LMH: We are using some of our surplus dollars to provide funding for institutions to develop programs that directly impact patient safety, both in the short- and long-run. We could have just given institutions money, but we decided that we would ask them to provide us with information regarding programs that they had in the planning stages, or partial implementation stages but just didn’t have enough funds to pursue it. The board of Blue Cross a number of years ago had set aside some funds that they wanted to use to help support facilities in our service area. At that time it was unclear how we could best do that. The patient safety initiative was fairly front-running in the minds of a lot of the medical people, so we decided to develop an initiative along those lines. We are the preeminent health insurer in our service area – we have about 70 percent of the market – and we were definitely interested in doing something that would improve safety and quality. We already have contracts with hospitals that we feel are reasonable to provide them with the revenue that they need for servicing our patients. It seemed that a grant would be a logical approach to providing necessary funds for patient safety improvements, and it would also give us the opportunity to evaluate proposals, which we have done. Our goals are to help hospitals develop a safety program that would fit their needs based on their type and size of institution, their talent and ability, and that would show an almost immediate return in terms of improving patient safety.

LMH: The board approved a budget of approximately $13 million over a three-year period. We sent out letters to all the institutions in our service area. Not all of them responded to the request. In the first round, which we started around the first of the year, about 12 facilities applied and we were able to give each of those facilities some funds. In the second round, six facilities have submitted a proposal. We’re in the process of reviewing those now. It was our intent to give money only to those proposals that were worthy in terms of criteria that we had established. We have a team of seven individuals who evaluate proposals using a point score system to determine the worthiness of projects submitted to us and the amount of funding that we can apply.

LMH: We’re looking primarily at the potential for impacting patient safety in the short-run and the long-run, whether the project is feasible and has a chance of actually succeeding. We’re looking at sustainability, in terms of what institutions were willing to put into the mix, and how it would be supported. We’re looking at the methods that facilities went through to gain the support of important stakeholders. We’re looking at whether or not there was any community collaboration in developing their proposal. We’re also looking to see that they were not suggesting anything that was actually a money-making endeavor for them, so we were not interested in them buying a new piece of equipment that was going to produce revenue, even it had a little bit of an element of patient safety to it. The primary focus was on safety and quality, and not revenue generation. We asked each institution to send us a budget for their proposal. In some cases we were able to fund an entire project because the amount that was requested was well within the budget for the amount of money we had to dispense. Most of the 22 hospitals in our service area in one way or another are going to be involved with this; only two did not submit a proposal.

LMH: The funding really depends on the board allocating the money, either out of surplus or from some other source. We will be looking at the types of results we see from these initial projects. It was not intended that this would be an ongoing type of situation, but there’s a possibility for that if the impact we have on hospitals, especially if measurable indices of patient safety improvement, are what we expect they might be. We could then perhaps go to the board with that information and request that this type of thing be done again at some point.

LMH: A number of them deal with physician order entry systems, and the hardware and software involved in that. A number of them that have to do with automated drug dispensing systems and bar-coding for patient identification. We’ve received one proposal that has as part of it education of the medical staff and other hospital personnel regarding safety issues, and the attempted establishment of a safety-conscious culture within the institution. There was one that represented a cooperative effort among three rural institutions for sharing pharmacy knowledge and data – none of these institutions were able to hire a clinical pharmacist for their small pharmacies, so they’re going to share the expertise of a pharmacist who is going to be linked electronically for formulary information and advice.

LMH: If you look at what has to be paid out, in terms of treating patients who are the objects of an adverse event, it probably will lower costs. We’re hoping to see that as part of the metrics that hospitals are developing for reporting outcomes of their programs. And we did include the necessity to gather information and report it as part of the grant process.

LMH: No.

LMH: We asked the hospitals up front to provide us with information regarding what their own internal quality or safety studies had uncovered, as part of the rationale for why they needed to go forward with a project like the one they proposed. We asked them, having that baseline data, to collect and report to us quarterly on the same types of information, so we’re looking at the same metrics to be used throughout the project, and then to report a final outcome at the completion of the project. We’re looking at frequency and types of adverse events. Most of them have to do either with errors and near misses associated with physician ordering or dispensing of medications.

LMH: The hospital grant program is one of three programs that we’re working on at this point. We did an initiative with physicians in which we provided them with Personal Digital Assistants (PDAs) that were preloaded with Epocrates software, as well as our formulary. We felt this would improve physicians’ ability to look up such things as drug interactions and to get important drug information – a brief description of current evaluation and testing for various diseases processes – right at the point of care. We started that process in January of 2005 and we completed it just last month. We had 250 PDAs and 250 certificates for the Epocrates software for physicians who already had PDAs and didn’t want to give theirs up. We first focused on physicians who saw a large volume of our patients and we next went to the entire community of primary care physicians. Any specialist who requested a PDA or certificate – we gave one to them, and we extended that opportunity to nurse practitioners, physician assistants, clinical pharmacologists and emergency room physicians. Well over half – maybe close to 70 percent of contracted physicians in our service area – now have the PDAs.

A third patient safety initiative – a pay-for-performance program – is now in the planning stage. We would be looking at larger groups of physicians within our service area to measure parameters in a similar fashion to the way HEDIS parameters are measured. We’re looking at focusing on major disease issues in our service area – such as diabetes, hypertension and depression – as areas we would develop metrics and parameters that we’d like to see improved, and would be offering some funds that are attached to various levels of improvement. Our current quality incentive program is not specifically focused on patient safety – it measures things like compliance with recommendations for immunizations, administrative parameters, percentage of claims that are submitted electronically, an index of efficiency with respect to utilization. The pay-for-performance program we are planning is focused on clinical performance. We’re hoping to start talking to physician groups in early November and, depending on how that goes, rollout of the program could begin as early as the first of 2006. But we want to make sure that we have physicians on board and satisfied with the way we intend to run the program before we actually start. Those three initiatives – hospital grants, PDAs and pay-for-performance – are all part of our $13 million, three year budget, of which $9 million is allocated to the hospital grant program.

LMH: What’s probably, in the long run, going to have the biggest impact is a recognition of the areas of contact with the patient that provide the opportunity for an adverse event to happen. There’s a focus on technology in helping to develop processes that become more automatic. You don’t have to have the technology to do that. You do have to have an awareness, among everybody who has anything to do with patient care, that there are opportunities for mistakes to occur, and to put into place a process that obviates that potential. So, it doesn’t really have to be high-tech, but there has to be an awareness and an attempt to focus on safety at every step. An example of a non-technological improvement could be a checklist for someone going to the operating room, say, for an orthopedic procedure. The checklist should have on it such things as whether the patient’s history and physical exam are present on the chart, appropriate cardiac clearance has been obtained, the permit for the surgery has been signed and witnessed, the limb is marked appropriately – such things as that. That’s paper and pencil, and it requires somebody checking those items. You could computerize that, but it wouldn’t have to be computerized. It should be built into the process – not one person goes through that checklist, but the checklist is gone through by two separate people in perhaps two separate areas. The checklist could have 20 or 30 items on it, depending on the institution and the type of surgery that’s contemplated.

LMH: Not by an intent on our side. We basically gave the institutions an idea of what we were looking for, but did not mention whether it had to be technologically based or not. One of the proposals did contain a request for funding to educate staff members and physician leaders by sending them away to conferences that dealt with building a safety-conscious culture and environment in the hospital. We really didn’t direct them toward technology. I think the technological solution is low-hanging fruit for some of the institutions, especially the smaller ones. And a number of them did go for the automatic drug dispensing system.