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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.

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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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. 

Maine’s Long-term Quality Investment Pays Off

The state has mandated data collection, eased into quality measurement, and made everything public.

Sparsely populated and not far from the medical mecca of Massachusetts, Maine is faced with many of the same health delivery challenges as other states. It is home to urban health systems and remote rural hospitals, all adapting to the value-based payment era.

The political battle over expanding Medicaid is raging, and so is the fight against the deadly opioid epidemic.

Yet according to the Leapfrog Group, a good percentage of the state’s hospitals earn an “A” for quality—enough to make Maine the top state in the Leapfrog Group’s hospital quality rankings this year.

Does the Pine Tree State have a quality blueprint it can share with other states? Not exactly. The well-established Leapfrog Group is just one many health quality measures, and no two states or ranking systems are alike.

For example, while still above the national average, Maine dropped from the No. 9 spot to No.15 in The Commonwealth Fund’s 2017 “Scorecard on State Health System Performance.”

Still Maine seems to have made some moves over the years that allowed it to ease into in the era of mega-measurement.

For one thing, the state began wrestling with quality measures more than a decade ago. In 2005, the state employee health plan began rewarding high quality hospitals by offering incentives to patients who used them. In order to do that, Maine had to put a system in place to measure quality.

Michael DeLorenzo is the chief operating office of the Maine Health Management Coalition (MHMC), an employer-led group. The organization was able to do that by deliberately engaging both providers and purchasers in the identification and development of quality measures.

“We don’t think it is more complex than that,” he said.

Other players include Maine Quality Forum, a state agency, and Maine Quality Counts, a non-profit that works to “implement practical health care quality solutions.”

The National Academy for State Health Policy, in a 2010 report, identified five “key components” of successful state plans to improve quality. Here’s how Mainers have put them in action.

1. Data Collection and Aggregation

Since 2003, the Maine Health Data Organization, a state agency, has collected claims data from commercial insurance carriers, third party administrators, pharmacy benefit managers, dental benefit administrators, Medicaid and Medicare.

The all-payer data is available to the public with the goal of providing a “useful, objective, reliable, and comprehensive health information database that is used to improve the health of Maine citizens.”

The agency’s website includes a long list of studies generated with the data. One recent analysis found “mixed results” in terms of cost, quality and utilization for the first two years of the state’s medical homes program.

2. Public Reporting

The “Get Better Maine” website invites patients to “Learn which hospitals have the highest quality of care” through a patient portal sponsored by the Maine Health Management Coalition’s Pathways to Excellence reporting program.

A state-mandated site called “Compare Maine” allows patients to compare the cost and quality of procedures at different facilities. Users can compare the average cost of more than 240 procedures at 150 healthcare facilities, along with a few quality data points.

For example, an entry on a screening colonoscopy shows an average cost of $3,800 in one hospital and $850 in another.

Continue reading at Health Leaders Media.