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Fact Sheet: Pennsylvania Hospitals’ Successful Quality and Safety Journey

Chart listing decreasing infection rates in PA hospitalsInflection Point: 1999 IOM Report

During 1999, a report released by the Institute of Medicine (IOM) focused a national spotlight on preventable errors in hospitals and the patient harm that can result. Always a top Bar chart showing reduced preventable erros from 2012 to 2017priority, Pennsylvania hospitals’ patient safety and quality goals and efforts were articulated as:

  • Establish patient safety as a visible commitment to our "putting patients first" philosophy
  • Move from blaming people to improving processes
  • Improve use of technology to prevent and detect error
  • Use data to identify and measure improvements

Results to Date

More lives saved, fewer repeat hospitalizations:  Pennsylvania Health Care Cost Containment Council’s (PHC4) 2017 Hospital Performance report shows that for many life-threatening conditions, Pennsylvania hospitals are:

  • Making substantial and statistically significant reductions in mortality
  • Reducing the need for re-hospitalizations (readmissions) within 30 days of discharge

Better infection prevention:  The Centers for Disease and Control Prevention’s (CDC) 2017 infection reporting shows how far Pennsylvania hospitals have come in reducing infections. The overall standardized infection ratios (SIR) for Pennsylvania hospitals are significantly below national baselines for six out of seven types of infections reported, with no statistical difference for the seventh category.

Pennsylvania’s Patient Safety Firsts

As a result of strong partnerships among hospital leaders and clinicians and with community, state, and national organizations, Pennsylvania became the first state to adopt many patient safety and quality initiatives now recognized as national models and best practices. These firsts include:

  • Pennsylvania Patient Safety Authority (PSA): PSA tracks and analyzes health care incidents and serious events that occur in health care facilities and publically reports its findings and recommendations for improvement
  • Infection reporting: Pennsylvania was the first state to publically release hospital-specific health care-associated infections (HAI) and to require reporting of HAIs of all types. Today, our state is one of just ten that require this comprehensive reporting
  • Patient and Family Advisory Council: HAP created the nation’s first hospital association- supported council to provide guidance to hospitals from a patient perspective

Increased Financial Accountability for Patient Safety and Quality

Hospitals’ patient safety and quality performance determines how much they are paid. For example:

  • Affordable Care Act: Results in reduced Medicare payments for acute care hospitals that have too many readmissions or hospital- acquired conditions
  • National programs: Incentivize improved hospital quality and outcomes with financial rewards and penalties. Programs include Hospital Value-based Purchasing, Readmission Reduction, and Hospital-acquired Conditions Reduction
  • Commercial health plans: Have similar value-based purchasing policies designed to improve quality and reduce costs
  • Pennsylvania’s Medicaid quality incentives: Reward hospitals for reducing potentially preventable admissionsChart containing information about HAP's hospital engagement networks

Reduced Harm and Improved Quality through Partnership with CMS

HAP has repeatedly been selected by the Centers for Medicare & Medicaid Services (CMS) to educate Pennsylvania providers and lead them in collaborative efforts to achieve additional quality and safety improvements.

HAP’s hospital engagement network was one of 27 funded by CMS for 2011–2014 and one of 16 hospital improvement innovative network contractors subsequently funded to the present.

Based on a formula from the Agency for Healthcare Research and Quality, these efforts alone have prevented an estimated 100,000 harm events, saving more than $740 million in health care costs.

Most recently, HAP, along with the New Jersey and Ohio hospital associations formed Q3 Health Innovation Partners (Q3HIP) to conduct joint multistate quality improvement initiatives.


Topics: Population Health, Quality Initiatives

Revision Date: 8/2/2019

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