RSSRecent Articles

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. 

Joint Commission comments on proposed CMS transparency rule

The Joint Commission has made a public comment regarding CMS’ proposed rule to require accrediting organizations (AO) to make their survey reports publicly available. The Joint Commission is opposed to sharing private survey reports and thinks making the reports public will harm patient care.

Currently, AOs like The Joint Commission and DNV aren’t required to make their survey reports or plans of corrections (PoC) available to the public. Under the proposed rule, AOs would have to post these on their websites. 

“Access to survey reports and PoCs will enable health care consumers, in addition to Medicare beneficiaries, to make a more informed decision regarding where to receive health care thus encouraging health care providers to improve the quality of care and services they provide,” CMS wrote in the proposal memo. If you want to read and comment on the proposed rule, you can find a copy of the memo and commenting instructions here. CMS will accept comments until June 13.

In an open letter to CMS, Joint Commission President and CEO Mark R. Chassin, MD, FACP, MPP, MPH, wrote that while the accreditor is a strong supporter of transparency, it believes revealing all accreditation survey reports to the public is a bad idea. The crux of the issue is that the contents of those survey reports are meant as tools for hospitals to improve. It’s not the same as healthcare quality data, a distinction that may be lost on the public.

“As an organization whose mission is to support quality improvement and patient safety and inspire excellence, we believe the proposal will have significant detrimental consequences on our nation’s ability to continually improve the delivery of health care services,” he writes. “To be clear, this opposition is not one against transparency, but one of creating the right balance between useful, publicly available information and improving the quality and safety of healthcare.”

Some of the Joint Commission’s concerns are:

  • It’ll be harder to get AOs and healthcare organizations to collaborate on patient safety and continuous quality improvement.Having AOs release collected information would make providers less candid about their weaknesses and create an adverse dynamic that will ultimately, there will be increased patient harm and lower quality.
  • It will stunt AO’s efforts to create new standards or raise compliance standards for existing requirements.
  • Healthcare organizations will be incentivized to use AOs that report on the least number of Medicare-comparable standards. This will spur a race to the bottom on quality and may also cause a growth in the number of non-accredited facilities that’ll be surveyed at taxpayer expense and with fewer oversight visits.
  • The proposal will diminish the value of accreditation as a way to motivate healthcare organizations to excel.
  • The proposal will increase costs for AOs and healthcare organizations.

Joint Commission clarifies four LSC-related requirements

The Joint Commission issued clarifications on some of its 2012 Life Safety Code®-related (LSC) requirements. In particular, the clarifications are aimed at the standards for fire doors, fire drills, and emergency department occupancy.

 

  1. Emergency department (ED) occupancy classification: Some EDs meet the qualifications to be considered healthcare or ambulatory healthcare occupancies. The clarification explains how to tell the difference.
  2. Annual door inspection: Fire and smoke doors must receive their annual inspection and testing before July 5, 2017. Corridor doors that aren’t required to be fire doors or smoke door assemblies aren’t subject to the National Fire Protection Association annual inspection and testing requirements. However, they should be routinely inspected as part of facility maintenance.
  3. Rated fire door assembly installed in lesser rated or non-rated assembly: If a fire-rated door is used in a nonrated barrier assembly, the fire door must be maintained as a fire door unless any markers identifying it as a fire door have been removed.
  4. Fire drills and varying times: There can’t be a pattern for conducting fire drills. But drills conducted no closer than one hour apart would be acceptable.

Joint Commission updates diagnostic equipment SEA

The Joint Commission has announced additions to Sentinel Event Alert (SEA) 47, which was first issued in 2011 and focuses on the radiation risks of diagnostic equipment. While most of the language in the alert remains the same, The following changes were made:

  1. Hospitals must comply with the Image Gently Alliance’s guidelines when using imaging radiation or fluoroscopy on pediatric patients..
  2. The alert contains a link to SEA 57, The essential role of leadership in developing a safety culture, replacing the previous link to SEA 43. Both alerts talk about leadership’s role in creating a safety culture, but SEA 57 is more recent. 
  3. The list of references has been updated to show which ones had been recently accessed.

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. 

Caucus pushes for telemedicine expansion in Congress

When it comes to healthcare and congress, finding bipartisan support on anything is a daunting task. That said, politicians from both sides are coming together in support of new bills aimed at improving and expanding telemedicine services in the United States.

The U.S. House of Representatives and Senate are considering both the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2017 and the Medicare Telehealth Parity Act (MTPA). The two bills are aimed at lowering CMS restrictions on telemedicine coverage and test the efficacy of telehealth services in Medicare healthcare delivery reform models. The Senate Finance Committee is also considering a bill called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, which includes a section that would allow greater use of telehealth.

Both CONNECT and MTPA had failed to advance during previous sessions of Congress, and were re-launched by members of the newly formed bipartisan Congressional Telehealth Caucus on May 19. The four founding members of that caucus are Representatives Mike Thompson (D-Calif.), Gregg Harper (R-Mass.), Diane Black (R-Tenn.), and Peter Welch (D-Vt.)

“Telehealth saves lives and reduces costs; it’s a win-win for both patients and providers,” said Thompson in a press release. “We’ve all seen how technology has made us more connected in our daily lives. These same advances allow physicians to provide more patients with better healthcare—especially patients in rural, difficult-to-access, and underserved communities. Unfortunately, regulations haven’t kept pace with the times. These commonsense, bipartisan policies will allow us to make sure every American gets the best care and the best treatment—no matter where they live. The Caucus will give us a venue to collaborate with our interested colleagues to advance the delivery of care via telemedicine.”

“My many years as a nurse, especially my time spent working in long-term care, taught me that if Medicare is to provide real benefit to seniors while ensuring real efficiency for taxpayers, it must embrace the advances in technology and innovation that are already taking place across the health care sector,” said Black. “That is what telehealth is all about—promoting cost savings and quality care through the use of technology like remote patient monitoring services. Harnessing the power of telemedicine is a win for seniors, a win for providers, a win for taxpayers, and a win for rural Tennessee.”

If passed, the Medicare Telehealth Parity Act would:

•    Allow for the provision of telehealth services in rural, underserved, and metropolitan areas, rather than just rural areas
•    Expand the types of providers who can be reimbursed for telehealth services to include several kinds of allied health professionals
•    Expand access to telestroke services
•    Allow remote patient monitoring for patients with chronic conditions
•    Allow a Medicare beneficiary’s home to serve as a site of care for remote dialysis, hospice care, outpatient mental health services, and home health services

If passed, the CONNECT for Health Act of 2017 would:

•    Expand originating sites for telehealth care
•    Create a Medicare remote patient monitoring benefit for certain high-risk, high-cost patients;
•    Lift restrictions on the use of telehealth in ACOs and Medicare Advantage plans;
•    Urge the Secretary of Health and Human Services to have CMMI evaluate the applicability of telehealth in demonstration projects;
•    Authorize a study on the use of telehealth services after restrictions on coverage have been lifted.
•    Save Medicare around $1.8 billion over the course of 10 years 

It’s important to remember that even if these bills become law, providers will still have to be licensed in whatever state their patient is physically located.

For example, if you’re in New York and one of your patients is on vacation in California, you have to be licensed by the California medical board to treat him via telemedicine. And you still have to meet the standard of care required under California law. That won’t change under these proposed laws.

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.

First set of SAFER Matrix data is online

The Joint Commission released the first set of data collected from its new Survey Analysis for Evaluating Risk™ (SAFER™) scoring methodology this May. The SAFER matrix was first rolled out to psychiatric hospitals as part of their accreditation surveys. It has been since implemented for all Joint Commission-accredited programs.

The accreditor made a chart of the most frequently cited compliance challenges for deemed psychiatric hospitals between Aug. 1, 2016 to Feb. 17, 2017.

The Joint Commission writes that it plans to keep analyzing aggregate SAFER data going forward to:

  • Continuously improve consistency
  • Identify potential EPs for revision
  • Assist in identifying areas of high risk noted within each program

Throwback Thursday: Boston Medical Center reduces alarm fatigue by recalibrating alarm limits

Siren

Editor’s Note: The following is a free Patient Safety Monitor Journal article from yesteryear! If you like it, check out more of our work covering quality and patient safety!

If you walk onto the medical-surgical units in Boston Medical Center (BMC), you may notice something strange: silence.

On a unit that is typically a cacophony of beeping emanating from cardiac monitors, silence is a strange occurrence. But thanks to BMC’s pilot study that began in August 2012, the unit is significantly quieter, the nurses are noticeably happier, and the hospital has positioned itself as a national model for reducing alarm fatigue-a recent hot topic in the patient safety world.

What began as a pilot study on one unit transformed into a hospitalwide initiative that reduced alarms on all medical-surgical units from 1 million to 400,000 per week.

“Our nurses threatened us that if we ever went back to the old settings; they never wanted us to end the pilot program,” says Deborah Whalen, MSN, APRN, ANP-BC, clinical service manager and cardiology nurse practitioner at BMC, and one of the coauthors of the study published in the Journal of Cardiovascular Nursing. “Initially they were terrified that there would be all these crisis alarms, but in fact, we made the changes and did it on a Monday at noon, changed the order sets on the pilot unit and educated staff, and then we stood there and there were no alarms.

“As a matter of fact I called Jim, our clinical engineer, at 2 a.m. to say the system was broken.”

The proof was in the pilot

The overwhelming success of the pilot study on one unit prompted BMC to expand the program to every medical-surgical unit and the hospital quickly became identified as a national leader in alarm management, during a time of heightened awareness and a new National Patient Safety Goal from The Joint Commission. Over the past several months The Boston Globe, NPR, and two local news channels have done stories about the hospital’s program. In May 2013, BMC’s work was featured in a Joint Commission webinar, exemplifying the steps hospitals could implement to better manage alarms and improve patient safety.

The results of the pilot program were published online in December in the Journal of Cardiovascular Nursing, which showed a reduction of 89% in total mean weekly audible alarms by dropping averages from 12,546 per day to 1,424. Weekly alarms averaged 87,823 but dropped to 9,967 during the pilot. The most significant decrease came from changes for bradycardia, tachycardia, and heart rate parameter limits, which started at 62,793 per week and dropped to 3,970 per week.

Perhaps the most telling statistic: The decibel level on the floor dropped from 90 decibels before the pilot to 72 decibels, the equivalent of noise levels generated by heavy traffic to normal conversation.

“It’s not silent by any stretch of the imagination, but it’s quiet and there aren’t these alarms constantly going off in the background,” Whalen says.

What made the study particularly appealing to other hospitals searching for ways to better manage alarms in their own facility was the fact that there were no adverse events related to missed cardiac events, and the pilot study required no additional resources or technology.

“While some hospitals are looking to add technology to combat this issue, BMC’s approach demonstrates the opportunity for clinicians to interact with current alarm systems more effectively to decrease clinical alarm fatigue while simultaneously capturing and displaying all important alarms,” James Piepenbrink, BSBME, director of clinical engineering at BMC and a study coauthor, said in a press release.

  [more]