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(TBT) Checklists: Easy to take for granted

Editor’s Note: This is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Checklist

In any organization’s quality department there lives a nefarious, ever-present beast. It’s usually in paper form and comprises a list of seemingly innocuous phrases or sentences and to the far right is the “checkbox.” It’s easy to become disdainful of checklists, but the reality is they play an important role.

I’m sure we’ve all heard some of the complaints.

Often these checklists include things such as, “Are there any wall penetrations?” or “Do staff know where the closest fire extinguisher is?” These questions often can be grating to hospital administrative teams because it’s “one more thing” they have to worry about and it can be frustrating during surveys to be “caught” on things that “don’t matter” in the clinical realm.

I hear the reactions to such mundane questions all the time, “Yes, it’s important but we are more concerned with medication errors, fall rates, sentinel events. Who has time to check for escusions? Shouldn’t there be a weighting scheme to it all?”

The reality is that checklists are important, and they’re focused on patient safety and care. Escusion plates and wall penetrations exist for those unthinkable times when hospitals catch fire, a rare and devastating event. When fires occur, though, those safety measures limit the impact fire and smoke can have to the most vulnerable of populations. The same can be said about medication errors and sentinel events: they are rare and potentially devastating. The measures organizations take to prevent harm must be all-encompassing.

When being confronted with checkboxes, do not put them off as non-mission critical, or roll your eyes at the people who bring them to your attention. These are safety measures, clear and simple, that must be addressed with the same type of immediacy.

Moreover, the idea of checkboxes must become incorporated into the everyday fabric of hospital operations and not delegated to one person doing safety rounds once per quarter. Educate frontline leaders to remain abreast of their own areas or have them round on other departments to keep a fresh set of eyes on the organization. Have it be part of the expectation as opposed to being something extra you ask of your leadership team.

Healthcare isn’t easy; it takes a concentrated effort to remain diligent. Healthcare exists to take care of people at their most vulnerable, which means being vigilant about the checkboxes, too.

Editor’s note: Patrick Pianezza, MHA, has worked with the Studer Group and Johns Hopkins Hospital. In his most recent role, Pianezza’s work drove organizational performance in HCAHPS to an all-time hospital best in the 90th percentile. He can be reached at ppianezza@gmail.com.

Today is Time Out Day for patient safety

June 14 is National Time Out Day, a Joint Commission and Association of periOperative Registered Nurses (AORN) campaign to promote patient safety before, during, and after surgery. The organizations also implore healthcare facilities to commit to conducting a safe, effective timeouts for each and every surgery.

This year’s theme calls on surgery staff to be a Time Out SUPERHERO, an acronym standing for the nine elements of a surgical timeout:

Support a safety culture
Use The Joint Commission’s Universal Protocol and AORN Surgical Checklist
Proactively reduce risk in the OR
Effect change in your organization
Reduce harm to patients

Have frank discussions about hazardous situations
Empower others to speak up when a patient is at-risk
Respect others on the surgical team
Openly seek opportunities for improving patient safety

“National Time Out Day is a powerful tool that supports surgical nurses’ ability to speak up for safe practices in the operating room,” AORN wrote in a brief. “It provides an opportunity to educate your community about this practice and become better informed patients (read more about this in Periop Insider). Time Out also demonstrates your role in patient care and commitment to patient safety as the perioperative nurse who cares for them.”

Wrong-site, wrong-procedure and wrong-person surgeries happen every day and surgical timeouts are key to preventing adverse and never events. Everyone on the surgical team has to be fully engaged, accountable, and empowered to speak up during the timeout process to prevent never events.

The Joint Commission has a list of free tools and resources available on surgical timeouts. 

CMS issues Legionella reduction memo

On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. Accredited facilities should double check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys.

Legionellosis is comprised of a sometimes fatal form of pneumonia called LD as well as Pontiac fever. The bacterium grows in the parts of hospital water systems that are continually wet and is spread through inhalation of aerosolized droplets of contaminated water. Legionellosis poses a particular risk to patients older than 50, who smoke or have chronic lung or immunosuppression conditions. Approximately 9% of reported legionellosis cases are fatal.

Badly maintained water systems have been linked to the 286% increase in legionellosis between 2000-2014. There were 5,000 cases of it reported to the Centers for Disease Control and Prevention (CDC) in 2014 alone. About 19% of outbreaks were associated with long-term care facilities and 15% with hospitals. Just a few items that can spread the contamination include:

•    Decorative fountains
•    Shower heads and hoses
•    Electronic and manual faucets
•    Hot and cold water storage tanks
•    Water heaters and filters
•    Pipes, valves, and fittings
•    Eyewash stations
•    Ice machines
•    Cooling towers
•    Medical devices (e.g., CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)

“Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of its patients,” the agency writes in its memo. “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.”

The memo tells surveyors to review policies, procedures, and reports documenting water management implementation results to ensure facilities:

1.    Conduct a facility risk assessment to identify where Legionella and other waterborne pathogens could grow and spread in the facility water system.

2.    Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit. The program should include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

3.    Specify testing protocols and acceptable ranges for control measures. Document the results of testing and corrective actions taken when control limits are not maintained.

The contents of this memo go into effect immediately.

TBT: Building a better self-reporting structure

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Does your organization have a formalized process for debriefing after an adverse event? And if so, is it working? For many organizations, reporting of adverse events can be problematic, with challenges ranging from time management and inefficient processes to the age-old challenge of shame?reporting near misses and adverse events can be a challenge in an industry where everyone pursues the field to help, not hurt.

“Everyone wants to leave work happy and feel like they did a good job,” says Anngail Smith, VP of operations and risk management for CRG Medical, Inc., in Houston. “Someone once said that healthcare is the intersection of care and being able to hurt people. A client told me that healthcare is a courageous activity.”

Because healthcare rides along that fine line between safe care and risk of harm, the industry needs to build an environment where people are willing to report errors and near misses so that the industry as a whole can work on the problem without being afraid.

“I think the fear of hurting someone is always there,” says Douglas Dotan, president and CEO of CRG Medical. “The question is, are you willing to incorporate that into learning how to make your processes better?”

The pressures to report are staggering for providers, Dotan says. Personal liability, risks to reputation, job security, and even peer pressure can all come into play with the issue of reporting. But the industry needs physicians to speak up and identify hazards to patient safety, share their knowledge about near misses, and propose actions to improve the delivery of care. This requires a culture change to create an environment in which providers feel safe to talk about these things without putting themselves at risk.

“If there is something that really stresses caregivers out, we need to find a way to fix it, and we need to share that fix,” says Dotan. “That won’t happen if they’re afraid.”

This is not a new issue, Dotan points out. Donald Berwick’s Institute of Healthcare Improvement talked about these factors 15 years ago, Dotan notes, and yet most events which occur today have occurred in the past, and the latest reports state that the industry has well over 400,000 preventable deaths in healthcare every year.

“That’s about 1,000 deaths that occur every day from preventable medical errors,” says Dotan.

And the contributing factors leading up to these preventable errors occur all the time. The same situation may occur 200 or 300 times before a sentinel event occurs, leading to hundreds of thousands of dollars spent in litigation and reparations because it wasn’t prevented the first 300 times, Dotan says.

This comes down to continual process improvement, he says.

“What we’ve been working on is identifying those hazards and unsafe conditions and putting an easier way for people to communicate in place,” says Dotan. “You need to have a way of documenting and giving feedback. If I continuously give you information I think is important to act on and leadership doesn’t act on it, I will stop communicating that information. So when future problems arise, they will not be reported.”

An open communication system will help overcome the fear of reporting, Smith says.

“Are you good at your job? If you did it badly would you want to tell someone? We spend more time doing our jobs than anything else. For an inexperienced person, if they make a mistake, they might report it. ‘I am new at this; I will make mistakes,’ ” says Smith. “But if the experienced person makes a mistake, they’d think they would be embarrassed to talk about it.”

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Joint Commission issues another warning about improperly cleaned medical devices

For the second time in three years, The Joint Commission has released a Quick Safety issue on the topic of improperly sterilized or high-level disinfection (HLD) equipment and devices. The accreditor writes that despite bringing the problem to light in 2014, there’s an increase in cases of medical devices not being cleaned properly.

“Immediate threat to life (ITL) declarations related to improperly sterilized or high-level disinfected (HLD) equipment have increased significantly from 2013-2016,” wrote Lisa Waldowski, DNP, PNP, CIC, Joint Commission infection control specialist, in a blog post. “In 2016, 74% of all ITL declarations from The Joint Commission were related to improperly sterilized or HLD equipment. As reports of sterilization and HLD-related issues continue to be received by our Office of Quality and Patient Safety, our surveyors also are seeing it firsthand in hospitals, ambulatory care sites and other healthcare settings across the country.”

According to Quick Safety Issue 33, noncompliance with standard IC.02.02.01 (which deals with sterilization) has been on the rise since 2009 in Joint Commission-accredited hospitals, critical access hospitals, ambulatory centers, and office-based surgery facilities.

There are several risks tied to improper reprocessing such as infection and outbreaks, loss of accreditation, litigation, negative publicity, and lost revenue. A prime example of this occurred during the 2015-2016 outbreaks, when it was discovered that the design of the duodenoscopes could prevent them from being properly sterilized.

There are several factors that are causing this rise in noncompliance, according to The Joint Commission. These include:

•    The incorrect assumption that the risk of infection to patients is low or nonexistent
•    Staff either don’t know how to properly sterilize or HLD equipment or they knowingly chose not to follow proper procedures
•    Lack of leadership oversight and the belief that sterilization or HLD is a low priority
•    A culture that discourages the reporting of safety risks
•    No dedicated staff person to oversee the proper sterilization or HLD of equipment
•    Facility design or space issues prevent proper sterilization or HLD of equipment
•    Lack of monitoring or documentation of sterilization or HLD of equipment

“Healthcare organizations need to prioritize improving sterilization and HLD efforts year-round and well before a survey occurs to best protect patients,” says Waldowski. “Together, we can work to change news headlines from reporting on sterilization or HLD-related outbreaks to touting reductions in outbreaks through quality improvement efforts.”

Why Are Medical Errors Still a Leading Cause of Death?

A more pressing question: ‘Why aren’t we doing more research into strategies that can reduce medical errors?’

The conversation around tracking medical errors highlights a lack of safety cultures.

Why are medical errors the third leading cause of death?

It was a question asked frequently by the consumer press back in May 2016, in response to an article in BMJ (Makary & Daniel, 2016) that analyzed medical literature on such errors to better understand their contribution to deaths.

However, there’s a more pressing question that the article by John Hopkins researchers Martin Makary, professor, and Michael Daniel, research fellow, sought to address: Why aren’t we doing more research into strategies that can reduce medical errors?

Getting data on the problem

The goal of the BMJ analysis was to encourage strong research into and better reporting on preventing medical errors. Makary’s chief concern is that medical errors are not cited as a cause of death, which limits research into effective solutions.

As the John Hopkins researchers point out, causes of death are reported using codes from the International Classification of Diseases (ICD). Those causes not associated with an ICD code—namely, medical errors—are not captured. One result of this is that medical errors will never be listed on the Centers for Disease Control and Prevention’s annual list of the most common causes of death in the United States, which guides national research priorities for the year.

Continue reading at Health Leaders Media. 

Study: SSI rates jump nearly 30% in the summer

A new study published in Infection Control & Hospital Epidemiology found that the changing of the seasons affects the rate of surgical site infections (SSI) in hospitals. If a patient is operated on when it’s over 90°F outside, there is a 28.9 % higher chance of contracting an SSI than if the temperature is less than 40°F, according to the study. The researchers say that SSI rates increased by 2% for every 5-degree increase in average monthly temperature.

“We show that seasonality of surgical site infections is strongly associated with average monthly temperature. As temperatures rise, risk increases,” wrote Philip Polgreen, MD, senior author of the study. “However, the odds of any one person getting an infection are still small, and due to the limitations of our data, we still do not know which particular surgeries or patients are at more risk from higher temperature.”

While the study doesn’t list any possible causes for the temperature/SSI link, it notes that the results could spur more research into this correlation.

However, it’s been known for years that PPE and handwashing compliance falls during warm months. There are other summer safety considerations that one should take into consideration, too.

AHA offering free cybersecurity training for hospitals

For years, security experts have tried to warn hospitals and clinics about the dangers of hackers and computer viruses. And as the recent Wanna Cry ransomware attack on the UK’s National Health Service (along with thousands of others) shows, many still haven’t taken the steps needed. The American Hospital Association (AHA) is now offering free cybersecurity training programs for hospital and health system leaders to help educate people on how to prevent and limit the effects of a cyberattack.

5ntkpxqt54y-sai-kiran-anagani“Every organization, no matter what its size, can do a great deal to reduce their risk and prevent attacks,” said Lawrence Hughes, AHA assistant general counsel, in a press release.

The remaining programs are scheduled for July 20 in San Francisco and October 26 in Chicago. To learn more and see the AHA’s library of cybersecurity tools, resources, click here.

Study: Single step reduces readmissions by 25%

A new study published in the Journal of the American Geriatrics Society has found that integrating informal, unpaid caregivers into the discharge process can cut readmission rates by a quarter. The study found that by using these caregivers when discharging elderly patients, they were able to reduce readmissions 25% over 90 days.  The study reviewed 4,361 patient cases and 10,715 scientific publications to come up with its results. The study found that:

•    66% of the caregivers were female
•    61% were a spouse or partner
•    35% were adult children

The study also found that informal caregivers significantly reduced time-to-readmission, rehospitalization lengths, and costs of post-discharge care.

“Due to medical advances, shorter hospital stays, and the expansion of home care technology, caregivers are taking on considerable care responsibilities for patients,” said lead author Juleen Rodakowski, OTD, MS, OTR/L, assistant professor in the Department of Occupational Therapy in the University of Pittsburgh’s School of Health and Rehabilitation Sciences, in a statement.

“This includes increasingly complex treatment, such as wound care, managing medications, and operating specialized medical equipment. With proper training and support, caregivers are more likely to be able to fulfill these responsibilities and keep their loved ones from having to return to the hospital.”

“While integrating informal caregivers into the patient discharge process may require additional efforts to identify and educate a patient’s family member, it is likely to pay dividends through improved patient outcomes and helping providers avoid economic penalties for patient readmissions,” said senior author A. Everette James, JD, MBA, director of the University of Pittsburgh’s Health Policy Institute, in a statement.

Caregiver statistics aggregated from the AARP, the Family Caregiver Alliance (FCA), the Institute of Medicine (IOM), and the National Alliance for Caregiving (NAC) reveal that:

•    More than 34 million unpaid caregivers provide care to someone age 18 and older who is ill or has a disability (AARP, 2008)
•    Unpaid caregivers provide an estimated 90% of the long-term care (IOM, 2008)
•    The majority (83%) are family caregivers—unpaid persons such as family members, friends, and neighbors of all ages who are providing care for a relative (FCA, 2005)
•    The typical caregiver is a 46-year-old woman with some college experience and provides more than 20 hours of care each week to her mother (NAC, 2004)

See the full article at HealthLeaders Media and read previous Accreditation Insiderarticles for more on readmissions:

CDC updates SSI prevention guidelines

For the first time in 18 years, the Centers for Disease Control and Prevention (CDC) has updated its surgical site infection (SSI) prevention guidelines. In its previous iteration, the guidelines were based on expert opinion rather than evidence-based practices on preventing SSIs.

“Unfortunately, in many cases the authors make no recommendation with respect to support or harm if the level of the evidence was low or very low or if they were unable to judge tradeoffs between harms and benefits of the proposed intervention because of lack of outcomes,” wrote Pamela A. Lipsett, MD, MHPE, MCCM, in the accompanying editorial. 

The CDC said it was heeding the call of healthcare professionals who said that guidelines needed to be based on evidence rather than opinions from 1999. The agency condensed thousands of studies into 170 high-quality trials to issue the following recommendations:

  • Patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before surgery.
  • Antimicrobial prophylaxis should be administered only when indicated and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made.
  • Skin prep in the OR should be done with an alcohol-based agent unless contraindicated.
  • For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the OR, even when a drain is being used.
  • Topical antimicrobial agents should not be applied to the surgical incision.
  • During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL.
  • Normothermia (i.e., normal body temperature) should be maintained in all patients.
  • For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, increased fraction of inspired oxygen should be administered during surgery and immediately after extubation in post-op.
  • Blood transfusions should not be withheld from surgical patients as a means to prevent SSIs.