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Adverse Event and Near Miss Reporting-Benchmarks Do Exist: A Review of Benchmarks and Best Reporting Practice from the National Aggregate Medical Error Database (401)
Dr. Thomas G. Lunquist, MD MMM
Many people operate under the assumption that national benchmarks in adverse event reporting do not exist and that voluntary reporting cannot and is not successful. Often heralded as the blueprint for healthcare, The Aviation Safety Reporting System has collected about 400,000 incident reports since they began collecting them in 1998. Does a comparable database exist in the United States for all types of medical errors (adverse clinical, administrative, falls, and medication/infusions events)?
Our work with over 200 healthcare facilities of all types (acute care hospitals, long term care facilities, ambulatory surgery centers, and primary care offices) has yielded one of the largest adverse event and near miss reporting databases in the country (over 100,000 adverse events and near misses in less than years time) and its lessons are many. Over 95% of the reports are filed by named individuals and the reporting rates often increase by 10 to 15-fold when the right cultural elements are addressed and leadership takes an active role in very specific ways.
Disease Management: The Theory (402)
Dr. Sandeep Wadhwa, MD MBA
In today's difficult economic times, many organizations -- from commercial payors to the federal government -- need ways to cut medical utilization and related costs while maintaining services to people with chronic illnesses.
A disease management program that utilizes a variety of methodologies can help control and lower certain, significant medical costs while improving participant health outcomes. This is especially important for organizations that serve people with chronic diseases because people with a "chronic illness cost 3.5 times as much to serve as all others," according to The Robert Wood Johnson Foundation, "A Portrait of the Chronically Ill in America, 2001."
Shared Visions-New Pathways: The Joint Commission's New Accreditation Process (403)
Linda S. Murphy-Knoll, MN
As part of its own continuous improvement initiative, the Joint Commission launched a review and dramatic redesign of it's accreditation process. This session will include Shared Visions - New Pathways and its key elements, including the Periodic Performance Review, Priority Focus Process, and Tracer Methodology. It will also include discussion of initial feedback from organizations that have gone through the new process and information on the pilot process for unannounced surveys.
Lessons Learned about Staffing Effectivness: The Quality Assessment and Research Connection (404)
Lee Ann Hanna, MSN RN CPHQ
So your staffing effectiveness data didn't show any relationships between your human resource and clinical indicators? Are you sure? Join this speaker as she reviews the staffing effectiveness experience at a large, tertiary care hospital and join the discussion as she asks the question, "Are simple performance improvement tools sensitive enough to pick up on relationships between complex staffing effectiveness indicators?"
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