All Entries in the "Joint Commission" Category
CAUTIs still a problem
Bit of a plug, but I think my visitors will find HCPro’s webcast on CAUTIs (catheter-associated urinary tract infections) extremely relevant, especially as CAUTIs cause 35% of all hospital-acquired infections every year, with 38,000 patient infections, and costing hospitals $400 million a year, according to an October 2011 National Quality Forum’s Partnership for Patients/ National Priorities Partnership webinar.
And don’t forget that The Joint Commission named CAUTIs a National Patient Safety Goal to be fully implemented by 2013. The Partnership for Patients also aims to reduce preventable CAUTIs by 50% by 2013.
So join nurse practitioner Mikel Gray, PhD, PNP, FNP, CUNP CCCN, FAANP, FAAN, and chief of infection prevention and 2012 APIC conference speaker Brian Koll, MD, FACP, FIDSA, for a live presentation of proven methods on CAUTI reduction, including how Beth Israel Medical Center reduced the number of CAUTIs by 83% using proven organization-wide catheter best practices such as evidence-based practice, staff education, daily need assessments, multidisciplinary teamwork, monitoring, and root-cause analysis. You’ll also get best practices to educate and train your entire staff.
Just a note that now, you can buy the live audio and download the on demand version free.
The push and pull of quality initiatives
Sometimes quality can be a bit like a game of whack-a-mole. As you try to improve in one area, another area falls off the radar, gets worse, and you winding up shifting resources every quarter, back and forth in a reaction to data. Like whack-a-mole, you keep trying to hit moving targets.
But perhaps there’s more happening behind the scenes than you think. Maybe it’s more like tug-of-war: As you pull at one quality initiative, you inadvertently cause the another one to suffer. This has more of an effect than simply shifting focus and resources away. For example: A hospital tries to reduce falls, and accidentally winds up increasing catheter-associated urinary tract infections because instead of working on mobility, staff are keeping patients in bed with catheters to ensure they don’t fall on their way to the bathrooms.
Now, here’s another one: Longer length of stay may actually reduce readmissions. As hospitals work to reduce length of stay, are they shooting themselves in the foot? An international study of 7,000 patients showed a significant relationship to length of stay and the probability of a readmission in heart failure patients. Although it’s unclear what about the extra time helps, it could be a number of things: better clinical stability, better discharge planning and patient education, etc.
My previous post that discussed how standardized quality measures might actually hurt perception of quality care is yet another example of this tug-of-war.
If one initiative hurts another, you might want to throw your hands up in the air and be done with it. But many of these complex issues have solutions, though the solutions are tough and often require more resources, especially up front: Working on mobility, which cuts falls and the need for catheters, spends nurses’ time–one of the most valuable items you can spend. Perception of care—if the care is actually good—can often be raised with better communication (e.g., explaining to a patient why a quality measure is implemented), but this again takes the time of nurses and physicians. Though harder to implement, these solutions do not harm other initiatives; instead, they coexist toward the same goal of improving patient health. Separate quality initiatives cannot be conducted in a vacuum. They all relate to one another, because they all relate to patient care.
Stop fighting these separate quality improvement battles that waste resources. (Remember, the problem might be worse than just an inefficient war strategy; one winning battle may actually be causing a loss somewhere else. And we want to fight a war against patient harm and inefficient healthcare, not each other.) Hospitals need leaders who have the ability to step back, see all the pieces of the puzzle, and take the time to think critically to coordinate these efforts toward the same goal. A well thought-out, truly patient-centered strategy may take more time and planning, but will use fewer resources and achieve better results. Work smarter, not harder!
What’s new with AHAP: We want your surveyor stories
Are you a member of AHAP (Association for Healthcare Accreditation Professionals)? No? Interested?
Whether you are or not, AHAP is running a fun little contest I thought I’d share:
Has a Joint Commission surveyor ever called you by the wrong name? Did you accidentally fumble your words while presenting the findings of your mock tracer to leadership? Or maybe you answered a series of survey questions perfectly only to find out you had a huge piece of spinach in your teeth the whole time.
We want to hear about it! If you have a funny or awkward story to tell involving a surveyor or survey prep activity that you’d like to share with your peers, please e-mail associate director Jackie Beck at jbeck@hcpro.com with your story. We’ll feature the collection of stories in our next issue of the AHAP Insider, a quarterly membership journal published exclusively for AHAP members.
It is our promise that your stories will be 100% anonymous.
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
AHAP Conference opportunities
The Association for Healthcare Accreditation Professionals (AHAP) is hosting its 6th Annual Conference May 10, 2012 – May 11, 2012 in Orlando, FL. It offers so many amazing opportunities to save money, get expert advice, and show off your hospital a bit. I should also note that if you’re one of the first 50 paid registrants you’ll receive a free full-day ticket to any Walt Disney World® Theme Park*! Download the online brochure to learn more.
So what is it and why am I talking about it? The 6th Annual AHAP Conference brings together survey professionals from across the country to discuss solutions and best practices to achieve continual survey readiness and compliance with ever-changing standards and regulations.
What are the opportunities?
- Accreditation Specialist Boot Camp.
- Presentation of the first annual Accreditation Professional of the Year award
- Unique roundtable discussion with representatives from HFAP, DNV, the American Heart Association, and The Joint Commission
- Exciting new poster event featuring research and best practices from your peers. Find out how to submit a poster and save 50% on your registration.
- Learn about:
- Regulatory changes in 2012 and top RFIs: Staying ahead of The Joint Commission and CMS
- What accreditation professionals need to know about Life Safety Code®
- To certify or not to certify? Seeking The Joint Commission disease-specific certifications
- Making the switch from The Joint Commission to DNV: One hospital’s experience with both surveys
- Understanding tracer methodology and the survey process
- A practical approach to policy management
- Suicide Risk: Solutions to rapid assessment, Environment of Care, and documentation issues
- Understanding hospital recognition programs for optimal cardiovascular and stroke care
*Offer ends March 8th.
Providence-based play tackles medical errors
Providence has dealt with its share of medical errors. Perhaps as a result, the issue is moving outside the health system and into artistic realm in the form of Love Alone, presented by the Trinity Reparatory Company.
Written by Deborah Salem Smith, whose partner is a physician, the play dives into the emotional turmoil of what happens after patient Susan dies on the operating table. The emotions of both family and physician are explored, along with the disconnect between hospital protocol toward the shocked and grieving family.
In a short audio recording of a pivotal scene from the play, the physician assures Susan’s daughter that she is a competent doctor:
“I’m not a monster. I was doing everything I could to save her. I’m a good doctor. Look at me, please. I’m a good doctor.”
“So what?”
“So what?”
“You’re a good doctor. I’m a good daughter.”
Medical-based dramas have always been popular, but is this a bringing things a step further? Do you think medical errors are being brought to the forefront of the general public would perhaps have a positive effect on hospitals, especially in regards to diminishing a punitive culture?
Share your thoughts below.
Visitation rights and restrictions
I wanted to share with you an opportunity to learn more about patient visitation rights and restrictions because who can and cannot visit a patient while he or she is in the hospital has changed in recent years.
Heavily covered in national news, new federal mandates give patients more authority and autonomy to decide who may visit them as they try to recover. To align with these mandates, The Joint Commission updated two Elements of Performance (EP) under its Patient Rights (RI) chapter. These changes were announced July 13, 2011, and were retroactively effective as of July 1, 2011.
Both changes were made under standard RI.01.01.01, which states that the hospital must promote, respect, and promote patient rights. EP 1 requires hospitals to have written policies on patient rights, and a new note for hospitals that use Joint Commission accreditation for deemed status, says the EP now requires hospitals address in those policies visitation rights procedures, such as restrictions or limitations (including those clinically necessary).
It’s safe to say that any hospital that either accidentally or purposely infringes on those rights is going to end up big trouble. And it’s not just implementing policy–educating patients to be empowered to know their rights, including their rights regarding visitation, is critical. It also enhances patient experience and satisfaction, another area laying heavy on the minds of quality professionals these days as reimbursement is now partially tied to HCAHPS scores.
Wouldn’t it be nice to have a patient safety expert and veteran guide you through this change? To help you do your job in ensuring your organization is compliant with federal and Joint Commission standards? Join Barbara Balik, RN, MS, EdD, senior faculty at the Institute for Healthcare Improvement (IHI), principal of Common Fire Healthcare Consulting, and a member of the National Patient Safety Foundation Board of Governors, for a January 26 webcast to learn what must be done.
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.
Joint Commission suggests “strategic caffeine consumption” as part of Alert
The Joint Commission issued a Sentinel Event Alert on healthcare worker fatigue and its effect on patient safety on December 14, 2011.
Of course, fatigue is a serious and prominent problem among healthcare workers. According to the Alert, a November 2007 issue of The Joint Commission Journal on Quality and Patient Safety found that nurses who work more than 12-hour shifts and residents working recurrent 24-hour shifts had three times more fatigue-related preventable adverse events.
So what can be done?
The Joint Commission recommends reviewing off-shift hours, consecutive shifts, and staffing levels, and involving frontline staff in creating practical solutions. It also advised taking a close look at handoffs, perhaps even putting in some methods during at-risk handoff times when staff may be particularly tired, relying on teamwork during at-risk time periods, and educating staff on good sleep habits.
Notably, The Joint Commission also wants hospitals to consider fatigue as a possible factor when reviewing adverse events—do you do this currently? When reporting an event, do you ensure to note fatigue if it was a potential factor? Such data would be interesting to understand how to improve healthcare across the nation.
Also of note, The Joint Commission officially asks hospitals to create a “fatigue management plan” which should include “strategic caffeine consumption and short naps.”
Pretty practical advice. If you’re looking for some evidence-based method of drinking coffee and napping, you might want to take a look at a recent report that says drinking a cup of coffee, then taking a 15-minute nap, is the best way to go. This way, you wake up just as the caffeine starts to kick in. Well, that’s the idea anyway.
Drink up and sleep tight!
Joint Commission proposes new goal to prevent harm, waste
Last week, The Joint Commission announced it was proposing a new National Patient Safety Goal. The goal would address overuse of treatments, procedures, and tests.
The idea is that if evidence shows no benefit, you are exposing a patient to only potential harm by giving an unnecessary test or treatment.
The proposed goal would have hospitals implement a program to address the issue by selecting a treatment or test to focus on. Pick something, evaluate it, monitor it, and implement new methods to decrease any overuse that’s found.
I find this proposed goal an interesting one. The other goals impose measures to decrease the risk of harm, but the risk here seems more minimal or evidence-based. I don’t mean to say there aren’t risks, I’ve discussed the risks of too much radiation over time, but there is no denying this goal would also reduce waste and cost, and those effects will be much easier to measure. Was this designed to back up physicians who don’t order a test for everything for fear of malpractice suits? Would this help if a physician was charged with negligence for not ordering a test that was not necessary but, as it turns out, would have discovered something?
What do you think of the proposed goal? Post your comments below.
And by the way, the The Joint Commission is taking comments until January 24!
