All Entries in the "State regulations" Category
California penalizes 13 hospitals for putting health and safety of patients in ‘immediate jeopardy’
The California Department of Public Health (CDPH) has fined 13 hospitals for placing the health and safety of patients in immediate jeopardy on 16 occasions in 2008 and 2009. The facilities were fined because their noncompliance with state regulations “has caused, or was likely to cause, serious injury or death to patients,” according to a news release.
California changed its law on January 1, 2007, to allow for monetary fines for these types of incidents, which was $25,000 per incident through 2008. Starting on January 1, 2009, that amount rose to $50,000 for the first incident, $75,000 for the second, and $100,000 for the third and any subsequent incidents at the same facility. Most of the fines announced today are from 2009. The CDPH did not announce them until now because there is a review process that each incident must go through.
To find a complete list of the incidents for which facilities were fined, click here to find a story from HealthLeaders Media.
What do you think about these state charges for adverse events? Since the fines were imposed, the state has assessed $3.675 million in fines, which according to the CDPH, will be used to prevent the events from occurring in the future.
Minnesota reports zero deaths from patient falls in 2009
Minnesota has been collecting data around and publicly reporting adverse events in hospitals for the past six years. However, 2009 was the first year that officials could say that there were no deaths resulting from patient falls, normally one of the most common adverse events, reports the St. Paul Pioneer Press. The state’s Department of Health released yesterday its sixth annual public report called Adverse Health Events in Minnesota. During the previous year there were ten deaths resulting from patient falls. The state launched a campaign called “Safe from Falls” in 2007 that aimed to bring attention to why patient falls were occurring and implementing best practices to prevent them. It’s because of this (which continued running in 2009) and other techniques that individual hospitals employed that the falls rate dropped to 76 reported events, a decline of 20%. Additionally, falls did not become a reportable adverse event in Minnesota until 2007.
Although this milestone is one to be celebrated, state officials told the Pioneer Press that they were not losing sight of the fact that there were still four patient deaths resulting from adverse events, and many other instances of harm. In total, hospitals reported 301 adverse events between October 2008 and October 2009 (the period of time during which data are collected). This number represented a decline of 3.5% from the prior year.
Pressure ulcers remained the top most reported event. Officials said that for the first time they noticed pressure ulcers were a bigger problem for surgical patients, who perhaps have not had all of the precautions for skin breakdown provided. Additionally, the number of wrong-site, -patient, or-procedure surgeries increased, from 39 to 44. This is most likely because hospitals are doing a better job of recording when they occur during minor procedures, reports the Pioneer Press.
Check out the article here. Does your state publish as thorough a report as Minnesota about adverse events? Do you wish you state was as vigilant about collecting this type of data at all?
OIG says adverse event reporting systems vary by state, many are limited
The Office of Inspector General released a memorandum last week saying that there is no standardized method of collecting adverse event information nationally, and that state systems vary on how they define and manage this information. The memorandum, mandated by the Tax Relief and Health Care Act of 2006, outlined the results of an examination of adverse event reporting systems in 17 states, as well as eight Patient Safety Organizations, and CMS’ “never events.”
Of the states it looked at, seven states made more information public than others. These were Maryland, Massachusetts (which has two systems), Minnesota, New Jersey, Oregon, and Pennsylvania. There were three states that disclosed less than the first seven, including Colorado, Maine, and Rhode Island, and seven other states had no public disclosure included with their adverse event reporting systems. These were Utah, Florida, Nevada, New York, South Carolina, South Dakota, and Vermont.
Overall, even with the inclusion of Patient Safety Organizations (which were launched a year ago as the byproduct of the Patient Safety Act of 2005), there is a lack of one central database to which all hospitals can submit adverse event data. PSOs have created the Network of Patient Safety Databases, as well as a list of common formats for which adverse event data can be in, but that is just for PSOs and not for the state adverse event reporting systems. Additionally, the data coming from the NPSD will not be available for analysis until early 2011.
Do you live in a state that collects adverse event reporting data and if so, is that data made available to the public? Do you think the government needs to take on a larger role in creating a standardized set of adverse events around which data should be collected at each hospital?
You can read more analysis about the memorandum in this HealthLeaders Media article.
It’s been 10 Years since “To Err is Human”; has patient safety improved?
November 2009 marks the ten year anniversary since the Institute of Medicine (IOM) released its groundbreaking ‘To Err is Human’ report, bringing to light the staggering number of medical errors and resulting preventable deaths that occur in U.S. hospitals each year (that report put the number at 98,000). Since then, entire organizations have been formed, laws passed, and new ways of thinking incorporated into healthcare in an effort to reduce this number. There has been much positive change.
My colleague Cheryl Clark at HealthLeaders Media published this article today that spells out some of the areas in which the healthcare industry has improved patient safety, as well as some of the areas that could still use attention. Some of the bright spots: Certain states have taken the lead on creating tough reporting laws and mandating detailed incident reports. The Institute for Healthcare Improvement has helped thousands of hospitals collaborate with each other and use best practices to reduce patient harm with its various campaigns. Healthcare providers have joined together to decide on common medication labeling practices to reduce the number of medication errors. The CMS will no longer reimburse hospitals for specific adverse events. There’s been a detailed look at how the culture of an organization can drive the performance of its staff members. I’d also add to this list that the AHRQ has played a huge role in funding patient safety research and spurring projects in the name of healthcare quality.
However, many adverse events continue to occur, despite the efforts of many within healthcare. The article names surgical safety, infection control, and medication safety as three areas to which more attention needs to be paid if we want to take a 20-year look back and find that even more progress has been made. I think that along with these issues is the topic of how technology will come to effect them as well. How will EMRs/ CPOE effect infection control and monitoring?
Do you think that the industry has shown significant progress since the IOM report was issued 10 years ago?
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?
Preventing Rehospitalizations audio conference on Monday!
Thought I’d highlight a fantastic program HCPro is offering next Monday from 1pm-2:30pm. The audio conference, titled Preventing Rehospitalizations: Engage Your Hospital and Healthcare Community, features two knowledgeable speakers.
Amy E. Boutwell, MD, MPP, director of strategic improvement policy for the Institute for Healthcare Improvement (IHI) will lead off the audio conference discussing the many factors that contribute to high rates of rehospitalization, some ongoing projects that have been working to reduce the number of readmitted patients, and the IHI’s recently launched STAAR initiative, which stands for STate Action on Avoidable Rehospitalizations. The second speaker, Margaret Namie, RN, BSN, MPH, CPHQ, vice president of quality at Mercy Health Partners of Southwest Ohio, will share her insights into creating a program for preventing rehospitalizations in heart failure patients.
I hope you consider listening in, it is going to be a great audio conference.
For more information, or to register for the audio conference, click here.
New bills, initiatives push for greater patient involvement in care
Today’s patients want to have a greater involvement in their care. To that end, both the federal government and several states are pushing forth new legislation to ensure that patients are in fact taking on a more expanded role in the decision-making processes for their care. The Wall Street Journal Health Blog yesterday posted a great summary of some of the initiatives currently in the works. These include:
- The Empowering Patient Choices Act: This federal proposal would form a pilot project to study the effects of shared decision-making.
- Washington State 2007 Law: Requires the study of how cost effective using decision aids are.
- Pending Maine bill: Would require the use of decision aids for patient care as a means of reducing unnecessary care and improving the quality of medical care.
Has your facility taken any action to involve patients more in the decisions concerning their own care?
Sidney Zion, advocate for limiting doctors’ hours, dies
Writer Sidney Zion, whose daughter’s death at New York Hospital led him to successfully advocate for reforms in residents’ hours, passed away on Sunday at the age of 75. He had been suffering from bladder cancer, the New York Times reports.
Zion was a well-known New York journalist and author who raised concerns about the long hours and workloads of interns and residents after the death of his 18-year-old daughter Libby. A freshman at Bennington College, she had been admitted to New York Hospital on March 4, 1984, with fever, chills, and agitation. She had a history of despression and cocaine use, but her condition was not diagnosed and two interns gave her a painkiller and sedative after consulting by phone with a senior clinician. Libby died eight hours after admission.
Zion and his wife Elsa sued the hospital and four doctors, alleging gross negligence in their daughter’s death. The Zions also campaigned for improved supervision and limited hours for hospital interns and residents, who at the time would work 100-120 hours per week and 36-hour shifts. The high-profile case led to many newspaper and magazine articles, TV coverage, and a book.
A grand jury in 1987 rejected Zion’s claim of medical “murder” charges, but said hospital errors may have contributed to Libby’s death. As a result, the hospital admitted some errors was fined $13,000 by New York State. Two years later, the state limited interns and residents to 80-hour weeks and 24-hour shifts, and said senior clinicians must be in hospitals at all times. In 2003, the Accreditation Council for Graduate Medical Education adopted similar standards nationally.
In 1995, a jury came back with a mixed verdict in the Libby Zion case, saying the hospital wasn’t to blame for her death but that an intern and two doctors had contributed to it by giving her a drug that could be fatal for patients on antidepressive medication. A damages award of $750,000 was cut in half because the jury found that Libby Zion was equally to blame for not disclosing that she had taken cocaine and prescription drugs. The trial judge threw out that latter finding, but kept the award at $375,000, according to the Times.
Rhode Island hospitals agree on protocol for preventing surgical errors
After a span of two years that has produced five wrong-site surgeries, Rhode Island’s (RI) 12 hospitals and 21 ambulatory surgery centers (ASC) have all agreed on a protocol for preventing surgical errors, reports the Providence Journal. The Hospital Association of Rhode Island announced yesterday that RI is the first state to employ a uniform procedure for preventing surgical errors.
Many hospitals around the country are now using The Joint Commission’s Universal ProtocolTM or a variation, and many are using the WHO’s surgical checklist. The procedure agreed upon by hospitals and ASCs in RI include four steps:
- The surgical site is marked, and after agreement from a surgeon, LIP, and patient or family member, the surgeon initials the site.
- The operating team introduce themselves and discuss specifics about the case at hand.
- A time out is performed prior to the surgery to confirm the patient, procedure, and site, and that the surgeon’s initials as well as surgical site are visible after the patient has been draped.
- After the surgery has been completed, the surgeon leads a debriefing session to discuss the case.
Among some of the reasons why surgical errors have occurred in the past include staff members not following the well defined procedures set out for them.
To read more from the Providence Journal, click here.
Do you think RI is on the right track? Would your state benefit from a standard, statewide process?
Kentucky tackles MRSA
We tend to tackle MRSA hospital by hospital, but healthcare leaders in Kentucky are thinking differently. Instead of quietly submitting to mandatory reporting of hospital-acquired infections, Kentucky’s hospitals and the University of Louisville School of Public Health and information Sciences have come together to combat MRSA statewide, according to a HealthLeaders piece. They brought the effort both to hospitals, nursing homes, home health, first responders, correctional institutions, school and athletic groups.
Initially, the plan was to focus on rural hospitals, using funding through a rural grant, explains Elizabeth Cobb, MPH, vice president of health policy with the Kentucky Hospital Association. As discussions continued, however, the University of Louisville was brought into the loop, and funding from emergency preparedness grants came into play.
