All Entries in the "quality improvement" Category
The human side of patient safety
An article appearing in the New York Times earlier this week addresses an interesting view on the world on patient safety: with so much focus on preventing adverse events, treating patients as human beings has fallen by the wayside. The author contends that in an attempt to fill out the right forms, ensure the correct tests have been ordered, and make sure all regulations have been complied with to get patients back on their feet, healthcare workers are more interested in “satisfying the system” than treating patients.
I wonder if this idea is true and if so, is there anything that can be done to both provide care in a manner that is ‘by the book’ and take the time to get to know patients, and in doing so, help them heal? I think there is some truth to the opinion but I also think that patients are better off today (patient safety-wise) than they were ten or 15 years ago. Although patients may not know personally their physicians as well as they have in the past, they can be sure that measures are in place at their hospitals to help prevent them from acquiring certain infections, or encourage proper medication labeling.
What are your thoughts on the topic?
Press Ganey report: Patient satisfaction increasing across the country
Patient satisfaction is on the rise, according to Press Ganey’s annual Hospital Pulse Report. The report surveyed nearly 3 million patients about their experiences at more than 2,000 hospitals nationwide during 2008. Overall, patient satisfaction has steadily increased since 2003, with 85% of those surveyed reporting satisfaction with care in October 2008. Additionally, Press Ganey found that more patients than ever before (a 1.96 % increase) were likely to recommend the facility where they had received care to a friend. The area that most affects how patients rate their care corresponds to communication—how staff members communicate with patients, especially when patients express concerns or complaints during their stays.
The report identifies as a catalyst for quality improvement that hospitals began publicly reporting their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data in March 2008, and in turn increased patient satisfaction scores. The scores are available on www.hospitalcompare.hhs.gov. Some members of the public are turning to the site to find information for comparing inpatient care in their area. However, according to the report, the larger effect has been that providers are aware of their own and their competitors’ scores, and are putting more effort into delivering patient-centered care as a result.
Have you seen a change in how services are offered, or how your day-to-day shifts occur due to some of the focus areas on the HCAHPS survey?
Diagnosis errors: No easy fix
Physicians are responsible forone of the most complicated and important decisions in medicine: the diagnosis. Any further treatment plan rides on this diagnosis, and it may not be surprising that diagnosis error is now being looked at as a significant percentage of all medical errors. A report published in the November 9 Archives of Internal Medicine showed that anonymously, 310 physicians revealed 583 diagnosis errors, of which 44% were related to lab and radiology testing errors, including test ordering, test performance, and clinician processing.
But why do physicians make diagnosis errors? The answer lies in both cognitive processes and they systemic factors that influence the way in which a medical decision is made.
I co-wrote an article for HealthLeaders Media today about diagnosis error. The idea came from listening to one of theInstitute for Healthcare Improvement’s recent WIHI programs on the topic, which, if you haven’t listened in to yet this year, are truly worth catching. There is a great dialogue between the expert speakers and the audience because they address many of the questions that listeners bring up while virtually “chatting” with one another. Anyway, the WIHI featured Gordon Schiff, MD, associate director at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston and Pat Croskerry, MD, PhD, professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia. Both of these men are leaders in the field of diagnosis error and recently helped plan the second annual conference on the topic. Schiff is an author on the aforementioned Archives of Internal Medicine report.
Both men discussed that diagnosis errors occur more often than they are reported, and they have not been given as much attention to errors like medication errors, falls, and other tangible errors. This is because of the underreporting and also because it is harder to make the case that someone’s thinking was the cause of an error. In fact, diagnosis errors are partially the result of a cognitive impairment and partially the result of systemic failures—meaning the hospital system sets physicians up for failure.
I find the topic fascinating, what are your thoughts? The idea that people create certain thinking biases, often without even knowing it, and that that bias can factor into a decision that may determine the course of a patient’s treatment, even if it is the wrong treatment—it is a scary thought, but interesting nonetheless.
I suggest checking out the HealthLeaders article, please let me know of any feedback!
HHS awards $17 million to projects dedicated to preventing healthcare-associated infections
Last week the Department of Health and Human Services (HHS) announced it awarded $17 million to specific projects in the name of fighting healthcare-associated infections (HAI). Of the total award, $8 million will specifically fund the national expansion of the Keystone Project, a program that successfully reduced the rate of central line-associated bloodstream infections (CLABSI) in Michigan hospitals within 18 months, saving 1,500 lives. The coordination of the program in all 50 states is being run through the American Hospital Association’s Health Research & Educational Trust. Last year, the Agency for Healthcare Research and Quality expanded the Keystone Project to 10 states.
The remaining $9 million will be spent on strategies to reduce other HAIs. In collaboration with the Centers for Disease Control and Prevention, HHS will fund projects that will investigate methods for:
- Reducing Clostridium difficile infections through a regional hospital collaborative.
- Reducing the overuse of antibiotics by primary care clinicians treating patients in ambulatory and long-term care settings.
- Evaluating two ways to eliminate MRSA in ICUs.
- Improving the measurement of the risk of infections after surgery.
- Identifying national-, regional- and state-level rates of HAIs that are acquired in the acute care setting.
- Reducing infections caused by Klebsiella pneumoniae Carbapenemase-producing organisms by applying recently developed recommendations from CDC’s Healthcare Infection Control Practices Advisory Committee.
- Standardizing antibiotic use in long-term care settings (two projects).
- Implementing teamwork principles for frontline health care providers.
I see the Keystone Project as one of the major successes in recent years in the patient safety world. Not only does it reduce the chance for patient harm from an HAI, but it reduces the excessive amount of money that is spent on HAIs each year—a $6.5 billion expenditure. There are lots of patient safety standards out there, but this project has guided facilities in lowering CLABSI rates by using succinct steps with an emphasis on building a culture of safety and top-down leadership engagement.
Has your hospital become involved yet in this project?
NCQA says quality of U.S. healthcare stagnant
After a decade of improvement, The National Committee for Quality Assurance has said that during last year the quality of healthcare was at a standstill in its annual State of Healthcare Quality Report. The study also found that there no links between higher spending and better healthcare outcomes. The quality data that the report is based off of was submitted by 979 health plans across the country that collectively cover 116 million Americans, which is a 9 percent increase over 2008. The health plans use the HEDIS measures, which stands for Healthcare Effectiveness Data and Information Set.
Some of the trouble spots from this year’s report include the following statistics:
- Only 46.4% of people taking anti-depressant drugs are monitored by their physicians;
- 34.1% of children prescribed medications for attention deficit hyperactivity disorder (ADHD) are seeing a doctor for follow-up care
- Half of patients previously hospitalized for mental illness see a physician for a follow-up visit
- 45.3% of people are receiving colon cancer screening at the appropriate age
- Only 42.6% of patients with alcohol or drug dependency are entering into treatment
There was also an increase in the overuse of medical imaging for back pain and breast cancer.
I think the most striking point to come out of the report is the NCQA’s estimation that if all health plans were able to perform at the level of the top 10 percent of plans, the U.S. would avoid up to 115,000 thousand deaths and save at least $12 billion in medical costs and lost productivity every year.
In light of this report, the NCQA asked Congress to include language about quality improvement in its final bill.
Does any of this surprise you? I was mostly shocked to hear that this was the first year that the report showed little change in quality improvement.
Mistake-proofing and its relation to process management
One of my colleagues at HealthLeaders Media, Cheryl Clark, wrote this columnyesterday about making things fail-proof–anything really. She starts out by giving the example of how her fancy refrigerator beeps when the doors have been open for too long, reminding owners to shut the doors. She used that analogy to draw some comparisons to many of the mistake-proofing devices in healthcare, and how we are now really are coming into the age of really predicting how an error might occur and designing systems better to prevent those errors.
I’ve been reading up a lot lately on process management and even when speaking with people in the healthcare industry, there seems to be a lot of momentum behind the Lean and Six Sigma, the notion of ridding our systems of waste if we truly want them to succeed–and be the easiest and most logical way of doing things. Designing processes so that they are “mistake-proof” certainly ties in.
I suggest reading her column, it’s a good one. Do you see a larger waste reduction and process improvement effort taking place at your facility?
Should physicians be required to take cultural competency courses?
It’s widely reported that racial and ethnic minorities receive less comprehensive healthcare than white patients. Some states have tried to address this by requiring physicians to undergo cultural competency training. Both California and New Jersey require such training and Maryland strongly recommends it. Nine other states are considering requiring some sort of cultural competency training.
However, an article in this week’s American Medical News points out that many physicians are opposed to such legislation mainly because it’s another topic around which they have to be educated. California and New Jersey have taken different approaches to mandating cultural competency training. California requires continuing medical education (CME) courses to contain information that is culturally and clinically relevant. New Jersey requires a specific amount of CME credits that must be earned in courses around cultural content as defined by the state medical board.
Some physicians opposed to the increased amount of cultural competence training wonder when the CME requirements will end and say that some requirements may not line up with what is clinically relevant. On the flip side, other physicians who are for such requirements say that without these mandates, most physicians would ignore the topic completely.
What does your state require? Do you think topic-specific CME mandates such as cultural competence are necessary for physicians? What about other healthcare workers?
October celebrates Health Literacy Month, National Healthcare Quality Week
The month of October brings us two health-related events to celebrate: Health Literacy Month and National Healthcare Quality Week (October 18-24). Both events give healthcare workers and their organizations a chance to think about current practices and how to improve in the name of patient safety.
Health Literacy Month, which was started by Helen Osborne, MEd, OTR/L, a health literacy consultant, in 1999. This year’s theme is “Why Health Literacy Matters: Sharing Our Stories in Words, Pictures, and Sound” and is accompanied by an informative Web site (www.healthliteracymonth.org). Each day during the month of October a new health literacy “story” is added to the “stories section of the Web site. One of these highlights a couple of songs sung by Mache Seibel, MD, in honor of the month. You can find more of his songs at the Web site www.healthrock.com. Additionally, the Health Literacy site provides different resources and materials for the month.
National Healthcare Quality Week (NHQW) is being observed next week and the National Association for Healthcare Quality’s (NAHQ) Web sitecontains news about continuing education opportunities and events in honor of the week. The time is meant to highlight those healthcare workers whose quality work influences patient outcomes for the better. It also provides suggestions for ways that healthcare facilities can promote and publicize NHQW or any NHQW-related events being put on in the organization or larger community.
Are any of your facilities observing Health Literacy Month or National Healthcare Quality Week? What has your hospital done?
The sleep factor: Do less tired physicians deliver safer care?
The debate on whether reducing the number of hours that graduate medical students can work consecutively, as well as per week, has had any effect on the safety of patient care continues, reports American Medical News. Last year the Institute of Medicine made even further recommendations for reducing the number of hours that residents can work, based on sleep science. Those suggestions have yet to be implemented. However, there is evidence both for and against further reducing the amount of hours that residents can work.
Since 2003, residents are allowed to work no more than 80 hours each work week. However, each time residents’ shifts are over, they must hand their patients off to new residents. More handoffs often lead to an increase in poor patient safety outcomes. However, tired residents also may not able to make appropriate decisions regarding patient care. Sleep deprivation affects each person differently. Additionally, it’s difficult to truly measure patient safety and what may affect it.
To read more from American Medical News, click here. Has your facility had any open discussions regarding resident hours?
The role of accountability in a culture of safety
Two well-known names in the patient safety field, Robert Wachter, MD, professor and associate chairman of the department of medicine at the University of California, San Francisco, and Peter Pronovost, MD, PhD, medical director for the Johns Hopkins Center for Innovation in Quality Patient Care, have published an article in the New England Journal of Medicine (NEJM) about the need to make accountability a larger part of the discussion when it comes to patient safety and a no-blame culture. The whole patient safety movement was set in motion ten years ago with the publication of the Institute of Medicine’s To Err is Humanreport. Wachter and Pronovost say that the industry has come a long way since then, and important steps have been taken in the name of patient safety.
However, it’s time to move past simply acknowledging that the majority of adverse events are the result of human factors, not malicious intent, say Wachter and Pronovost. It’s time that hospital leaders take responsibility for those staff members who routinely fail to perform simple safety checks and actions that would prevent adverse events from occurring. In Wachter’s most recent blog post on his blog “Wachter’s World”, he discusses how he and Pronovost are expecting a backlash from the field for asking for more accountability in the patient safety world. It is time to ask for more from leaders and caregivers to do simple things like handwashing or using a checklist before surgery, though. If the steps have been taken to change how processes work and to emphasize a culture that acknowledges that most errors are systems-based accidents, and those errors continue to occur, it is time to move on and incorporate some amount of accountability into the system, say Wachter and Pronovost.
You can find the NEJM excerpt here, but Wachter’s posts a good summary on his blog if you don’ t have full access to the journal.
This is a topic that touches many emotions, and you may have differing opinions on the topic. I’d welcome any comments on the blog post or how your hospital has attempted to address the culture of safety.
