All Entries in the "HHS" 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
Dreaming the dream (by Peter Provonost)
Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy
Do Electronic Medical Records Save Money?
What’s in a Name? Safer care, for one.
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
Understanding HIT nationally and on the local front lines
Editor’s note: Columnist Catherine Hinz, MHA, works at PatientSafe Solutions, Inc. Previously, she served as the patient 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. The following is an excerpt from the January 2011 issue of Patient Safety Monitor Journal.
In the past couple of months, there have been numerous publications around health information technology (HIT) and patient safety. In November 2011, the Institute of Medicine (IOM) released its report, Health IT and Patient Safety: Building Safer Systems for Better Care. Right on its heels, the ECRI Institute released its top 10 list of technologies1 posing hazards to healthcare delivery. The list exposed dangerous medical devices and other technology systems. It was inclusive of everything from surgical fires to radiation therapy exposure risks. Through these reports and a variety of other publications in recent months, one of the primary take-home messages is clear: It is exceedingly difficult to prioritize where attention should be focused given the breadth and scope of HIT and its potential effects on patient safety and care delivery.
The work of the IOM was particularly interesting as its charge was threefold: summarize the existing knowledge of the effects of HIT on patient safety, make recommendations to the Department of Health and Human Services regarding specific actions that federal agencies should take to maximize safety, and make recommendations concerning how private actors can promote the safety of HIT-assisted care.2 The confluence of those goals came down to understanding the broader design of a safe system, of which HIT is a component part. Indeed, after our patients and caregivers, HIT could be the most significant part of care delivery going forward; it is permeating almost every aspect of the care delivery process.
1. www.ecri.org/Pages/default.aspx
2. www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx
Top 10 most read blogs posts from 2011
The new year is upon us. I thought before we dive into what’s to come for patient safety and quality in 2012, we might want to look back at 2011 and see what grabbed the attention of the patient safety world.I calculated the top ten by how many times each post was viewed. They are:
10. Joint Commission and FDA to focus on alarm fatigue
The Joint Commission (TJC) told The Boston Globe that it would work with the Food and Drug Administration (FDA) to make alarm fatigue—a worrisome problem in most hospitals—a priority.
9. Disruptive behavior, negligence, endangered patients, and millions of dollars
In August, settlements for old patient safety incidents in Boston and recent investigations in Dallas found more recent patient safety infarctions.
8. Rewarding near-miss reporting
This post discusses the importance–and challenge–of getting staff to report near misses, highlighting an example in one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards.
7. Joint Commission issues Sentinel Event Alert about workplace violence
The Joint Commission issued an alert on workplace violence in July 2010, but workplace violence was a hot enough topic to remain at the top in 2011.
My personal story of a patient and family whose anger and frustration grew as they faced an elusive plan of care and a care team who seemed uncommunicative.
5. New York Times article exposes radiation therapy errors
Another post that was published in 2010, but the issue of radiation errors and over-radiation remained hot in 2011. This post highlights one of the first articles in a series The New York Times ran from 2010 and into 2011 on radiation concerns.
4. Medication error prompts lawsuit for Massachusetts General Hospital
A medication error that resulted in a death and a lawsuit was met with a communicative response from hospital representatives, who said systematic improvements implemented since the error now help staff to avoid making similar errors.
3. Boston hospital admits three spinal surgery errors in two months
Published at the very end of 2010, this is yet another post on a hospital admitting to errors—this time surgical site errors—that did not need to happen. Beth Israel Deaconess Medical Center in Boston is in the spotlight after its surgeons made errors in three separate spinal operations in two months.
This post explaining how a resident failed to carry out an order on her mobile device after she was interrupted by a personal text messaged grabbed the attention of Patient Safety Blog readers. With this anecdote as proof, social media concerns have leaped from HIPAA violations to immediate threats to patient safety.
1. Can a video really help curb infections?
Perhaps videos are just more fun to watch. This post embedded the winning video of the APIC Infection Prevention Film Festival, which lays blame on frontline providers who fail to do everything they can to “do no harm—” in this case, failing to wash their hands.
What do you think? Any of your favorites missing? Let me know.
Can a video really help curb infections?
For quite some time now, hospitals have been creating and posting videos to create awareness about proper infection control protocol for patient caregivers (most focus on hand washing or vaccination).
The Association of Peri-operative Nurses (AORN) and 3M had a contest for nurses to submit videos on hand hygiene. The World Health Organization (WHO) posted a video on hand hygiene, and even the Department of Health and Human Services (HHS) had a contest for people to submit a public service announcement video for preventing flu. And of course, hospitals have created videos on their own to help raise awareness and educate.
Videos are fun—they have the power to get staff out of their daily routine, dancing in sterile hospital hallways and awkwardly singing their newly-crafted lyrics over popular hits (think “I’m Gonna Wash My Hands” or “Pump It”). I also assume that while the video is being made, hospital staff are more focused on proper patient safety protocol. But do videos actually make a lasting effect on ensuring staff wash their hands or get vaccinated?
After watching the APIC Infection Prevention Film Festival winner’s video, I think some might. About forty entries were submitted, but the winner takes a less gimmicky approach and “depicts the tragedy and irony of healthcare-associated infections, transforming the statistics into a story of a patient who gets an infection,” according to the APIC press release. In my opinion, the video directly connects the simple–and sometimes annoying–act of hand washing to the safety of the patient, leaving the responsibility square on the shoulders of healthcare professionals. In fact, I would go as far as to say that the fun, light-hearted videos may be downplaying the danger. But that’s just what I think; I’d love to hear what you think of the video posted below. Over dramatic? Right on target? Play movie critic and share your thoughts below.
Is Disney aiming to make your hospital the happiest place on earth?
The Disney Institute, which helps apply universal Disney best practices to other organizations, has announced a professional development program to help hospitals increase their patient satisfaction, called “Building a Culture of Healthcare Excellence.” The program focuses on helping managers create methods to ensure the entire patient experience–not just clinical outcomes–is a positive one.
With HCAHPS scores now publicly posted (and reimbursement tied to doing so), I expect we might see more of these programs in the future. But only the test of time will tell whether consumers actually use Hospital Compare, the public website that offers such data, to lead their decision-making when choosing hospitals. I imagine if they do visit the site, HCAHPS scores might the easier to understand than other publicly posted measures that are focused on clinical outcomes, and as a result, gain more attention.
I should note, however, that the site is certainly easier to navigate and understand than when first launched a few years ago. It’s now easier on the eyes, includes easier navigation, and offers patient help tools like maps to hospitals, an option to make hospitals “favorites,” and short descriptions of measures and what results might indicate.
Also, as mentioned in an earlier post, local news outlets have begun in earnest to inform the public that these data and resources are available to them.
Still, I suppose time will tell how this public reporting affects the way hospitals operate. Have you noticed patient satisfaction become a more highly prioritized goal in your organization? Where is it compared to five years ago? Where do you think it will be in five years from now? Share your thoughts below.
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.
HHS recognizes hospitals’ patient safety successes
The U.S. Department of Health and Human Services (HHS) recognized 37 hospital and healthcare facilities for their efforts to prevent – and eventually eliminate – healthcare-associated infections (HAIs), a leading cause of death in the United States.
The organizations are the first to be honored as part of a new national awards program to highlight successful and sustained efforts to prevent healthcare-associated infections, specifically infections in critical care settings. This initial set of awards recognizes critical care professionals and healthcare institutions for their efforts to reduce, and eventually eliminate, ventilator-associated pneumonia and bloodstream infections associated with central intravenous lines.
Awards were conferred on two levels, according to specific criteria tied to national standards. The “Outstanding Leadership Award” went to teams and organizations that sustained success in reaching their targets for 25 months or more. The “Sustained Improvement Award” recognizes teams that demonstrated consistent and sustained progress over an 18- to 24-month period.
CMS to invest $1 billion toward patient safety initiative
Health and Human Services Secretary Kathleen Sebelius, and Centers for Medicare & Medicaid Services (CMS) Administrator Donald Berwick, MD, along with other leaders in the healthcare and patient safety field announced today that the government will invest up to $1 billion toward Partnership for Patients, a new initiative that aims to reduce hospital-acquired conditions (HAC) by 40% and hospital readmissions by 20% by 2013.
The funding would be made available under the Affordable Care Act. More than 500 hospitals, as well as physician and nurses groups, consumer groups, and employers have pledged commitment to the initiative. The CMS Innovation Center will help hospitals adapt evidence-based care to prevent HACs and test different methods of improving care.
“We will provide hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals and hospitals to support their efforts to reduce harm,” said Berwick in an HHS press release.
Berwick appointed to head CMS
It is being widely reported this morning that Donald Berwick, MD, president and co-founder of the Institute for Healthcare Improvement, is receiving a recess appointment to the post of Centers for Medicare and Medicaid Services (CMS) administrator. Berwick, who was nominated for the position back in March, was supposed to have gone through a Senate confirmation hearing. However, President Obama has decided to use his power to bypass the Senate hearing and appoint Berwick.
There was expected to be some debate over Berwick’s ability to serve, mainly based on his previous expressions of admiration for Britain’s National Health Service, as well as some fear of his thoughts on rationing. However, many in the healthcare industry will see his appointment as a huge win. Berwick has been a patient safety and quality improvement advocate for years, and his leadership will be greatly valued at the CMS.
To read more about Berwick’s recess appointment, you can click here for the New York Times story.
HHS, AHRQ announce patient safety and medical liability grants
The Department of Health and Human Services (HHS) and the Agency for Healthcare Research and Quality (AHRQ) announced last Friday, June 11, that they had awarded $23 million in grants in the name of a patient safety and medical liability initiative, as well as $2 million for final contract evaluation. The grants are the product of an announcement on patient safety that President Barack Obama made in September 2009 to a joint session of Congress.
The initiative includes grant money for both demonstration and planning grants in the realm of patient safety and medical malpractice, as well as funding to review existing reforms of the medical liability system.
The demonstration grants, which were awarded in allotments of up to $3 million and total $19.7 million, were given for projects that will be implementing and evaluating evidence-based patient safety and medical malpractice projects. To view the full list of recipients of demonstration grants, click here.
The planning grants, which were awarded in allotments of up to $300,000 and total $3.5 million, allow recipients to do some detailed planning around patient safety and medical liability reform. To view the full list of recipients of planning grants, click here.
President Obama originally said that the initiative should award grants to programs that trial models for:
- Focusing on patient safety by reducing preventable injuries
- Encouraging better communication between doctors and patients
- Compensating patients quickly and fairly for medical injuries, but also discouraging frivolous lawsuits
- Reducing liability premiums
To find more about the initiative, visit www.ahrq.gov/qual/liability/
