Early in 2008, the Oregon Patient Safety Commission (OPSC) a semi-independent state agency challenged the state to develop the safest healthcare system in the nation. The Commission wants to have complete information on how well the state is doing in providing safe care. So far, the indices either look at individual components such as adherence to known best practices or they are bundled into large aggregate quality measures, but there has not been enough focus exclusively on safety.
In November 2008, the Commission published a report that addressed hospital safety in six critical areas. For each area, the Commission established a baseline that explains where the state is now and what is needed to be done by the end of 2010.
The Commission made their initial benchmarks and summary of findings concerning hospital measures in terms of:
- Outcome measures—are the hospitals eliminating preventable harmful events? The Commission looked at the number of retained objects accidentally left after surgery or a procedure. Fifty such events occurred in Oregon hospitals in 2007
- Safe practice measures in terms of using evidence-based best practices and the percentage of hospitals that have implemented three specific best practices to eliminate surgical site infections. Seventy five percent of Oregon patients currently receive optimal care
- Risk assessment measures in terms of the number of hospitals that actively share data with the Commission and the learning that resulted from the experience. Thirty nine out of fifty five participating hospitals with 110 reports received have shared adverse event data since the program began in 2008
- Culture safety measures and the need for a culture that supports learning and improvement. The Commission looked at the number of hospitals that routinely monitor their safety culture in terms of learning from adverse events. Currently 80% of Oregon’s hospitals report using such a survey
- Patient empowerment and the need for patients and consumers to play an active role. This can be measured in terms of the number of hospitals that actively encourage their patients to report patient safety concerns. Eighty seven percent of hospitals reported that they have mechanisms in place
- Connectivity measures and the ability to create a connected system of care with progress going towards implementing electronic medical records. Oregon’s hospitals average score is 2.25 and this means that Oregon ranks 17th in the nation
Overall Oregon hospitals are doing a good job in addressing patient safety issues but as the report shows, more work is needed. In the coming months, the Patient Safety Commission will publish separate benchmark reports for nursing homes and for ambulatory surgery centers.
For more information, go to www.oregon.gov/OPSC.
