How GE, Rhode Island and SAS are collaborating to lead a revolution in patient safety

By Joanne Dooley, Jean Marie Rocha, Patricia Daughenbaugh, Kathy Martin and Cindy Berry

Nearly 100,000 Americans die each year due to medical errors and many more are injured, according to the Institute of Medicine. Change has been slow since the IOM first reported these statistics more than a decade ago. There are many examples of individual hospitals making inroads across specific issues, yet it remains that widespread improvement in patient safety is hard, and traction elusive.

The Hospital Association of Rhode Island (HARI), an advocacy organization for hospitals, co- led the initiative with William Cioffi, MD, Surgeon-in-Chief at Rhode Island Hospital. Hospitals in the Ocean State have demonstrated a continued commitment to improving the safety and quality of patient care. Past accomplishments have included statewide adoption of a uniform surgical protocol and creation of the Rhode Island ICU Collaborative, an initiative that has successfully reduced the incidence of infections in critical care units.

An executive steering committee was formed with representatives from HARI and 13 Rhode Island hospitals, including chief nursing officers (CNOs), quality/risk managers and IT personnel.

A critical need for standardized reporting
The key issue for the executive steering committee was transparency - improving the way in which data on adverse events was being reported, analyzed and utilized to reduce patient harm.  A critical component in achieving transparency on a statewide scale was to have all Rhode Island hospitals implement the same medical event-reporting technology and standardize their reporting criteria. At that time, the hospitals used a variety of manual and electronic methods to track adverse events. Also, event definitions differed widely from institution to institution. Even if hospitals were to find a way to share data with one another, there would be little common ground for analysis and interpretation.

Having a standardized reporting platform was important for another reason. Rhode Island was in the process of creating a statewide patient safety organization (PSO). PSOs were established by Congress in 2005, and are administered by the Agency for Healthcare Research and Quality (AHRQ). A PSO is a protected central repository that enables health care providers to report data on adverse and near-miss events without risk of liability. This "safe harbor" environment encourages the sharing of information so that institutions can uncover and correct the systemic factors that undermine patient safety. In order for the PSO to be effective, a standardized event-reporting system that could be used by all hospitals to populate the repository was needed.

Compliance and accountability
The executive steering committee assessed a number of event-reporting systems and selected the Medical Event Reporting System (MERS) software from GE Healthcare. This Web-based system met three key criteria: it was easy to use so hospital personnel would be more likely to enter data, improving compliance; its routing function sent reports automatically to managers and administrators, improving the speed of follow-up; and its color-coded dashboard gave managers clear visibility into the status of each event inquiry, improving transparency for each organization.

Knowing that a standardized reporting platform using advanced technology and innovative processes was critical for the next phase, the PSO and GE collaborated with SAS to develop the GE Healthcare PSO technical capability. Hosted in a secure environment at SAS' OnDemand Center in Cary, North Carolina, the PSO's Web access, reporting and analytics will help hospitals identify and isolate factors that contribute to adverse events, such as administering the wrong medication or wrong-site surgery. By addressing common, preventable adverse events, a health care setting can become safer, thereby enhancing the quality of care delivered.

Benefits emerge early
A PSO board has been established - with experience in many areas of health care and other industries - to offer broader insights on safety  Currently, the GE Healthcare PSO has member facilities in the states of Illinois and Rhode Island, with plans to expand nationally. 

Project teams made up of staff from member hospitals are contributing to the standardization effort and overseeing implementations at the individual organizations in Rhode Island. As the standardization effort progresses, clear benefits are emerging for the hospitals even before the final work is completed. Among them:

• Better communication. The process is improving communication channels among the hospitals.  Prior to this initiative, communication channels were limited.
• Shared learning. By arriving at a common language to talk about patient safety and track events, the hospitals are able to share information and learn from one another more quickly and effectively.
• Accelerated implementation. Rhode Island's group initiative uses a structured approach and a detailed timeline, which has forced timely decision making and is allowing for rapid implementation.