Archive for May, 2009

Data management virtual workshop

HCPro is offering a great opportunity to help you learn how to better collect, analyze and use your data to make more sound performance improvement decisions. Managing Your Data: Virtual Workshop Series features Greeley Consultant Ken Rohde who will spend time going over how to put the multitudes of data that your organizations collect to work for you. Your facility will get the chance to learn from Ken in a conference-style setting without having to travel!

The first virtual conference, Managing Your Data: Methods for Understanding and Collecting, is coming up next week on June 4. This first installment will help attendees better understand how to better use your time to collect valuable data, and not waste energy on data that will not provide positive change for your organization.

The other installments, on July 9 and July 30, talk about tools for analysis and best practices for presentation of data. You can purchase each installment separately but you do receive a substantial discount for purchasing the entire virtual workshop ($597 in total, vs $259 individually).

I hope you consider this great opportunity for learning better how to use your data effectively and improve your patient safety processes.

When saying “I’m sorry” keeps patients safer and saves money

I came across this article from Crain’s Detroit Business published earlier this month. It outlines how hospitals in Michigan are reaping the benefits of an unanticipated bonus of admitting medical errors to patients: increased financial incentive to do so. Over the past few years, a group of Michigan hospitals been doing the opposite of what most lawyers would advise–that is own up to medical mistakes as soon as they have happened. They decided to do this because it was part of “the right thing to do”–that is, it was thought to help increase transparency, improve patient outcomes, and bring more of an ethical approach to care. An additional benefit, however has been the cost savings.

Henry Ford Health System in Detroit, which has had a “patient apology program” for eight years, has reduced its medical malpractice expenses by 62%, from $45 million to $17 million. The University of Michigan has lowered the amount of money it reserves for medical litigation over the past eight years from $72 million to $16 million, a reduction of 65%. These savings have been able to be put directly back into these institutions to pay for further patient safety programs, equipment, and tools.

Simply being more open with patients has resulted in these savings. The hospitals also make a large effort to illustrate to the patient and/ or the patient’s family why the error occurred through the root cause analysis process.

You can read more here. Has your hospital used any sort of apology technique like this as standard policy? It is certainly not the norm, but perhaps it should be.

New Universal Protocol video is an easy training tool, offers credits

I wanted to let our readers know that a new video from HCPro’s patient safety market is available! It’s a 20-minute video that helps train staff on the up-to-date Joint Commission Universal Protocol standard. I’m personally excited about this as I helped to create the video (and I’m actually in it), and can tell you that it easily explains each of the three main components of the standard (preprocedure verification, site marking, and time out), and also explains how to avoid common mistakes most hospitals make.

The video even offers continuing education credits. (For more information on how to receive the video and credits, click here.) You can also watch the trailer below!

Wrong-site surgery, suicide top Joint Commission sentinel event list

Wrong-site surgery, suicide, and operative/postoperative complications topped The Joint Commission’s latest tally of most frequently reported sentinel events, according to the May Joint Commission Online. The accreditor has reviewed 5,901 sentinel events since it began maintaining its database in January 1995 through March 31, 2009.

A total of 6,036 patients were affected by the events, with 4,132 (68%) resulting in patient death. The rest of the top 10 sentinel events over the last 14 years are medication error, delay in treatment, patient fall, unintended retention of foreign body, assault/rape/homicide, patient death or injury in restraints, and perinatal death or loss of function.

Click here for a more detailed view of the sentinel event statistics.

Media technology used more frequently as means of marketing for healthcare facilities

Until recently, it would have been unheard of to broadcast a live brain operation. Social media has changed that, however, as it becomes more common for private medical procedures to be described and even recorded live and posted online for the public to view, reports The New York Times. New tools like Twitter, live blogging, Facebook, and YouTube have given hospitals a new space to market themselves. More than 250 hospitals are involved in some sort of social media, and many of those are looking to see if they can attract patients from an increasingly competitive market.

Some questions arise concerning the use of such media to promote a facility, however. Does discussing a patient’s condition in this forum violate patient privacy rules? What kind of picture does this type of media paint of patient care? What if something goes wrong during a procedure being broadcast live?

To read the article, click here. Has your hospital experimented with any new, creative marketing techniques? Have they succeeded in bringing new patients?

Increased hospital spending does not equal greater quality

Yet another study has shown that greater spending does not mean higher quality of patient care. Published in yesterday’s Health Affairs, the study examined the rate of spending compared with the quality of care at individual hospitals around the country. Previously studies have shown that greater spending does not always correlate to higher quality of care on a regional level. The authors wanted to more closely look at this relationship at a more individual hospital level simply because hospitals in one region are not always linked.  The study, funded by the National Council on Aging, examined spending and care related to three quality measures:

• acute myocardial infarction (AMI)
• pneumonia
• congestive heart failure (CHF)

The study mostly focused on the costs associated with the two years of end of life care given for these conditions.

After comparing spending rates with quality scores for more than 2,700 hospitals nationwide, the authors found that the lowest mean spending for end of life care was around $16,000 and the highest mean spending was more than double that at more than $34,000. The authors found almost no correlation between spending and quality for non academic medical centers for the quality measures listed above, and for academic medical centers the same is true except for one negative correlation for AMI.

You can read the full results here.

Has your hospital been able to perform well on these quality measures without increasing spending?

Consumers Union says healthcare lacks progress in reducing medical errors

It’s been 10 years since the Institute of Medicine (IOM) published its groundbreaking report To Err Is Human, which detailed the need for reform in healthcare. The report, published in 1999, estimated that 98,000 American die every year from preventable medical errors.

Ten years later and the Consumers Union has issued a new report, To Err is Human-To Delay is Deadly, its own version of the current state of progress in reducing preventable medical errors. Director of Consumer Union’s Safe Patient Project Lisa McGiffert said there’s little evidence to suggest much progress has been made, yet billions of dollars have been spent. She says the U.S. healthcare system failed to adopt the reforms recommended by the IOM in 1999. [more]

Evidence-based hospital design: Coming to a hospital near you

Most brand new hospitals being built today take evidence-based hospital design into account, and really they should. An article in the May 18 New York Times points out that taking hospital design into consideration can not only reduce medical errors, but it can offer a higher standard of quality care because it helps alleviate patient stress. Those in the field of evidence-based design say that the design of a hospital has a stronger effect on patient care than previously thought. For example, simply having single patient rooms takes away an entire level of stress that was not considered until recently. This includes stressors like noise and privacy concerns.

My fellow blogger  Tami Swartz wrote this article about evidence-based design for HealthLeaders Media a couple of weeks ago, which specifically highlights some projects being done by the Center for Health Design.  The Pebble Project, one of the CHD’s research initiatives, was as such because of the ripple effect caused by a pebble thrown into a pond. Likewise, the effect that good design can have on a patient’s stay in a hospital is being examined through this initiative. Additionally the use of light is being examined.

Do you work for a newer hospital that utilizes some principles of evidence-based design? If so, have you noticed any effect on patient care? 

R.I. hospital commits to further education after wrong-site event

Rhode Island Hospital is buckling down to revise and teach its procedures for safe surgery after a surgeon began operating on the wrong side of a child’s mouth, reports the Providence Journal.

The hospital promises to examine and revise policy, and then spend a few hours in meetings re-training each specialty on correct procedure. The new training will be conducted under the terms of an agreement with the Health Department, reports the Journal.

Health Director David Grifford is not sure what procedural flaws attributed to the mistake-he says that forms and consent were filled out correctly, and a proper time out was performed, yet the surgeon cut into the wrong side. He stopped when a resident noticed he was working on the wrong side. The patient did not have further complications. Brian Murphy, the hospital vice president, noted that staff members in the room may not have been able to see the surgeon was on the wrong side, because it was oral surgery on a child.

In addition to the re-training meetings, the hospital plans to:

• Contract with a patient-safety consultant to establish a reporting system for near misses
• Develop method to regularly confirm all surgical staff members understand current policy and procedure
• Clarify and standardize its time out procedure

Joint Commission solicits feedback on NPSG, Universal Protocol updates

Get your two cents in–The Joint Commission has asked the field to review and comment on revisions to the 2009 National Patient Safety Goals and 2009 Universal Protocol as part of an ongoing effort to improve clarity of the standards.

The Joint Commission has crafted these revisions in the hopes of clarifying language and increasing relevancy to the settings where they are applied. Proposed revisions have been posted to The Joint Commission’s Web site identifying standards and Elements of Performance proposed for revision or deletion.

Feedback will gathered over a six week period beginning May 12, 2009.