All Entries in the "AHRQ" Category

Patient safety in 140 characters

In honor of patient safety week, the National Patient Safety Foundation hosted a tweet chat, in which participants all follow the same hashtag (#keyword) to have a large conversation. If you missed it, you can read the conversation by searching twitter for “#PSAW2012.” I suggest checking it out (you don’t even have to have Twitter to conduct a search) for the resourceful links alone. Comment below or tweet @PSeditor if you joined and what you liked about it.

Here are some of the topics and facts brought up in conversation:

Health literacy:

Twelve percent of adults have good health literacy

E-literature might help follow up with patients post-visit

MDs tend to interrupt patients after 18 seconds of speaking

PSAW:

Getting PSAW recognized by more of the general public to spread awareness beyond the healthcare setting

Why PSAW is observed, recognized, but not celebrated

Next PSAW is March 3 –9, 2013!

Here are some resources brought up in conversation:

NSPF’s new “Ask Me” video

AHRQ’s “Questions are the Answer” video

IMSP has new tools and resources

Health Literacy: Reducing the Burden of a Complex Healthcare System

Patient Safety Week 2012: Informing the Journey, Not Changing the Destination

Checklists that patients and doctors follow can improve hospital care

Patient Safety Knowledge Quiz

Dreaming the dream (by Peter Provonost)

Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy

The Price of Tradition

Do Electronic Medical Records Save Money?

Words to Watch – Fact Sheet

What’s in a Name? Safer care, for one.

20 Tips to Help Prevent Medical Errors: Patient Fact Sheet

NPSF Tools and Resources for Patients and Consumers

No One Should Celebrate National Patient Safety Week

March 07, 2012 | Tami Swartz | Comments 0

Ask your staff: How can we earn your trust?

Every time I explore a quality improvement initiative with a hospital for Patient Safety Monitor Journal, I always ask two questions:

What was your biggest challenge?
What advice would you give to other hospitals?

Especially as of late, the answers revolve around just culture. Quality directors, nurse managers, patient safety professionals, CNOs all tell me the biggest challenge is staff trust and buy-in; the key to success is involving them in the process. We all know the key to improving is knowing what’s wrong, but unless there’s trust between the organization and the staff, you won’t find out that information.

The most recent AHRQ Culture of Safety survey – Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report – leads me to believe perhaps the knowledge of how to improve culture and safety is there, but it’s not yet in practice to the fullest extent.

This is a big survey, including data from more than a half million healthcare staff from more than 1,000 hospitals, and deserves a good look:

Teamwork within a unit was strong; 80% of respondents agreed or strongly agreed to that sentiment. Generally, staff felt that management supported them and a culture of safety, and that the organization was including systems meant to support staff and reduce errors. To me this says that the talk is there: Staff members are aware that managers and leadership care about safety, and those systems should support them, not hinder them. Seventy-five percent say that management’s actions show dedication to patient safety; 72% believe the systems are in place to prevent mistakes.

Yet when it comes to reporting or speaking up, staff are still wary. Only 62% felt there was communication openness in their organization, and the lowest scoring domain was nonpunitive response to error, with only 44% positive response to questions related to the subject.

When it gets more specific – and more personal–the rates drop lower. Most interestingly is the difference between these two questions:

Staff will freely speak up if they see something that may negatively affect patient care: 75% agree/strongly agree
Staff feel free to question the decisions or actions of those with more authority: 47% agree/strongly agree

To whom staff must speak their concerns seems to be a critical indicator as to whether they actually will. This is certainly an issue with culture. The vast majority of respondents (76%) had direct patient involvement, and 35% were nurses. Considering disparate levels of authority create the team responsible patient care, I find this low response to that particular question quite concerning.

Also noteworthy: exactly half believed mistakes are held against them. It’s no wonder the survey indicates vast under-reporting of adverse events, a claim supported by the recent report by the inspector general of the Department of Health and Human Services.

I think the next step for hospitals is to find out what it will take for staff to trust hospitals. What will it take to get a nurse to report an adverse event he or she was involved in? Or demand a time out be performed to a surgeon?

Such a large shift in thinking might take time, as we all k now in decades past healthcare has been notoriously punitive. Still, perhaps we should start by asking our staff what it will take to earn their trust.After all, involving them has been the key to so many other instances of quality improvement success.

February 21, 2012 | Tami Swartz | Comments 0

You can’t improve without knowing what’s wrong

In the healthcare quality improvement field, there has been much talk about reporting errors, about a just culture, about using occurrence reporting data to implement quality improvement initiatives, and sharing results with staff. But it seems, according the latest Office of the Inspector General (OIG) report that many of you have probably seen, that hospitals aren’t cutting it.

In summary, the report concludes:

Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).

So, the majority of events go unreported because staff didn’t think the event qualified for the reporting system.

A list of common events is coming (via AHRQ and CMS), and it’s sure to be helpful. Until then, hospitals should work on what Occurrence Reporting: Building a Robust Problem Identification and Resolution Process author Ken Rohde calls this a reporting threshold.

“If your staff question whether they should report something, they are asking themselves a threshold question,” says Rohde. He advises the threshold to be either low or nonexistent.

“A good way to communicate a lower threshold is to tell staff: ‘If it was important enough for you to think about it or if it disrupted your day, then report it,’” says Rohde.

Though a higher reporting volume may require a more efficient screening process, more information about adverse events is usually better.

Here’s a quick tip sheet from Rohde’s best-selling book for improving your error reporting in your system: http://patientsafetymonitor.com/tools-library (starred, at the bottom, free for download).

January 09, 2012 | Tami Swartz | Comments 2

Texting while rounding :(

Everyone knows that texting while driving is dangerous—and illegal in many states. It’s obvious why: The driver gets distracted and takes his or her eyes–and mind–off the road.

But what about frontline care staff? Can they text on the floor? If so, when? Does your hospital have guidelines about this? Many hospitals are worried about the content of texts and other uses of social media, such as Facebook. They worry HIPAA will be violated. But a recent incident exposed on the AHRQ’s “morbidity and mortality rounds on the web” proves that texting while rounding, no matter what the content, can prove distracting and near disastrous, especially when smartphones serve as both a hospital tool for ordering medication and the portal to a resident’s social life.

The case involves a resident and intern who discussed the plan of care for a patient while rounding. An attending told the resident to stop warfarin until an echocardiogram of the heart could be taken.

Here’s a key part to this case: The hospital’s CPOE system allows providers to enter orders in the system through smartphones, a convenient option that allows real-time ordering. The resident began submitting the orders on her smartphone. Then she got a text about an upcoming party. The resident chose to respond to the text. The order for the patient was never completed, and the patient continued to receive warfarin for three days. Because of the CPOE system, no one reviewed the medication list, and everyone thought the order for warfarin was stopped. Though not stated in the case, I’m sure at least some of them thought they actually saw the resident put through the order on her phone.

The problem was realized when the patient developed shortness of breath, tachycardia, and hypotension from blood thinning. He needed emergency open heart surgery, and was in the hospital for three weeks before being discharged.

For those who use smartphones, it’s incredibly easy to understand how this happened. Once the decision is made to view a text (or if it pops up automatically), you are interrupted. Your screen is filled with only this text. You reply. Thoughts are now with that conversation, and there is nothing to remind you that another application is open, that you never finished the task.

Mobile devices and social media have brought personal lives into the workplace. However, when the finished product is a healthy patient, we need stringent rules for such devices. A personal phone call regarding a party would never be allowed on rounds. Nor would her friends, decked in party hats, be allowed to show up in person to disrupt her to find out whether she’s coming. But these scenarios are very similar to texting; you are communicating with others outside of your work, which brings thoughts elsewhere. Forget call lights and pages, this is the ultimate distraction because it’s intimate, private, easily hidden, and has absolutely nothing to do with work. Despite what we want to believe, no one can do two things at once, no matter how many apps you have.

It may be time to consider whether it makes sense to allow work and play to be conducted on the same device in healthcare. Mobile technology has many benefits, but perhaps the mobile devices staff use in the hospital to submit orders should be different than the devices they use to manage their social life. Many workplaces see this as a matter of etiquette. They trust employees to limit personal use of mobile devices during work hours. However, when you’re talking about the difference between sending a smiley face to confirm you’re attending tomorrow night’s party and submitting orders to stop an anticoagulant for a patient in danger of excessive blood thinning, you’re talking about much more than etiquette.

What do you think? What are your hospital’s guidelines on this?

December 13, 2011 | Tami Swartz | Comments 0

Who’s the boss?

Last month, I had the personal experience of experiencing the frustration that happens when a care plan for a patient needs to be coordinated across specialties—over a weekend, nonetheless. Just as importantly, the care plan needed to be communicated to the patient. Neither, in my opinion, was accomplished.

Within the first 24 hours of care, I could tell the patient felt communication among caregivers lacked. Trying to nip the problem in the bud, I called a patient grievance line just to ensure the team of caregivers coordinated within a reasonable amount of time. But apparently, grievances must be by the patient, and must be from 9am-5pm. This only led to an irate voicemail left by yours truly. I received a call back first thing the next morning. I explained that I didn’t want to “report a physician,” as suggested. I wanted to report a concern about care. To me, there is a big difference. Why, at that moment, would I care about reporting a physician? The patient was my concern. I decided that we would let things pan out, and to call her if needed.

I handed the number to the patient and told him to call if he felt he needed help getting his care team to work as a, uh, team.

Getting the gastroenterologist in the room, and getting him to speak to his team and the patient’s cardiologist, seemed as easy as moving mountains. The patient stayed trapped to a bed in a large academic teaching hospital, frustrated, afraid to sleep and miss his one and only chance to speak to someone. But eventually, he was told two tests would be run that night and that the results would direct a plan of care. Finally, a plan to a plan. He did not call the grievance line.

The only problem was, one of those tests never happened. Despite voicing concerns, the test did not happen the next day either. Nurses came in and out, speculating on what physicians might be thinking or doing about the patient. It was a Friday, and I became increasingly worried that this routine test would be pushed until Monday. But, the patient was told the physician would be in to see him that day—a ray of light. This would surely clear things up. Maybe the test wasn’t necessary.

When a resident came in after dinnertime Friday night, who was not the lead physician the patient was told he’d see, it was too little too late. Where was the test? (No answer.) Where was the physician? (No good answer.) And most frustratingly, what was a plan of care? (Vague, unclear answer.) Attention to the case, and answers to these questions, came only after demands and threats were made by the on-painkillers patient and his tired-from-sitting-in-a-hospital-all day-without-answers family.

Only when those threats and demands were made, was the patient told of any plan—which was now “wait until Monday so we can do that test.” He was discharged on Tuesday. If there was another reason (other than that test) for keeping him three extra days, it was never shared with the patient.

Though the patient’s condition did not deteriorate rapidly at any point, there was nothing more I wanted than to call a rapid response team just simply to get this care “team” together to talk about the case, a conversation I would bet money on never occurred.

So my question is, how do you ensure the patient doesn’t get lost? The AHRQ report Communication Failure—Who’s in Charge? sheds some light on a different case with somewhat similar problems—mainly, who communicates to who, what do they communicate, and who is in charge? In this case, the situation was much more urgent, and the result sadly much more serious. The patient died.

Is the problem that different specialties have different methods of management? Is the problem still handoffs? Is it a question of who is in charge, not just of care, but of communication? Or, seeing that the patient ultimately was not in danger, was it simply a matter of failing to manage the patient’s expectations? Was he expecting too much action for a large, busy healthcare system?

Please, let me know what you think below.

October 11, 2011 | Tami Swartz | Comments 0

Challenging the ‘business as usual’ patient interaction

Catherine Hinz, our monthly columnist for Patient Safety Monitor Journal, often brings new thoughts and ideas to those in quality and patient safety, and so I thought you may find this interesting.

Challenging the ‘business as usual’ patient interaction

I was recently out to a business lunch and had an amazing server who clearly delighted in the work she was doing. When a colleague complimented her service excellence, she replied, “I think of each table as a new experience.” She went on to describe her good fortune to work in an environment that appreciates her extroverted style.

I’ve been thinking about this woman’s positive attitude, but more so her philosophy and outlook about the work she does. Instead of viewing her job as routine, she engaged herself in her work with attentiveness and passion. It made me wonder how often our caregiving and leadership teams challenge the status quo of how routine care is delivered-not only for the sake of service excellence, but also for that of patient safety.

Let’s take the medication administration process as an example. The process typically starts by obtaining the medications from the pharmacy or a dispensing cabinet, doing the prep work, and, depending on available technology, taking steps to scan the medication barcodes and reconcile physician orders. The nurse will then administer the medications, hopefully coupled with an explanation of possible side effects to the patient and their loved ones. As it stands today, this practice seems to me to be one-sided and anything but engaging.

As health reform introduces new rewards and penalties for service excellence, especially for interactions surrounding medication delivery, does this particular routine process and others like it provide a golden opportunity for redesign? I believe it does. Perhaps we would be inspired to do things differently if we asked ourselves questions such as, “If Walt Disney had to administer a medication, how would he do it?” (In fact, Disney is capitalizing on its universal success and offering service excellence programming tailored for healthcare professionals through the Disney Institute.) Or maybe, “If Richard Branson, visionary chairman of Virgin Group, was inserting an IV, how would he engage the patient?” He certainly has changed the flying experience for consumers through unique aircraft and travel experience strategies. Or even, “What if WalMart® or Nordstrom’s had stations for medications, what would they look like?”

How does your hospital’s patient safety culture compare?

The Agency for Healthcare Research and Quality (AHRQ) has released Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. You can compare your hospital’s culture to 1,032 others in the U.S.

The survey was developed in 2004 to help hospitals assess their patient safety culture in 2004. The first benchmarking database was released in 2007 and included data from 382 hospitals.

Out of 472,397 staff working in these hospitals, teamwork within units had the most positive response (80%). Most also rated their hospital well in regard to managers listening to input from staff about patient safety and praising staff for following patient safety protocol (75%).

Staff did not rate their hospitals as well when it came to creating a nonpunitive response to error (44%), or implementing safe handoffs and transitions (45%).

Interestingly, 54% of respondents, on average, reported no adverse events in their hospital over the past year, an indication of possible underreporting.

The survey results urge me to do a bit of promoting of two books I truly think readers might have interest in:

First is Creating a Just Culture: A Nurse Leader’s Guide. The authors go into detail about what it actually takes to create a nonpunitive culture (hint: it’s not easy, but in time it can be done!). It’s an easy read that provides sample incident reporting policies, a sample just culture principles document, case scenarios, advice on disclosure, and more.

Second is Occurrence Reporting: Building a Robust Problem Identification and Resolution Process. What’s to love about this book? It takes the overwhelming process of event reporting and whittles it down, giving advice on which events to collect, which events to focus on, how to implement a system that staff actually use, how to make sure actual, quality improvement actions come out of all the work, etc.

Okay, I’ve said my piece. Now say yours: Does this report surprise you? Does your hospital leadership let you know where you stand, comparatively? What’s holding up nonpunitive culture and event reporting? Share your thoughts below.

July 05, 2011 | Tami Swartz | Comments 0

Readmissions reduction program to be adopted by hundreds of others

Reducing readmissions is certainly on the forefront of the future of healthcare. Through Partnership for Patients, we know the government is working to reduce hospital readmissions by 20% by 2013 by granting up to $500,000 toward the effort.

We also know that The Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposed rule would establish a new hospital readmission reduction program, under which hospitals with excessive readmissions within a 30-day period would receive reduced payments. The proposed rule applies to discharges after October 1, 2012 and applicable conditions include myocardial infarction, heart failure, and pneumonia—based on the current inpatient quality reporting measures.

So the ducks are in a row and now the work begins. A few years ago, in the June 2009 issue of Briefings on Patient Safety (now Patient Safety Monitor Journal), we explored a program called Project RED (Re-Engineered Discharge), which has actually been evolving since 2003 (according to a timeline on its website). The program now involves a thorough discharge process and allows patients to use a virtual education program (a computer-animated “Nurse Louise”) to better understand their discharge plan.

Joint Commission Resources has received funding from the Agency for Healthcare Research and Quality to help 250 hospitals adopt Project RED, which helped cut readmission at Boston University Medical Center by 30% in a 2008 study, reports the Wall Street Journal, which has has posted two separate blogs on readmissions, found here and here.

Hospitals can currently download tools from Project RED by visiting the website.

June 07, 2011 | Tami Swartz | Comments 0

Organizational issues for prevention of HAIs and the systemic nature of the problem

Healthcare-associated infections are no doubt a focal point of every patient safety professional. This month’s column by Catherine Hinz in Patient Safety Monitor Journal explores how organizations might lower their rates.

The following is an excerpt of a Patient Safety Monitor Journal column that explores patient safety from the perspective of a newcomer to the patient safety field. Columnist Catherine Hinz, MHA, currently works at PatientSafe Solutions, Inc. Previously, she was the patient safety lead at HealthEast Care System in St. Paul, MN, worked for seven years as an ED health unit coordinator, and has completed a patient safety internship with the Agency for Healthcare Research and Quality.

You can’t read anything about patient safety and quality or health reform without running into the topic of healthcare-associated infections (HAI). The issue tops a list of priorities for many health-related government institutions (e.g., Agency for Healthcare Research & Quality, CMS), nonprofit organizations (e.g., IHI, National Patient Safety Foundation), current research and publications, and patient advocacy groups. Popular media has recently been ¬shining a light on the problem as well as the use of tools, such as checklists, as part of the solution for prevention.

Intense process improvement and research efforts in Michigan ICUs have gained a lot of ¬attention for demonstrating significant reductions (and subsequent sustainability of those reductions) of HAIs. The work of Peter Pronovost, Atul Gawande, and others is quickly gaining traction. One of the troubling aspects of HAIs is the systemic nature of how they occur, the complex contributing factors, and the organizational issues of detecting and preventing them (not to mention their breadth of type and severity). HAIs are a problem wrought with cost and reimbursement pressures, challenges in allocating organizational resources, and care team performance factors.

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

April 13, 2011 | Tami Swartz | Comments 0