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(TBT) Diffusing disruptive physician behavior

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

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

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

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

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

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Patient Medication Errors Double

The most common errors were taking or giving the wrong medication or incorrect dosage, and inadvertently taking or giving a medication twice. One-third of medication errors resulted in hospital admission.

The frequency of serious medication errors by patients or their caregivers outside of a healthcare setting more than doubled from 2000 to 2012, according to a study in Clinical Toxicology.

Researchers from the Center for Injury Research and Policy and the Central Ohio Poison Center at Nationwide Children’s Hospital analyzed calls to poison control centers across the country over the 13-year period about medication errors that resulted in serious medical problems. The rate of serious medication errors per 100,000 people more than doubled from 1.09 in 2000 to 2.28 in 2012. These errors occurred mostly in the home, affected people of all ages, and were associated with a wide variety of medications.

“Drug manufacturers and pharmacists have a role to play when it comes to reducing medication errors,” said Henry Spiller, a co-author of the study, and director of the Central Ohio Poison Center at Nationwide Children’s. “There is room for improvement in product packaging and labeling. Dosing instructions could be made clearer, especially for patients and caregivers with limited literacy or numeracy.”

The most common errors were taking or giving the wrong medication or incorrect dosage, and inadvertently taking or giving the medication twice. Among children, dosing errors and inadvertently taking or giving someone else’s medication were also common errors. One-third of medication errors resulted in hospital admission.

The medication categories most frequently associated with serious outcomes were cardiovascular drugs (21%), analgesics (12%), and hormones/hormone antagonists (11%). Most analgesic exposures were related to products containing acetaminophen (44%) or opioids (34%), and nearly two-thirds of hormone/hormone antagonist exposures were associated with insulin. Cardiovascular and analgesic medications combined accounted for 66% of all fatalities in this study.

Among children younger than six years, the rate of medication errors increased early in the study and then decreased after 2005, which was associated with a decrease in the use of cough and cold medicines attributable to the Food and Drug Administration’s 2007 warning against giving these drugs to children.

“Managing medications is an important skill for everyone, but parents and caregivers have the additional responsibility of managing others’ medications,” said study lead author Nichole Hodges, a researcher at the Center for Injury Research and Policy at Nationwide Children’s. “When a child needs medication, one of the best things to do is keep a written log of the day and time each medication is given to ensure the child stays on schedule and does not get extra doses.”

Data for the study were obtained from the National Poison Data System, which is maintained by the American Association of Poison Control Centers.

This story first ran at HealthLeaders Media

Uniqueness is not unique

Editor’s Note: This is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

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

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

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

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

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

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

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

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

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

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

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

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

Editor’s note: Patrick Pianezza, MHA, has worked with the Studer Group and Johns Hopkins Hospital. In his most recent role, Pianezza’s work drove organizational performance in Hospital Consumer Assessment of Healthcare Providers and Systems. to an all-time hospital best in the 90th percentile. He can be reached at ppianezza@gmail.com.

Maintaining security during a Joint Commission survey

Facilities often have questions when surveyors come to visit. Some of the most frequently asked questions involve security and confidentiality, how to make sure surveyors see what they need to without violating hospital safety. In the July issue of Perspectives, The Joint Commission answered some of the most frequent questions.

Access to Computer Systems: Surveyors will sign security agreements with the facility in order to receive a user ID and password to access a computer system (for example, in order to review policies and medical records) if the facility requires it.

Confidentiality Agreements: If a facility wants surveyors to sign a confidentiality agreement, then that agreement has to be sent to the Joint Commission Central Office for review before the survey.

That said, asking surveyors or reviewers to sign an agreement is unnecessary, according to The Joint Commission. Accreditation and certification contracts, plus the Business Associate Agreement between The Joint Commission and the facility, already bind individual surveyors and reviewers to confidentiality.

Security Sign-In: If a facility requires visitors to sign into the building as part of the organization’s regular security process then surveyors will sign in too. In lieu of asking to copy a surveyor’s driver’s license, Joint Commission badge, or any other form of ID, facilities should refer to surveyors’ pictures and biographies on the Joint Commission Connect™ secure extranet site.

Videotaping Survey Activities: Videotaping or recording any part of a survey or review, including the exit conference is forbidden.

Joint Commission: Six EPs deleted for Critical Access Hospitals

Later this year The Joint Commission will delete six elements of performance (EPs) from the Distinct Part Unit (DPU) standards for Critical Access Hospitals. The accreditor says this will streamline the standards and the changes go into effect on September 24, 2017.

The deleted EPs are from the Medical Staff, Leadership, and Rights and Responsibilities of the Individual chapters. You can read all six standards at the Joint Commission website. Those with questions can contact Laura Smith, MA, Joint Commission project director at lsmith@jointcommission.org.

https://www.jointcommission.org/standards_information/prepublication_standards.aspx

The Focused Standards Assessment tool goes temporarily offline in July

The Focused Standards Assessment (FSA) tool on The Joint Commission’s Intracycle Monitoring (ICM) Profile will be taken offline from June 30, (5:00 PM Central Time) through  July 10 (9:00 PM CT)

The FSA is an interactive standards self-assessment tool for facilities that lists the standards applicable to each organization’s accredited programs and services. An extension due date will be set to Monday, July 24, 2017 for facilities with an ICM submission date between July 1 and July 10.

https://www.jointcommission.org/facts_about_the_intracycle_monitoring_process/

(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 releases interpretive guidance on emergency preparedness

CMS unveiled interpretive guidance and survey procedures on its emergency preparedness rule. The emergency preparedness rule went into effect last November. The interpretive guidelines apply to all 17 provider and supplier types.

Read the full memo here. 

Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

The Joint Commission has revised several of its requirements for National Patient Safety Goal (NPSG) 7, which focuses on the issue of healthcare-associated infections (HAI). The revisions go into effect on January 1, 2018, and apply to hospitals, critical access hospitals (CAH), and nursing care centers (NCC).

NPSG 07.03.01: Multidrug-resistant organisms (MDRO)

•    NCCs are now expected to follow the MDRO NPSG.07.03.01. Nursing homes experience a high rate of MDROs such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). This was particularly concerning because nursing home patients were bringing MDROs to hospitals and vice versa.
•    The Joint Commission is adding a new infection, carbapenem-resistant enterobacteriaceae (CRE) to NPSG.07.03.01. This change applies to hospitals, CAH, and NCCs.

NPSG 07.04.01: Central line-associated bloodstream infections (CLABSI)

•    The EPs for the NPSG 07.04.01 have been reordered.
•    EP 11 was revised to specify the use of chlorhexidine for antiseptic skin preparation.
•    For both NPSG 07.03.01 and NPSG 07.04.01, facilities are now allowed to determine how frequently they need to re-educate staff and licensed independent practitioners on MDROs and CLABSIs.

Today is Time Out Day for patient safety

June 14 is National Time Out Day, a Joint Commission and Association of periOperative Registered Nurses (AORN) campaign to promote patient safety before, during, and after surgery. The organizations also implore healthcare facilities to commit to conducting a safe, effective timeouts for each and every surgery.

This year’s theme calls on surgery staff to be a Time Out SUPERHERO, an acronym standing for the nine elements of a surgical timeout:

Support a safety culture
Use The Joint Commission’s Universal Protocol and AORN Surgical Checklist
Proactively reduce risk in the OR
Effect change in your organization
Reduce harm to patients

Have frank discussions about hazardous situations
Empower others to speak up when a patient is at-risk
Respect others on the surgical team
Openly seek opportunities for improving patient safety

“National Time Out Day is a powerful tool that supports surgical nurses’ ability to speak up for safe practices in the operating room,” AORN wrote in a brief. “It provides an opportunity to educate your community about this practice and become better informed patients (read more about this in Periop Insider). Time Out also demonstrates your role in patient care and commitment to patient safety as the perioperative nurse who cares for them.”

Wrong-site, wrong-procedure and wrong-person surgeries happen every day and surgical timeouts are key to preventing adverse and never events. Everyone on the surgical team has to be fully engaged, accountable, and empowered to speak up during the timeout process to prevent never events.

The Joint Commission has a list of free tools and resources available on surgical timeouts.