Archive for September, 2011
NAHQ raffle winners!
Just a quick post to congratulate our NAHQ raffle winners:
- Emelia Lewis from Woodstock, VA won our free AHAP membership.
- Janet Lucchesi from Morrison, CO won our free Kindle!
Congratulations to both and we hope you enjoy your winnings!
Cappiello named COO of Healthcare Facilities Accreditation Program
We’d like to report some exciting news: former Joint Commission vice president and long-time advisor to HCPro’s own Briefings on The Joint Commission, Joseph L. Cappiello, has been named the chief operating officer for the Healthcare Facilities Accreditation Program (HFAP). Mr. Cappiello has been a great help to HCPro’s Association for Healthcare Accreditation Professionals (AHAP) and Briefings over the years. You also might know some of the books he’s authored, including The Chapter Leader’s Guide to Emergency Management. We’d like to congratulate Joe on his latest endeavor!
Were you at NAHQ?
I spent last week at the National Association for Healthcare Quality’s 36th Annual Conference in sunny Sacramento, CA, as I’m sure many of you did as well.
I was lucky enough to attend a few sessions. Our own Ken Rohde presented his session on polices & procedures, which many of you seemed to enjoy immensely. Though the session included many, many great ideas, a great portion was dedicated to separating your procedures from your polices, as both require different workflows. Procedures in need of change require a quicker turn around time than policies allow for–that makes sense, right? I saw many nodding heads.
I also learned just how much new nurses and residents must learn at orientation – and I’m just talking about the patient safety rules and regs! Presenter Orpha Lubeen’s first tip? Offer food and drinks.
And as I blog, I can’t help but think of the Patient Safety and Social Media session I attended, presented by Anne Huben-Kearney. The session ended with a great conversation about how to educate staff on what is appropriate and what they really need to think about before the click of a camera or mouse. Many of you had specific concerns that are no doubt tough to navigate in this ever-changing arena.
So, my big question is, did you attend? Did you go to these sessions or others? Share your experience and thoughts below, I’d love to start a conversation!
Rewarding near-miss reporting
By now, most of us involved in patient safety understand the importance of reporting, collecting, and analyzing near misses. More and more, healthcare providers are beginning to understand that more often than not, a systematic problem—not an individual—is behind potentially dangerous errors.
But how do you get staff to report them? No really—actually report them? Including physicians? Many healthcare providers have been working in the field for decades, and for many of those decades, mistakes were swept under the rug—especially mistakes that luckily did not reach the patient. No harm, no foul, no reporting–this was a common way of thinking for many years. When providers have learned and worked in an environment where reporting errors often meant severe individual punishment, how do get them to trust you that reporting is okay?
It’s critical to show staff the positive effects of near miss reporting. It’s also a good idea to publicly and consistently reward those who “see/experience something and say something.” A good example is one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards. After 24 months, the health center provided a table of 27 good catches that shows how systems were changed in response to the catch, including one that led to a national recall of an improperly labeled drug that lead to look-alike medication errors.
Clinicians honored with an award receive public recognition with wall boards on the surgical suite. The system is not yet implemented hospital-wide, but continues at the Weinberg OR Suite at Johns Hopkins Hospital.
Do you have a near-miss reporting system? Is it used? Do staff receive public recognition for their efforts? Have you had trouble getting staff to trust that reporting is benefits all? Post your comments below.
Disruptive behavior, negligence, endangered patients, and millions of dollars
August had been filled with a number of different patient safety rulings and findings that show poor patient safety can be costly in many different ways.
Let’s start with Boston, where two old cases have been settled.
First, parents of a newborn who died at Beth Israel Deaconess Medical Center in Boston seven years ago were awarded $7 million by the Suffolk County Superior Court after a physician and nurse practitioner were found negligent in their care. The parents claimed they did not react quickly enough to the infant’s deteriorating condition. The premature infant developed necrotizing entercolitis, something caregivers should have been watching for as it is common in infants delivered prematurely.
The parents alleged they came to visit their daughter and found her discolored and unresponsive, and said staff took more than an hour to respond.
In another recent decision, the U.S. Court of Appeals upheld a lower court verdict against Brigham and Women’s Hospital involving alleged disruptive behavior exhibited by Arthur Day, MD, the former head of neurosurgery. Sagun Tuli, MD, claims the hospital retaliated against her for complaining about her work environment.
The court ruled that Tuli was defamed and that her career was affected.
Now, on to Dallas.
It was recently reported that in March, 2010, Parkland Medical Memorial Hospital in Dallas, TX, informed 73 female patients that instruments that were not properly sterilized had been used on them, putting them and any sexual partners at risk of infections.
Following that incident, the Centers for Medicare & Medicaid Services (CMS) investigated the hospital in July, 2011. The investigation led to the finding that the hospital created an “immediate and serious threat to patient health and safety.” The report found that ED patients in severe pain were given maps of the hospital to find the appropriate place for treatment and children sent home without screenings.
Meanwhile, in a separate investigation, Parkland Memorial Hospital, along with the University of Texas Southwestern Medical Center, agreed to pay $1.4 million after a four-year Medicare billing fraud investigation revealed that resident surgeons were not properly supervised and also failed to comply with informed consent requirements.
Another Dallas hospital, Methodist Dallas Medical Center, was also recently cited for 10 violations by CMS, some which include failing to screen and stabilize emergency department (ED) patients and understaffing the ED.
Do these more recent findings indicate that CMS is getting tougher? Would similar findings be found elsewhere, if investigated? Is this the sign of the times of healthcare reform? What do you think? Share thoughts below.
