Issue: Quality & Patient Safety Initiatives

Overview:
While health care delivery has always focused on quality, recent developments on both a national and a regional level are forcing clinical quality to the forefront as a critical issue confronting health care providers. The great impetus for this increased focus arose out of the seminal studies published by the Institute of Medicine (IOM). First, the 1999 "To Err Is Human" study estimated that nearly 98,000 deaths occur annually from preventable hospital mistakes or mishaps. The second study, "Crossing the Quality Chasm" outlined principles and guidance for redesigning structures and processes within an environment in which health care organizations and professionals function. NJCTH members have embraced this roadmap and work within their organizations and with external stakeholders such as PRONJ, DHSS, NJCQI to realize substantial improvement throughout New Jersey.

The National Quality Forum (NQF):
The National Quality Forum (NQF) was established in late 1999 to facilitate widespread healthcare quality improvement by, among other things, endorsing national healthcare quality performance measures and designing a national quality of care measurements and reporting system. In response to a request from the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, NQF began work on promulgate national voluntary consensus standards for hospital care performance measures in 2001. Thirty nine measures have been disseminated and are intended to promote both public accountability and quality improvement. Additionally, NQF has released the "Safe Practices for Better Healthcare" report. This publication overviews 30 practices that have been demonstrated to be effective in reducing the occurrence of adverse health care events. To read more about the National Quality Forum, access www.qualityforum.org.

Leapfrog Group:
Composed of more than 135 public and private organizations that provide health care benefits, The Leapfrog Group works with medical experts throughout the U.S. to identify problems and propose solutions that it believes will improve hospital systems that could break down and harm patients. Representing approximately 33 million health care consumers in all 50 states, Leapfrog provides important information and solutions for consumers and health care providers.

The Leapfrog Group focuses on the quality of certain aspects of care relevant to urban area hospitals. Patients are usually in fragile health when in the hospital and the consequences of preventable medical mistakes can be serious.

Medical mistakes in hospitals can range from receiving an incorrect procedure or prescription to being served a meal that violates dietary restrictions set by the patient's physician. The problem is not carelessness, but that highly qualified people are working under stress in a setting with many complex processes. Those processes could be improved to reduce avoidable errors.

Hospitals are already taking important steps to ensure patients' safety. Based on overwhelming scientific evidence, The Leapfrog Group decided to focus on three practices that have tremendous potential to save lives by reducing preventable mistakes in hospitals:

           1. Computer physician order entry (CPOE)
           2. Evidence-based hospital referral (EHR)
           3. ICU physician staffing (IPS)

While these steps will not prevent all mistakes in hospitals, they are a vital first effort. If these practices are implemented, they could prevent a substantial number of hospital deaths caused by preventable mistakes every year.

To read more about the Leapfrog Group, access www.leapfroggroup.org.

**Excerpts taken from the Leapfrog Group's website

Current Action by NJCTH:
The Council supports the Leapfrog initiative and is in the process of implementing all of Leapfrog's recommendations. To improve patient safety and health outcomes in New Jersey, we must continually improve the care we provide to our patients as well as focus on responding to patients' needs. This will require the leadership and commitment of senior executives, trustees, physicians, nurses, and all others who work in our organizations. Without this leadership, neither change nor progress will not occur. NJCTH also supports legislation that mandates reporting of all adverse reactions as called for by JACHO. The Council is also working with the NJ Department of Health and Senior Services to improve Medicare outcomes.

For more information:

From Sister Organizations:
American Hospital Association Website
PRONJ - The Healthcare Quality Improvement Organization of New Jersey, Inc.
New Jersey Health Care Quality Institute
The National Quality Forum