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Before the Plane Crash

In January 2009, all eyes were focused on the Hudson River after a plane flying out of New York’s LaGuardia Airport struck a flock of geese and crash landed in the river. Thanks to fast acting by the pilots, all 155 passengers survived, with few major injuries, in the disaster dubbed “the Miracle on the Hudson.” However, trouble emerged in the aftermath when people tried to find out which hospital their loved ones had been sent to.

“Some of the patients went to New York and some went to New Jersey. And because of HIPAA laws, it was very difficult for airline authorities to get the names of who was where,” says Sharon Carlson, RN, director of Emergency Preparedness at Sharp HealthCare in San Diego, CA. “As a family member you can imagine your terror knowing that your loved one was in a plane crash and not knowing where they are. That’s a big issue we always have, reunifying people after a disaster.”

“Because of [the Miracle on the Hudson] we decided in San Diego that we needed to make relationships before an event happens,” she adds. “Get to know each other, work together, know each other by first name, know each other’s number.”

Using the lessons learned from the Hudson, Carlson and her health system joined a disaster partnership with their local airport, San Diego International (SAN.) The airport has been growing steadily over the past decade, with over 22 million people flying in and out of it in 2017. The airport partnership was started originally in 2010 by UC San Diego Health system.

The transportation administration requires SAN to conduct major disaster drills periodically. As part of the partnership, Sharp Healthcare is included in those drills, Carlson says. They practice their communication process once a year to ensure everybody is on the same page and that there’s been no changes in the contact information.

“We have a partnership with the airports, so they know who to contact at our hospitals,” she says. “And we’ve sent it through our compliance and legal departments, they know what kind of information we can give them.”

In the event of a plane crash or disaster, airport staff have a list of hospital contacts so they can reach out, then read names off the plane’s manifest and the hospital will be able to tell them which people on the list are there or not.

“We don’t give out conditions, injuries, or illnesses,” she says. “We just say if they’re here or not. Because the airline is wanting to tell the family members ‘ok, go over here, your loved one is at this hospital.’”

Checklist: Re-opening after a disaster

On October 10, Hurricane Michael made landfall in Florida, forcing two Florida hospitals to evacuate more than 300 patients due to building damage. On the same day, The Joint Commission (TJC) published a new Emergency Management Health Care Environment Checklist on its website, which helps healthcare organizations reopening their facilities after a disaster.

While the timing of these two events were coincidental, providers should to take time to go over the checklist and their emergency plans in general.

A TJC workgroup developed the checklist at the request of the U.S. Department of Health & Human Services’ Office of the Assistant Secretary for Preparedness and Response. It aligns with the accreditor’s Emergency Management standards, covers both clinical and environmental issues, and addresses crucial post-disaster elements that need addressing before reopening. It should be noted that the checklist isn’t hurricane-specific.

Jim Kendig, TJC’s field director of Life Safety Code surveyors, says it’s critical that hospitals customize the checklist for their needs by examining the relationships they establish in the community, and at the regional and state levels.

“For example, in Florida, a county Office of Emergency Management met with utilities and other emergency support functions to determine hospitals and PSAPS [public safety answering points] are the first to receive power restoration,” he says. “Establishing an unidentified victims process is also a good start, as it the ability to share that information within an hour of a disaster event.”

“The Joint Commission’s Emergency Management Committee continues meeting with organizations after disaster events to glean important information to share with the field through our Environment of Care News and ongoing communications,” he adds. “This also give us the opportunity to ensure that our standards and elements of performance are effective and contemporary.”

WEBINAR – Preliminary Denial of Accreditation: Actions, Recovery, and Prevention

Presented on: Wednesday, December 12, 2018 |1:00-2:30 p.m. EST

Presented by: Kurt A Patton, MS, RPh.\

Register: https://hcmarketplace.com/preliminary-denial-of-accreditation

When the Joint Commission hands out a Preliminary Denial of Accreditation (PDA) decision, you have a small window to set things right. If you can’t get your hospital to band together to fix the problem, a PDA can cost you your accreditation, reputation, and ability to treat patients. And that’s before CMS gets involved.

Join former Joint Commission surveyor Kurt Patton, MS, RPh, this August as he reviews how you might get a PDA, what you can do about it, and what surveyors will expect during their follow-up.

At the conclusion of this program, participants will be able to:

  • Contest a PDA decision
  • Develop a corrective action plan in less than 10 days
  • Focus and prepare for the 60-day PDA follow-up survey
  • Get organized and keep staff and leaders accountable for deadlines
  • Prioritize the most difficult performance-based findings in preparation for the 60-day follow-up survey

Agenda

  • What to do if you think an “immediate threat” or “immediate jeopardy” situation is pending
  • What to do if your report is posted and you are surprised to learn it is PDA
  • How to develop a strategy to dig your way out of this situation
  • How to do a corrective action plan in contrast with an Evidence of Standards Compliance (ESC)
  • How to prepare for the most difficult survey you’ve ever experienced: the 60-day PDA follow-up survey
  • Live Q&A

Tapping Patient Engagement to Reduce Diagnostic Errors

By Christopher Cheney at HealthLeaders Media

Drawing information from patients can help boost understanding of why diagnostic errors happen and reduce the risk of future errors, research published this week says.

Diagnostic errors are a serious patient safety problem, impacting about 12 million adult outpatients each year and causing as many as 17% of adverse events for hospitalized patients.

“Health systems should develop and implement formal programs to collect patients’ experiences with the diagnostic process and use these data to promote an organizational culture that strives to reduce harm from diagnostic error,” researchers wrote in an article published today in the journal Health Affairs.

The research features an examination of 184 narratives from patients or family members about diagnostic errors collected in a new database maintained by the Empowered Patient Coalition.

The data provide unique and valuable insight into diagnostic errors, the researchers wrote.

“Patients’ reports of their experiences of diagnostic errors can provide information that traditional measurement mechanisms often fail to capture. Given the absence of diagnosis-specific experiences in most surveys and patient-reported outcomes, the only current way to capture patients’ experiences of diagnostic error is via patient complaints. However, complaints are often viewed as satisfaction matters rather than safety signals,” the researchers wrote.

Pain points

The Empowered Patient Coalition narratives identified four areas where poor clinician-patient relations contributed to diagnostic errors.

  • Patient knowledge was ignored in 92 of the narratives. Patients or family members said that clinicians ignored or disregarded reports of clinical indications such as symptoms and changes in patient status.
  • Disrespect of patients was considered a possible contributing factor in several diagnostic errors. Clinician disrespect of patients was reported in several forms such as belittling, mocking, and stereotyping.
  • Failure to communicate was another theme in the narratives, with clinician failings ranging from ineffective communication styles to refusal to talk with patients and family members. Examples of poor communication included unanswered phone calls and unresponsiveness to questions.
  • Manipulation or deception was reported in 15 of the narratives. This behavior fell into two categories: Clinicians using fear to influence care decisions or patients who were misled or misinformed.

Addressing the problem

To help reduce diagnostic errors, the Health Affairs researchers propose five methods to collect patient experience data and encourage better communication between clinicians and patients.

  • Creating new requirements for clinicians to conduct lifelong communication training. These requirements could include training to manage patient expectations through discourse.
  • Including communication skills, professionalism, and safety knowledge in certification and continuing medical education programs.
  • Health systems and providers should encourage patient engagement in safety through active and systematic collection of patient observations of clinician behaviors. These patient engagement efforts should be incorporated in mechanisms that are designed to change clinician behaviors.
  • Patient reports identifying clinician behaviors that pose a risk of diagnostic errors should result in interventions to foster patient-centered communication. These reports should be corroborated through the medical record or some other form of independent analysis.
  • Hospitals and health systems should include patient reports of diagnostic errors into training and patient safety programs.

A multi-pronged approach is needed to address aberrant clinician behaviors that lead to diagnostic errors, Traber Giardina, PhD, lead author of the Health Affairs research, told HealthLeaders today.

“We recommend health systems use a systematic method to collect patient reports of these types of behaviors. This would allow for these behaviors to be identified and monitored. A safety culture that encourages not just patients but also clinicians and staff to report these behaviors is needed. Additionally, we suggest reforms in medical education that highlight patient safety,” she said.

These efforts require walking a fine, said Giardina, a patient safety researcher at the Michael E. DeBakey VA Medical Center and assistant professor of medicine at Baylor College of Medicine, both in Houston.

“Fostering clinician accountability for the unprofessional behaviors experienced by the patients who reported diagnostic errors is sure to be challenging and will need to be balanced by the need to address pressures on clinicians that lead to burnout, which may even contribute to these behaviors. These at-risk behaviors that compromise patient safety must be addressed though. More policy priority to nurture the patient-physician relationship is long overdue.”

Biased Against Accredited Hospitals? Joint Commission Refutes Study

By Steven Porter

A study that found independent hospital accreditation carries no real benefit for patient outcomes has garnered a formal rebuttal from The Joint Commission, which argues the researchers reached faulty conclusions due to a number of methodological flaws.

Authors of the original report, published last month in the BMJ, said their findings show that hospitals accredited by private organizations were no better than those reviewed by a state survey agency, and at least one researcher involved in the project cited it as evidence that the status quo should be upended.

“We need to rethink what private accreditation buys us. Its a huge industry,” Ashish K. Jha, MD, MPH, a professor of global health and health policy at the Harvard T. H. Chan School of Public Health and a practicing internist at the Veterans Affairs Boston Healthcare System, wrote last month in a tweet linking to the report. “We find little evidence that its doing patients good.”

Jha expounded on the report’s conclusions this month in a JAMA Forum article.

“The findings are clear: accredited hospitals do not seem to be providing better care,” he wrote.

“We need to reexamine the standards required for accreditation to ensure that they are promoting what’s actually important: the health, safety, and optimal experience of patients,” Jha added.

The Joint Commission, however, contends that the study drew invalid conclusions by trying to compare “two radically different groups of hospitals” resulting in a bias against accredited hospitals. The organization, which is the predominant independent hospital accrediting organization in the U.S., submitted a formal response that the BMJ published last week, followed by aseparate statement.

One of the big complaints raised by The Joint Commission was the difference in size of hospitals in the group accredited by independent organizations versus the group reviewed by state survey agencies. While two-thirds of the hospitals in the former group have more than 100 beds, an overwhelming majority, 93%, of hospitals in the latter group have fewer than 100 beds, the organization said.

Larger hospitals and teaching hospitals, especially, tend to care for more-seriously ill patients, too, but the researchers made their comparisons worse by failing to adjust for differences in patients’ severity of illness, according to The Joint Commission’s healthcare quality evaluation division Executive Vice President David W. Baker, MD, MPH, FACP, and President and CEO Mark R. Chassin, MD, FACP, MPP, MPH, who drafted the organization’s formal response.

What’s more, the study reviewed mortality for six categories of surgical procedures, but a majority of the hospitals in the group reviewed by state survey agencies didn’t perform some of the procedures being studied (because some procedures are uncommon at smaller hospitals), Baker and Chassin wrote.

“[D]espite the small numbers of cases, the authors combined the outcomes of the six types of surgery into a single multivariate model,” they wrote, arguing that this is problematic because more than 80% of all surgical cases for hospitals reviewed by state survey agencies were for hip replacements, while hospitals with independent accreditation covered all six categories.

“For three of the five other surgical procedures, the results favored [accrediting organization] hospitals,” they wrote.

Baker and Chassin complained that the authors minimized the importance of lower readmission rates for independently accredited hospitals.

“Based on the 3 million medical admissions at Joint Commission-accredited hospitals, which represent 88% of all medical admissions to [accrediting organization] hospitals, the findings indicate that patients treated in Joint Commission-accredited hospitals experienced 12,000 fewer deaths and 24,000 fewer readmissions,” they wrote. “These differences matter to patients.”

Jha, who is listed as the point of contact for the authors of the original report, did not respond to HealthLeaders‘ request for a response to The Joint Commission’s concerns.

CMS Extends Time to Finalize Discharge Planning Proposal

By AJ Plunkett

If you were expecting to implement the latest discharge planning revisions to the Medicare Conditions of Participation soon, you can breathe a little easier for now. CMS took the unusual step on October 30 of announcing a year’s time extension to publish the final rule. The extension runs through November 3, 2019.

By federal regulation, such rules must be finalized and published with three years of proposal “except under exceptional circumstances.” In announcing the time extension for the final rule, which could have significant impact on hospitals and home health agencies, CMS noted that it received 229 comments after it first proposed the rule November 3, 2015.

“In this case, the complexity of the rule and scope of public comments warrants the extension of the timeline for publication,” according to the Federal Register notice published online October 30.

The rule, “Medicare and Medicaid Program; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies,” has been under review by CMS’ legal team since at least April, according to consultants and other officials.

CMS wants to coordinate with IT

CMS indicated that part of the delay was in order to collaborate with HHS’ Office of the National Coordinator for Health Information Technology.

Among other things, CMS is proposing to “implement the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185), that requires hospitals, including, but not limited to, short-term acute care hospitals, CAHs and certain post-acute care (PAC) providers, including long term care hospitals, inpatient rehabilitation facilities, HHAs, and skilled nursing facilities, to take into account quality measures and resource use measures to assist patients and their families during the discharge planning process in order to encourage patients and their families to become active participants in the planning of their transition to the PAC setting (or between PAC settings),” according to the extension announcement.

Based on information received from the public and other stakeholders, CMS says it needs more time to evaluate the impact of the proposed rule.

“The commenters presented procedural and cost information related to their specific circumstances, and the information presented requires additional analysis,” says CMS, adding that “we have determined that there are significant policy issues that need to be resolved in order to address all of the issues raised by public comments to the proposed rule and to ensure appropriate coordination with other government agencies.”

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.

More on this topic can be found on

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.

Go Vote!

Today is Election Day, and we here at HCPro want to encourage all our readers to get out and vote!

The site below shows you where your local polling places are:

www.vote.org/polling-place-locator

 

 

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