Patient safety is defined by the Institute of Medicine (IOM) as “freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur.”

Problems in patient safety were documented by the IOM in its 1999 report, To Err is Human. Since that time, all sectors of the healthcare system have been called upon to reduce medical errors and harm to patients. The IOM reports that 44,000 to 98,000 people are killed each year from inpatient medical errors alone, and the Kaiser Family Foundation found that 42 percent of consumers and 35 percent of physicians say they or a family member has experienced a medical error that caused a “serious health consequence.” According to the IOM’s Preventing Medication Errors report, hospitalized consumers may experience at least one medication error per day. It is estimated that 40 percent of medication errors are the result of inadequate reconciliation during transitions of care, resulting in harm to approximately 20 percent of consumers.

Developing a Safety Mindset

In 2001, the IOM released Crossing the Quality Chasm: A New Health System for the 21st Century. It pointed to the systemic problems in healthcare that lead to poor outcomes: uncoordinated organization within the delivery system; fragmentation in care delivery that slows care and removes a sense of personal accountability; poor communication and use of information technology; and failure for all health professions to work together to ensure that care is appropriate, timely and safe.

The report suggested ways to reinvent the health system through six aims for care: safety, timeliness, efficiency, effectiveness, equity and patient-centered. Crossing the Quality Chasm began the discussion of long-term healing relationships in healthcare and the need to create an overall culture of safety.

URAC is an organization upon which patient safety is the basis for all accreditation modules. Nearly all of the standards pertain to patient safety. The case management standards require that medication safety be assessed for each patient involved in the program. This identifies whether consumers are taking the right drug at the right dose and at the right time. It assesses the consumer’s knowledge of side effects and reason for taking the medications. And it evaluates the need for a referral for medication reconciliation. This process helps avoid omissions, duplications, harmful drug interactions and dosing errors.

In 2003, URAC issued a report, Patient Safety Capabilities of UM Organizations. Its findings showed that medical management organizations have untapped resources which could be used to promote patient safety, including the oversight role of clinical encounters; direct patient interface through case management and disease management; data infrastructure and guidelines and algorithms to identify unanticipated events.

Accreditation’s Contribution to Patient Safety

URAC’s previous studies of medical management programs and preferred provider organizations showed that many of them had some approaches to tracking or managing patient safety problems. However, these efforts were not universal or specifically focused on patient safety. For example, the indicators, or triggers, that flag a case for further investigation vary considerably from organization to organization, as do follow-up actions. Data from an earlier URAC medical management survey showed that accredited organizations had adopted the following approaches to addressing patient safety:

• Sentinel events tracking or flagging. Events may include nosocomial infections, injury and/or error in inpatient settings or in-patient admissions indicating an out-patient failure (e.g. diabetic ketoacidosis, coagulation therapy).
• Medication assessments (based on patient reported or electronic data). Assessments may address errors – contraindicated or inappropriate medications, interaction assessment, dose evaluation and refill tracking.
• Adherence to treatment guidelines. Programs compare requested treatments to guidelines to conduct assessment of appropriate medications, assessment of sequencing and appropriateness of diagnostic tests or treatment procedures and assessment of appropriate monitoring (e.g., eye, foot, blood exams).
• Discharge planning issues. Discharge activities could include home/physical safety assessment (e.g., falls, nutrition, physical safety, coordination of follow up regarding medications and clinical care).
• Interventions. Passive approaches to address identified patient safety problems by tracking events, or active programs such as reporting of trends or individuals to facilities or to purchasers, provider counseling, network de-selection of facilities or providers, channeling patients to quality providers.

Accreditation requires that written policies and/or documented procedures clearly delineate the various possible decision points and steps in the process used to address potential or known safety issues through to resolution. The various possible decision points and next or final steps are listed below:

• A potential safety issue needs to be referred to another entity or authority in order to determine if it is a safety issue.
• A potential safety issue needs to be researched by the organization in order to determine if it is a safety issue.
• A known safety issue is referred to another entity or authority for further action.
• A known safety issue is referred internally within the organization for further action.

Organizations have risen to the challenge and implemented mechanisms to increase patient safety. One such organization, CarePartners Plus, LLC, recently received a Best Practices award for its program, Charting a Path to Patient-Centered Quality & Cost Improvements. CarePartners’ Wellby System™ uses a process that enables 100 percent of the patient population to provide feedback on their experience at the point of care. The data is available to the organization in real-time and complements high-performing continuous improvement programs by offering a functional means to indicate levels of self-management and medical professionalism.

Other approaches that organizations have adopted to address patient safety include:

• Creating formal committees or programs to assess patient safety issues separate from the quality management program.
• Conducting patient safety studies.
• Addressing patient safety in the quality management process.
• Tracking/information system that has the capability to flag possible problems with patient safety (e.g., unexpected return to operating room, complications, extended length-of-stay or other sentinel events).
• Tracking patient safety indicators by physician or by facility.
• Contacting providers or facilities who appear to have high rates of possible patient safety problems.

By collecting information and reporting it back to the appropriate parties – contracted providers as well as regulators – health management organizations become a part of a closed-loop system that creates a culture of safety. In this collaborative manner, and without being punitive, organizations can to move consumer safety forward so that everyone is taking a role in the process, and everyone benefits.

Benefits of Achieving Accreditation

1. Accreditation serves as a valuable supplement to licensure and regulation.
   • URAC works in collaboration with state and federal regulatory agencies to provide the best outcomes for consumers.
   • Accredited companies keep pace with leading standards for healthcare operations and patient care more readily because standards are updated every two to three years.
   • While state regulations for healthcare may vary, accreditation standards are consistent across jurisdictions. This creates a level playing field and ensures that consumers receive consistent quality oversight no matter where they live.
2. Accreditation inspires healthcare organizations to make meaningful improvements in their operations.
   • Accreditation encourages operational efficiencies that often improve results and reduce costs for healthcare companies.
   • URAC reviewers report significant improvements over the course of the accreditation process. Reviewers apply their vast experience conducting reviews to educate accreditation applicants about improvements they may not have considered before.
3. Accreditation organizations collect and analyze data on the state of the healthcare industry that can help consumers and employers make decisions about their healthcare.
   • Many URAC-accredited organizations are required to report to URAC on a set of performance measures. URAC uses this data to create public reports to support informed decision making by consumers and employers.
   • URAC requires measurement reporting for case management, pharmacy benefit management and wellness and developed new consumer-focused measures for health plans.
   • URAC maintains a directory of accredited organizations available to the public at www.urac.org. URAC also produces quarterly reports for state regulatory agencies on companies that have failed to maintain their accreditation.
4. Consumers can rest assured that the participating providers in their health plan have been vetted and appropriately credentialed.
   • URAC requires that participating providers be re-credentialed every three years and that current providers be listed in the provider directory. These credentialing reviews include a provider’s history of education and professional training, license history, professional liability claims history, any prior loss of privileges and prior disciplinary activities. In some cases, a hospital may revoke or restrict a doctor’s practice privileges, but the physician will not be disciplined by his or her state medical board. In fact, according to a report by the consumer advocacy group Public Citizens, 55 percent of doctors in that position never had any action taken against them.
   • Even in incidences where loss of privileges does not result in sanctions from a professional board, URAC-accredited companies consider loss of privileges before listing a physician in the provider directory.
   • Most important, URAC-accredited health plans are required to continuously monitor their provider networks and take action as necessary, such as suspending providers, investigating patient safety events and monitoring timely access to care from treating providers. Mechanisms to address this include monitoring complaints, promoting access to care by arranging for specialty care when the network does not have available providers, and evaluating the outcome of care delivered, such as readmission rates or avoidable events.
   • Case management organizations can provide feedback to health plans on their ancillary providers regarding delays in discharge planning, home care adherence to the visit schedule and availability of providers to accept new patients in outpatient settings, such as mental health, hospice and specialty pharmacy. Case managers are in the unique position to capture consumer complaints and report those to the health plan.

Taking action to enhance service delivery is essential for promoting patient safety. Through its Health Care Stars! Awards program, URAC recognizes individual healthcare professionals who deliver on the mission of protecting and empowering consumers and promoting quality care. One such individual is Pat DeFransisco, a registered nurse with 35 years of experience who is the product manager for catastrophic case management at Coventry. Under her guidance, Coventry’s catastrophic case management program has become a successful, award-winning program that provides the structure, resources and support necessary to navigate the industry’s most challenging clinical events.

As healthcare reform reshapes the industry, the demand for quality improvement programs and quality outcomes is increasing in the marketplace. URAC’s Community Pharmacy Accreditation Program is being developed in response to the need to differentiate community pharmacies that engage in patient counseling and education, medication therapy management and quality initiatives that improve care and reduce overall costs. This new accreditation seeks to improve quality, efficiency, patient safety and outcomes, while contributing to lower costs.

URAC also is developing a new accreditation product, Clinically Integrated Networks, in response to the increase in physician practices across the country joining together to enhance the quality of care by negotiating with payers as a network and responding to health plans’ requests for quality data. This program will focus on the integration of ambulatory primary and specialty care – specifically IPAs and multispecialty group practices – and could extend to pharmacies and community resources. This product is viewed as a building block to full accountable care organization models.

Resources on Patient Safety

For more resources on patient safety, use the links below. URAC also invites organizations to submit information that will assist in identifying feasible and effective approaches to improve patient safety. More general information on patient safety is available from the following sources:

• Agency for Healthcare Research and Quality – www.ahrq.gov/qual/errorsix.htm
• The Leapfrog Group – www.leapfroggroup.org
• The National Patient Safety Foundation – www.npsf.org
• Institute of Medicine – www.iom.edu/Global/Topics/Quality-Patient-Safety.aspx

About URAC

URAC, an independent, nonprofit organization, promotes healthcare quality through its accreditation, education and measurement programs. URAC offers a wide range of quality benchmarking programs and services that provide a symbol of organizational commitment to quality and accountability.

 

Christine G. Leyden, RN, MSN, is URAC’s Senior Vice President and GM Client Services and Chief Accreditation Officer. Leyden has been with URAC since 2001 and has served as an accreditation reviewer and the director of accreditation. Maureen Ryan, MS, a communications professional with more than 20 years of experience, joined the URAC team in December 2011 and manages the communications and marketing department.