Archive for July, 2010

Joint Commission tailors “Speak Up” campaign

In late July, The Joint Commission released an update to its popular “Speak Up” campaign, specifically targeting patient falls. The Speak Up campaign has been in existence since 2002 and its main purpose is to encourage patients to become more involved in their own care. Many organizations use the free, downloadable forms on The Joint Commission’s website regarding “Speak Up” to help inform their patients that they can participate in their care.

The latest iteration of the campaign involves preventing patient falls. It’s widely acknowledged that falls are the cause of many minor and major injuries, as well as death. Data from the Centers for Disease Control and Prevention show that falls are the number one reason that elderly patients are admitted to the hospital.

“Falls can cause serious to life-threatening injuries; however, there are steps people can take at home or in a health care facility to reduce their risk of falling,” says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission. “We want people to be aware of these simple yet important precautions and avoid preventable injuries,” says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.

The Joint Commission’s new campaign includes action items to help people reduce their own risk of suffering a fall. Two of these include taking extra precautions in the hospital or in a nursing home and making small changes at home to prevent falls.

To learn more, visit The Joint Commission’s website.

I wrote about another version of the Speak Up campaign almost a year ago. At that time, The Joint Commission had released a campaign encouraging parents to become involved in preventing medical errors in their childrens’ care. Do you think these various versions are useful to hospitals? Do you think the latest “Speak Up” campaign, regarding patient falls, will be something your facility promotes?

AHRQ updates State Snapshots with 2009 information

The Agency for Healthcare Research and Quality has updated its State Snapshots with data from 2009. The State Snapshots break down healthcare quality information by state to help both the public and private sectors understand disparities among states. The latest update includes new data on health insurance.

The data to create the snapshots comes from the 2009 National Healthcare Quality Report. This year states can compare how their care for certain types of insured patients compares with the rest of the nation, or other states. As in previous years, the Snapshots show that all states have a mix of measures on which they perform well and on which they perform poorly.

To find the State Snapshots and check out your own individual state, click here. Readers, have you ever utilized this tool to get a better idea of where your state ranks in terms of quality? How have you used it?

Joint Commission says no new NPSGs for 2011

About a month ago I posted to this blog about some minor changes The Joint Commission had made to the National Patient Safety Goals. Well, TJC recently announced in the latest issue of Perspectives that those changes would be it as far as updates to the 2011 NPSGs and that no new goals would be released.

This doesn’t really come as a surprise to me, and I’m sure it isn’t to you either, readers. I am also fairly certain that anyone who works at a hospital will see this as good news, and that it falls in line with the strategy of late at TJC–to be more customer focused and also lessen the burden on hospitals looking to comply with their requirements.

Do you have any feedback about the lack of new NPSGs for 2011?

Press Ganey Report finds ED wait times increase

Press Ganey’s 2010 Emergency Department Pulse Report: Patient Perspectives on American Health Care reveals that in 2009, the average time patients in the U.S. spent between walking in the door and exiting the emergency department (ED) increased by four minutes to four hours and seven minutes. This is up 31 minutes in total since 2002, when ED reports were first made available. However, one positive note is that 32 states either reduced wait times, or kept increases in wait times to less than five minutes.

In addition, patient satisfaction has stayed the same as it was in 2008, part of an upward trend over the last five years. Communication proved to be important in keeping patients satisfied—those patients who were informed of any delays in care and had ED stays of longer than four hours were just as satisfied as those patients who had ED visits of less than one hour. The report was based on data from1.5 million patients treated at 1,893 hospitals nationwide.

To find the full Press Ganey report, click here.

Has your hospital’s ED implemented some process or new addition to inform patients of how long their care will likely take?

Some medical students already taking patient safety courses

Students at medical schools across the country are being given the opportunity to take elective courses in patient safety and error prevention. However, there are far less that actually require these types of courses as part of their curriculums, reports the Providence Journal. This is often because there is so much medical knowledge that students need to absorb during their time at medical school that patient safety takes a backseat.

However, the Lucian Leape Institute released a report in March calling out residency programs for not focusing enough on patient safety. Some schools that are requiring courses on patient safety, like Brown University’s Warren Alpert Medical School, where students take a course just before they begin their hospital rounds. The instructor of the course relates physicians to airplane pilots, who rely on good communication, the use of checklists, and can often fall prone to “solo thinking.” One issue medical schools are coming up against is that they cannot find qualified physicians to teach these types of courses, because they were never taught this way of thinking when they themselves were in medical school.

Readers, if you work in a teaching facility, do you think that medical students have a better grasp of how to prevent adverse events when they enter hospitals for their residencies? Have you seen any effects of a patient safety curriculum?

You can read the full article from the Providence Journal here.

Heart attack death rates are decreasing in U.S. hospitals

Heart attack death rates are on the decline at hospitals nationwide, according to a new report card released earlier in July by the Centers for Medicare and Medicaid Services (CMS), reports USA Today. At those hospitals that treat patients suffering heart attacks, death rates dropped from 16.6% to 16.2%. This is due to an increased effort to ensure all heart attack patients receive a certain set of treatments upon arrival to the hospital.

Additionally, there is a question as to whether the improvement is related to the fact that measures have been publicly reported for three years. That may be the case, but there’s too little data to draw any conclusions yet. Although death rates in heart attack patients have dropped, readmission rates within a month of discharge for these patients has not improved, saying at around one in five patients.

USA Today, click here. Has your hospital made any great strides in reducing mortality rates in heart attack patients? Do you have any creative campaigns related to heart attack?

IHI’s Bisognano says future holds more patient involvement in care

In a Q & A published Monday with The Boston Globe, Maureen Bisognano, the new president and CEO of the Institute for Healthcare Improvement, said that she sees the future of patient care as becoming much more patient-centric. She feels that the best encounters between patients and their physicians come when the physician has educated him or herself about the patient’s condition prior to the encounter; however, during the encounter the physician works with the patient to come up with a plan of care based on what the patient says as well.

Bisognano also said that the incentive system in the United States has forced physicians into moving away from this patient-centered type of care.

To read The Boston Globe’s full Q & A with Bisognano, click here.

Handoff communication: What’s your best practice?

I’ve been writing a lot about handoff communications lately. Although there are many standardized methods out there for encouraging communication practices (SBAR) there are many new inventions that hospitals pilot on their own, and it got me wondering-how many great ways of communicating patient information are there out there? Additionally, what potential does using the electronic medical record hold for restructuring handoff communication for the better?

In honor of World Patient Safety Day coming up on Sunday, July 25th, the Patient Safety Monitor Blog is going to sponsor a contest with the theme of handoff communication in mind. Readers are encouraged to send in descriptions of the handoff communication technique at their hospitals and any accompanying materials. This week and next week, the blog will feature entries from readers, and hopefully will inspire readers to take back new ideas to their own facilities.

The winner will be selected as soon as the contest ends by a panel of editors here at HCPro and receive a copy of HCPro’s book The Patient Safety Officer’s Handbook.

For rules on entering any contests on the Patient Safety Monitor Blog, click here. Please e-mail me to enter at hcomak@hcpro.com.

More hospitals using manufacturing methods to streamline processes

More and more hospitals are turning to “Lean” thinking to cut waste, improve efficiency, and streamline processes, reports The New York Times. Although this is a newer way of thinking for hospitals, manufacturers have been using these principles for years. Hospitals are now doing things like looking at the number of steps in a process to retrieve a medication, for example, and examining where those steps could be cut or made simpler.

The article uses Seattle Children’s Hospital as an example, citing many of the new practices its incorporated in the past two years. The hospital has utilized a program called “continuous performance improvement” to help them reduce waste, and in turn not only improve patient care but save money.

You can find the full New York Times article here. Reading through it reminded me of the book I just recently finished editing for HCPro, about Lean healthcare in action. The authors, Sarah Cottington and Shawna Forst, tell of Pella (IA) Regional Health Center’s (their facility) improvement journey using Lean techniques, principles, and training. I learned a lot from them, about how simple things like organizing and cleaning can go a long way toward simplifying processes. The book, called “Lean Healthcare: Get Your Facility Into Shape” can be found here, if you’re interested.

The ideal just culture

Briefings on Patient Safety recently launched a new column that explores patient safety from the perspective of a newcomer to the field. Columnist Catherine Hinz, MHA, was the patient safety lead at HealthEast Care System in St. Paul, MN, until she recently accepted a position with Patient Safe Solutions. Previously, Hinz worked for seven years as an ED health unit coordinator, completed a patient safety internship with the Agency for Healthcare Research and Quality, and finished a residency with The Studer Group.This column contains information from her experience at HealthEast.

The Patient Safety Monitor blog will be featuring excerpts of Catherine’s columns on the blog, beginning with the most recent, about just culture:

The concept of a just culture is relatively new to the healthcare industry and has become a critical and necessary component of any organization’s approach to improving patient safety. I have quickly learned the importance of just culture as I review patient safety events, attend root cause analysis sessions, engage in committee discussions, and even observe nurses and providers on the units. The cultural impact of redesigning policy, process, and work flow cannot be underestimated. Just culture spans across our health systems, from guiding provider interactions on the front lines of care to organizational strategic planning and public reporting.

The Agency for Healthcare Research and Quality (AHRQ) defines just culture as one in which “frontline personnel feel comfortable disclosing errors—including their own—while maintaining professional accountability.”¹ Definitions and descriptions of just culture widely vary, as do the actual leadership execution and implementation practices that would embed this kind of culture into organizations. Health systems and hospitals are looking to patient safety experts, high-reliability organizations, and outside industries for examples and frameworks to hardwire just culture.

A just culture gap analysis

Our health system, similar to other health organizations across the country, is pursuing a just culture. We recently commissioned an internal, interdisciplinary group of leaders to conduct a gap analysis that would determine how our organization is achieving the basic principles of a culture of patient safety: justice, learning, and accountability.

Our leaders (myself included) spent nine months deploying a patient safety climate survey, conducting leader interviews and frontline staff focus groups, reviewing policies and procedures, and evaluating our event reporting and investigation mechanisms (including root cause analysis and failure modes and effect analysis). The gap analysis concluded with a report and comprehensive list of recommendations to be implemented over the course of the next year; however, the just culture work will continue indefinitely.

Performing the gap analysis took our hospital on an amazing journey; it delved into the deep patient safety perceptions, attitudes, and practices of our frontline staff and unit/department leadership. In my opinion, the most valuable experience and information came from our physician leadership and frontline nursing staff focus groups. The leaders conducting the gap analysis attended nursing shared leadership councils; I attended and led the conversation at our physician leadership meetings. Both of these meetings occur monthly at our four hospitals. Once the topic was introduced and explained, the ensuing candid conversation was incredible. In fact, one of our hospital CEOs said it was the most engaged he had seen providers at the leadership meeting in years.

The providers and nurses spoke about perceptions of leadership, their experiences on the front line, and the emotions that run high after a never event or near miss occurs. What’s more, they shined light on the relationship between nurses and providers when an event or near miss occurs; they discussed team dynamics that leadership may have not identified otherwise. The information was meaningful and shared in a respectful and trusting manner. Much of the discussion focused on physicians’ and nurses’ responses to error, whether via immediate conversations and disclosure or continued follow-up.

1. AHRQ Patient Safety Network Glossary, “Just Culture.” Online April 2, 2010.

To read Catherine’s full column on just culture, see the August issue of Briefings on Patient Safety (a part of your Patient Safety Monitor subscription for those blog readers out there who are also subscribers.)