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CMS Report: AOs missing fire safety and IC deficiencies during survey

Expect CMS to continue pressuring The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious life safety, environment of care, and infection control issues the federal agency says they are still missing during surveys.

In the newest report to Congress assessing AO performance, CMS says the overall disparity rate between serious problems identified by the AOs at hospitals and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, says the report. CMS is particularly concerned that AOs are missing key Life Safety Code® (LSC) deficiencies, with fire and smoke barriers, sprinkler systems, electrical systems, hazardous areas, and means of egress taking the top five categories for missed problems in fire safety at hospitals.

Hospitals already face funding challenges to meet fire code requirements after CMS finally adopted the 2012 LSC, and it will get even worse as survey scrutiny increases, predicts Ernest E. Allen, a former TJC surveyor and current consultant and patient safety executive with The Doctor’s Company in Columbus, Ohio.

This is on top of TJC’s response to criticism in the report released last year. TJC began pushing its own surveyors to cite every life safety deficiency, no matter how small, Allen says.

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This simple tool predicts readmission risk for heart attack patients

By Christopher Cheney, HealthLeaders Media

A new risk model provides a simple and inexpensive way to determine whether acute myocardial infarction (AMI) patients are at high risk for hospital readmission.

The risk model, which is detailed in a recent study published in the Journal of the American Heart Association (JAHA), features seven variables that can be scored in as little as five minutes during a patient’s first day of hospital admission. With a simple calculation at the bedside or in an electronic health record, physicians can determine whether a heart attack patient is at high risk for readmission and can then order interventions to help the patient avoid a return to the hospital after discharge.

Research published by the Healthcare Cost and Utilization Project shows that about one in six AMI patients are readmitted to a hospital within 30 days of discharge, with annual healthcare costs estimated at $1 billion. Targeting AMI patients who are at high risk of readmission also helps hospitals avoid financial penalties under the federal Hospital Readmissions Reduction Program and promotes cost-effective interventions, the JAHA researchers wrote.

“Although federal readmission penalties have incentivized readmissions reduction intervention strategies (known as transitional care interventions), these interventions are resource intensive, are most effective when implemented well before discharge, and have been only modestly successful when applied indiscriminately to all inpatients,” the researchers wrote. “The acute myocardial infarction READMITS score (renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure) is the best at identifying patients at high risk for 30?day hospital readmission; is easy to implement in clinical settings; and provides actionable data in real time.”

The AMI READMITS risk model is superior to other models, they wrote. “The few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time.”

Key findings 

The JAHA research, which examined health outcomes for 826 AMI patients at six hospitals in north Texas, has several key findings:

  • The AMI READMITS score accurately predicts which heart attack patients are at high risk or low risk of readmission. In the JAHA research, about one third of AMI patients that were deemed at high risk through the AMI READMITS score had a 30-day readmission. Only 2% of patients considered at low risk experienced a readmission.
  • The AMI READMITS score can accurately predict readmission risk during the first 24 hours of a hospital inpatient admission, which gives clinicians the ability to make timely interventions.
  • Clinical severity metrics such as shock, heart strain or failure, and renal dysfunction, as well as timely percutaneous coronary intervention, were strongly associated with readmission risk.

Why this model matters

Assessing the readmission risk of AMI patients during the first day of hospital admission is crucial, says Oahn Nguyen, MD, MAS, the lead author of the JAHA research and an assistant professor at UT Southwestern Medical Center in Dallas. “[The model] gives you more time to intervene and try to prevent someone from having to come back to the hospital. It gives you more time to optimize someone’s path to recovery,” she said.

She said development of the AMI READMITS risk model is the first step toward significantly reducing readmissions for AMI patients. “Studies of interventions to reduce readmissions for other conditions suggest that the earlier you can intervene, the better. One caveat is those interventions have yet to be assessed in acute myocardial infarction.”

The current primary strategy to prevent readmissions for heart attack patients is transitional care intervention, and the AMI READMITS score helps physicians target patients for this intervention, she said.

“Transitional care intervention is a bundle of care to promote a safe transition from hospital to home. One way I like to think of it is deploying a medical SWAT team in the hospital to make sure that everything you can do for a patient is being done to ensure the transition from the hospital to the community is as smooth as possible,” Nguyen said.

A “SWAT team” approach to care is often costly, so the capability of the AMI READMITS score to target patients who are at high risk of readmission improves the cost-effectiveness of care.

There are several primary elements to transitional care intervention:

  • Medication counseling to make sure AMI patients know how to take their medications
  • Making sure patients get their medications when they leave the hospital
  • Connecting patients with the most appropriate outpatient care, such as setting up clinic appointments
  • Conducting phone calls to patients’ homes to check on their health status after discharge

Major strengths of the AMI READMITS score include the risk model’s simplicity and low cost, said Nguyen. “Our goal in creating this model was creating something that was simple and pragmatic; so, it’s parsimonious because there are only seven variables that go into it. The seven variables are also information that is commonly and routinely collected during most hospitalizations.”

The AMI READMITS risk model does not require sophisticated support systems, Nguyen said. “In an age when there is a lot of hype about machine learning and big data, we were able to distill the big data of an electronic health record down to small, simple, parsimonious data that is easily applied at the bedside by clinicians.”

Plus, the time expense for the AMI READMITS risk model is minimal.

“It’s low cost because a clinician could look at our [research], then see how many of the seven factors a patient has in the hospital. You can literally spend less than five minutes summing up the points in the model scale, add them up, and determine whether a patient is at high risk or not. It does not take a fancy new IT infrastructure to implement,” Nguyen said.

Nurses Report Gaps in Quality and Safety Competencies Based on Education

By Jennifer Thew- 

While quality and safety measures are key to delivering excellent nursing care, new graduate nurses are not always adequately prepared in these areas, reports a new study by researchers at NYU Rory Meyers College of Nursing.

Educational preparation appears to be tied quality and safety competencies. The study found there is a growing gap in preparedness in quality and safety competencies between new nurses with associate and bachelor’s degrees. Nurses with BSN degrees report they are “very prepared” in more quality and safety measures than their ADN peers.

“Understanding the mechanisms influencing the association between educational level of nurses and patient outcomes is important because it provides an opportunity to intervene through changes in accreditation, licensing, and curriculum,” Maja Djukic, PhD, RN, associate professor at NYU Meyers and the study’s lead author, says in a news release.

Nurses With BSNs More Prepared

For the study, the researchers examined quality and safety preparedness in two groups of new nurses who graduated with either associate or bachelor’s degrees in 2007 to 2008 and 2014 to 2015. They surveyed more than a thousand new nurses (324 graduated between 2007 to 2008 and 803 graduated between 2014 to 2015).

The nurses were asked how prepared they felt about different quality improvement and safety topics. The responses of nurses with ADNs and BSNs were analyzed for differences.

There were significant improvements across key quality and safety competencies for new nurses from 2007 to 2015, however, the number of preparedness gaps between BSN and ADN graduates more than doubled during this time.

In the 2007 to 2008 cohort, nurses with BSNs reported being significantly better prepared than those with ADNs five of 16 topics:

  • Evidence-based practice
  • Data analysis
  • Use of quality improvement data analysis and project monitoring tools
  • Measuring resulting changes from implemented improvements
  • Repeating four quality improvement steps until the desired outcome is achieved

Of the 2014 to 2015 graduates, those with BSNs reported being significantly better prepared than those with ADNs in 12 of 16 topics:

  • The same five topics as the earlier cohort
  • Data collection
  • Flowcharting
  • Project implementation
  • Measuring current performance
  • Assessing gaps in current practice
  • Applying tools and methods to improve performance
  • Monitoring sustainability of changes

How to Affect Change

“The evidence linking better outcomes to a higher percentage of baccalaureate-prepared nurses has been growing. However, our data reveal a potential underlying mechanism—the quality and safety education gap—which might be influencing the relationship between more education and better care,” Djukic, says.

Laws and organizational policies encouraging or requiring bachelor’s degrees for all nurses could close quality and safety education gaps, note the researchers.

New York was recently the first state to pass a law, often called the BSN in 10, requiring new nurses to obtain their bachelor’s degree within 10 years of initial licensure.

Additionally, nurse leaders and employers can affect change by:

  • Preferentially hiring nurses with BSNs
  • Requiring a percentage of the nurse workforce to have BSNs
  • Requiring nurses with ADNs to obtain a bachelor’s degree within a certain timeframe as a condition of maintaining employment

Patient Outcomes No Better For Joint Commission–Accredited Hospitals Than Peers

By John Commins

Hospitals that earn certification by independent accreditors, such as The Joint Commission, have no better outcomes than hospitals reviewed by a state survey agency, according to a new report in the BMJ.

“Furthermore, we found that accreditation by The Joint Commission, which is the most common form of hospital accreditation, was not associated with better patient outcomes than other lesser known, independent accrediting agencies,” the study concluded.

Researchers at Harvard T.H. Chan School of Public Health compared 4,400 hospitals across the United States, of which 3,337 were accredited, including 2,847 by The Joint Commission, and 1,063 hospitals that underwent state-based reviews between 2014 and 2017.

The study reviewed more than 4.2 million Medicare inpatient records for people ages 65 and older who were admitted for 15 common medical and six common surgical conditions, and respondents to the Hospital Consumer Assessment of Healthcare Provider and Systems survey.

“Hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study,” the study said.

Among the findings:

  • Thirty-day readmissions for The Joint Commission-accredited hospitals were 0.4% lower than those at hospitals that were reviewed by state survey agencies, which the researchers called “not statistically significant lower rates.”
  • Mortality rates for the six surgical conditions were “nearly identical,” and “no statistically significant differences were seen in 30-day mortality or readmission rates (for both the medical or surgical conditions) between The Joint Commission-accredited hospitals, and hospitals rated by other independent accreditors.
  • Readmissions for the 15 medical conditions “were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (−1.2% to 1.6%), the study found.
  • Patient experience scores were modestly better at state survey hospitals than at accredited hospitals. Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations.

While not the only hospital accrediting entity in the United States, the study authors note that private, not-for-profit The Joint Commission plays an outsized role, and controls more than 80% of the accreditation market as the accrediting agency of choice for nearly all major hospital systems.

“There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization,” the study concluded.

The Joint Commission could not immediately be reached Friday morning for comment.

Catheters Pose More Risks Than Just CAUTIs

Catheter-associated urinary tract infections are a well-known issue related to urinary catheters. However, a new study in JAMA Internal Medicine finds the devices can cause more issues that previously thought. In fact, UTIs are five times less common than non-infectious problems caused by indwelling urinary catheters.

In-depth interviews and chart reviews from more than 2,000 patients found more than half of catheterized hospital patients experienced a complication of some kind.

The issues ranged from pain, bloody urine and activity restrictions while the catheter was in, to problems with urination and sexual function after it was removed.

“Our findings underscore the importance of avoiding an indwelling urinary catheter unless it is absolutely necessary, and removing it as soon as possible,” says the study’s lead author Sanjay Saint, MD, MPH, chief of medicine at the VA Ann Arbor Healthcare System, George Dock professor of internal medicine at the University of Michigan and director of the U-M/VA Patient Safety Enhancement Program.

A wide array of issues

For the study, Saint and his colleagues from U-M, VAAAHS, and two Texas hospitals analyzed data from 2,076 patients who had recently had a catheter placed for short-term use. Most catheters were placed because the patients were having surgery. Researchers followed-up with patients two weeks after catheter placement and again one month after their catheter placement to ask about their catheter-related experience.

Nearly three quarters of the patients were male, and the catheter was removed within three days of the insertion for 76% of patients. Among the study’s findings:

  • Just over 10% of patients reported infections
  • 55% of patients reported at least one complication of a non-infectious kind
  • 31% of patients whose catheters had been removed at the time of the first interview said it hurt or caused bleeding coming out.
  • More than half of those interviewed while the catheter was still in place said it was causing them pain or discomfort.
  • One in four patients reported the catheter had caused bladder spasms or a sense of urgency about urinating.
  • 10% said the catheter led to blood in their urine.
  • Nearly 40% of patients interviewed while a catheter was still in place, said it restricted their daily activities
  • About 20% who had their catheters removed said they experienced urine leakage, or difficulty starting or stopping urination.

“While there has been appropriate attention paid to the infectious harms of indwelling urethral catheters over the past several decades, recently we have better appreciated the extent of non-infectious harms that are caused by these devices,” says Saint.

Story first appeared in PSQH.

Report: Medication Errors Led to Patient Death at Boston Children’s Hospital

Boston Children’s Hospital was threatened with termination from Medicare last year after three patients suffered from serious medication errors. An inspection report revealed that one of the patients waited 14 hours for an antibiotic and later died, while two others suffered overdoses of a powerful anesthetic, according to the Boston Globe.

The errors took place between January and November 2017, involving two medications and leading CMS surveyors to threaten Boston Children’s with potential termination from the Medicare program. The patient who died had been prescribed Zosyn, an antibiotic, at noon, but the drug was not administered until 14 hours later, the Globe reported. Two days later, the patient died after developing a sepsis infection.

The other two medication errors involved patients receiving overdoses of Propofol, an anesthetic. The first overdose occurred in January 2017 and was followed by a recommendation from leadership for an improved procedure for measuring Propofol doses. But the recommendations were never developed and 10 months later, another patient was given an overdose of the drug by a doctor using the same procedure. The inspection report said both patients eventually recovered, although the second patient had to be resuscitated.

Boston Children’s was able to avoid disciplinary measures this spring by adding improvement plans to treat sepsis patients immediately and for proper Propofol administration. The inspection report said the hospital failed to properly analyze the errors and correct the conditions that led to them.

The Globe reported that in 2016, Massachusetts hospitals reported 47 medication errors that killed or injured patients.

First published in PSQH. 

National Guidelines, Quality Measures Clearinghouses Shutting Down

If you or anyone at your hospital use the National Guidelines Clearinghouse or National Quality Measures Clearinghouse operated under the auspices of the Agency for Healthcare Research and Quality (AHRQ), download the information you need soon.

Both online clearinghouses will go dark after July 16 as federal funding runs out. Neither site is accepting new guidelines or quality measure sets in anticipation of shutting the databases down.

Announcements on each website note that that AHRQ has received “expressions of interest from stakeholders” that want to takeover maintenance of the databases, but AHRQ officials have declined to identify who those stakeholders are for now.

The clearinghouses were set up more than two decades ago as central sites to help hospitals, clinicians and others in health care find evidence-based information on which to set policy, create clinical treatment plans and objectively measure quality outcomes.

The guidelines and measures are submitted by various professional or academic health organization and must meet detailed criteria to be included in each database. As guidelines or measures are updated or become outdated, the information is removed.

AHRQ evaluating options

“AHRQ recognizes the importance of this resource and is evaluating potential options, including the participation of stakeholders who may wish to operate the Clearinghouse in the future,” stated Alison Hunt, MPH, with AHRQ’s Office of Communications, Media Division.

If public or private stakeholders are found to take over the clearinghouses, ARHQ still has not decided what role it will continue to play, Hunt said.

While the federal sites may go away, the information will still be available from each of the professional society, academy or other healthcare group that originated the material, notes Karen Schoelles MD, SM, FACP, director of ECRI Institute’s Penn Medicine Evidence-based Practice Center (EPC) and project director for both clearinghouses.

ECRI was the original contractor hired by AHRQ to set up and run the guidelines clearinghouse in 1987.

Besides having information in one place, one of the advantages in having each of the clearinghouses is that users could have some assurance that the information had been professionally vetted and was up-to-date.

Having evidence-based information to back a policy or best practice is one of the key mantras of both The Joint Commission and CMS.

Hospital leaders or others who need information about the validity of a particular set of guidelines or best practice can still seek out help from any of the Evidence-based Practice Centers (EPC) set up through AHRQ, says Schoelles. ECRI-Penn Medicine is one of 12 EPCs across North America.

EPC programs offer help

The EPCs develop evidence reports and technology assessments to assist public- and private-sector organizations, and “provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies,” according to a AHRQ research white paper released in December. Schoelles was a work group leader on the paper, A Framework for Conceptualizing Evidence Needs of Health Systems.

The paper sets out to determine the evidence needs of health systems to both guide future EPC programs and ultimately help organizations as they seek “evidence to inform decisions about acquiring new or emerging medical technologies; implementation or expansion of service offerings; and selection of governance, finance or delivery system models,” notes a summary.

As part of the group’s research it looked at information requests made at four large health institutions;  Kaiser Permanente Southern California, the Veterans Health Administration’s Evidence Synthesis Program, ECRI Institute’s Health Technology Assessment Information Service, and Penn Medicine Center for Evidence-based Practice.

“A wide range of clinical and administrative decision-makers requested evidence reviews, and the topics were similarly broad—ranging from evidence to guide clinical care; purchasing of medications and devices; procedural and non-procedural interventions; and processes of care,” according to the paper.

Highlighted throughout the requests was a need for trustworthiness of information, notes Schoelles.

If you are seeking to verify or evaluate information and are part of a larger health system, Schoelles suggests starting with the larger organization to see what help it can offer. Often health systems will evaluate a guidelines or best practice and then establish a policy or guidelines based on that information, or can share the evaluation throughout the system’s smaller organizations, she said.

ECRI, for instance, offers a variety of evaluation services. Some ECRI services are free to members, others are fee-based. ECRI Institute also is currently exploring ways to maintain a guideline repository, notes Schoelles.

Resources

This article was originally published in Inside The Joint Commission.

Study Questions Effectiveness of Performance Measures

study published in the New England Journal of Medicine asserts that the U.S. healthcare system does a poor job of measuring quality. The study’s researchers led by lead author Catherine McLean, MD, PHD, chief value medical officer, Hospital for Special Surgery, recommend that organizations should stop using performance measures until they can be assessed and revised.

The study notes that a recent survey found that 63% of physicians said that current performance measures do not capture the quality of the care physicians provide. The Performance Measurement Committee (PMC) of the American College of Physicians (ACP) had developed criteria to assess the validity of performance measures. McLean and researchers applied the ACP criteria to the measures included in the Medicare Merit-based Incentive Payment System (MIPS)/ Quality Payment Program (QPP), hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, physicians would have more confidence in using them to improve patient outcomes.

In this study, the researchers identified and rated the validity of 86 measures on the 2017 QPP list that were considered relevant to ambulatory general internal medicine. Of those, 32 (37%) were rated as valid by this method, 30 (35%) were found to be not valid, and 24 (28%) were of uncertain validity. For each measure, the committee rated validity using five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability.

“We believe that the next generation of performance measurement should not be limited by the use of easy-to-obtain (e.g., administrative) data or function as a stand-alone, retrospective exercise,” the researchers wrote. “Instead, it should be fully integrated into care delivery, where it would effectively and efficiently address the most pressing performance gaps and direct quality improvement. For now, we need a time-out during which to assess and revise our approach to physician performance measurement.”

Joint Commission Urges Hospitals to Protect Workers from Abuse

This story originally ran on HCPro’s OSHA Healthcare Advisor.

The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.

About 75% of workplace assaults occur in healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries.

The purpose of the new alert is to help hospitals and other healthcare organizations better recognize workplace violence directed by patients and visitors toward healthcare workers and better prepare healthcare staff to address workplace violence, both in real time and afterward, The Joint Commission wrote in this latest Sentinel Event Alert publication.

Sentinel Event Alert 59 has some overlap with Alerts 40 and 57—which were released in 2008 and 2017, respectively, and focused on the development and maintenance of safety culture—and therefore were not addressed in this alert.

Per the Occupational Safety and Health Administration (OSHA), about 75% of workplace assaults annually occurred in the healthcare and social service sector. Violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries, according to the Bureau of Labor Statistics (BLS).

The Joint Commission cites both of those facts in this Sentinel Event Alert publication and adds that Joint Commission data show 68 incidents of homicide, rape, or assault of hospital staff members over the past eight years—and that’s mostly only what hospitals voluntarily reported.

The Joint Commission is calling for each incident of violence or credible threat of violence to be reported to leadership, internal security, and—if necessary—law enforcement, and it also wants an incident report to be created. Under its Sentinel Event policy, The Joint Commission says that any rape, any assault that leads to death or harm, or any homicide of a patient, visitor, employee, licensed independent practitioner, or vendor on hospital property should be considered a sentinel event and requires a comprehensive systematic analysis.

Additionally, The accreditor says it’s up to the healthcare organization to specifically define unacceptable behavior and determine what is severe enough to warrant an investigation.

This Sentinel Event Alert, which you can download here along with other resources, comes on the heels of an emergency preparedness rule from CMS that recently went into effect and efforts from the National Fire Protection Association to fast-track its new standard for active shooter events and other violent incidents. OSHA is also considering a standard to help protect healthcare and social workers from violence.

CDC Warns of New Wave of Antibiotic-Resistant Germs in U.S.

A new Centers for Disease Control and Prevention (CDC) Vital Signs report released this week said health departments found more than 220 cases of germs with “unusual antibiotic resistance genes” in the United States last year. These germs include those that cannot be killed by all or most antibiotics, are not common to a geographic area or the U.S., or have specific genes that enable them to spread their resistance to other germs, according to a CDC release.

The CDC’s Antibiotic Resistance (AR) Lab worked with local health departments to deploy a containment strategy to stop the spread of antibiotic resistance. The first step is rapid identification of new or rare threats; after a germ with unusual resistance is detected, facilities must quickly isolate patients and begin aggressive infection control and screening actions, according to the release.

“CDC’s study found several dangerous pathogens, hiding in plain sight, that can cause infections that are difficult or impossible to treat,” said Anne Schuchat, MD, CDC’s principal deputy director, in the release. “It’s reassuring to see that state and local experts, using our containment strategy, identified and stopped these resistant bacteria before they had the opportunity to spread.”

After rapid identification of antibiotic resistance, the CDC strategy calls for infection control assessments, testing patients without symptoms who may carry and spread the germ, and continued assessments until the spread is stopped. It requires coordinated response among healthcare facilities, labs, health departments, and the CDC through the AR Lab Network.

The CDC study also found that about one in 10 screening tests of patients without symptoms found a hard-to-treat germ that spreads easily, which means the germ could have spread undetected in that facility. For carbapenem-resistant Enterobacteriaceae (CRE), the report estimates that the containment strategy would prevent as many as 1,600 new infections in three years in a single state, which would be a 76% reduction.

Story originally published by our friends at PSQH!