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New may not be better: hospital returns to paper and happier docs

The Illinois Pain Institute (IPI) was having trouble with its electronic health records (EHR). So they got rid of them and went back to paper. And they aren’t planning on going back anytime soon.

Two years ago, all 70 members of the IPI voted unanimously to get rid of its EHR saying it was slowing down care and alienating patients.

“We felt the level of patient care was not enhanced by an electronic health record. We saw it was inefficient and added nonproductive work to physicians’ time,” John Prunskis, MD, IPI founder and co-medical director told Becker’s Hospital Review. 

Since the switch, IPI has reported greater ease communicating information between hospital systems, less time spent on data entry, happier patients and staff.

“The EHR hinders data exchange,” he says. “One EHR doesn’t talk to another EHR, and there’s many reasons for that. The other thing is when you dictate a paper note with the relevant clinical findings and history, it’s rather succinct, but with the EHR, there’s a problem. The EHR is pages and pages of mind-numbing text, where important labs and information can be lost. Before, a note might be a half-page long, but now it can be five, six pages long, and doctors frequently can’t find what’s relevant through the reams of text and clutter.”

The IPI’s feelings are echoed by many physicians, according to the Mayo Clinic, which in 2016 found in EHR usage reduces physician satisfaction and increases burnout. Another study from the same year found that for every hour physicians spend with patients, they spend two hours interfacing with their EHR.

“Electronic health records hold great promise for enhancing coordination of care and improving quality of care,” said Tait Shanafelt, MD, Mayo Clinic physician and lead author of the study, in a statement. “In their current form and implementation, however, they have had a number of unintended negative consequences including reducing efficiency, increasing clerical burden and increasing the risk of burnout for physicians.”

 

Fire and smoke: CMS clarifies which doors must be inspected annually

After pushback, federal officials backed away from their claim that smoke barrier doors must be inspected and tested annually.

More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline would be pushed back nearly six months, giving facilities until New Year’s Day 2018 to comply with an annual testing requirement for certain doors.

David Wright, director of the CMS Survey and Certification Group, made the announcement in a memo to state survey agency directors. He acknowledged that there had been a fair amount of confusion concerning the change, and he offered some pretty consequential clarifications that could affect whether the new requirement applies to your facility at all.

“[C]onsidering the level of reported misunderstanding of this requirement, CMS has extended the compliance date for this requirement by six months,” Wright wrote.

Within the National Fire Protection Association’s (NFPA) 2012 Life Safety Code® (LSC), which CMS adopted last year, there is a requirement that fire doors and smoke barrier doors be tested annually. Officials with CMS had taken the position that the new requirement applies to healthcare occupancies; that position, however, was met with pushback.

A petition objecting to the CMS position was discussed at length in June by members of the NFPA Healthcare Interpretations Task Force (HITF), says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance. That petition objected to the notion that the LSC specifically requires annual inspections of smoke barrier doors in healthcare occupancies.

“The HITF members did discuss the issue and agreed that healthcare occupancies were exempt from complying with section 7.2.1.15.2 … because the healthcare occupancies did not specifically require compliance with that section,” Keyes says in an email.

The committee decided to table its decision on the matter to give CMS an opportunity to review its position, as it did, Keyes says.

“I am pleased that the system worked in favor for the many hospitals that are certified by the Federal agency,” he adds.

Although the LSC does include provisions requiring annual inspections of smoke barrier doors and fire doors alike, section 7.2.1.15.1 states that these standards apply only where required by Chapters 11–43. Since the chapters governing healthcare occupancies make no direct reference to Section 7.2.1.15.1, the door inspection provisions do not apply to healthcare occupancies, Wright acknowledged in his memo.

Based on that conclusion, Wright spells out a few key takeaways:

  1. Fire doors. In healthcare occupancies, all fire door assemblies must be inspected and tested annually in healthcare occupancies, based on section 8.3.3.1 of the 2012 LSC, which applies to all occupancies.
  2. Smoke barrier doors. Non-rated doors (including smoke barrier doors and corridor doors to patient care rooms) aren’t subject to the annual inspection and testing requirements, but they “should be routinely inspected as part of the facility maintenance program.”
  3. Deadline. The compliance deadline has been pushed back from July 6, 2017, to January 1, 2018.
  4. Citations. Any LSC deficiencies related to annual fire door inspections should be cited under K211—Means of Egress—General.

But what if a healthcare organization was already cited at some point during the three-week gap between the original compliance date and the clarifying memo (July 6–28) for a failure to conduct an annual test of its smoke doors? Multiple CMS representatives did not respond to requests for an answer. Keyes says CMS has been a stickler in the past, holding that a finding cannot be removed once it is written on a survey report.

“There was an accreditation organization [AO] that used to allow findings to be removed from their survey report if the hospital could demonstrate compliance at the time of the survey,” Keyes says. “CMS has said that the AOs may no longer remove findings, even if the hospital was compliant at the time of the survey.”

The Joint Commission stated in the July edition of Perspectives that it requires annual testing for fire door and smoke door assemblies alike, despite acknowledging that the healthcare occupancy chapters don’t cite section 7.2.1.15 specifically. (To support the requirement, The Joint Commission noted that Section 18/19.2.2.2.1 references section 7.2.1, and cited a belief that the annual tests are beneficial.)

Keyes adds a word of caution: “The AOs are not locked into complying with everything CMS says or does. The AOs may have standards that exceed what CMS requires.”

That means the guidance in Wright’s memo might not trickle down to the AOs and state agencies that conduct surveys at your facilities, especially considering how widely advertised the original compliance date has been.

“So, I suspect many of the AOs will keep the start date at July 5, 2017, since they are already enforcing that,” Keyes says.

With that in mind, he recommends that all healthcare facilities have their fire doors tested as soon as possible, rather than waiting until the new deadline—because another authority having jurisdiction might keep to the stricter timeline.

Joint Commission revises Medication Management EPs

The Joint Commission has revised Medication Management elements of performance (EP) for several of its programs. The changes will go into effect on January 1, 2018 and will impact hospitals, ambulatory care, behavioral care, home care, nursing care centers, critical access hospitals, and office-based practices accredited by The Joint Commission. The revisions will require organizations to:

•    Record the date and time of any medication administered in the patient’s clinical record.
•    Implement a policy to provide emergency backup for essential medication dispensing equipment and for essential refrigeration for medications.
•    Have a written policy addressing the control of medications between when they are received by a provider and given to a patient. Those policies should now include what to do for the “wasting of medications.”
•    Implement a policy describing the types of medication overrides for automatic dispensing cabinets that will be reviewed for appropriateness and the frequency.

The revisions vary depending on the program.

CMS withdraws proposal to have AOs post survey reports online

A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.

CMS first made the proposal in April, tucking it into the latter pages of the always-long proposed on changes to the Inpatient Prospective Payment System (IPPS) for the upcoming fiscal year.

The proposal was to have AOs post final survey reports online within 90 days that the same information is available to the hospital or other health care organization, including details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoCs).

AOs now post only whether an organization is accredited or not, and do not make details of findings public.

CMS argued its proposal was to promote transparency in health care, and noted that it posts its own  survey reports online. But critics responded that the CMS reports are made available in a hard-to-read spreadsheet and that the federal agency was responsible for far fewer surveys at health care organizations that were often surveyed only after a complaint (IJC 5/1/17).

In public comments to CMS concerning the proposal, The Joint Commission said that requiring survey details be made public would have “chilling effect” on efforts to raise standards of quality. Dr. Mark R. Chassin, president and CEO of The Joint Commission, wrote: “There will be a race to the bottom on quality as health care organizations seek out oversight bodies that will report on the least number of standards comparable to the Medicare requirements. This may also lead to a growth in non-accredited facilities that will then be surveyed at taxpayer expense and with fewer oversight visits.”

Other groups similarly weighed in against the proposal, and offered alternatives. In the end though, it was shot down because it might potentially be prohibited.

In the IPPS final rule published Aug. 2, CMS noted that its proposal included revising the federal regulations overseeing Medicare to incorporate the requirement for AOs to post report details publically.

“Section 1865(b) of the Act prohibits CMS from disclosing survey reports or compelling the AOs to disclose their reports themselves. The suggestion by CMS to have the AOs post their survey reports may appear as if CMS was attempting to circumvent the provision of section 1865(b) of the Act. Therefore, this provision is effectively being withdrawn.” — A.J. Plunkett (aplunkett@h3.group)

Resource:

Joint Commission: Half of blood transfusions are unnecessary and cost millions  

Hospitals could save more than $1 million per year by eliminating unnecessary red blood cell (RBC) transfusions, according to a new study. Blood transfusions are the most frequently performed hospital procedure in the country and costs $1,000 per unit of blood. Transfusions also come with potential health risks like allergic reactions, fever, and iron overload.

A study in the August 2017 issue of The Joint Commission Journal on Quality and Patient Safety found that RBC transfusions have increased 134% between 1997 to 2011. However, 50% of them may be unnecessary, costing each hospital an average $1 million per year.

“The cost and risks of RBC transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care,” the study’s authors wrote. “Excessive transfusions have been identified as an improvement priority in the Choosing Wisely lists of wasteful practices by six professional organizations, including obstetric, hematology, critical care, and anesthesiology societies, and the Society of Hospital Medicine (SHM), and reducing excessive transfusion is the subject of an SHM-Society for the Advancement of Blood Management improvement guide. The Joint Commission, the AABB, and the U.S. Department of Health and Human Services have recognized the importance of improving blood management.”

The study looked at ways to reduce unnecessary blood transfusions as well; these include educational tools, real-time clinical decision supports to reduce unnecessary blood products and costs, providing information at point-of-care to inform decisions about a patient’s care, and enhancing health systems’ computerized provider order entry system. By using these methods, test hospitals were able to decrease RBC transfusions per 1,000 patient days from 90-78% during the study to 72.1% following the interventions.

(TBT) Diffusing disruptive physician behavior

Disruptive behavior can come in a variety of forms, from yelling and inappropriate language to physical altercations in the worst-case scenario.

A report released in May by QuantiaMD indicated that disruptive physician behavior is still an issue in hospitals around the country. The report surveyed more than 840 physicians and physician leaders at QuantiaMD and the American College of Physician Executives. Survey results showed that 70% of those physicians said disruptive physician behavior occurs at least once per month and 11% said it occurs daily. An overwhelming­ 90% of respondents also indicated that disruptive physicians ultimately affect patient care, and 21% reported experiencing adverse clinical events that could be ­attributed to disruptive physician behavior.

Although patient safety is the primary concern in any healthcare facility, disruptive behavior must be dealt with regardless of who it affects, says Dean White, DDS, MS, a medical staff consultant in Granbury, TX.

“Disruptive behavior, particularly repetitive disruptive behavior, doesn’t necessarily have to be tied to patient safety or quality,” White says. “In other words, it’s just unacceptable. You don’t have to have a bad outcome because of the behavior to make it wrong. It’s not the outcomes we’re looking at here, it’s the behavior.”

The ultimate decision on how best to deal with or punish a disruptive physician usually falls to medical staff leaders and hospital administrators.

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Uniqueness is not unique

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! 

With all the regulatory and reimbursement changes occurring in our industry at an ever-increasing rate, one thing is for certain: Your organization is not unique.

When speaking to organizations, I often hear things like, “Well, we don’t have the resources that the university hospital has” from community hospitals and then the university hospitals will say things like, “We aren’t as nimble as those community hospitals.” It’s frustrating and ultimately self-defeating. It creates a semi-plausible excuse that permits low performance, and it must be stopped.

I see it in everything from patient experience, core measures, throughput, and profitability. “We are unique,” “Our patients are sicker,” “Our payer mix is bad,” “We have more psych patients,” “We have more beds,” and the list goes on and on.

The reality is that all hospitals are facing the same issues at the same time and those that are top performing do not allow themselves to take this mindset. Simply put, none of our organizations is unique.

Imagine if we took that same mentality when it came to treating patients. If clinicians second-guessed every cardiac rhythm that came across a monitor, think of the conversations between cardiologists. “Maybe ventricular fibrillation is good for this patient. I mean it’s not like he looks like the last guy who had it.” It is an absurd example that makes my point.

Hospitals can argue about the metrics and the systems in place for a millennium, doctors can debate the efficacy of the data points and whether things are “good measure” and that is healthy. However, the reality is just because you don’t like it doesn’t mean you are allowed to not do it or succumb to the idea that it is an impossible goal based solely on the fact that “your hospital is different.”

The metrics in healthcare are to create as level a playing field as there can be while trying to ensure high-quality care at reasonable or decreasing costs. Is it perfect? No, it is not, but it’s a start and part of the calling of being in medicine.

Clinicians don’t come to work expecting to provide bad care. In all my experience, I have never met a clinician that had that motive. The excuses come when compared to similar organizations and not performing well. The excuses come from everywhere rather than focusing on the core issue of poor performance.

Top-performing entities move through the Kübler-Ross 5 stages of grief faster and focus on the acceptance. Once that happens and the organization gets past its uniqueness, true organizational change can begin.

When dealing with an issue that causes your organization to lament how different it is to the standard, try these techniques. Allow the leaders an unadulterated complain fest. It’s a period of time not to last more than a day where complaining and feeling sorry for yourself is encouraged, get it all out on the table. It’s unfair, they don’t like us, and so on. Get all the negativity out in one moment of time. Grieving is natural and needs to happen. People in organizations need to feel like they are being heard and empathized with.

Next, require all the leaders to come up with short action plans that will move the organization forward. It does not have to be a total change in how you do business, but it starts the momentum going in the correct direction. This is not easy, and requires a substantial amount of effort. It shifts the energy in a positive direction and is the first essential step toward making a positive difference. Finally, reward and recognize people and departments making the gains, and the ones that are putting forth a strong effort.

The data is never perfect. There will always be concerns about percentiles, and comparative measures for everything we do in healthcare. Accepting it and focusing on the care each patient receives every time is the single most powerful curative tool an organization has in its armory. Doing the right thing, the right way, for the right reasons will always be correct, regardless of what the metric is.

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 Hospital Consumer Assessment of Healthcare Providers and Systems. to an all-time hospital best in the 90th percentile. He can be reached at ppianezza@gmail.com.

(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.

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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