Be a Baldrige Examiner in 2011

Baldrige Examiners contribute to the process of determining each year's Baldrige Award recipients. Last year, 1/3 of all examiners were from the healthcare industry.

Why is the Baldrige Criteria for performance excellence so important to healthcare? Rulon Stacy, the CEO for Pouder Valley Health Systems says that "...as soon as you become a Baldrige organization, it will cost you less to run your business, and your outcomes will be better."

Organizations will a Baldrige Examiner on staff will have a unique resource that will give them insight on how to best align themselves to the Baldrige criteria to improve their performance.

Applications for next year's Baldrige Board of Examiners are being accepted until January 13, 2011.

You can learn more about the Baldrige Criteria here: http://www.nist.gov/baldrige/
You can learn more about the examiner application process here: http://www.nist.gov/baldrige/examiners/index.cfm

Berwick Testifies to the Senate Finance Committee

On November 17th, Donald Berwick testified before the Senate Finance Committee. As you can imagine, there was a lot of political tension surrounding this event.

The video of the entire senate hearing is here: http://finance.senate.gov/hearings/watch/?id=280ebc81-5056-a032-5254-1010c1e9b945

Berwick's prepared statement can be found here: http://finance.senate.gov/imo/media/doc/FINAL%20Donald%20Berwick%20Testimony%2011.15.101.pdf

Bacus' prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/11172010%20Baucus%20Hearing%20Statement%20Regarding%20New%20Patient%20Protections%20to%20Strengthen%20Medicare%20and%20Medicaid1.pdf

Grassley's prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/health%20care%2011-17-10%20hearing%20with%20Dr.pdf

Kaiser Health News, a program of the Kaiser Family Foundation, consolidated a resource page about Dr. Donald Berwick. It contains both what he has said as well as what others have said about him (and what he said). It can be found here: http://www.kaiserhealthnews.org/Stories/2010/June/30/Donald-Berwick-Resource-Guide.aspx

RAC for Medicaid?

The following is a press release from CMS (Nov 5, 2010) announcing some of the details for the implementation of Medicaid RAC. Items of interest to quality professionals are in red.

MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS
CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM

The Centers for Medicare & Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act’s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.

“Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,” said CMS Administrator Donald Berwick, M.D. “We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.”

Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.

Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments.

CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.

Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.

Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled “Medicaid RACs: Are You Ready?” targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS’s experience with Medicare RACs.

A copy of the regulation may be viewed at the Federal Register’s website, http://www.ofr.gov/inspection.aspx. For Additional information on the Affordable Care Act can be accessed at, http://www.healthcare.gov/.

Indiana Performs Well on HCAHPS

The following is a table of how States performed on the HCAHPS overall rating question from Jan 09 to Dec 09. The table is sorted from high to low based on the percentage of patients responding with a rating of 9 or 10 on this 10 point scale.

As you can see, the average of Indiana hospitals ranks 7th of all states for this question.

% State
73 SD
72 KS
72 LA
72 IA
71 NE
71 ME
71 IN
70 VT
70 ID
70 NH
70 WI
69 CO
69 UT
69 MN
69 NC
68 AL
68 MI
68 OK
68 KY
68 TX
68 SC
67 MO
67 MS
67 MA
67 OH
67 OR
67 TN
66 WA
66 AZ
66 AR
66 GA
65 CT
64 AK
64 WV
64 VA
64 PA
64 IL
64 RI
63 WY
63 MT
63 CA
62 DE
62 NV
62 ND
62 FL
61 MD
61 NM
60 NJ
59 HI
58 NY
58 DC

Indiana Hospitals HCAHPS Performance

The following is a table of the performance of Indiana hospitals (Jan 09 to Dec 09) on the HCAHPS overall rating question. The table is sorted from high to low based on the percentage of patients providing a response of 9 or 10 on this 10 point scale.

% Hospital and City
94 SURGICAL HOSPITAL OF MUNSTER of MUNSTER
89 INDIANA ORTHOPAEDIC HOSPITAL LLC of INDIANAPOLIS
87 ST VINCENT HEART CENTER OF INDIANA LLC of INDIANAPOLIS
87 WOMEN'S HOSPITAL THE of NEWBURGH
86 PHYSICIANS' MEDICAL CENTER LLC of NEW ALBANY
85 INDIANA HEART HOSPITAL THE of INDIANAPOLIS
82 HENDRICKS REGIONAL HEALTH of DANVILLE
80 CLARIAN NORTH MEDICAL CENTER of CARMEL
80 ST VINCENT CARMEL HOSPITAL INC of CARMEL
80 PARKVIEW LAGRANGE HOSPITAL of LAGRANGE
79 ST FRANCIS HOSPITAL MOORESVILLE of MOORESVILLE
79 SCHNECK MEDICAL CENTER of SEYMOUR
78 GOOD SAMARITAN HOSPITAL of VINCENNES
78 DEKALB MEMORIAL HOSPITAL INC of AUBURN
78 PARKVIEW WHITLEY HOSPITAL of COLUMBIA CITY
78 TIPTON HOSPITAL of TIPTON
78 PARKVIEW NOBLE HOSPITAL of KENDALLVILLE
78 DUPONT HOSPITAL LLC of FORT WAYNE
77 COMMUNITY HOSPITAL of MUNSTER
77 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC of EVANSVILLE
77 MEMORIAL HOSPITAL AND HEALTH CARE CENTER of JASPER
77 MARGARET MARY COMMUNITY HOSPITAL INC of BATESVILLE
77 ST VINCENT FRANKFORT HOSPITAL INC of FRANKFORT
76 FRANCISCAN PHYSICIANS HOSPITAL LLC of MUNSTER
76 ST VINCENT DUNN HOSPITAL INC of BEDFORD
76 WITHAM HEALTH SERVICES of LEBANON
76 PARKVIEW HUNTINGTON HOSPITAL of HUNTINGTON
75 SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH of PLYMOUTH
75 THE ORTHOPAEDIC HOSPITAL OF LUTHERAN HEALTH NETWOR of FT WAYNE
75 ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC of FORT WAYNE
75 MEMORIAL HOSPITAL OF SOUTH BEND of SOUTH BEND
75 MONROE HOSPITAL of BLOOMINGTON
75 CLARIAN WEST MEDICAL CENTER of AVON
74 LUTHERAN HOSPITAL OF INDIANA of FORT WAYNE
74 BLUFFTON REGIONAL MEDICAL CENTER of BLUFFTON
74 COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY of ANDERSON
74 CLARK MEMORIAL HOSPITAL of JEFFERSONVILLE
74 ST VINCENT WILLIAMSPORT HOSPITAL INC of WILLIAMSPORT
74 GOSHEN GENERAL HOSPITAL of GOSHEN
74 ST VINCENT HOSPITAL & HEALTH SERVICES of INDIANAPOLIS
74 PARKVIEW HOSPITAL of FORT WAYNE
74 FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES of NEW ALBANY
73 JAY COUNTY HOSPITAL of PORTLAND
73 MAJOR HOSPITAL of SHELBYVILLE
73 ST MARY MEDICAL CENTER INC of HOBART
73 BEDFORD REGIONAL MEDICAL CENTER of BEDFORD
73 RIVERVIEW HOSPITAL of NOBLESVILLE
73 ST FRANCIS HOSPITAL AND HEALTH CENTERS-INDIANAPOLI of INDIANAPOLIS
73 ST VINCENT MERCY HOSPITAL of ELWOOD
73 ST JOSEPH HOSPITAL & HEALTH CENTER INC of KOKOMO
72 SAINT JOSEPH REGIONAL MEDICAL CENTER of MISHAWAKA
72 HARRISON COUNTY HOSPITAL of CORYDON
72 CLARIAN-ARNETT HEALTH SYSTEM INC of LAFAYETTE
72 WABASH COUNTY HOSPITAL of WABASH
71 CAMERON MEMORIAL COMMUNITY HOSPITAL INC of ANGOLA
71 GIBSON GENERAL HOSPITAL of PRINCETON
71 HANCOCK REGIONAL HOSPITAL of GREENFIELD
70 REID HOSPITAL & HEALTH CARE SERVICES of RICHMOND
70 FAYETTE REGIONAL HEALTH SYSTEM of CONNERSVILLE
70 TERRE HAUTE REGIONAL HOSPITAL of TERRE HAUTE
70 COLUMBUS REGIONAL HOSPITAL of COLUMBUS
70 SAINT JOHN'S HEALTH SYSTEM of ANDERSON
70 HENRY COUNTY MEMORIAL HOSPITAL of NEW CASTLE
70 ST VINCENT JENNINGS HOSPITAL INC of NORTH VERNON
69 COMMUNITY HOSPITAL NORTH of INDIANAPOLIS
69 SULLIVAN COUNTY COMMUNITY HOSPITAL of SULLIVAN
69 ST CATHERINE HOSPITAL INC of EAST CHICAGO
69 SAINT ANTHONY of CROWN POINT
69 MARION GENERAL HOSPITAL of MARION
68 ST ANTHONY MEMORIAL HEALTH CENTERS of MICHIGAN CITY
68 UNION HOSPITAL CLINTON of CLINTON
68 DEACONESS HOSPITAL INC of EVANSVILLE
68 ST ELIZABETH CENTRAL of LAFAYETTE
68 LAPORTE HOSPITAL AND HEALTH SERVICES of LA PORTE
68 JOHNSON MEMORIAL HOSPITAL of FRANKLIN
68 DAVIESS COMMUNITY HOSPITAL of WASHINGTON
68 KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICESTHE of MADISON
68 WILLIAM N WISHARD MEMORIAL HOSPITAL of INDIANAPOLIS
67 ST FRANCIS HOSPITAL AND HEALTH CENTERS of BEECH GROVE
67 WESTVIEW HOSPITAL of INDIANAPOLIS
67 BLOOMINGTON HOSPITAL of BLOOMINGTON
67 DECATUR COUNTY MEMORIAL HOSPITAL of GREENSBURG
67 BALL MEMORIAL HOSPITAL INC of MUNCIE
67 ST VINCENT CLAY HOSPITAL INC of BRAZIL
66 SCOTT COUNTY MEMORIAL HOSPITAL AKA SCOTT MEMORIAL of SCOTTSBURG
66 ELKHART GENERAL HOSPITAL of ELKHART
66 UNION HOSPITAL INC of TERRE HAUTE
66 ST JOSEPH HOSPITAL of FORT WAYNE
66 HOWARD REGIONAL HEALTH SYSTEM of KOKOMO
65 COMMUNITY HOSPITAL SOUTH of INDIANAPOLIS
64 DEARBORN COUNTY HOSPITAL of LAWRENCEBURG
64 MEMORIAL HOSPITAL of LOGANSPORT
63 ST VINCENT RANDOLPH HOSPITAL INC of WINCHESTER
63 CLARIAN HEALTH PARTNERS INC D/B/A METHODIST IU RIL of INDIANAPOLIS
62 KOSCIUSKO COMMUNITY HOSPITAL of WARSAW
61 ST MARGARET MERCY HEALTHCARE CENTERS of DYER
61 STARKE MEMORIAL HOSPITAL of KNOX
60 DUKES MEMORIAL HOSPITAL of PERU
60 ST ELIZABETH EAST of LAFAYETTE
59 COMMUNITY HOSPITAL EAST of INDIANAPOLIS
57 MORGAN HOSPITAL AND MEDICAL CENTER of MARTINSVILLE
55 ST CLARE MEDICAL CENTER of CRAWFORDSVILLE
55 PORTER VALPARAISO HOSPITAL of VALPARAISO
55 ST MARGARET MERCY HEALTHCARE CENTERS of HAMMOND
48 SAINT CATHERINE REGIONAL HOSPITAL of CHARLESTOWN
41 METHODIST HOSPITALS INC of GARY

Note that the following hospitals were tagged as "Survey results are not available for this reporting period".

WHITE COUNTY MEMORIAL HOSPITAL
UNITY MEDICAL AND SURGICAL HOSPITAL
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC
ST MARY'S WARRICK HOSPITAL INC
PUTNAM COUNTY HOSPITAL
PINNACLE HOSPITAL
PERRY COUNTY MEMORIAL HOSPITAL
KENTUCKIANA MEDICAL CENTER LLC
JASPER COUNTY HOSPITAL
GREENE COUNTY GENERAL HOSPITAL
COMMUNITY HOSPITAL OF BREMEN INC
ADAMS MEMORIAL HOSPITAL

The "Gift"

This is not exactly "Healthcare Quality", but it is well worth the 3 minutes. It keeps our work in perspective.



(If you don't see the video embedded above, it is being blocked.)

National Health Care Quality Strategy and Plan

The Secretary of the Department of Health and Human Services recently put out a call for public input on a national strategy for healthcare quality. You can see the document here.

The proposed framework of the national strategy centers around three principles: 1) Better Care; 2) Affordable Care; 3) Healthy People/Healthy Communities.

The specific questions that the HHS Secretary is asking the public are:

Question 1: Are the proposed Principles for the National Strategy appropriate? What is missing or how could the principles be better guides for the Framework, Priorities and Goals?

Question 2: Is the proposed Framework for the National Strategy sound and easily understood? Does the Framework set the right initial direction for the National Health Care Quality Strategy and Plan? How can it be improved?

Question 3: Using the legislative criteria for establishing national priorities, what national priorities do you think should be addressed in the initial National Health Care Quality Strategy and Plan in each of the following areas. Better Care: Person-centered care that works for patients and providers. Better care should expressly address the quality, safety, access, and reliability of how care is delivered and how patients rate their experience in receiving such care; Affordable Care: Care that reins in unsustainable costs for families, government, and the private sector to make it more affordable; and Healthy People/Healthy Communities: The promotion of health and wellness at all levels.

Question 4: What aspirational goals should be set for the next 5 years, and to what extent should achievable goals be identified for a shorter timeframe?

Question 5: Are there existing, well-established, and widely used measures that can be used or adapted to assess progress towards these goals? What measures would best guide public and private sector action, as well as support assessing the nation’s progress to meeting the goals in the National Quality Strategy?

Question 6: The success of the National Health Care Quality Strategy and Plan is, in large part, dependent on the ability of diverse stakeholders across both the public and private sectors to work together. Do you have recommendations on how key entities, sectors, or stakeholders can best be engaged to drive progress based on the National Health Care Quality Strategy and Plan?

Question 7: Given the role that States can play in organizing health care delivery for vulnerable populations, do the Principles and Framework address the needs and issues of these populations?

Question 8: Are there priorities and goals that should be considered to specifically address State needs?

Question 9: What measures or measure sets should be considered to reflect States’ activities, priorities, and concerns?

Question 10: What are some key recommendations on how to engage with States and ensure continued alignment with the National Quality Strategy?

The deadline for public submission is October 15, 2010 at 5pm. The HHS has created a convenient website for feedback submission at: http://www.hhs.gov/news/reports/quality/nhcqsap.html

Rounding to Influence

A former boss of mine introduced me to the concept of "Management by Walking Around". I've seen many leaders fully endorse using this concept with highly variable results. Maybe there's something more than just being visible?

The Sept/Oct 2010 edition of Healthcare Executive published an article from Dr. James Reinertsen about rounding to influence staff behavior and adoption of best practices. The Institute for Healthcare Improvement has made available the reprint here.

The following is an excerpt of the article:

Rounding to Influence
Rounding to influence is one element of an evidence-based bundle of leadership methods used in highly reliable organizations. Rounding to influence is not quite the same thing as leadership safety walkrounds, in which leaders go to hospital units and visit with staff to send a signal that they care about the hospital’s improvement agenda, want to gain better awareness of safety issues and want to build relationships with frontline staff. While these are all desirable outcomes, they don’t drive the successful execution of specific safety or infection control practices. Rounding to influence is much more focused. It’s not just about leaders being seen—it’s about what leaders are seen doing and asking.

Reducing Avoidable Hospital Readmissions

On June 4, 2010, at the Florida Hospital Association Meeting, the Health Research & Educational Trust provided this presentation, "Reducing Avoidable Hospital Readmissions," to give recent evidence of the extent and causes of avoidable hospital readmissions, describe congressional action in Patient Protection and Coverage Act, and describe support now available to help hospitals respond to heightened concern and financial pressures.

The presentation can be downloaded here: http://www.ahrq.gov/news/kt/red/readmissionslides/readmission.ppt

Within the presentation, the HRET's Health Care Leader Action Guide to Reduce Avoidable Readmissions is referenced. It can be downloaded here: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jan/Readmission%20Guide/Health%20Care%20Leader%20Readmission%20Guide_Final.pdf

With readmission rates already being publicly reported and penalties scheduled to be imposed on hospitals with "excessive" readmission rates starting Oct 2013, now is a great time to optimize the care transition process.

Joint Commission Publishes Roadmap towards Patient Centered and Family Centered Care

Patient centeredness is probably the most difficult to define and thus difficult to improve dimension of healthcare quality (the other dimensions being safety, timeliness, effectiveness, efficiency, and equability). Nevertheless, sensitivity to the concepts surrounding patient centeredness is essential for a multitude of clinical and strategic reasons.

To help hospitals prepare for the Joint Commission's upcoming Patient-Centered Communication accreditation standards, the Joint Commission recently published a monograph titled Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.

The monograph can be download here.

CMS Posts Final FY11 Inpatient Rules, Payment Updates, and RHQDAPU Measures.

On Friday afternoon, CMS issued a press release announcing that the final FY11 inpatient prospective payment system rules have been posted to the Federal Register.

Excerpts of the press release is cut and pasted below wiht items of interest to healthcare quality professionals in red:

"In today’s action, CMS is updating acute care hospital rates by 2.35 percent. This update reflects a market basket increase of 2.6 percent for inflation, which is a slight increase over the FY 2010 inflation rate. The final rule reduces the 2.6 percent inflation update by 0.25 percent, as required by the Affordable Care Act. Further, CMS will apply a “documentation and coding” adjustment of -2.9 percent. Hospital coding practices following adoption of the Medicare severity DRGs increased aggregate payments to hospitals, but did not reflect actual increases in patients’ severity of illness. Under legislation passed in 2007, CMS is required to recoup the entire amount of FY 2008 and 2009 excess spending due to changes in hospital coding practices no later than FY 2012. CMS has determined that a -5.8 percent adjustment is necessary to recoup these overpayments. The -2.9 percent adjustment for FY 2011 is one-half of this amount. CMS estimates that payments to general acute care hospitals for operating expenses in FY 2011 will decline by 0.4 percent, or $440 million, compared with FY 2010 under the final rule, taking into account all factors that would affect spending."

"The final rule adds 12 measures to the RHQDAPU set, and retires one current measure – Mortality for selected surgical procedures (composite). However, only 10 of the new measures – including rates of occurrence for 8 of 10 categories of conditions that are subject to the hospital-acquired conditions (HACs) policy ‑ will be considered in determining a hospital’s FY 2012 update. The remaining 2 measures to be reported in 2011 would be considered in determining the hospital’s FY 2013 update."

The 1877 page document can be found here: http://www.ofr.gov/OFRUpload/OFRData/2010-19092_PI.pdf

• Changes to RHQDAPU start on page 505.
• The list of 47 measures adopted for FY11 start on page 517.
• The list of 55 measures adopted for FY12 start on page 567.
• The list of 57 measures adopted for FY13 start on page 595.
• The list of 60 measures adopted for FY14 start on page 606.
• A list of future potential measures being considered for adoption into RHQDAPU starts on page 608.

Healthcare Leading the Way in 2010 Baldrige Award Applications

Last month the NIST announced that of 83 Baldrige applicants for 2010, 54 were for the healthcare category.

Excerpts from the press release follows.
(Note: No Indiana based organization has ever won the Baldrige Award.)

Eighty-three organizations are in the running for the 2010 Malcolm Baldrige National Quality Award, the nation’s highest recognition for organizational performance excellence through innovation and improvement. Applicants include three manufacturers, two service companies, seven small businesses, 10 educational organizations, 54 health care organizations and seven nonprofits/governmental organizations. The number of applicants is up 20 percent over 2009 and marks the fifth consecutive year that there have been 70 or more organizations seeking the award. Additionally, the 54 health care applicants are the largest number in that category since it began in 1999.

The 2010 applicants will be evaluated rigorously by an independent board of examiners in seven areas: leadership; strategic planning; customer focus; measurement, analysis and knowledge management; workforce focus; process management; and results. Examiners provide each applicant with 300 to 1,000 hours of review and a detailed report on the organization’s strengths and opportunities for improvement.

Thousands of organizations use the Baldrige Criteria for Performance Excellence to guide their enterprises, improve performance and get sustainable results. This proven improvement and innovation framework offers organizations an integrated approach to key management areas.

“I see the Baldrige process as a powerful set of mechanisms for disciplined people engaged in disciplined thought and taking disciplined action to create great organizations that produce exceptional results,” says Jim Collins, author of Good to Great: Why Some Companies Make the Leap ... and Others Don’t.

To learn more about starting or advancing your organization’s quality journey, go to www.nist.gov/baldrige/publications/criteria.cfm and www.nist.gov/baldrige/enter/self.cfm.

Joint Commission Posts Accountability Measures FAQ

On July 19th, the Joint Commission posted its FAQ concerning it's recently announced accountability measures. It can be found here. The following are excerpts from the FAQ:

Accountability Measures - Frequently Asked Questions

What are “Accountability Measures?”
Accountability measures are quality measures that meet four criteria that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement on them.

The criteria for classifying accountability measures include:

Research: Strong scientific evidence exists demonstrating that compliance with a given process of care improves health care outcomes (either directly or by reducing the risk of adverse outcomes).
Proximity: The process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs.
Accuracy: The measure accurately assesses whether the evidence-based process has actually been provided. That is, the measure should be capable of judging whether the process has been delivered with sufficient effectiveness to make improved outcomes likely. If it is not, then the measure is a poor measure of quality, likely to be subject to workarounds that induce unproductive work instead of work that directly improves quality of care.
Adverse Effects: The measure construct is designed to minimize or eliminate unintended adverse effects.
These criteria are based on The Joint Commission’s experience implementing and evaluating the outcomes of quality measures for more than a decade. The criteria provide a more rational approach to the process of collecting and reporting quality data.

Why is The Joint Commission reclassifying the core measures as accountability measures and how will this help hospitals?
The Joint Commission wants to help hospitals improve performance on accountability measures in an effort to promote excellence in the delivery of care and maximize health outcomes, and in anticipation of the Centers for Medicare & Medicaid Services incentive payments that become effective in 2013. The Joint Commission will eliminate measures that do not work well, include performance on accountability measures in accreditation standards and include only accountability measures in the ORYX program.

Why not remove non-accountability measures from use?
Measures that do not meet the accountability measures criteria can still prove to be a valuable source of information to hospitals. These measures are also currently used by other initiatives as standardized performance measures for assessing and reporting on hospital performance.

How will The Joint Commission utilize accountability measures in future accreditation activities?
The Joint Commission currently is considering a variety of innovative approaches to integrating hospital performance on the accountability measures into its survey and accreditation activities. To promote improved performance on accountability measures, and help hospitals prepare for the increasing reliance on attaining high performance on quality measures. The Joint Commission will be engaging accredited hospitals through focus groups and online surveys over the next few months.

Where can I locate additional information on accountability measures?
Additional information on accountability measures can be found in the June 23, 2010 special issue of Joint Commission Online and the June 23, 2010 on-line issue of the New England Journal of Medicine, “Accountability Measures: Using Measurement to Promote Quality Improvement.” Additional information will be posted on The Joint Commission’s Web site and in the August 2010 issue of Joint Commission Perspectives.

Will The Joint Commission continue to categorize measures as accountable and non-accountable measures?
In the future, The Joint Commission will only adopt accountability measures for use in its ORYX initiative.

Hospital Infection Rates Now Publicly Available

The Commonwealth Fund announced today that it has made hospital central line - associated bloodstream infection rates available on its www.whynotthebest.org website. The data source varies by state. Ten states have mandatory reporting. Data from other states are based on the hospital's voluntary reporting to the leapfrog group.

Specifically, a hospital specific standardized infection ratio is reported to enable comparison across hospitals.

Excerpts from the announcement is cut and pasted below:

Hospital Infection Rates Now Available on WhyNotTheBest.org
Users of WhyNotTheBest.org can now search for and compare data from more than 900 hospitals on the incidence of central line–associated bloodstream infections (CLABSIs)—one of the most lethal hospital-acquired complications. The data show wide variation in CLABSI incidence, in spite of strong evidence on how to prevent them. The data are available on WhyNotTheBest.org through a partnership among The Commonwealth Fund, The Leapfrog Group, and Consumers Union. Click here for information on how to locate hospitals reporting CLABSI data.

Recent improvements to the site make it easier to identify the time frame of performance data (by pointing to the information button above the measure names) and to view comparisons and trends (by following the links from the summary report to access "In-Depth Reports").

The goal of WhyNotTheBest.org is to foster health care quality improvement by promoting transparency and public reporting, and by providing tools and case studies to aid organizations in their own improvement efforts. According to patient safety expert Lucian Leape, M.D., public reporting and feedback are the best ways to encourage providers to deliver safer health care.

ISMP: Guidelines for Standard Order Sets

On March 11, 2010, the Institute for Safe Medication Practice (ISMP) published guidelines for creating standard order sets. The document can be found here.

The following are excerpts from the guidelines document:

Content
Careful attention to the content of standard order sets helps ensure they:

1. are complete,
2. include important orders beyond what the prescriber may initially consider (e.g., specific monitoring requirements),
3. reflect current best practices, and
4. are standardized among various practitioners who provide care to patients.

Examples of frequently observed problems with the content of standard orders follow.

• Numerous practitioner-specific order sets for the same conditions resulting in variability in the clinical management of these patients
• Content that is a compilation of multiple prescribers’ preferences instead of a streamlined, consensus-based order set
• Outdated order sets that do not reflect current evidence-based or best practices
• Incorrect or outdated terminology used to prescribe therapy (e.g., prescribing a “heparin lock flush” when only saline is used to flush the port)
• Mistakes and inaccuracies in the orders, such as incorrect or missing doses (e.g., magnesium sulfate 16 g instead of 16 mEq), routes, frequencies of administration, and rates of infusion; typos; and spelling errors, particularly with drug names
• Order set includes a medication that is typically contraindicated in the targeted population (e.g., aspirin on pediatric order sets)
• Order set does not include duration of therapy if appropriate (e.g., ketorolac limited to 5 days)
• Order set includes potentially dangerous combinations of products (e.g., IV morphine and epidural HYDROmorphone/bupivacaine, with boxes that allow both orders to be activated)
• Order set includes two or more medications with known drug interactions
• An exhaustive variety of medications to cover every possible scenario a patient may face (e.g., orders that include multiple analgesics by various routes, laxatives, antacids, a bedtime sedative, antidiarrheal, antiemetic, and others); we’ve previously called these “Don’t bother me” orders, which lead to crowded medication administration records and leave treatment decisions to nurses’ subjective, variable judgment
• Order set includes organization-prohibited orders or ambiguous blanket orders such as “take home meds” or “resume pre-op orders”
• “If…then” orders that inappropriately shift responsibility from the prescriber to the nurse or pharmacist to determine whether an order should be activated (e.g., give RhoGAM if indicated)
• Types and/or frequency of necessary patient assessments (e.g., pulse oximetry) and laboratory monitoring are not specified
• Orders to address known potential emergencies not specified (e.g., rescue agent available, when to administer the rescue agent or call the prescriber)
• Single and/or multiple analgesics which, if administered as frequently as prescribed, could result in an overdose (e.g., acetaminophen or opioid toxicity)
• Dosing guidance not provided (e.g., mg/kg or mg/m2 dose not specified along with the calculated dose, particularly for neonatal/pediatric drugs and chemotherapy; safe dose range or maximum safe doses not specified; dosing parameters for titrated drugs not provided)
• Chemotherapy order sets that include the total course dose instead of the single, daily dose
• Medications without indications
• Medications prescribed by volume or number of tablets
• Titrated medications without a measurable description of the desired effects, rate of titration, and maximum doses that should not be exceeded and/or the dose at which the prescriber should be called
• Administration directions not provided (e.g., timeframe for IV push or bolus doses)
• Critical clinical decision support information, reminders, precautions, and/or safety measures not included, such as: monitoring requirements; administration precautions; adjustments for renal impairment or age; maximum adult total dose of acetaminophen not to exceed 3 to 4 grams per 24 hours

Approval and Maintenance

Managing the initial approval of standard order sets and keeping them current present numerous challenges to organizations. Without a standard process to address the approval and revision of standard orders, unacceptable variations in care and errors are possible. Examples of frequently observed problems with the approval and maintenance of standard orders follow.

• Order set never approved by the organization’s pharmacy and therapeutics (or another appropriate) committee
• Outdated order sets that have not undergone recent clinical review
• Old typed preprinted order sets that are copies of copies (information cut off, stray marks on the forms)
• Outdated order sets that are still in use for months/years after new/revised order sets have been adopted
• Staff unable to access updated order sets online via an Intranet
• Order sets sent or brought into the hospital from physician offices or other hospitals that have never been approved
• Order sets that include nonformulary items, drugs with therapeutic substitutions not specified, and medications that have been withdrawn from the market or have new boxed warnings that should limit their use
• Order sets with conflicting instructions that do not coincide with current hospital policy (e.g., drug verification checking processes) and equipment (e.g., types of infusion pumps available)
• Order sets without a tracking number and approval/revision date

Ensuring consistent use of well-designed order sets and maintaining the orders in accordance with best practices requires vigilance and a team approach. Because standard order sets are often an important component for implementing clinical protocols, algorithms, critical pathways, and guidelines, organizations should establish an interdisciplinary process with rules to help design, evaluate, use, and maintain these orders. Professional staff need clear directions to follow if they encounter order sets that do not comply with these rules.

To assist with the evaluation of order sets, ISMP has created Guidelines for Standard Order Sets in the form of a checklist, which is on our Web site (www.ismp.org/Tools/guidelines/default.asp). Additionally, in the Agency for Healthcare Research and Quality publication, Advances in Patient Safety: New Directions and Alternative Approaches, Ehringer and Duffy have published findings from a study they conducted on preprinted orders and how they can be used to promote best practices (www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Ehringer_17.pdf) The authors include several tables and an appendix that can be used to guide the creation and review of standard order sets. With these two resources, hospitals can begin to establish an effective process for designing, evaluating, updating, and enforcing safe use of standard order sets.

CMS to inspect 1/3 of all Ambulatory Surgery Centers this Year Regarding Infection Prevention Practices

In a press release from HHS Secretary Kathleen Sebelius on June 8, a clear signal was sent to ambulatory surgery centers that they will be receiving additional attention from CMS regarding their infection prevention and control practices.

The press release is cut and pasted here. Sections of interest to the healthcare quality professional are highlighted in red.


FOR IMMEDIATE RELEASE
Tuesday, June 8, 2010
Contact: HHS Press Office
(202) 690-6343


HHS Secretary Kathleen Sebelius Statement on Recent Study of Infection Control Practices in Ambulatory Surgical Centers

“Today, the Journal of the American Medical Association published a new study from the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS), which underscored the urgency behind the Obama Administration’s efforts to reduce healthcare-associated infections (HAIs).

The study found that among a sample of ambulatory surgical centers (ASCs) in three states, two-thirds had infection control lapses identified during routine inspections. This is concerning, because when lapses in infection control occur, in any healthcare setting, it puts patients at risk.

The good news is that we have seen progress in the reduction of HAIs in the hospital setting. Just last month, a new report from CDC demonstrated progress made in reducing HAIs in hospitals, further indicating that the steps we’re taking to reduce these often preventable infections are working. The report showed an 18-percent decrease in national central-line associated bloodstream infection incidence in hospitalized patients.

Ensuring the safety of all patients in all healthcare settings is a top priority for HHS. That’s why I announced last year that $50 million of American Recovery and Reinvestment Act funds to help states fight HAIs. Of that funding, $10 million went to states to improve the process and increase the frequency of inspections for ambulatory surgical centers.

In addition, the Affordable Care Act calls for improvements in healthcare quality and HAIs. Research shows that when healthcare facilities identify where and when infections are likely to occur and take concrete steps to prevent them, some infection rates have dropped more than 70 percent in hospitals.

We also continue to strengthen our collaborative efforts to achieve the goals in the HHS Action Plan to Prevent Healthcare-Associated Infections (http://www.hhs.gov/ophs/initiatives/hai/). In 2010, HHS will expand its Action Plan to include strategies to eliminate HAIs in ambulatory surgical centers and hemodialysis centers.

HHS’ Agency for Healthcare Research and Quality (AHRQ) is contributing to the reduction of infections in ASCs by investing in research projects to better understand the factors that lead to HAIs in ambulatory surgical settings. HHS agencies are also working together to incorporate infection control into the inspection process. CMS has committed to inspecting one-third of all ASCs nationwide this year. All ASCs have a responsibility to correct deficient practices. Failing to correct serious deficiencies will mean the risk of termination from the Medicare program.

Just because procedures are being performed outside the hospital doesn’t mean patient safety standards and attention to infection control do not need to be met. All healthcare providers and suppliers should take this as an opportunity to evaluate their current infection control policies, and more importantly, make sure their staff understand and follow them.”

To view the infection control audit tool currently used by CMS to better assess infection control practices in ambulatory surgical centers, please visit: http://www.cms.gov/manuals/downloads/som107_exhibit_351.pdf

Ventilator Bundle Adjusted: Daily Oral Care with Chlorhexidine

The following was posted on the IHI website regarding adjustments to the ventilator bundle made in May 2010. You can read the update (as well as implementation tips) in its entirity here.

You can read the updated description of the IHI Ventilator Bundle here: here



Daily Oral Care with Chlorhexidine
IHI added this element to the Ventilator Bundle in May 2010 following continued review of the literature and use of the element in the IHI Ventilator Bundle in Scotland for over a year. The recommended chlorhexidine solution strength is 0.12%.

Dental plaque biofilms are colonized by respiratory pathogens in mechanically ventilated patients. Dental plaque develops in patients that are mechanically ventilated because of the lack of mechanical chewing and the absence of saliva, which minimizes the development of biofilm on the teeth. Dental plaque can be a significant reservoir for potential respiratory pathogens that cause ventilator-associated pneumonia (VAP). Chlorhexidine antiseptic has long been approved as an inhibitor of dental plaque formation and gingivitis. As early as 1996, DeRiso and colleagues published a study that provided evidence to support the use of 0.12% chlorhexidine oral rinse as a prophylactic measure to reduce nosocomial respiratory tract infections in cardiac surgery patients. [1]

Since that time there has been much discussion about the utilization of chlorhexidine as an important adjunct to oral hygiene, but there have been few studies published that provide firm evidence that the use of chlorhexidine as a decontamination antiseptic reduces the incidence of ventilator-associated pneumonia. Chlorhexidine has been studied in two strengths: 0.12% and 0.2%. The US Food and Drug Administration recommends 0.12% oral chlorhexidine for use as mouth rinse. In a meta-analysis published in 2007 by Chan and colleagues in the British Medical Journal, eleven studies were evaluated for effect of oral decontamination on the incidence of ventilator-associated pneumonia and mortality in mechanically ventilated adults. Results of that analysis concluded that oral decontamination of mechanically ventilated adults using chlorhexidine is associated with a lower risk of ventilator-associated pneumonia. [2]

There is little if any evidence of other oral care processes having an effect on the development of VAP, but it makes sense that good oral hygiene and the use of antiseptic oral decontamination reduces the bacteria on the oral mucosa and the potential for bacterial colonization in the upper respiratory tract. This reduction in bacteria has been shown to reduce the potential for the development in ventilator-associated pneumonia for patients on mechanical ventilation.

References:

1. DeRiso AJ, Ladowski JS, DillonTA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109:1556-1561.
2. Chan EY, Ruest A, O’Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. British Medical Journal. 2007;10:1136.

Additional Reference:
Munro CL, Grap MJ, Jones DI, McClish DK, Sessler CN. Chlorhexidine, tooth brushing and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care. 2009 Sep;18(5):428-437.

Hospitals in 16 Indiana Counties Qualify for Higher Medicare IPPS Payment

In the June 2, 2010 updated CMS IPPS Proposed rules for FY2011, increased payment was described for hospitals in counties with the lowest per capita Medicare spending (lowest quartile).

Counties in Indiana that qualified are:

• Adams
• Brown
• DeKalb
• Elkhart
• Franklin
• Huntington
• Jackson
• Kosciusko
• LaGrange
• Marshall
• Monroe
• Noble
• Orange
• Wabash
• Wells
• Whitley

The following is excerpt of text from the proposed rule. You can read the complete proposed rules at the following: http://edocket.access.gpo.gov/2010/pdf/2010-12567.pdf (starts on page 30926)

E. Additional Payments for Qualifying Hospitals With Lowest Per Capita Medicare Spending

1. Background
Section 1109 of Public Law 111–152, provides for additional payments for FY2011 and 2012 for ‘‘qualifying hospitals.’’ Section 1109(d) defines a ‘‘qualifying hospital’’ as a ‘‘subsection (d) hospital * * * that is located in a county that ranks, based upon its ranking in age, sex and race adjusted spending for benefits under parts A and B * * * per enrollee within the lowest quartile of such counties in the United States.’’ Therefore, a ‘‘qualifying hospital’’ is one that meets the following conditions: (1) A ‘‘subsection (d) hospital’’ as defined in section 1886(d)(1)(B) of the Act; and (2) located in a county that ranks within the lowest quartile of counties based upon its spending for benefits under Medicare Part A and Part B per enrollee adjusted for age, sex, and race. Section 1109(b) of Public Law 111–152 makes available $400 million to qualifying hospitals for FY 2011 and FY 2012. Section 1109(c) of Public Law 111–152 requires the $400 million to be divided among each qualifying hospital in proportion to the ratio of the individual qualifying hospital’s FY 2009 IPPS operating hospital payments to the sum of total FY2009 IPPS operating hospital payments made to all qualifying hospitals.

Thoughts on Pay-for-Performance

IHI Open School posted this video on their blog yesterday. It is very thought provoking.

The title of this RSA Animate is: Drive: The surprising truth about what motivates us. It is based on a talk by Dan Pink.

(note: This is a youtube video. If you don't see anything below, it is probably being blocked)

Eight Recommendations for Policies for Communicating Abnormal Test Results

The Joint Commission recently published this article in its Joint Commission Journal on Quality and Patient Safety (May 2010, Volume 36 No 5).

The article can be downloaded free from AHRQ here: http://psnet.ahrq.gov/public/Singh-JCJQPS-2010_PSNetID18026.pdf

The eight recommendations are:

1. Policies should be introduced with clear definitions of key terms.
2. Policies should clearly outline provider responsibilities.
3. Policies should specify procedures for fail-safe communication of abnormal test results.
4. Policies must define verbal and/or electronic reporting procedures for both critical and significantly abnormal laboratory, imaging, and other test values.
5. Policies should specify "Critical Tests" and acceptable length of time between their ordering and reporting.
6. Policies should define time lines between the availability of test results and patient notification, and institutions should specify preferred mechanisms for patient notification.
7. Policies must be of "real world" value and written with feedback from key stakeholders.
8. Policies should establish responsibilities for monitoring and evaluating communication procedures.

The following is the text of the Article-at-a-Glance:

Background: Health care organizations continue to struggle to ensure that critical findings are communicated and acted on in a timely and appropriate manner. Recent research highlights the risks of communication breakdowns along the entire spectrum of test-result abnormality, including
significantly abnormal but nonemergent findings. Evidence-based and practical institutional policies must uphold effective processes to guide communication of abnormal test results. Eight recommendations for effective policies on communication of abnormal diagnostic test results were developed based on policy refinement at the Michael E. DeBakey Veterans Affairs Medical Center
(Houston), institutional experience with test result management, and findings from research performed locally and elsewhere.

Key Facets of Effective Policies: Research findings on vulnerabilities in existing policies and procedures were taken into consideration. The eight recommendations are based on important refinements to the policy which clarified staff roles and responsibilities for test ordering, follow-up, and communication; defined categories of abnormal test results to guide appropriate follow-up action; and elaborated procedures for monitoring the effectiveness of test result communication
and follow-up. Participation of key stakeholders is recommended to enhance buy-in from personnel and to help ensure the policies feasibility and sustainability.

Conclusions: The proposed recommendations for ensuring safe test-result communication may be potentially useful to a wide variety of institutions and health care settings. These practical suggestions, based on research findings and experiences with a previous policy, may be a useful
guide for designing or amending policies for safe test-result communication in both inpatient and outpatient settings.

A3 Thinking

Those of you familar with Lean will recognize A3 as a way of thinking to solve a problem. I came across this presentation on Jamie Flinchbaugh's blog (http://jamieflinchbaugh.com/) that does a great job at providing an understandable overview.

Developing People Using A3 Thinking

View more presentations from Jamie Flinchbaugh.

A Guide to Achieving High Performance in Multi-Hospital Health Systems

On March 29, the Health Research and Educational Trust (HRET) released a study of what high performing hospital systems did that differentiated them from lower performing hospital systems.

The report can be downloaded here.

The webpage at the Commonwealth Fund can be found here.

The executive summary is cut and pasted below with areas of interest to healthcare quality professionals in red.

-------------------------------

Overview
Through the use of publicly available quality data, interviews with leaders of 45 multi-hospital health systems, and analysis, this report identifies three major themes, four major best practice categories, and 17 specific best practices that are associated with high performance.

Executive Summary
Multi-hospital health system leaders have a significant impact on the quality of health care in the United States. The 200 largest hospital systems (a hospital system being defined as having 2 or more general acute care hospitals) account for over half of all hospital admissions in the United States.

Through generous support from The Commonwealth Fund, the Health Research & Educational Trust (HRET) embarked on a project to identify and disseminate best practices associated with high performing health systems. Through the use of publicly available quality data, interviews with leaders of 45 multi-hospital health systems, and analysis, identified below are three major themes, four major best practice categories and seventeen specific best practices that are associated with high performance.

Major Themes
1. No one system type was most associated with high performance
We examined the relationships of many system characteristics to an overall composite measure of quality as well as to more specific measures, such as the HQA core measures, overall patient satisfaction, and a combined, risk-adjusted readmission rate and mortality rate. From the analysis, it was evident that high
quality scores were achieved by a variety of different system types—large or small systems, geographically regional or multi-regional systems, systems from all regions of the country, and systems with differing levels of teaching components.

2. No one factor was clearly associated with high performance
Over 50 system factors that might distinguish between top performing systems and those with lower quality scores were analyzed, and no one factor clearly separated the top systems from the others. In every single case, factors that were observable in high performing systems also existed in at least some of the lower performing systems. Moreover, there was no unanimity among top performing systems with respect to factors associated with high performance. As discussed in this guide, success depends on a range of actions.

3. Creating a culture of performance excellence, accountability for results, and leadership execution are the keys to success
From the study, a culture of performance excellence and accountability for results was strongly exhibited during the interviews with the high performing health systems. This was best defined through cultural markers such as: focusing on continuous improvement, driving towards dramatic improvement or perfection versus incremental change, emphasizing patient-centeredness, adopting a philosophy that embraces internal and external transparency with regard to performance, and a having a clear set of defined values and expectations that form the basis for accountability of results. The other finding connected with the culture of performance excellence was a disciplined and persistent focus by leadership on execution and implementation to achieve the lofty goals. The culture of performance and excellence was strongly connected to leadership’s execution doctrine.

Best Practices Associated with High Performing, Multi-Hospital Health Systems
1. Establish a System-wide Strategic Plan with Measurable Goals
A. Set both measurable short and long-term goals.
B. Set goals for quality and safety based on the pursuit of perfection rather than improvement.
C. Link the system’s quality goals with its operational and financial goals.

A system-wide strategic plan for quality and safety with measurable goals across
multiple dimensions is a best practice for improving system performance. Many
systems also establish threshold, stretch, and (in some cases) high stretch
goals. They then track the progress of achieving these through frequently using
system performance dashboards.

2. Create Alignment Across the Health System with Goals and Incentives
A. Establish system-level quality steering/oversight committees to provide direction to system leaders in setting system-wide goals and aligning them with all hospitals.
B. Embed health system goals into individual hospital leaders’ goals.
C. Link annual bonuses for system and hospital leaders to performance targets in the system’s key strategic areas.
D. Align incentive pay and/or accountability for achieving system-level quality and patient safety targets into contracts with physicians.
E. Align emphasis on culture with efforts to understand and improve it.

Aligning the system’s quality and safety goals with the goals of the individual
hospitals as well as the hospital leaders’ is a practice used by top performing
systems to improve system performance. Having highly aligned goals facilitates
performance tracking and reporting across multiple hospitals and promotes
standardization in performance measurement. Additionally, aligning performance
incentives (financial or other) for system and hospital executives with the
system’s strategic goals (e.g., quality, patient satisfaction, financial) is a
strategy top performing systems use to improve overall performance.

3. Leverage Data and Measurement Across the Organization
A. Use an “all or none" or “perfect care” approach to set targets for all performance measures.
B. Consider setting targets based upon event counts (numerator) as well as rates.
C. Share dashboards with hospital leaders and staff frequently to identify areas in need of improvement and then take immediate actions to get back on track.
D. Post dashboard information on the system’s intranet.
E. Engage in national benchmarking initiatives to achieve greater transparency as well as foster healthy competition between hospitals.
F. Utilize corporate support through data mining of existing information systems, frequent analyses, and reporting of measures for hospital-level performance improvement.

High performing systems use dashboards (e.g., a balanced scorecard) to measure
and manage system performance. Setting system-level targets within each
strategic priority area is also a strategy used by top performing systems to
improve performance across hospitals. Additionally, sharing system dashboards
regularly with hospital leaders, clinicians, and other staff helps promote
quality improvement and accountability.

4. Standardize and Spread Best Practices Across the Health System
A. Establish a process to identify and select practices for standardization.
B. Use ongoing education and skills development to spread best practices.
C. Effectively disseminate best practices across the system.

In order to successfully adopt best practices, the standardization of care
processes and the use of education and skills development programs are vital in
the spread of best practices as well as the acceleration of their use among the
entire health system.

Multi-hospital health system leaders can employ a variety of practices to improve care across their multi-facility organizations that focus upon overall system improvement. However, the keys to success are not the specific practices themselves, but the execution of those practices and the creation of a culture that supports performance improvement.

CitationJ. Yonek., S. Hines., and M. Joshi, A Guide to Achieving High Performance in Multi-Hospital Health Systems, Health Research & Educational Trust, March 2010.

HCA achieved >96% Healthcare Worker Flu Immunization!!!

At the March 2010 meeting of the 5th Decennial International Conference on Healthcare Associated Infections, the Hospital Corporation of America reported that they were able to achieve >96% healthcare worker vaccination for seasonal influenza.

The Institute for Healthcare Improvement posted the powerpoint presentation on its website yesterday. You can find it here: http://www.ihi.org/IHI/Topics/HealthcareAssociatedInfections/InfectionsGeneral/EmergingContent/ImplementationFluVaccineStrategy.htm

The conference website has posted an abstract. It is copied and pasted below:

Abstract Title: Implementation of a Successful Seasonal Influenza Vaccine Strategy in a Large Healthcare System

Background: As part of a comprehensive seasonal influenza prevention strategy, the Hospital Corporation of America (HCA) implemented a program that required employees who could infect or become infected by a patient to receive the seasonal influenza vaccine or wear a surgical mask in patient care areas. HCA is the nation's largest provider of healthcare services, composed of locally managed facilities that include 163 hospitals, 112 outpatient centers and
368 physician practices in 20 states. The strategy was announced by the corporate CEO and Chief Medical Officer. A core group representing emergency preparedness, infection prevention, human resources, legal, pharmacy, communications, and supply was formed. This core group recommended strategy, provided tools, resources, and regular flu updates for the program. The reason for the program, as well as implementation strategies were relayed in a webcast to all facilities. Non vaccine strategies, such as cough and sneeze etiquette, proper hand hygiene, proper cleaning techniques, and hazards of Presenteeism were also introduced. Human resources policies were changed to accommodate time off needed by employees ill with the flu. Prior to the program, seasonal influenza vaccine rates for the 2008-2009 influenza season varied from a low of 20% to a high of 74% (Mean 58%).

Objective: To review the strategies and outcomes of a comprehensive seasonal influenza prevention program to include vaccination and declination rates.

Methods: Concurrent analysis. Consents and declinations were documented in a corporate wide electronic database.
Results: As of November 1, 2009, 140,599 employees were offered the seasonal influenza vaccination, with 135,584 accepting, or 96%. This correlates to clinical employees (98,067 total with 94,530 accepting.) A total of 5,015 employees declined the seasonal influenza vaccine. Reasons for declination were allergy (12%), contraindicated (7%), Fear (4%), pregnant (1%), religion (3%), and no reason given (73%).

Conclusions: The program resulted in a 65% increase in employee vaccine rates. Vaccine rates at unionized facilities were 95%; in non-unionized facilities they were 97%. A comprehensive vaccine strategy which includes vaccine or surgical mask use is successful in increasing vaccination rates.

Patient Safety ...in 3 words?

The following is cut and pasted directly from Abington Memorial Hospital's patient safety & quality web page.

You can go directly to the page here: http://www.amh.org/aboutus/patientsafetyandquality/three-words-video.aspx

You can go directly to the video here: http://amhweb.cachefly.net/Videos/aboutus/3Wordsvideo.swf

It only takes three words to tell someone how you feel, what you believe in or what’s important to you. At Abington Memorial Hospital, three words can describe our entire culture — Patient Safety First.

Patient Safety is AMH’s number one priority, and AMH employees are letting their patients, and each other, know just how important that priority is — with just three words.

Inspired by the popular Good Morning America segment, “Your Three Words,” AMH’s Center for Patient Safety and Healthcare Quality made a four-minute long video using the three-word concept. The video
features AMH employees from all departments — clinical, ancillary, support staff — offering their own personal three-word message of patient safety, while promoting safe behavior and teamwork.

Joint Commission Updates Sentinel Event Statistics

The Joint Commission reported today that it has updated its sentinel event statistics through December 31, 2009.

The updated statistics can be found here: http://www.jointcommission.org/NR/rdonlyres/377FF7E7-F565-4D61-9FD2-593CA688135B/0/SE_Stats_31_Dec_2009.pdf

The sentinel events data webpage is here: http://www.jointcommission.org/SentinelEvents/Statistics/

Wrong site surgery is still the leading sentinel event.

Joint Commission Releases First Sentinel Event Alert for 2010: Prevention of Maternal Death

By: LMcBride

Whether your facility is accredited by The Joint Commission (TJC) or another accrediting body, there should be an interested in reducing risks of maternal death. The U.S. government’s Healthy People 2010 initiative set a target of 3.3 maternal deaths per 100,000 live births, but according to the CDC’s (TJC, 2010) most recent statistics there are 13.3 maternal deaths per 100,000 live births. Further, U.S. Department of Health and Human Services (USDHHS), Health Resources and Services Administration (HRSA) (2008) released disparities of care based on ethnicity for maternal deaths for the year 2005 indicating that if you are non-Hispanic Black woman your rate is 39.2 per 100,000 live births which is three (3) times more than the rate of non-Hispanic White women (11.7 per 100,000 live births) and more than four (4) times the rate among Hispanic women (9.6 per 100,000 live births). TJC (2010) indicates the greatest risk is among women who present with high blood pressure, diabetes and/or obesity.

What can hospitals do to prevent maternal deaths? TJC (2010) has suggested the following actions:

1. Educate physicians and other clinicians who care for women with underlying medical conditions about the additional risks that could be imposed if pregnancy were added; how to discuss these risks with patients; the use of appropriate and acceptable contraception; and pre-conceptual care and counseling. Communicate identified pregnancy risks to all members of the health care delivery team.
2. Identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix system problems that would prevent optimal care.
3. Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths may occur in another hospital, away from the woman’s usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment.
4. Refer high-risk patients to the care of experienced pre-natal providers with access to a broad range of specialized services.
5. Make pneumatic compression devices available for patients undergoing Cesarean section who are at high risk for pulmonary embolism.
6. Evaluate patients who are at high risk for thromboembolism for low molecular weight heparin for post partum care.

References:
Health Resources and Services Administration (HRSA). (2008). Women’s health USA 2008: Maternal mortality. HRSA website. Rockville, Maryland: U.S. Department of Health and Human Services (USDHHS). Retrieved January 31, 2010: http://mchb.hrsa.gov/whusa08/hstat/mh/pages/234mm.html
The Joint Commission (TJC). (2010). Issue 44, January 26, 2010: Preventing maternal death. The Joint Commission website. Retrieved January 31, 2010: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm

CMS Announces Indianapolis as site of a New Medicare Demonstration Project

CMS announced today that the Indiana Health Information Exchange (IHIE) will be a Medicare demonstration project to examine the impact of quality reporting and pay-for-performance.

The press release is pasted below in its entirety with sections relevant to Indiana in Red.


For Immediate release
January 27, 2010

New Medicare Quality Demonstrations in North Carolina, Indiana to Address Quality Improvement Efforts

Two demonstrations comprised of a community-wide health information exchange in Indiana and a consortium of several community care physician networks in North Carolina are being implemented to encourage the delivery of improved quality care to an estimated 130,000 beneficiaries in those states, according to the Centers for Medicare & Medicaid Services (CMS).

The demonstrations are part of the national, five-year Medicare Health Care Quality (MHCQ) demonstration mandated by Congress in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The Indiana and North Carolina demonstrations will make more effective use of best practice guidelines, encouraging shared decision making between providers and patients, and altering incentives for care delivery.

Each demonstration uses a different approach but each is intended to improve quality of care received by Medicare beneficiaries at less cost to Medicare.

The Indiana Health Information Exchange (IHIE) demonstration is the first large-scale Medicare study to examine the impact of a multi-payer, quality reporting and improvement, and pay-for-performance program. It is unique among recent Medicare projects because Medicare data will be used by the IHIE, along with clinical and administrative data from other sources, to provide participating physicians with better information on the patients they are treating and to use common quality measures to create incentives to improve the quality and cost of care provided to patients covered by private insurers, employer-sponsored group health plans, Medicare, and Medicaid. IHIE’s program will test whether quality improvement and pay-for-performance initiatives are more effective in a multi-payer environment.

The IHIE project is a community-wide effort involving a coalition of providers (roughly 800) treating the majority of Medicare fee-for-service patients in the Indianapolis area; regardless of the patient’s health status or affiliation with a specific physician group, health system, or insurance type.

“IHIE is uniquely suited to implement and capture health care activities for about 100,000 Indiana Medicare beneficiaries, largely due to a demonstrated proficiency as a regional health information exchange, with a coalition that includes regional employers, public and private payers and local physicians working together to treat patients with a more complete picture of common quality measures and the overall health care being provided, or not being provided, to people with Medicare benefits,” said J. Marc Overhage, IHIE president and chief executive officer.”

“Under the current health care system, patient data is often inconsistent and housed in different systems making it less useful to physicians,” said CMS Acting Administrator Charlene Frizzera. “As quality measures and incentives vary across payment and delivery systems, IHIE and subsequent demonstrations will work to combine fragmented data and standardize quality reporting and payments for greater efficiency for health care providers to improve quality and cost of care for their patients.”

The North Carolina Community Care Networks (NC-CCN) demonstration will extend the ‘medical home’ concept to low-income Medicare beneficiaries, those eligible for both Medicaid and Medicare. NC-CCN consisting of eight regional health care networks in several North Carolina counties combines community-based care coordination and health information technology to support more effective care management.

Care for Medicare and Medicaid dually eligible beneficiaries can be fragmented even when care for Medicaid eligibles is coordinated well. Often states, which utilize effective care management programs in their Medicaid programs, do not extend them to those eligible for both Medicaid and Medicare. In this demonstration the concepts which have worked well in the past will be extended to Medicare. Eventually the NC-CCN intends to extend their program to those only eligible for Medicare.

The networks, consisting of community physicians, hospitals, health departments, and other community organizations will serve as the medical home or primary source of care for dual eligible beneficiaries. Each network employs clinical care coordinators who work with practices to plan and coordinate care for all of the patients in the medical home. The networks will also measure care performance through quality measurement and implement performance incentives for effective care.

Both CMS demonstrations allow the organizations to share in a portion of Medicare savings achieved once quality of care and cost objectives are met. The demonstrations are described at the following CMS Web site: http://www.cms.hhs.gov/demoprojectsevalrpts/md/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS023618&intNumPerPage=10

Discharge Instructions vs Hospital Readmission Rates

The Dec 31, 2009 edition of the New England Journal of Medicine published an article titled "Public Reporting of Discharge Planning and Rates of Readmission".

The abstract can be found here: http://content.nejm.org/cgi/content/abstract/361/27/2637

The pdf is currently available here: http://content.nejm.org/cgi/reprint/361/27/2637.pdf

Excerpts of the abstract is cut and pasted below with items of interest to healthcare quality professionals in red.
------------------------
Public Reporting of Discharge Planning and Rates of Readmissions
Ashish K. Jha, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.

Background A reduction in hospital readmissions may improve quality and reduce costs. The Centers for Medicare and Medicaid Services has initiated a national effort to measure and publicly report on the conduct of discharge planning. We know little about how U.S. hospitals perform on the current discharge metrics, the factors that underlie better performance, and whether better performance is related to lower readmission rates.

Methods We examined hospital performance on the basis of two measures of discharge planning: the adequacy of documentation in the chart that discharge instructions were provided to patients with congestive heart failure, and patient-reported experiences with discharge planning. We examined the association between performance on these measures and rates of readmission for congestive heart failure and pneumonia.

Results We found a weak correlation in performance between the two discharge measures. We found no association between performance on the chart-based measure and readmission rates among patients with congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile), and only a very modest association between performance on the patient-reported measure and readmission rates for congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile), and pneumonia.

Conclusions Our findings suggest that current efforts to collect and publicly report data on discharge planning are unlikely to yield large reductions in unnecessary readmissions.
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Interestingly, within the article, Indiana was referenced a few times:

• Munster, Indiana, was identified as having one of the highest readmission rates for CHF in the nation (29.4%).
• Lafayette, Indiana, was identified as having one of the lowest readmission rates for CHF in the nation (15.2%)
• South Bend, Indiana, was identifed as having one of the lowest pneumonia readmission rates in the nation (10.9%)