Dear Administrator Letter Regarding 2006 Patient Safety Awards

November 3, 2005

Hospitals/FQHCs

Dear Chief Executive Officer (CEO):

I am pleased to announce the 2006 Patient Safety Award competition in New York State. The New York State Patient Safety Award Program was created to highlight best practices developed and implemented in our facilities statewide, and recognize their successful quality improvement efforts. Two hospitals, two nursing homes, one adult care facility, and one federally qualified health center (FQHC) will be selected to receive a grant of $200,000 and will be publicly acknowledged for their accomplishments in promoting patient/resident safety and reducing the prevalence of medical errors/adverse events.

All New York State licensed hospitals, nursing homes, federally qualified health centers (FQHC), and adult care facilities are eligible and encouraged to submit applications. Awards will be based on the demonstration of ongoing quality improvement systems and evidence demonstrating the effectiveness of quality improvement efforts. There will be two award categories based on bed size for hospitals; one for hospitals with greater than 200 beds, and one for hospitals with less than 200 beds. There will also be two categories for nursing homes based on bed size; one award will be granted to a nursing home with greater than 150 beds and one for a nursing home with less than 150 beds. One award will be granted to a licensed adult care facility and one award will be granted to a federally qualified health center.

Enclosed are application instructions that provide additional details on the award program and information applicants will need to submit a proposal. Applications must be received by the New York State Department of Health by close of business Wednesday, February 15, 2006.

If you have any questions regarding the award program or the application process, please contact: Cathy Blake, Director, Healthcare Quality Initiatives, Office of Health Systems Management, at 212-417-4111.

Sincerely,

Antonia C. Novello, M.D., M.P.H., Dr. P.H.
Commissioner of Health

Enclosures

New York State Patient Safety Awards - 2006

I. Introduction

The New York State Department of Health (Department) is petitioning New York State licensed hospitals, nursing homes, federally qualified health care centers (FQHCs) and adult care facilities for applications that demonstrate successful medical error/adverse event reduction/quality improvement strategies. Six awards totaling $1,200,000 will be granted to facilities that have implemented the most successful strategies. These awards are intended to support the implementation of effective quality improvement/medical error/adverse event reduction models statewide.

II. Background

Healthcare errors are a leading cause of morbidity and mortality in the United States (National Quality Forum consensus Report 2002, Institute of Medicine Report). The New York State Health Information and Quality Improvement Act was signed into State law by Governor George Pataki in October 2000 to focus attention on the problem of medical errors in New York State and generate solutions. The New York State Health Department is charged with developing a statewide health information center to collect, analyze, and disseminate quality improvement information (Title I). The Act also calls for the establishment of a Patient Safety Center within the New York State Department of Health to increase information available to patients regarding health care providers (Title II). The New York State Patient Safety Award is among the Department's initiatives established to improve the dissemination and utilization of successful error reduction strategies and promote their adoption statewide.

The continued acknowledgement of health care facilities for successful quality improvement initiatives remains a priority of New York State. Over the past four years, the patient safety award program has expanded to include all licensed hospitals, nursing homes, federally qualified healthcare facilities, and adult care facilities. Recent award distributions represent initiatives which have made substantial improvements in access to care, increases in patient and staff education, fall reduction, and medication management. The following are examples of award winning proposals. Other proposals can be viewed on the DOH web site.

In the year 2004, awards were granted to four facilities for their outstanding efforts in improving the quality of care for their patients/residents:

Brookdale University Hospital and Medical Center: For the successful implementation of infection control policies and procedures to reduce patient risk of central venous catheter related blood stream infections. Brookdale was able to demonstrate an 89% reduction in catheter related infections within three years of implementation.

Geneva General Hospital: Established and refined protocols to require lipid profiles for patients receiving care in the emergency department for acute myocardial infarction. When a patient presents to the emergency department with chest pain, orders for lipid profiles are submitted from a preprinted cardiac admitting form. The compliance rate for patients receiving lipid profiles within 24 hours improved from 43% in 2000 to 80% in 2003.

Bellevue Woman's Hospital: Created a comprehensive prenatal case management and incentive program to identify and assess women for potential high-risk pregnancies. The case management program promotes healthy lifestyles for women and includes access to educational classes and materials on child bearing, referrals to employment services, access to mental health services, and alcohol and substance abuse counseling. Since the program's inception in 1999, there have been no infant deaths or pregnancy terminations involving participating women.

Morris Heights Health Center: Developed an Advanced Access Program to ensure patient access to primary care physicians for all visits and tailored the visits to the needs of every patient. The program includes strengthened triage and assessment policies that have led to improved patient care.

In the year 2005, six awards of $200,000 were granted to facilities for their outstanding efforts in improving the quality of care for their patients/residents:

St. Francis Hospital, Poughkeepsie: Implemented and enhanced protocols designed to raise awareness and staff accountability to improve the accuracy of patient identification. The protocols emphasize accurate patient identification through required inter-department review and comparison of patient ID bands with the patient census reports to identify patients who did not have ID bracelets or their bracelets contained incorrect information.

St. Mary's Hospital, Amsterdam: An interdisciplinary Quality Improvement Team was convened to assess the entire medication administration process. Multiple decision points and variations between and among units were identified. Adding unit coordinator positions, expanding pharmacy hours, automated dispensing machines and continuous education and reassessment of patients has improved medication management and related services.

Long Island State Veteran's Home, Stony Brook: The nursing home undertook an extensive review to accurately identify and address the root causes of falls. By reassessing the incident process the committee was able to completely overhaul the incident reporting system. A daily log for trending causes, staff education, and a new accident reporting form has been implemented as a result. This successful falls prevention program has resulted in a significant reduction in the number or incidents involving resident falls within the home.

Beechwood Continuing Care, Getzville: By establishing the Building on Excellence – ACTT for Quality program the facility has seen documented and sustained improvements in the incidence of falls and pressure ulcers. The four step program along with consistent leadership and more effective utilization of existing resources have contributed to a major change in current practice. As a result, the quality indicators used to identify and respond to falls and skin ulcers among residents have been refined and strengthened.

Madison York Assisted Living, Corona: Implemented a multi-directional strategy for improving medication management that focused on substantially improving the documentation of prescription drugs provided to patients and strengthening incident reporting. This adult care facility demonstrated significant improvements to the medication management system through training sessions with staff, as well as residents and their families. As a result, systems were refined to better address incidents, patients' refusal to take medication, pharmacy initiated events and discontinuance of medication instructions from outside physicians.

Hudson Headwaters Health Network, Glens Falls: By undertaking an extensive analysis of the policies in use at each of the network's eleven facilities, the incident reporting process was found to be cumbersome, confusing and inconsistent. Streamlining the reporting process, allowed the network to better track prescription drugs and put safeguards in place to help prevent the potential for drug diversion and the improper use of medications.

Dr. Novello also presented certificates of recognition to Mount Sinai Medical Center (New York City), Strong Memorial Hospital (Monroe County), Huntington Living Center (Seneca County) and DePaul Adult Care Community (Monroe County) for their efforts in the advancement of patient/resident safety initiatives.

III. Objective

The Department recognizes that many hospitals, nursing homes, federally qualified health care centers, and adult care facilities have successfully implemented quality improvement/medical error/adverse event reduction strategies. It is the intent of the Department to award two hospitals, two nursing homes, one federally qualified health care center, and one adult care facility in the amount of $200,000 each for their continued risk reduction efforts. The results of these successful quality improvement efforts will be shared with facilities statewide and recommendations for replication and implementation will be disseminated.

IV. Eligible Applicants

All New York State licensed hospitals, nursing homes, federally qualified health care centers (FQHCs) and adult care facilities are eligible to submit applications to the New York State Department of Health by Wednesday, February 15, 2006. The application must detail previously implemented programs established to improve the process of patient/resident care and/or reduce medical errors/adverse events. A direct relationship between the intervention and outcome must be demonstrated. Applicants must also demonstrate continued integration of risk reduction strategies and an ongoing commitment to quality improvement activities in their facility.

Two hospitals, two nursing homes, one federally qualified health center, and one adult care facility will receive an award of $200,000. Distinct categories of bed size will determine hospital and nursing home award distribution.

One award will be given to a hospital with over 200 certified beds and the other hospital award will go to a facility with 200 or less certified beds.

One nursing home award of $200,000 will go to a successful applicant with greater than 150 beds and the other nursing home award will be granted to a facility with less than 150 beds.

There will be one award to a federally qualified health center (FQHC) and one award to a licensed adult care facility.

V. Application Review Process

All applications will be reviewed using an objective rating system reflective of required items specified for each component. A two level review consisting of an internal Department panel and an external panel will be conducted in the evaluation of applications submitted.

VI. Submission Criterion

The original application bearing the signatures of the chief executive officer/president of each applicant organization and seven (7) copies with all attachments, must be received by close of business on Wednesday, February 15, 2006. Please submit to:

Cathy A. Blake,
Director, Healthcare Quality Initiatives
Office of Health Systems Management
161 Delaware Avenue
Delmar, NY 12054
NYC Phone: 212-417.4111
Email: cab16@health.state.ny.us

The applications should include the following:

  • Name and address of facility, project by title and function, and contact persons;
  • Number of certified beds (hospitals and nursing homes); patients/residents served per year in FQHC and adult care facilities;
  • Network or system affiliation;
  • Analysis of target area, timeframe for development and implementation strategies, including barriers to success;
  • A description of any formal process of identifying areas for error/adverse event reduction/performance improvement initiatives;
  • A detailed description of successful quality improvement and/or medical error/adverse event reduction efforts previously and currently implemented in your facility;
  • Identification of measures used to determine effectiveness, standards and milestones for evaluation, and benchmark improvement indicators;
  • Explanation of protocol development and steps taken to implement quality improvement strategies;
  • Data reflecting favorable results directly related to quality improvement/error/adverse event reduction strategies; and
  • Evaluation of outcomes and discussion of collaborative efforts and future goals for continued improvement activities.

You must include the attached applicant cover page and completed checklist (PDF, 26KB, 2pg.) with your application.

The award recipients will be notified by the Department of Health in April 2006. The Commissioner of Health will make a public announcement of the award recipients at the Public Health Council meeting in May 2006.

VII. Grant Funding

Each award recipient will establish a contract relationship with the Department within eight weeks of award notification. The award recipient is expected to provide the Department with a written report detailing performance outcomes and project expenditures on a quarterly basis. The award recipients are also expected to conduct educational and promotional seminars statewide during the contract period.