformation
Networks: peer-based
learning networks designed
to coach, mentor, and assist
2) Support and Alignment
Networks: provides a system
for workforce development
utilizing professional
associations and public-
private partnerships

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 Eliminate patient harm
 Focus on better care, smarter spending, and healthier
people within the population you serve
 Engage in accountable care and other alternative payment
contracts that move away from fee-for-service to model
based on achieving better outcomes at lower cost
 Invest in the quality infrastructure necessary to improve
 Focus on data and performance transparency
 Test new innovations and scale successes rapidly
 Relentlessly pursue improved health outcomes
What can you do to help our system achieve the goals of Better
Care, Smarter Spending, and Healthier People?

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Submit A Question

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Visit Our New Interactive Website
www.UnitedForPatientSafety.org
Take the Pledge | Join a Discussion | Share Best Practices | Add Your Voice

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