AHRQ Tools and Resources to Prevent HAIs.

In early September, the AHRQ released a webpage highlighting research and resources related to the prevention of hospital acquired infections. This is an excellent site that links to tools and resources for both healthcare providers as well as healthcare consumers.

You can find the website here.

ThedaCare - "No Medication Errors in 2 years"??? via Lean

Fox News in Wisconsin recently interviewed the CEO of ThedaCare and discussed their Lean journey.

http://www.foxnews.com/search-results/m/25995300/what-is-thedacare.htm#q=thedacare

http://www.foxnews.com/search-results/m/25995305/what-works-what-doesn-t.htm#q=thedacare

http://www.foxnews.com/search-results/m/25995515/collaborative-care.htm#q=thedacare

Specifically, in these videos, you will hear the CEO talk about the Lean tools, the control boards, the improvement methodology, and the fact that their staff are empowered to solve the problems themselves rather than wait for a manager to solve the problem for them.

...a very interesting discussion.

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

Three Indiana Regions Identified as "Low-Cost, High Quality".

The Institute for Healthcare Improvement recently concluded a "How did they do that?" conference where invited healthcare leaders from regions around the US identified as "Low-Cost, High Quality" met in Washington, DC to talk about their experiences.

Although no region from Indiana participated in this meeting, the IHI did publish their methodology in identifying eligible regions. You can find that document here.

Based on their methodology, approximately 70 regions were identified as "Low-Cost, High Quality". The list of regions can be found here.

Three Indiana regions were named in this document. They are:

• Fort Wayne
• Muncie
• South Bend

Opening slides that compare "Low-Cost, High Quality" regions to "all others" from this meeting can be found here.

Maybe the three large Central Indiana health systems can learn a thing or two from the the three Indiana regions above?

CMS Announces New IPPS Quality Measures for FY2010

On Firday afternoon, CMS released the final rules for FY2010 IPPS. You can find the federal register entry here.

Ther press release from CMS is as follows. Areas of interest to acute care healthcare professionals are in red.


FOR IMMEDIATE RELEASE
July 31, 2009

MEDICARE ADDS QUALITY MEASURES FOR REPORTING BY ACUTE CARE HOSPITALS FOR INPATIENT STAYS IN FY 2010

OVERVIEW:
On July 31, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises policies and payment rates for general acute care hospitals that are paid for inpatient services under the Inpatient Prospective Payment System (IPPS), effective for discharges in fiscal year 2010 – that is, on or after October 1, 2009. In addition to promoting accurate payment for inpatient services to Medicare beneficiaries, the final rule strengthens the relationship between payment and quality of service, by expanding the quality measures that hospitals must report in order to receive the full market basket update in fiscal year 2011. Under the Medicare law, hospitals that choose not to participate in the voluntary reporting program or do not participate successfully will receive an inflation update equal to the hospital market basket less two percentage points The final rule sets the market basket at 2.1 percent, and, therefore, hospitals that do not successfully report the quality measures will receive updates of 0.1 percent.

The final rule does not change the list of hospital-acquired conditions (HACs) in FY 2010, but describes CMS’s plans to evaluate the impact of the existing policy on hospital practices and patient care.

This Fact Sheet discusses only the quality provisions of the IPPS FY 2010 final rule; separate fact sheets also issued today provide more detail on the payment and policy changes.

BACKGROUND: The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) and HACs initiatives represent significant steps toward implementing value-based purchasing (VBP) in Medicare. VBP is intended to transform Medicare from a passive payer for
services to a prudent purchaser of services, paying not just for quantity of services but for quality as well.

The RHQDAPU initiative grew out of the Hospital Quality Initiative developed by CMS in consultation with hospital groups. Participation in the program is voluntary, but after initial levels of participation proved disappointing, Congress added a financial incentive to the program in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. Under the MMA, hospitals that chose not to participate or failed to meet the criteria for successful reporting in a given year received the annual payment update reduced by 0.4 percentage points. The Deficit Reduction Act of 2005 increased this reduction to 2.0 percentage points. Since the implementation of the financial incentive, hospital participation has increased to 99 percent and, of participating hospitals, 97 percent receive the full annual payment update in FY 2009.

In the meantime, the RHQDAPU measure set has grown from a starter set of 10 quality measures in 2004 to the current set of 43 quality measures. The 43 measures include 25 chart-abstracted measures (heart attack, heart failure, pneumonia, surgical care improvement), 16 claims-based measures (mortality and readmissions measures for heart attack, heart failure, pneumonia; AHRQ Patient Safety Indicators and Inpatient Quality Indicators; nursing sensitive care), 1 survey-based measure (patient satisfaction), and 1 structural measure (participation in a cardiac surgery registry).

CHANGES TO THE RHQDAPU PROGRAM FOR FY 2011:
Additions: The IPPS FY 2010 final rule adds four new measures and program requirements to the current measures for which hospitals must submit data under the RHQDAPU program to receive the full market basket update in FY 2011. This includes two new chart-abstracted measures for surgical care improvement and two structural measures. The new Surgical Care Improvement Project (SCIP) measures are additions to the existing SCIP measure set for which data elements are already being collected and submitted to CMS. Therefore, the additional chart abstraction burden for hospitals will be minimal. CMS believes that the two structural measures will promote hospital participation in nursing-sensitive care and stroke care registries that collect quality data.
The additions to the quality measures are summarized in the following table:

Surgical Care Improvement Project (SCIP) Measures
SCIP INF 9 - Urinary Catheter Removed on Postoperative Day 1 (POD1) or postoperative Day 2 (POD2)
SCIP INF 10 - Surgery Patients with Perioperative Temperature Management

Structural Measures
Participation in a Systematic Clinical Database Registry: Nursing Sensitive Care
Participation in a Systematic Clinical Database Registry: Stroke Care

Retirement of Measure: The final rule notes that CMS retired the Acute Myocardial Infarction (AMI)-6 – Beta-blocker at arrival measure. CMS took this action based on the evolving evidence for care of AMI patients and changes in the American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines. The new guidelines recommend that early beta-blockers should be avoided in certain patient populations due to increased mortality risk. Retirement of this measure is based on evidence that revision of the measure would be impractical and might cause unintended consequences, including harm to certain AMI patients.

Program Requirements: CMS currently provides hospitals that will not be receiving the full market basket update an opportunity to submit a RHQDAPU reconsideration request to CMS. The final rule now requires hospitals that are denied the full market basket update for FY 2010 because they fail to meet the RHQDAPU validation requirements to submit a copy of all the paper medical records that they submitted to the CMS contractor each quarter for purposes of the validation, along with a copy of the reconsideration request form. CMS believes this new process will streamline the reconsideration process and reduce the number of subsequent hospital appeals to the Provider Reimbursement Review Board (PRRB).

The final rule also provides hospitals that receive a new CMS Certification Number (CCN) more time - 180 calendar days from the date identified as the ‘‘open date’’ on CMS’s Online System Certification and Reporting (OSCAR) system - to submit a RHQDAPU participation form. This change will make it possible for CMS to verify accurately whether these hospitals intend to participate in the RHQDAPU program, while ensuring that they have a sufficient amount of time to implement the operational requirements. Hospitals will still be required to report data starting with the calendar quarter following the date that they submit their RHQDAPU participation form.

Finally, CMS has modified the validation requirement starting with FY 2012 to improve the reliability and quality of the process. CMS will randomly select 800 hospitals on an annual basis, and will validate 12 medical records on a quarterly basis throughout the year from each selected hospital. CMS will increase the quarterly sample size from the current 5 records to 12 records to achieve a more reliable validation estimate of the RHQDAPU data reported by the hospital. CMS will also develop targeting criteria to supplement the random sample beginning in FY 2011 to make sure that hospitals do not receive quality payments that have failed validation in the past or have not been included in the sample several years in a row.

HOSPITAL-ACQUIRED CONDITIONS UPDATE: The final rule does not change the list of hospital-acquired conditions (HACs) in FY 2010. During the coming fiscal year, CMS is planning to conduct a joint evaluation of the program’s impact, working with sister agencies within the Department of Health and Human Services - the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), and the Office of Public Health and Science (OPHS). The evaluation will provide valuable information about the program’s impact with regard to preventing HACs.

Under the HAC payment provision, Medicare has selected ten categories of conditions that are reasonably preventable through adherence to evidence-based guidelines, and that, when present as a secondary diagnosis at discharge, result in the case being assigned to a higher paying MS-DRG. Beginning for discharges on or after October 1, 2008, CMS no longer pays at the higher MS-DRG if the only secondary diagnoses on a claim are on the HAC list and were not reported as present at admission.

The HAC payment provision was mandated by the Deficit Reduction Act of 2005 to provide hospitals a payment incentive to encourage the prevention of these conditions. CMS designated eight categories of conditions as HACs during the IPPS rulemaking for FY 2008 and expanded the list of HACs in FY 2009. Although CMS has not yet evaluated the impact of this policy, CMS has received anecdotal reports that hospitals across the country are increasing their efforts to prevent HACs from occurring.

The final rule was placed on display at the Federal Register today, and can be found under Special Filings at: www.archives.gov/federal-register/public-inspection/index.html.
It will appear in the August 27, 2009, Federal Register.
For more information, please see: www.cms.hhs.gov/AcuteInpatientPPS/01_overview.asp.

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.

AHRQ says Health Care Quality in Indiana is "Weak".

After compiling over 100 measures for all states, Indiana falls between weak and average on the National Health Care Quality Report (NHRQ) - a report funded by the Agency for Health Care Research and Quality (AHRQ).

You can view the dashboard and the elements that contribute to Indiana's overall score here.

Indiana Heart Failure Readmission Rates

CMS has made available the heart failure readmission rates for all hospitals in the country on its http://www.hospitalcompare.hhs.gov website.

The database behind the website is also available from CMS.

In the State of Indiana:

• 12 hospitals were better than the national average.
• 103 hospitals were no different than the national average.
• 2 hospitals were worse than the national average.

Who were these top performing hospitals?

• BALL MEMORIAL HOSPITAL INC
• COLUMBUS REGIONAL HOSPITAL
• KOSCIUSKO COMMUNITY HOSPITAL
• LAPORTE HOSPITAL AND HEALTH SERVICES
• MEMORIAL HOSPITAL AND HEALTH CARE CENTER
• MEMORIAL HOSPITAL OF SOUTH BEND
• PARKVIEW HOSPITAL
• PORTER, VALPARAISO HOSPITAL
• SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND
• SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH
• ST FRANCIS HOSPITAL AND HEALTH CENTERS
• ST VINCENT HEART CENTER OF INDIANA LLC

Additional Notes:

• Readmission rates for the Indiana better than national average hospitals ranged from 19.3% to 21.5%.
• Readmission rates for the two Indiana worse than national average hospitals were 27.7% (pt. n=690) and 28.7% (pt. n=606).

$10 Million for your idea?

Do you have an idea for changing healthcare in the US that will improve the health value of a 10,000 person community by more than 50% in 3yrs? The X PRIZE Foundation is creating a competition where the team to achieve this first will be awarded $10 Million.

Note: This is the same X-Prize foundation that awarded $10M to the first team to build a privately funded spaceship to deliver a 3 person crew to space x2 within 2wks. http://space.xprize.org/ansari-x-prize

From the Website:
The Grand Challenge for the Healthcare X PRIZE is to create an optimal health paradigm that empowers and engages individuals and communities in a way that dramatically improves health value. The proposed prize is designed to improve health value by more than 50 percent in a 10,000 person community during a three year trial. In order to effectively compete for this prize, teams will need to fundamentally change health financing, care delivery, and create new incentives that will result in achieving the required improvements in health value for both individuals and communities.

http://www.xprize.org/future-x-prizes/healthcare-x-prize

CMS updates RAC Schedule

CMS released an updated schedule of RAC roll out. The updated schedule can be found here: http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf

Note that Indiana is considered a yellow/green state.

Medicare Fraud Strike Force Hits Detroit

HHS issued a press release on 6/24/09 detailing the arrests of 53 physicians and healthcare executives. You can find the complete release at: http://www.hhs.gov/news/press/2009pres/06/20090624a.html

Excerpts:

Today, federal agents from the FBI and the HHS Office of Inspector General
(HHS-OIG) began executing arrest warrants in Detroit, Miami and Denver as part
of a concentrated effort to address fraud in the metro-Detroit area. Charges
were unsealed today against 53 individuals who are accused of various Medicare
fraud offenses, including conspiracy to defraud the Medicare program, criminal
false claims and violations of the anti-kickback statutes. The Strike Force
operations in Detroit have identified two primary areas – infusion therapy and
physical/occupational therapy providers – in which schemes were allegedly
orchestrated to defraud the Medicare program.

According to the indictments, the defendants charged today participated in
schemes to submit claims to Medicare for treatments that were in fact medically
unnecessary and oftentimes, never provided. In many cases, indictments
allege that beneficiaries accepted cash kickbacks in return for allowing
providers to submit forms saying they had received the unnecessary and not
provided treatments. Collectively, the physicians, medical assistants,
patients, company owners and executives charged in the indictments are accused
of conspiring to submit more than $50 million in false claims to the Medicare
program.

Side-by-Side Healthcare Reform Proposal Comparisons

http://www.kff.org/healthreform/sidebyside.cfm

The Kaiser Family Foundation has created a website that will allow you to compare all the current healthcare reform proposals. It is at the link above. The website says that the information was last updated 6-16-09. Very interesting site.

APIC Study Finds Hospitals Are Cutting Back on Infection Prevention???

The Association for Professionals in Infection Control and Epidemiology issued a press release on June 9th reporting its findings that hospitals are cutting back on the infection control/prevention function across the country.

You can download the press release here.

Excerpts:

The “2009 APIC Economic Survey” found that of nearly 2,000 infection preventionists who responded, 41 percent reported reductions in budgets for infection prevention in the last 18 months due primarily to the economic downturn.

According to the survey, three-quarters of those whose budgets were cut experienced decreases for the necessary education that trains healthcare personnel in preventing the transmission of healthcare-associated infections (HAIs) such as MRSA and C. difficile. Half saw reductions in overall budgets for infection prevention, including money for technology, staff, education, products, equipment and updated resources. Nearly 40 percent had layoffs or reduced hours, and a third experienced hiring freezes.

“Infection prevention departments at our nation’s healthcare facilities are severely understaffed and under-resourced,” said APIC CEO Kathy L. Warye. “Without enough trained professionals, funding and high-tech solutions that speed access to infection-related data, we are not going to continue to make progress in eliminating preventable infections. While cuts in staff, training and technology may ease budgets in the shortterm, the effect of increased infections will erode the bottom line over time, not to mention cause needless pain, suffering and death.”

First RAC, now HEAT????

The new HHS Secretary issued a press release on May 20th announcing a new interagency Healthcare Fraud Prevention and Enforcement Action Team (HEAT).

You can find the press release here: HEAT

The following are some excerpts from the press release:

• Holder (Attny General) and Sebelius (HHS Secretary) also announced the expansion of Strike Force team operations to Detroit and Houston. Medicare Fraud Strike Forces, currently in operation in South Florida and Los Angeles, fight Medicare fraud on a targeted local level.
• “Today, we are turning up the heat on perpetrators who steal from the taxpayers and threaten the future of Medicare and Medicaid,” said Secretary Sebelius. “Most providers are doing the right thing and providing care with integrity. But we cannot and will not allow billions of dollars to be stolen from Medicare and Medicaid through fraud, waste and serious abuse of the system.
• The HEAT team will include senior officials from DOJ and HHS who will build upon and strengthen existing programs to combat fraud while also investing new resources and technology to prevent fraud, waste and abuse before it happens.
• Efforts will include the expansion of joint DOJ-HHS Medicare Fraud Strike Force teams that have been successfully fighting fraud in South Florida and Los Angeles. Established in 2007, these teams have a proven record of success using a “data-driven” approach to identify unexplainable billing patterns and investigating these providers for possible fraudulent activity.
• Prevention is critical to reforming the system and the HEAT team will also focus critical resources on preventing fraud from occurring in the first place. The team will build on demonstration projects by the HHS Inspector General and the Centers for Medicare & Medicaid Services (CMS) that focus on suppliers of durable medical equipment (DME).
• The Attorney General and the HHS Secretary also called on the American people to visit a new Web site www.hhs.gov/stopmedicarefraud or call 1-800-HHS-TIPS (1-800-447-8477) to report suspected Medicare fraud.