Hospitals treat the sick and injured. But they can be dangerous places. A unit of the Health and Human Services Department aims to reduce the harm to the patient and health care workforce by 50%. So it’s set up a dashboard that aggregates safety information. Craig Umscheid, director of the Center for Quality Improvement and Patient Safety for the Agency for Healthcare Research and Quality, joined the Federal Drive with Tom Temin for details.

Interview transcript:

Tom Temin: And give us a sense of what it is you’re trying to do here. I mean, how widespread is hospital and injuries to patients and health care? It’s a really big country with a lot of hospitals.

Craig Umscheid: Most of us who have been patients in hospitals or have had family members as patients in hospitals know that hospitals can be a dangerous place and all types of safety events can occur from healthcare-associated infections like getting a central line associated bloodstream infection, where medication safety errors that may occur at the hospital. So there are many studies, particularly recent studies, that suggest up to 25% of hospital admissions have these safety events occurring. And what we’re trying to do at the Agency for Health Care Research and Quality is address these safety events and reduce them.

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Tom Temin: And how do you get the information nationally, globally on this? I mean, do hospitals, are they required to report infections or how do you know what’s going on?

Craig Umscheid: Yeah, it’s a great question. So we set up this national health care safety dashboard to allow us to track our progress on improving safety over time. And the dashboard includes data from a number of different data sets. So some of those data sets are from our agency. And they’re looking at patient safety indicators, for example, adverse events that might occur in the course of a surgery or procedure such as increased bleeding, which you may not expect, or acute kidney injury, which you may not expect. Some of the data comes from hospitals who report safety measures to insurers like Medicare in order to get reimbursements. And so some of those safety measures are measures like do you have infections when you get a hip transplant or a knee replacement? Other measures are measures from hospital staff who complete surveys about the safety aspects of their environment. So, for example, do their supervisors support a culture of safety? Do they have enough staff in their health care setting to provide safe care? So the measures really come from different data sets, both from our agency as well as CMS, CDC and other groups.

Tom Temin: Right. Because patients enumerated a lot of things that can happen with patients. But the staff of hospitals, nurses, doctors, orderlies, everyone, they’re dealing with dangerous equipment in some cases, or I guess in mental situations, the patients themselves can cause harm. So the workforce is a big part of this study sounds like.

Craig Umscheid: They are. What we’ve understood over the years is that it’s very difficult to provide safe care to patients without providing a safe environment for the health care workforce. So this dashboard tracks both patient safety measures as well as health care workforce safety measures. The first set of health care workforce safety measures that we’re evaluating comes from our agencies’ surveys on patient safety culture where hospital staff have to complete surveys every two years about their safety culture. And they voluntarily submit that data. And so that’s the data that we’re reporting on.

Tom Temin: This effort then brings together these multiple databases, some generated federally, some may be generated at the state level and puts them in one place then essentially.

Craig Umsheid: Exactly. And it allows us to track our progress on safety over time. So one of the things that we noticed during the COVID pandemic was that there was a real increase in adverse events in 2020, in 2021. And the Secretary of Health and Human Services, Javier Basara, asked health care systems across the country to recommit to patient safety. We put together a National Action Alliance for Patient and Workforce Safety to align federal agencies around this goal. We’ve put together resources to help health care systems address safety in their institutions. And this dashboard is part of this effort to help us track our progress over time. We have an ambitious goal of reducing adverse events by 50% by 2026, compared to the peak of adverse events in 2021 at the height of the pandemic.

Tom Temin: And what have the trends been since the height of the pandemic? Are they going down only slower than you’d like?

Craig Umscheid: It’s a great question. So our data at this point tracks to 2022. We’ll be uploading data from 2023 shortly. We’re seeing that the peak of adverse events really seemed to occur in 2020, 2021. And we’re seeing some improvements in patient safety in 2022, ranging from about 10% reductions in adverse events to 15% reductions depending on what dataset you look at.

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Tom Temin: We are speaking with Dr. Craig Umsheid. He’s director of the Center for Quality Improvement and Patient Safety. That’s part of the Agency for Health Care Research and Quality at HHS. And first of all, I wanted to ask about the data that’s displayed. Is that available to the public or only to HHS staff or who can look at this data?

Craig Umscheid: The website to the National Action Alliance for Patient Workforce Safety is publicly available on the AHRQ website. It’s ahrq.gov, and you can find the National Action Alliance website on the homepage. And in that National Action Alliance website, you can find a section for safety measurement. If you look at that section, you’ll see the dashboard right there. So it’s available to the public.

Tom Temin: And it is one thing to measure the problem and examine it. What is the feedback mechanism such that you can discover what are the biggest instances of harm and get after those, and how does it change things?

Craig Umscheid: Yeah, it’s a great question. There a number of priority safety measures that we’ve been tracking over the years, and those are really the safety measures that we continue to track and that we’ve seen a real increase in the last number of years. So that’s our priority focus and we’ve seen improvement. And a big part of getting to improvement is having health care systems do baseline safety self-assessments. And we provide an example of those types of self-assessments on our website. Once a health care system does a baseline safety self-assessment, they can understand where the gaps are in their health care system. And we have a set of tools and resources and improvement initiatives that are available to hospitals and health care systems to help them address those safety gaps.

Tom Temin: I would think that CMS would be a source of a lot of information here because they pay for so much health care and they know what they’re paying for. Everybody spends 50% of a practice’s time as coding for Medicare and Medicaid. And with those codes, they can tell what might be treatment for adverse situations that weren’t the original cause of the health care need, which would be the kind of thing you’re trying to get at. Is CMS a major contribution here?

Craig Umscheid: You’re exactly right. CMS is a critical contributor to this dashboard. So two of the data sets that we have in this dashboard are from our agency. Two of the data sets are collaborations between CMS and our agency, as well as the CDC, which also provides data for one of the data sets.

Tom Temin: And are you looking at maybe data analytics and maybe a little touch of AI here to maybe discover trends, say geographical trends or trends related to bad outcomes or events with certain procedures, that kind of thing, or the use of certain techniques or medicines? I mean, it seems like there’s a lot more under-the-surface discovery possible here.

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Craig Umscheid: Yeah, it’s a great question. So what we’ve tried to do is make the displays on these dashboards really straightforward. So the default setting of the dashboard is to be able to track performance on these safety measures year to year over time. But there are different functions that allow you to stratify performance on these safety measures by variables such as race, ethnicity or insurance type or region of the country. So that can allow you to better understand how safety is progressing based on these different variables.

Tom Temin: And by the way, what is the biggest harm that is caused? I’m guessing it’s infection, say, after surgery.

Craig Umscheid: Currently, our dashboard is specifically looking at safety events in acute care hospitals, and some of the most common harms that we see are falls with injury, pressure ulcers that occur for patients who are admitted. And they may be frail and it’s difficult for them to get out of bed. And they’re in the hospital for a long period of time and they start to develop pressure ulcers. Hypoglycemia is also a major patient safety event that we see in hospitals. So this is often because patients are fasting for different procedures. They may be diabetic and they may be getting too much insulin and not enough food during their hospitalization. So those are three of the big inpatient events that we see. But you’re right, other very common safety events include healthcare-associated infections, other medications, safety errors such as bleeding from anticoagulants, too many opioids being given that cause somnolence. We see errors related to surgeries and procedures. We see blood clots. So these are all very common errors that occur during hospitalizations.

Tom Temin: And how are you getting the word out to the affected institutions that, hey, here’s a source that you might be able to hold a mirror up to yourself for?

Craig Umscheid: So for many institutions, they’re tracking their data in more real time. So this dashboard is more for policymakers to understand trends and safety over time across our country. Patient safety advocates, whether those are patients, families, professional associations who want to understand our progress on safety over time. And arguably most importantly, this is a really important resource for us in this National Action Alliance to be able to track our progress on our goal of a 50% reduction in harm by 2026.

Tom Temin: And do you ever log into the dashboard and just take a look around for your own curiosity?

Craig Umscheid: Absolutely. Yeah, I do it regularly. We’ve launched the dashboard in early December. We’ve kept close track of it over time, and it’s just a starting point. We’re going to add newer data at the start of the next calendar year. That data will reflect information from 2023. And we also want to include new measures not just from acute care hospitals, but other health care settings such as nursing homes, ambulatory care. And we’d love to include more health care, workforce safety data as well, such as data from OSHA, the Bureau of Labor Statistics. So a lot more to come.

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