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.