Joint Commission launches Center for Transforming Healthcare

The Joint Commission announced a new effort to address the nation’s biggest issues in terms of quality care and patient safety yesterday when it launched the Center for Transforming Healthcare. At the crux of the Center’s approach to improving patient safety is using Lean and Six Sigma to improve processes and address some of the challenges facing caregivers and patients. It hopes to offer specific guidance on how to solve issues like preventing healthcare-acquired infection, ensuring medication safety, coordinating safe patient handoffs, and focusing on surgical safety.

This not-for-profit has coordinated with some of the nation’s leading health systems to work on some of the above mentioned issues. You can find the full list by clicking here.

I did find it useful to know that starting midway through 2010, hospitals that are Joint Commission-accredited will be able to utilize an application on the site that will work with each facility individually to develop custom solutions.

You can find more information about the Center here.

Joint Commission posts prepublication 2010 National Patient Safety Goals

The Joint Commission has posted the 2010 National Patient Safety Goals (NPSG) on its Web site today, although they aren’t official. There are no “new” goals for 2010; however, significant changes have been made to the existing NPSGs. Seven of the 2009 NPSGs, of which there were 20, have been moved to the general standards, one has been completely deleted (this one, NPSG07.02.01, which required organizations to consider a healthcare-acquired infection a sentinel event, was deleted because it is covered in the sentinel event policy), and one, medication reconciliation, is still up in the air, and more information concerning the Goal will be released in the spring of 2010. The Joint Commission announced earlier this year that it would no longer cite facilities for failing to comply with medication reconciliation, NPSG 8, to “reduce the burden” on hospitals. Since its introduction as a goal, medication reconciliation has been one of the most frequently scored and most difficult for organizations to get a handle on. New for 2010, hospitals will be required to comply with NPSGs 07.03.01, 07.04.01, and .07.05.01 which have to do with preventing healthcare-acquired infections, central line infections, and surgical site infections respectively. In 2009, facilities were given a “phase-in” period to prepare themselves for being surveyed on the topic.

Some of the changes made included in the 2010 NPSGs are effective immediately. These include any deletions of EPs, and some changes made to the Universal Protocol. In its publication Joint Commission Online, The Joint Commission says that ”for the remainder of 2009, during the on-site survey, surveyors will not evaluate compliance with the requirements that have been deleted.” Additionally, for the rest of 2009, because in the 2010 NPSGs the Universal Protocol elements of performance (EP) were either deleted or substantially modified, facilities will not be scored on the following 2009 EPs during survey: UP.01.01.01 (conducting a preprocedure verification) EPs 1, 2; UP.01.02.01 (marking the site) EPs 1, 2, 3, 7; UP.01.03.01 (conducting a time out prior to a procedure) EPs 1, 5, 6.

Overall the NPSGs are less detailed and represent a reduction in the amount of requirements. The Joint Commission is hoping that by reducing the amount of EPs with which hospitals have to comply, focus can be placed back on delivering quality care and on making patient safety the biggest priority–rather than compliance.

Have any of you taken a look at the 2010 NPSGs today? If so, do you have any initial reactions?

You can find more information about the 2010 NPSGs here.

Tips for creating a patient advisory committee

I wrote an article for an upcoming issue of Briefings on Patient Safety about how to create and sustain patient advisory boards/committees. As part of that article, I put together the following succinct points to help readers focus on defined ways to create effective advisory boards:

• Scope the project: Make sure you have a detailed idea of what the patient advisory committee is there to address, whether that is one specific topic (e.g., medication safety) or a process that involves general patient safety practices (e.g., like discharge)
• Recruit the right patients on board: It might even be necessary to conduct one-on-one interviews to determine whether a patient is the right choice to serve on an advisory board. He or she may not be right for the board based on the topic, his or her experience, or demographic
• Clearly outline board members’ responsibilities: If patients serving on an advisory board are unaware of the time commitment, energy required, and that they are going to be asked their opinions on how to improve patient care in front of hospital staff members, they may feel uncomfortable and/or may not be a valuable board member who will provide feedback.
• Set up an orientation: Many people serving on an advisory board—whether they are from the community or work at the hospital—will be doing so for the first time. Allowing everyone to get to know each other before they get down to discussing improving patient care will make future conversations more comfortable.

Do you have any points you could list that have made your patient advisory boards successful?

David Blumenthal releases personal message about importance of HIT

David Blumenthal, MD, national coordinator for Health Information Technology, recently released a message with the Department of Health and Human Services extolling the benefits of health information technology (HIT). Blumenthal is in charge of a large portion of funds ($19.2 billion, to be specific) made available by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act. In addition to ultimately making the jobs of doctors, nurses, and other clinicians easier and more efficient, introducing electronic medical records (EMR) as a part of an HIT initiative will greatly increase the quality of care afforded to patients, Blumenthal says.

Part of his message, however, is acknowledging the uphill battle at hand. Making each patient’s healthcare record electronic will require effort on the part of the healthcare system and the government. Additionally, providing a secure platform, one which will ensure patients a level of privacy expected with medical information, is a must.

You can read Blumenthal’s full message about the HITECH Act here.

I also saw this article from HealthLeaders Media on the topic of electronic health records, chronicling one hospital’s transition from paper records to electronic records, and any effects the HITECH Act has had on the facility.

What has your facility done in the way of readying for the EMR revolution?

Google treats e-mail outage as “sentinel event”

On Tuesday, Gmail, the e-mail arm of Google, suffered an outage for about an hour and forty minutes. Although Gmail is an e-mail service, it has many functions including a chat capability which many business use to speak to other businesses and for staff members within a business to speak to each other. So, when Gmail was inaccessible for that period of time, it negatively affected many people and companies.

Why I’m mentioning the incident on the Patient Safety Monitor Blog is because shortly after Gmail came back online, the engineers at Google published their own blog post (on the Gmail blog, of course) apologizing to Gmail users, as well as hashing out just what went wrong to cause the outage. Throughout the post, the repeatedly tell readers that they were treating the outage as a major event and are working to ensure that it never happens again.

After reading the post, it occurred to me that Gmail had suffered a “sentinel event” of its own, and Google was treating it as such. The post describes the “route cause analysis” that was undertaken to determine what went wrong, as well as the “process changes” made to make sure the problem occurs again (albeit, in different language).

Of course, when Gmail suffers a “sentinel event” it inconveniences, annoys, and perhaps even really upsets users. However, it doesn’t cause permanent harm or worse to its users, which is what makes this event very different from a medical error. However, the lessons struck me as similar.

How often does your organization evaluate how it treats sentinel events, and the steps taken after one occurs?

APIC urges healthcare facilities to require staff vaccinations

More news about the flu today- whether that’s H1N1 or the seasonal flu.

The Association for Professionals in Infection Control and Epidemiology (APIC) urged healthcare organizations to mandate that staff members in direct contact with patients be vaccinated during the upcoming flu season. The group made its recommendation earlier this week as predictions continued to surface about the number of  Americans who may be infected with the H1N1 virus during the upcoming flu season. Last week a presidential panel estimated that up to half of the U.S. population could become infected, and 1.8 million people could be hospitalized, resulting in up to 90,000 deaths. APIC issued a similar recommendation during the 2008-2009 flu season.

APIC issued a similar recommendation during the 2008-2009 flu season. Currently rates of healthcare provider vaccination hover at the 42% mark, which has not budged much in the last ten years. The Centers for Disease Control and Prevention (CDC), as well as APIC, recommend that all healthcare workers in direct contact with patients get a flu vaccination as a means of keeping patients safe. Some staff members employed at private organizations see mandatory vaccination requirements as infringements on privacy.

Has your facility decided to take the “mandatory flu vaccination for employees” rotue? How do you and your fellow staff members feel about this policy?

Improving efficiency, reducing waste are keys to safe, quality patient care

For years the healthcare industry has maintained that it is unlike others simply because caring for people is more complex than creating cars, shipping goods, or generating energy. However, hospitals are being forced to examine their processes this year as the healthcare reform debate continues. Healthcare has been exposed as being extremely wasteful and has not embraced simple technology that other industries adopted years ago to improve their workflows and products. In two separate stories, The Boston Globe and Business Week examine instances in which hospitals adopted new, more efficient practices and have seen positive outcomes.

The Boston Globe articletakes the case of Cincinnati Children’s Hospital (CCH). The facility reached out to well known flow and efficiency expert Eugene Litvak, a professor at Boston University and Harvard University, as well as a patient flow advisor to the Institute for Healthcare Improvement. He was asked by CCH to help them streamline the flow of patients from the emergency department waiting room to the recovery area for patients post-surgery. Over the past six years, the facility has seen both quality and economic improvements.

The Business Week articleexamines how administrators at the Moffitt Cancer & Research Institute in Tampa, FL, used a consulting group within General Electric to help them learn how to better manage and run the facility. The facility analyzed how time in the operating rooms was being used, then scheduled surgeries in a more efficient manner. Although this disruption required some new ways of thinking, ultimately it has led to improved performance and better outcomes.

Has your hospital or healthcare facility taken the first steps into better managing its processes to produce better outcomes via more efficient care? Have you experienced any major changes to how you do your work, and if so, have they been for the better?

Vote for your favorite flu prevention commercial in HHS contest

The Department of Health and Human Services (HHS) recently put out a call for entries into its contest for a new public service announcement about preventing the spread of the flu. Now you can vote once a day on your favorite commercial out of the finalists chosen by HHS’ expert panel. Some of the clips are funny, some are straight and to the point, but all of them touch on the basics of infection prevention–namely by handwashing and practicing safe sneezing and coughing techniques. Some of the commercials also recommend that viewers get vaccinated for the flu. The commercials are not specifically for preventing the spread of H1N1, but various strains of the flu. Health officials expect the seasonal flu and H1N1 to together pack a decent sized punch–the WHO expects that within two years, one third of the world’s population will have caught the H1N1 virus. Certainly the messages contained in these videos could apply to preventing both types of the flu (although currently, only certain sectors of the population are being flagged to receive the H1N1 vaccine).

Voters have until September 16 to visit HHS’ YouTube channel and click the “thumbs up” or “thumbs down” icons on each of the finalists. The winner of the contest receives a $2,500 prize! This is a great way to get your fellow staff members into reminding patients about flu prevention techniques. So, vote on your favorite, mine is the clip below.  Although it’s a serious topic, I think that humor usually connects viewers with a subject more so than just straight facts.

Joint Commission releases Sentinel Event Alert

The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur. The alert, titled “Leadership committed to safety,” reflects many of  the changes made to the leadership chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals (which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.)

The alert asks leaders to recognize that if there is a failure of some sort in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, building a culture of safety is part of preventing medical errors and is something that can only truly happen when leaders buy-in and show that that doing so is not just something they are preaching–it is something they live every single day.

The alert gives some recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility’s trouble spots without being penalized. Similar to this, one recommendation is to support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors. However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.

You can read the full list of recommendations, as well as the Sentinel Event Alert here.

Announcing the winner of the Patient Safety Monitor Contest!

The month-long Patient Safety Monitor Contest has come to a close, and I’d like to thank everyone who sent in entries, read the creative ideas of the week, and commented on the blog. Although there were many great ideas entered into the contest, our panel of judges at HCPro has chosen Abington Memorial Hospital’s  (AMH) “Patient Safety First” education program as the winner!

Entered by Robert C. Giannini, NHA, safety/quality specialist at AMH in Abington, PA, the program includes a month-by-month effort to focus on a different patient safety topic each month on a hospital-wide level. It’s an education campaign to train all staff members about the patient safety issues facing hospitals today.

In Robert’s words:

The objective of this monthly program is to promote communication (“a behavior a month”) and hospital-wide alignment in our efforts to establish and maintain a safe and reliable healthcare culture.

The program meshes the Joint Commission’s National Patient Safety Goals for 2009 with the hospital’s own internal goals. Part of the effort involves safety coaches, who are frontline caregivers that make it a goal to involve all of their fellow staff members in the theme of the month. This has been such a success at AMH partly because staff members know that the effort is not going away. It’s publicized in some of the hospital’s newsletters and materials are posted throughout the facility to remind staff members the focus of the month.

For 2009, AMH developed a 12-month Patient Safety First schedule. The focus in January was on hand hygiene. The hospital developed patient education materials to alert patients that handwashing was a focus that month and asked them to be a partner in their own safe care. Additionally, those in charge of the campaign created separate materials for staff members, reminding them that January’s patient safety topic was performing hand hygiene before and after contact with patients or the hospital environment.

Thanks for entering, Robert! As the winner of the contest, Robert receives a complimentary copy of the Patient Safety Officer’s Handbook.