Release of 2010 Indiana Medical Errors Report Poorly Covered by Media

Although dated for 11/7/2011, the 2010 Indiana Medical Error Report was released to the public on 11/28/2011.

The link to the press release is here.
The link to the report itself is here.
The link to the data tables (containing facility specific numbers) is here.

In the month since the release of this report, coverage from the media has been disappointing. A brief google scan of Indiana news coverage shows the following:

• The Indy Star and WTHR carried the same small piece on 11/29/2011 highlighting that bed sores were the most commonly reported error and foreign objects left inside patients after surgery was the second. To it's credit, the report did not single out any hospital with high raw numbers.
• However, on the day that the report was released, WTHR posted a separate story on its website highlighting that medical errors had reached a new high. Unfortunately, it reported raw numbers of events at various central Indiana facilities without any type of responsible interpretation. This story did attempt to offer readers advice on how to stay safe, however, the reporter clearly confused prevention concepts (surgery site marking, patient turning) with error reporting ("...what can you do if you suspect an error?).
• On 12/2/2011, the Palladium-Item from Richmond, IN, carried a story highlighting the performance of its local hospital (Reid). It focused on the two patients that Reid reported fell in 2010 causing serious disability or death. It appears that the reporter (Pam Tharp) did interview hospital officials (a vice president, the director of patient safety and quality, and a spokesman) and provided quotes to balance the reported numbers. The story then proceeded to report the 5-Year reporting high, but noted possible explanations (changes in operational definitions) for this.
• The Herald-Bulletin (Anderson), ran a story on 12/8/2011 describing the performance of the two area hospitals. The CEO of Community hospital provided detail of the hospitals process to minimize missing sponges and that it seeks to learn from its errors. The President of Saint John's Hospital and its CNO both provided similar detail as to how it prevents bed sores. Healthcare quality professionals will be happy to see that this article also noted that "Medical errors generally are not the sole result of people’s actions but rather the failure of the systems and processes used in providing health care... The requirement to report events identifies persistent problems, encourages increased awareness of patient safety issues and assists in the development of evidence-based initiatives to improve patient safety."

Of the above referenced coverage, it would appear that the reporter from the Herald-Bulletin (Abbey Dole) provided the most responsible reporting of the annual Medical Error report. With a story that could easily be irresponsibly covered to incite and inflame the public, this reporter educated the public on how the medical error reporting system helps healthcare in Indiana become safer.

CMS Announces final details of Value Based Purchasing for Inpatient Acute Care

On April 29th, CMS announced the final rules of its upcoming Value Based Purchasing program for Inpatient Acute Care. This long anticipated program transitions the inpatient care provided to Medicare beneficaries from "pay for reporting" to "pay for performance".

The HHS press release itself is of little value to the healthcare quality professional. You can view it here: http://www.hhs.gov/news/press/2011pres/04/20110429a.html. However, it links to a CMS press release that contained more details. You can view it here: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3947.

Although these rules become effective with fiscal year 2013, CMS also released the list of measures for 2014 as well.

The following are excerpts from the CMS press release:


PERFORMANCE SCORING:

Performance Period: CMS has established a performance period that runs from July 1, 2011 through March 31, 2012, for the FY 2013 Hospital VBP payment determination. CMS anticipates that in future program years, if it becomes feasible, it may propose to use a full year as the performance period.

Scoring Methods: CMS will score each hospital based on achievement and improvement ranges for each applicable measure. A hospital’s score on each measure will be the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period.

For scoring on achievement, hospitals will be measured based on how much their current performance differs from all other hospitals’ baseline period performance. Points will then be awarded based on the hospital’s performance compared to the threshold and benchmark scores for all hospitals. Points will only be awarded for achievement if the hospital’s performance during the performance period exceeds a minimum rate called the “threshold,” which is defined by CMS as the 50th percentile of hospital scores during the baseline period.

For scoring on improvement, hospitals will be assessed based on how much their current performance changes from their own baseline period performance. Points will then be awarded based on how much distance they cover between that baseline and the benchmark score. Points will only be awarded for improvement if the hospital’s performance improved from their performance during the baseline period.

Finally, CMS will calculate a Total Performance Score (TPS) for each hospital by combining the greater of its achievement or improvement points on each measure to determine a score for each domain, multiplying each domain score by the proposed domain weight and adding the weighted scores together. In FY 2013, the clinical process of care domain will be weighted at 70 percent and the patient experience of care domain will be weighted at 30 percent.

Incentive Payment Calculations: CMS will utilize a linear exchange function to calculate the percentage of value-based incentive payment earned by each hospital. Those hospitals that receive higher Total Performance Scores will receive higher incentive payments than those that receive lower Total Performance Scores. CMS will notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012. CMS will notify each hospital of the exact amount of its value-based incentive payment on Nov. 1, 2012.

FISCAL YEAR 2013 MEASURES

Clinical Process of Care Measures
AMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
HF-1 - Discharge Instructions
PN-3b - Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6 - Initial Antibiotic Selection for CAP in Immunocompetent Patient
SCIP-Inf-1 - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 - Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 - Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2 - Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP-VTE-1 - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience of Care Measures (HCAHPS)
· Communication with Nurses
· Communication with Doctors
· Responsiveness of Hospital Staff
· Pain Management
· Communication About Medicines
· Cleanliness and Quietness of Hospital Environment
· Discharge Information
· Overall Rating of Hospital

ADDITIONAL MEASURES FINALIZED FOR FY2014

Mortality Measures:
· Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
· Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
· Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Hospital Acquired Condition Measures:
· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Pressure Ulcer Stages III & IV
· Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
· Vascular Catheter-Associated Infections
· Catheter-Associated Urinary Tract Infection (UTI)
· Manifestations of Poor Glycemic Control

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite Measures:
· Complication/patient safety for selected indicators (composite)
· Mortality for selected medical conditions (composite)

CMS Proposes Value Based Purchasing Program Rules for Hospital Inpatient

On Friday, CMS announced its highly anticipated proposed rules for its new hospital value based purchasing program. The pdf of the proposed rules can be found here: http://www.ofr.gov/OFRUpload/OFRData/2011-00454_PI.pdf
(Note: this link will not likely become live until 1/13/2011).

Although these are "new" proposed rules, there are really no surprises in terms of payment methodology. The amount "at risk" due to poor performance is probably lower than what was initially expected (ie: 1-2% rather than 4-5%).


The following are excerpts from the CMS press release and fact sheet that may be of interest:

• Under the program, hospitals that perform well on quality measures relating both to clinical process of care and to patient experience of care, or those making improvements in their performance on those measures, would receive higher payments.
• The financial incentives would be funded by a reduction in the base operating DRG payments for each discharge, which under the statute will be 1% in FY 2013, rising to 2% by FY 2017.
• CMS will accept comments on the hospital value-based purchasing Program proposed rule until March 8, 2010, and will respond to them in a final rule to be issued next year.
• For the FY 2013 hospital value-based purchasing program, CMS proposes to use 17 clinical process of care measures as well as 8 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that document patients’ experience of care.
• CMS also proposes to adopt three mortality outcome measures, eight Hospital Acquired Condition (HAC) measures, and nine Agency for Healthcare Research and Quality (AHRQ) measures for the FY 2014 Hospital VBP program.
• Proposed Performance Period: As required by the Affordable Care Act, CMS is proposing a performance period that ends prior to the beginning of FY 2013, specifically from July 1, 2011 through March 31, 2012, for the FY 2013 hospital value-based purchasing payment determination. CMS anticipates that in future fiscal years, the Agency may propose to use a full year as the performance period. In addition, CMS is proposing to use an 18-month performance period for the three proposed mortality measures for the FY 2014 Hospital VBP payment determination, and expects to propose a performance period for the eight HAC and nine AHRQ measures in future rulemaking.
• Proposed Scoring Methods: CMS proposes to score each hospital on relative achievement and improvement ranges for each applicable measure. A hospital’s performance on each quality measure would be evaluated based on the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period of performance. For each of the proposed clinical process and patient experience of care measures that apply to a hospital for FY 2013, CMS proposes that a hospital would earn 0-10 points for achievement based on where its performance for the measure fell within an achievement range, which is a scale between an achievement threshold and a benchmark. With regard to the improvement score, CMS proposes that a hospital would earn 0-9 points based on how much its performance on the measure during the performance period improved from its performance on the measure during the baseline period. Finally, CMS would calculate a Total Performance Score (TPS) for each hospital by combining its scores on all of the measures within each domain, multiplying its performance score on each domain by the proposed weight for the domain, and adding the weighted scores for the domains.
• Proposed Incentive Payment Calculations:  CMS proposes to translate each hospital’s TPS into a value-based incentive payment using a linear exchange function.  The linear exchange function provides the same marginal incentives to both lower- and higher-performing hospitals.
• CMS proposes to notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012.  CMS proposes to notify each hospital of the exact amount of its value-based incentive payment on or about Nov. 1, 2012.
• CMS will accept public comments on the proposed rule through March 8, 2010  CMS will review all comments and respond to them in a final Hospital VBP rule scheduled to be released some time in 2011.

PROPOSED QUALITY MEASURES FY2013   
AMI-2: Aspirin Prescribed at Discharge
AMI-7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival
 
HF-1: Discharge Instructions
HF-2: Evaluation of LVS Function
HF-3: ACEI or ARB for LVSD

PN-2: Pneumococcal Vaccination
PN-3b: Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient
PN-7: Influenza Vaccination 
SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2: Surgery Pts. on a Beta Blocker Prior to Arrival... 
SCIP-VTE-1: Surgery Pts. with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2: Surgery Pts. Who Received Appropriate Venous Thromboembolism Prophylaxis...
 
HCAHPS: Communication with Nurses
HCAHPS: Communication with Doctors
HCAHPS: Responsiveness of Hospital Staff
HCAHPS: Pain Management
HACHPS: Communication About Medicines
HACHPS: Cleanliness and Quietness of Hospital Environment
HACHPS: Discharge Information
HACHPS: Overall Rating of Hospital

PROPOSED ADDITIONAL QUALITY MEASURES FOR FISCAL YEAR 2014

Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III & IV
Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
Vascular Catheter-Associated Infections
Catheter-Associated Urinary Tract Infection (UTI)
Manifestations of Poor Glycemic Control

PSI 06 – Iatrogenic pneumothorax, adult
PSI 11 – Post Operative Respiratory Failure
PSI 12 – Post Operative PE or DVT
PSI 14 – Post Operative would dehiscence
PSI 15 – Accidental puncture or laceration
IQI 11 – Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume)
IQI 19 – Hip fracture mortality rate

Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)

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

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.

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.

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.

AHRQ: 10 Patient Safety Tips for Hospitals

The Agency for Healthcare Research and Quality (AHRQ) recently updated their publication titled "10 Patient Safety Tips for Hospitals".

The 10 Tips are:

1. Prevent central line-associated blood stream infections.
2. Re-engineer hospital discharges.
3. Prevent venous thromboembolism.
4. Educate patients about using blood thinners safely.
5. Limit shift durations for medical residents and other hospital staff if possible.
6. Consider working with a Patient Safety Organization.
7. Use good hospital design principles.
8. Measure your hospital's patient safety culture.
9. Build better teams and rapid response systems.
10. Insert chest tubes safely.

The AHRQ publications contains links to resources supporting each of the above tips. The publication can be found here: http://www.ahrq.gov/qual/10tips.pdf.

The home page of the publication is here: http://www.ahrq.gov/qual/10tips.htm

IHI Assembles Leadership Resources to Assist with Crisis Management

The Institute for Healthcare Improvement (http://www.ihi.org/) recently assembled a set of resources to assist hospital executives with effective crisis management.

At the core of the resources page is a power point presentation (and soon to be publication) from Jim Conway, Senior VP of IHI, summarizing what a well coordinated crisis management plan would look like when put into action. The page is then peppered with a series of resources and links to other sites describing recent adverse events and how they were handled.

The Jim Conway presentaton is here.

The IHI resource site is here.

Joint Commission issues Sentinel Event Alert Regarding Leadership

On 8-27-09, the Joint Commission released a Sentinel Event Alert regarding leadership and its commitment to safety.

You can find the entire alert here.
The press release can be found here.

Within the alert are 14 recommendations for the governing body, CEO, and senior managers:

1. Define and establish an organization-wide safety culture that includes a code of conduct for all employees, including contract workers.
2. Institute an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
3. Make the organization’s overall safety performance a key, measurable part of the evaluation of the CEO and all leadership.
4. Ensure that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive and timely. Also, make sure they have the opportunity to fully participate in the investigation, risk identification and mitigation activities that will prevent future adverse events.
5. Create and communicate a policy that defines behaviors that are to be referred for disciplinary action; include the timeframe that the disciplinary action should take place.
6. Regularly monitor and analyze adverse events and close calls quantitatively and communicate findings and recommendations to leadership, the board and staff. Conduct root cause analyses of adverse events. Look for patterns in root causes that identify latent hazards and weaknesses in the defenses against errors—the holes in the slices of cheese—and make sure they are addressed.
7. Regularly hold open discussions with risk management, performance improvement, physician, nursing and pharmacy leaders, and with physicians and staff caring for patients, to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care could provide the ideal opportunity for these discussions, which should focus on learning and improvement, not blame or retribution.
8. Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention. Make a visible commitment of time and money to improve the systems and processes needed to defend against hazards and minimize unsafe acts. For example, some organizations create an emergency patient safety fund.
9. Establish partnerships with physicians and align their incentives to improving safety and using evidence-based medicine.
10. Add a human element and a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to board members, executive leadership, medical staff, and other key leadership groups; also solicit patient input into safety design.
11. When planning and implementing safety improvements, use the expertise of front-line staff who understand the risks to patients and how processes really work.
12. Regularly measure leadership’s commitment to safety using climate surveys and upward appraisal techniques (in which staff review or appraise their managers and leaders).
13. When leaders assess managers during the annual performance review, make sure they ask about the safety issues the manager encountered, how they were handled, and the impact their actions had on reducing unsafe conditions.
14. Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety.

Personal Opinion: Although senior leadership has the responsibility for creating a structure that is conducive to improving patient safety, senior leadership is also the least effective group to actually improve patient safety. It is the bedside staff that can impact patient safety the most - if allowed to by senior leadership. Maybe this list should have included more recommendations for senior leadership to empower the bedside staff to proactively assess and redesign their work flow to minimize risk factors?

2008 Indiana Medical Errors Report Released

On 8-20-09 the Indiana State Dept. of Health released its 2008 report on medical errors reported by hospitals, ambulatory surgery centers, and abortion clinics via the reporting system mandated by the Governor in 2005 to start CY2006.

The State's Medical Error Reporting System webpage is here: http://www.in.gov/isdh/23433.htm (Note: The State frequently changes its webpage urls and thus the link may become useless at any time. It was working this morning.)

The 2008 report itself can be found here: http://www.in.gov/isdh/files/2008_MERS_Report.pdf
Data Tables: http://www.in.gov/isdh/files/2008_MERS_Data_Tables.pdf
Appendix: http://www.in.gov/isdh/files/2008_MERS_Appendices.pdf

The 2008 Report also contains descriptions of patient safety improvements efforts and activities that are ongoing throughout the state.

Note that the reporting rules have changed for CY2009. Prior to 1-1-09, 27 events had to be reported. Twenty-Eight events are now covered by the reporting system. The new list is here: http://www.in.gov/isdh/files/28_REPORTABLE_EVENTS.pdf

The release of the report has been lightly covered by local media:
IndyStar: http://www.indystar.com/apps/pbcs.dll/article?AID=2009908210343
WTHR: http://www.wthr.com/Global/story.asp?s=10964770

Hospital Aquired Conditions Section @ National Guideline Clearinghouse

Most of us are probably aware of www.guidelines.gov as being a searchable clearinghouse of evidence-based clinical practice guidelines.

Did you know that there is a section specifically about preventing the hospital acquired conditions that CMS says they will no longer pay for?

http://www.guideline.gov/resources/hac.aspx


It appears that they (National Guidelines Clearinghouse (NGC), an initiative of the Agency for Healthcare Research and Quality (AHRQ)) intends to keep this page current. The most recent update was July 27th.

IHI Global Trigger Tools (Second Edition)

The IHI recently released a document describing the concept of Global Trigger Tools to identify adverse events that are unreported through the usual voluntary event reporting systems.

The description of the document is here.

...or you can go directly to the document here. You may need to log in to the IHI website to download the document.

In my previous hospital, I was able create a monitoring system that would scan the EMR from the previous day to look for these events. If a person with limited SQL programming skills can do this (via an ODBC connection to the back-end tables of the EMR), you can be sure that EMR vendors in the future will be offering such a module (at a high cost no doubt!).

Having such a global trigger function in your organization via EMR is a great way to add a little more objectivity in what was a voluntary, subjective, and political function in the past.

AHA: Hospitals in Pursuit of Excellence

Hospitals in Pursuit of Excellence is a resource for healthcare performance improvement professionals created by the American Hospital Association.

http://www.ahaqualitycenter.org/ahaqualitycenter/hpoe/index.html

The site provides some information about the IOM 6 aims or dimensions of healthcare quality. However, the vast majority of the content is case studies of how other hospitals have addressed common issues that we all have; ie hospital aquired infections, patient throughput, patient safety, etc...

This is a great place to start if you are about to launch a performance improvement project.

"Hospitals in Pursuit of Excellence is a strategic platform to identify and
disseminate field-tested practices, proven strategies, tools and resources that
can support and advance hospital leaders’ ongoing efforts to achieve performance
excellence— care that meets the 6 IOM aims— safe, timely, efficiency,
effectiveness, equity and patient-centered."

ISBAR?

The IHI posted a tool from Rhode Island Hospital that they call ISBAR.

At first glance, this appears to be the same as SBAR with I (Identify) inserted at the beginning of the process.

The full text as well as the tool itself can be downloaded from the IHI website at: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/ISBARTripTick.htm

You will need to be logged into the IHI website to download the tool.

NQF Releases Safe Practices for Better Healthcare 2009 Update: A Consensus Report

A few days ago, the NQF released its 2009 Update of a previously released consensus report: Safe Practices for Better Healthcare.


The following is an excerpt of the document description posted on the NQF website:

Safe Practices for Better Healthcare—2009 Update presents 34 practices that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events. This revised set of NQF-endorsed safe practices has been updated with current evidence and expanded implementation approaches, and it provides additional measures for assessing the implementation of the practices.

As of today, only the electronic pdf version of the report is available. You can buy it here for $29.99.
A free summary report is here.


Did you miss out on the 2006 version? ...Not sure if your hospital can pay you back the $30? You can download the 2006 version for free at: http://www.qualityforum.org/pdf/projects/safe-practices/SafePractices2006UpdateFINAL.pdf

Interestingly, a quick Internet search will reveal the draft version of the 2009 version here.

Kaiser Permanente MedRite Program

The IHI recently posted a summary of the Kaiser Permanente MedRite Program. Components of this program to reduce medication errors included:

1. Step-by-step workflow of RNs to administer medications.
2. No Interruption Wear - no one should interrupt the RN wearing the NIW sash unless there is an emergency.
3. Sacred Zone - no one should cross or talk to an RN when they are in this zone marked in front of the area where medications are pulled/prepared.

The description of this program can be found at the IHI website here. The tools of this program (including overview, leadership change package, nurse change package, and project manager package) can be found here. Note that logging into the IHI website is required to access these tools. If you have not yet registered for access to the IHI webpage, you are missing out on a lot of quality improvement resources.

Joint Commission to review NPSG 8 - Medication Reconciliation

The Joint Commission posted on their website yesterday that, due to the difficulty hospitals are having with implementation, they will be reviewing NPSG 8 - Medication Reconciliation.

Specifically:

Today, The Joint Commission Accreditation Committee determined that effective January 1, 2009, survey findings on National Patient Safety Goal 8 (Accurately and completely reconcile medications across the continuum of care) will continue to be evaluated during the on-site survey. However, given the difficulties that many organizations are having in meeting the complex requirements of NPSG 8, the Accreditation Committee agreed that The Joint Commission should evaluate and refine the expectations for accredited organizations. While this evaluation is being conducted, survey findings from NPSG 8 will not be factored into the organization’s accreditation decision. In addition, survey findings on NPSG 8 will not generate Requirements for Improvement (RFIs) and will not appear on the accreditation report.

You can read the entire posting at the Joint Commission Website here.

Indiana House Bill 1237 - Hospital Charges Resulting from Medical Errors

First reading of House Bill 1237 was this morning (1-12-09). It was then referred to the Committee on Family, Children, and Human Affairs.

The bill seeks to prevent hospitals from knowingly billing patients for charges that are the consequence of medical errors.

The following is the current text of the bill:

IC-16-21-2-17
Sec. 17. (a) As used in this section, "harm" means the temporary or permanent impairment of a body function or structure that requires additional intervention for the patient, including an increase in monitoring of the patient's condition, a change in therapy, or active medical or surgical treatment.
(b) A hospital may not knowingly collect or attempt to collect from a patient, the patient's estate, or the patient's family the payment of a charge for medical services or products that are required as the result of a medical error or event if:
(1) the medical error or event resulted in significant harm or death to the patient;
(2) the medical error or event occurred in the hospital; and
(3) the medical error or event occurred as the result of the negligence or lack of reasonable care by:
(A) the hospital;
(B) an agent, a servant, or an employee of the hospital;
(C) an independent contractor working on behalf of the hospital; or
(D) a physician or other health care provider who has privileges to perform medical services at the hospital.

This is probably the bill that will generate the most debate and scrutiny from the hospital associations. I agree with the philosophy but the execution of the bill as currently written will be quite difficult. If this bill passes, it will be interesting to compare its final form with the current text.