September / October 2005
NEWS ITEMS FROM SOURCES WORLDWIDE
Pulse
World Health Organization Partners with Joint Commission and Joint Commission International to Eliminate Medical Errors Worldwide
Recognizing that healthcare errors seriously harm 1 in every 10 patients around the world, the World Health Organization (WHO) has designated the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission International (JCI) as the world's first WHO Collaborating Centre dedicated solely to patient safety. This action is aimed at reducing the unacceptably high numbers of serious medical injuries around the world each day.
"The most important knowledge in the field of patient safety is how to prevent harm from happening to patients during treatment and care," says Sir Liam Donaldson, MD,İchair of the World Alliance for Patient Safety, who traveled to Washington, D.C., in late August to launch the Centre. "The belief that one day it may be possible for the clinical error suffered by a patient in one part of the world to be a source of transmitted learning that benefits future patients in many countries is a powerful force behind the work of the Collaborating Centre and the WHO World Alliance for Patient Safety."
"Together, we can measurably strengthen and improve patient safety worldwide by spreading proven practices without regard to borders or other barriers that frequently exist in the international arena," says Dennis S. O'Leary,İMD,İpresident, Joint Commission.
The collaboration among the Joint Commission, JCI, and WHO will focus worldwide attention on patient safety and best practices that can reduce safety risks to patients and coordinate international efforts to spread these solutions as broadly as possible. This will be accomplished by collaborating internationally with ministries of health, patient safety experts, national agencies on patient safety, healthcare professional associations, and consumer organizations.
The Joint Commission International Center for Patient Safety, which was launched earlier this year by the Joint Commission and JCI, will operationalize this effort by forging partnerships with leaders in both developing and developed countries to identify healthcare safety needs and match these with proven solutions and best practices.
Source: Joint Commission on Accreditation of Healthcare Organizations
Australian Council for Safety and Quality in Health Care: Final Report Provides Solid Platform for New Era
The Australian Council for Safety and Quality in Health Care presented its 6th and final report to health ministers in late July. Ministers also discussed new future national governance arrangements to improve safety and quality in healthcare.
Council Chair, Professor Bruce Barraclough, noted that the Council's achievements include the development of procedures to improve surgical safety; incident management systems in all states and territories including a national system for reporting, collection, analysis and correcting the causes of severe adverse events; programs to improve medication safety including a single national medication chart; and the development of national standards in relation to open disclosure and for credentialing and defining the scope of clinical practice, as well as hospital based, patient safety risk management plans.
Other major Council initiatives that will continue to have a long-term benefit for the Australian community include the development of a National Centre for Research Excellence in Patient Safety and the development of a National Patient Safety Education Framework to define the competencies needed at all levels of the system to meet this agenda.
The Safety and Quality Council was set up in 2000 supported by all Australian Health Ministers. The Council was originally established for five years with an agreed extension until June 2006. Since its establishment, the Council has worked closely with all states and territories, health and human services departments and the private sector, to improve the safety and quality of healthcare.
Barraclough said the Council was extremely proud of the work it had led and the enthusiasm for improving patient safety and quality that has been engendered in the healthcare system. "Working with all involved in healthcare, the Council has put in place a solid platform of reforms to help improve safety and quality in the Australian healthcare sector," he said. "Whilst we are achieving a lot in the context of an increasingly complex system and more sophisticated treatment options, there still remains much to be done. A future national authority will be able to build on and benefit from the extensive platform of work that has been put in place by the Australian Council for Safety and Quality in Health Care. This is about the difficult task of going from good to even better in one of the world's better health systems."
The Council's 6th Annual Report to Australian Health Ministers, Achieving Safety and Quality Improvements in Health Care, together with information on other Council initiatives and resources, are available from the Council's Web site at www.safetyandquality.org.
Source: Safety & Quality Council
National Project Launched to Reduce Surgical Complications
In an effort to improve surgical care in hospitals nationwide, a partnership of leading public and private healthcare organizations in the United States has launched a project to reduce surgical complications by 25% by the year 2010.
Surgical complications can take a measurable toll on a patient's health and safety, extending treatment and leading to longer hospital stays. The Surgical Care Improvement Project or SCIP (pronounced "skip") is designed to provide hospitals, physicians, nurses, and other caregivers with effective strategies to reduce four common surgical complications: surgical wound infections, blood clots, perioperative heart attack, and ventilator-associated pneumonia. The strategies are based on the best available science and will be refined and improved as new scientific information becomes available.
Hospitals were asked to join SCIP at the American Hospital Association's Health Forum meeting in San Diego on July 28. SCIP is one of the first national quality improvement initiatives to unite national hospital, physician and nursing organizations; the federal government; the organization that accredits hospitals; and private sector experts in far-reaching quality improvement and patient safety efforts.
"One reason SCIP is so important is because of the partnership," said Mark B. McClellan, MD, PhD, administrator, Centers for Medicare & Medicaid Services, one of 10 national organizations spearheading SCIP. "The only way to get to a better healthcare system is if we're all working together with efforts that are led by health professionals — the surgeons, the anesthesiologists, the registered nurses, the other health professionals, and hospitals. They are absolutely critical elements to the success of quality improvement. The reason that CMS is such a strong supporter of SCIP is because it has such broad involvement and leadership from health professionals."
SCIP focuses on process measures, such as the appropriate use of antibiotics near the time of surgery and the use of beta blockers to prevent cardiovascular events.
The SCIP Partnership includes the Agency for Healthcare Research and Quality, American College of Surgeons, American Hospital Association, American Society of Anesthesiologists, Association of periOperative Registered Nurses, Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, Institute for Healthcare Improvement, Joint Commission on Accreditation of Healthcare Organizations, and Veterans Health Administration.
For more information about SCIP, please visit www.medqic.org/scip.
Source: American Hospital Association
Documentary on Patient Safety to Air on Public Television
Good News: How Hospitals Heal Themselves, a documentary film about how two large American hospital systems have significantly reduced errors, infections, waste, cost, deaths, and suffering, will be available on public television stations in November.
The report explains how more than 40 Pittsburgh hospitals and the SSM hospital system in the Midwest have used system management principles and Toyota production methods to teach healthcare workers — including doctors, nurses and administrators — to see their work with "new eyes." This allows them to identify problems, eliminate blame and waste, and practice continual improvement.
The doctors, nurses, and administrators frankly discuss the errors and infections caused by increasing complexity and improved medical technology in hospitals as well as the difficulties of treating sicker patients who are staying fewer days. They say that "working harder," "doing their best," and repeating what worked last year does not solve patient safety problems, which continue to increase.
Implementing systems management, the documentary says, can begin immediately in any hospital and does not require funds or action from the federal government or insurance companies. The only requirements are leadership, focus on perfect patient safety, and systems thinking.
Source: www.ManagementWisdom.com
First Global Harmonization Workshop for Blood Services
At the end of a day-and-a-half conference on global harmonization, sponsored by America's Blood Centers (ABC) and the European Blood Alliance (EBA) in Quebec City in August, participants agreed that it is time to take steps toward harmonizing at least some standards for blood and blood components worldwide to advance patient safety.
ABC leadership suggested that a combined effort could immediately focus on the leading causes of transfusion-related adverse events and fatalities. More than 150 people participated in the first-of-its-kind conference, held in conjunction with ABC's summer membership meeting. They included blood bankers from the United States, Canada, Europe, and Australia; regulatory and other government officials from U.S. Food and Drug Administration, Canada and Europe; regulatory consultants; and representatives from the device, drug, and plasma fractionation industries. Hema-Quebec, whose CEO, Francine Decary, MD, is president of the International Society for Blood Transfusion, served as host.
With the increase in travel and the widespread use of advanced technology, transfusion medicine has gone global. Blood services around the world have been dealing with increased potential threats to blood supplies, such as variant Creutzfeldt-Jakob disease (vCJD), the human form of mad cow disease, and have had to make numerous decisions as to how to keep supplies safe.
"Decisions made by individual countries have become 'contagious' and tend to spread around the world because of local political pressures and the lack of a common and scientifically-based decision making process," said ABC Executive Vice President Celso Bianco, MD, who chaired the workshop's program committee. Dr. Bianco said that examples of local decisions with global implications include measures to prevent transmission of vCJD by transfusion; the exclusive use of male plasma in England to prevent transmission of transfusion-related acute lung injury (TRALI), and the preparation of "B19 safe" cellular components in the Netherlands.
Recommendations from roundtable discussions included a proposal to set up a Blood Harmonization Forum, with the participation of a range of stakeholders including patient representatives; a proposal to initiate a work group of blood collectors to identify early goals and to define a process; and a suggestion to develop a model based on the NATO Blood Alliance.
Leaders from Europe also expressed hope that harmonization among blood services will lead to better treatment for patients, not only in developed countries, but also in those with struggling healthcare systems. "It's [harmonization] about safety and quality and ensuring that science makes a proper contribution," said EBA President Martin Gorham. "The fact that it also offers an opportunity for us to help developing countries is very powerful."
Founded in 1962, America's Blood Centers is North America's largest network of community-based blood programs. Seventy-seven blood centers operate more than 600 collection sites in 45 U.S. states and Canada, providing half of the United States, and all of Canada's volunteer donor blood supply. ABC's U.S. members are licensed and regulated by the U.S. Food & Drug Administration. Canadian members are regulated by Health Canada.
The European Blood Alliance (EBA) is the network of national blood organizations, which provide a substantial part of blood services in the European Union Member States and some other European countries.
Source: America's Blood Centers
eHI Foundation Releases National Report on Health Information Exchange Efforts
The majority of state, regional and community-based health information exchange initiatives are already beginning to exchange electronic healthcare data, and they identify funding as the major barrier in their collaborative effort to connect for faster, safer, and better quality healthcare, according to a study released today by the eHealth Initiative Foundation (eHI).
The study is the first of its kind to report trends in health information exchange. eHI's survey of health information exchange collaborators takes the pulse of progress of the more than 100 multi-stakeholder efforts across the country, representing initiatives in 45 states and the District of Columbia. The study shows that these state, regional, or community efforts are rapidly advancing through the steps necessary to electronically exchange health information in an effort to improve healthcare quality and safety and healthcare savings while preserving the security of individual healthcare information.
The survey was conducted by the eHealth Initiative Foundation with support under a cooperative agreement with the Health Resources and Services Administration Office of the Advancement of Telehealth of the Department of Health and Human Services.
The survey analyzed data from 109 responses from health information exchange efforts across the country. Respondents were asked to identify their stage of development within a range of six clearly defined stages. Forty-four respondents said they were still within the early stages of development (between stages 1 and 3). Sixty-five identified themselves as being in the advanced stage of development (between stages 4 and 6). Among those in the latter stages, 25 HIE efforts described themselves in the fully operational - a significant uptick from a 2004 eHI assessment of only nine operational HIE efforts nationwide.
We saw a dramatic increase in the level of interest in and activity related to HIE in regions across the country, said Janet Marchibroda, chief executive officer of eHI. A number of new HIE efforts have emerged over the last year and survey results show that these efforts have matured considerably with respect to engagement of key stakeholders, organization and governance, functions and services offered, and the development and execution of technical infrastructure to support their efforts.
The eHI Foundation survey results will be made available to eHI members, the general public and several public and private sector bodies, including the Agency for Healthcare Research and Quality National Resource Center for Health Information Technology. The latter is supporting leaders using health information technology to promote patient safety and quality through over 100 grants and contracts.
Since 2003, the eHealth Initiative Foundation has been working with leaders at the state, regional, and community levels to build multi-stakeholder collaborations focused on mobilizing healthcare information across organizations to improve the quality, safety, and efficiency of care.
The eHealth Initiative and its Foundation are independent, non-profit affiliated organizations whose missions are the same: to drive improvement in the quality, safety, and efficiency of healthcare through information and information technology. For more information, go to http://www.ehealthinitiative.org.
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