All Entries Tagged With: "adverse events"
The many measures of patient safety and quality
Defining quality through a patient’s eyes
Editor’s note: Columnist Catherine Hinz, MHA, works as a leader in patient safety at HealthEast Care System in St. Paul, MN. Hinz previously worked at PatientSafe Solutions, Inc. Hinz has also completed a patient safety internship with the Agency for Healthcare Research and Quality. The following is an excerpt of her monthly column, which can be found in its entirety in Patient Safety Monitor Journal.
There are always times to come back to center-to return to why we work so hard to improve processes, performance, and measures like overall hospital ratings. In the sea of scores, metrics, and meetings we often drown in, we forget to come up for air and see that relationship with patients who seek care and healing from (and with) us.
As of late, I’ve spent more time learning about very specialized patient populations. These are patients who are served by disparate health systems, and who are often cared for by community or state organizations. These are patients with many needs and challenges-mental illness, chemical addiction, homelessness, and other atypical situations where the normal metrics of quality may not apply in the ways they were originally designed.
Think of the patient population suffering from traumatic brain injuries, who may now pose a substantial safety risk to themselves. This population has intensive and specific care needs, and thus they have a different set of expectations of quality, which may be defined in terms of activities of daily life and relationships with caregivers and family.
Through learning more about specialized patient populations, I’ve learned that “quality” can be ambiguous and that its true definition is a moving target. I’ve come to the conclusion that quality really needs to be dictated by the specific needs and desires of the patients and the families who care for them-not by the organizations, who are searching for a simple way to measure and ultimately pay for care.
Patient safety, while closely related to quality in many ways, is far different in that it represents freedom from accidental injury and harm.
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.
Win-lose? Why quality measures might lead to poor HCAHPS scores
New research indicates that implementing quality measures can improve clinical outcomes but may create a lower patient perception of quality care.
Ohio State University researchers studied lots of data from all over and determined that, at least in the short-term, implementing standard quality measures might negatively hit your patient satisfaction scores.
The problem is this: Standardization is good for preventing and catching potential errors, and it’s good for tracking and benchmarking. It’s also necessary for regulatory compliance in a lot of ways. Unfortunately, this standardization sometimes overshadows the patient, who can be treated a bit like a cog in the machine instead of a unique individual.
Is this a problem in your hospital? Like most things, I think communication here is the bridge that can melt standardized processes and patient perception into a one cohesive and positive experience. For example, if you give a patient a test or medication because the quality measure indicates the patient qualifies for it, does the patient know that?
An semi-educated guess of mine is that physicians often withhold telling patients that standards, regulations, and public reporting make them prescribe or do anything. But I think if you let patients know that based on research, doing X, Y, and Z is shown to help patient like yourself, most will be appreciative and find the experience more pleasant.
Ultimately, better clinical care and standardized processes will allow for providers to have more time with patients and patients will be healthier, so it may very well smooth over in the end. Right?
What do you think? Is it communication, or are hospitals becoming too standardized and obsessed with quality measures? Or is this a blip that will pass?
Transparency… are we there yet?
Apparently not. Public reporting of surgical site infections is required in only eight states. That fact was brought to light by a new Johns Hopkins University report, which calls for more reporting. Lead author of the report, Martin Makary, MD, notes that patients still have little information when choosing hospitals.
Personally, I think the bigger issue is that public reporting gives hospitals, from the top down, a real push to do better. I think Makary does too:
“Nothing motivates hospitals to improve quality and listen to their front line staff like public reporting,” he says. “In order for the consumer to interpret publicly reported SSI rates, it is imperative that the data be collected and reported in a standardized manner,” he and his co-authors wrote.
I would have to agree. Surgical site infections not only result in 8,000 deaths a year in the U.S., they occur in 4% to 25% of patients who undergo major surgical procedures, and their cost to the healthcare system is about $10 billion annually (these stats are mentioned in the report and come from other studies).
Makary calls out state hospital associations for not supporting public reporting. What do you think? Is public reporting the way to change hospital culture?
A win for public reporting?
We all know that CMS is collecting, publicly reporting, and basing reimbursement on quality efforts. We also know that not all hospitals are happy about this. There has been much debate over these quality measures, whether they actually measure quality, the fact that they’re untimely and unfair. But today we have news and some data that might show that at least on a smaller scale, public reporting drives change.
Enter The New Jersey 2011 Hospital Performance Report, the New Jersey Department of Health and Senior Services eighth annual report on the quality of care in New Jersey hospitals. The state’s hospitals outperformed the national average in seven of 10 patient safety metrics, jumping from the bottom 10 to the top 10 nationally for quality over the last 12 years.
Improvements at the state’s hospitals “did not just happen by chance,” said Dr. Peter Gross, former chief medical officer at Hackensack University Medical Center and a co-chair of the state’s quality improvement advisory committee, who participated in the commissioner’s teleconference. “The health department … by setting up this report, encouraged competition among hospitals to get better, and it obviously has worked.”
What do you think? Is this a win for public reporting?
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
Ask your staff: How can we earn your trust?
Every time I explore a quality improvement initiative with a hospital for Patient Safety Monitor Journal, I always ask two questions:
- What was your biggest challenge?
- What advice would you give to other hospitals?
Especially as of late, the answers revolve around just culture. Quality directors, nurse managers, patient safety professionals, CNOs all tell me the biggest challenge is staff trust and buy-in; the key to success is involving them in the process. We all know the key to improving is knowing what’s wrong, but unless there’s trust between the organization and the staff, you won’t find out that information.
The most recent AHRQ Culture of Safety survey – Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report – leads me to believe perhaps the knowledge of how to improve culture and safety is there, but it’s not yet in practice to the fullest extent.
This is a big survey, including data from more than a half million healthcare staff from more than 1,000 hospitals, and deserves a good look:
Teamwork within a unit was strong; 80% of respondents agreed or strongly agreed to that sentiment. Generally, staff felt that management supported them and a culture of safety, and that the organization was including systems meant to support staff and reduce errors. To me this says that the talk is there: Staff members are aware that managers and leadership care about safety, and those systems should support them, not hinder them. Seventy-five percent say that management’s actions show dedication to patient safety; 72% believe the systems are in place to prevent mistakes.
Yet when it comes to reporting or speaking up, staff are still wary. Only 62% felt there was communication openness in their organization, and the lowest scoring domain was nonpunitive response to error, with only 44% positive response to questions related to the subject.
When it gets more specific – and more personal–the rates drop lower. Most interestingly is the difference between these two questions:
- Staff will freely speak up if they see something that may negatively affect patient care: 75% agree/strongly agree
- Staff feel free to question the decisions or actions of those with more authority: 47% agree/strongly agree
To whom staff must speak their concerns seems to be a critical indicator as to whether they actually will. This is certainly an issue with culture. The vast majority of respondents (76%) had direct patient involvement, and 35% were nurses. Considering disparate levels of authority create the team responsible patient care, I find this low response to that particular question quite concerning.
Also noteworthy: exactly half believed mistakes are held against them. It’s no wonder the survey indicates vast under-reporting of adverse events, a claim supported by the recent report by the inspector general of the Department of Health and Human Services.
I think the next step for hospitals is to find out what it will take for staff to trust hospitals. What will it take to get a nurse to report an adverse event he or she was involved in? Or demand a time out be performed to a surgeon?
Such a large shift in thinking might take time, as we all k now in decades past healthcare has been notoriously punitive. Still, perhaps we should start by asking our staff what it will take to earn their trust.After all, involving them has been the key to so many other instances of quality improvement success.
Bloodstream infections in pediatric ICUs
A Consumers Report study has found that many pediatric ICUs have high rates of bloodstream infections, often higher than adult ICUs—on average, 20% higher.
As you may recall, Josie King, whose unfortunate story has been made famous by her mother who now advocates for better patient safety, had complications after a central-line bloodstream infection.
Hospitals may want to look at the strategy of 2010 Baldrige-award winner Children’s Hospital at Providence in Anchorage, AK. Children’s cut catheter-related bloodstream infections in the neonatal ICU. Though they didn’t focus on central lines, the strategies might be of interest. They resisted the typical “see one, do one, teach one” method and instead implementing standard teaching methods. The hospital also ensured peace and quiet upon insertion by moving the patient into a quiet room during the procedure. Read more about this in Patient Safety Monitor Journal.
Still, there’s a problem a bit more concerning than the infections: a lot of pediatric ICUs aren’t reporting the data publicly, according to the report::
Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.
The investigation was left to focus on the 92 pediatric intensive-care units in 31 states plus Washington, D.C. that did report rates.
What can be done? What’s missing? Why aren’t we reporting rates? How can hospitals emulate others that have low rates if we can’t identify which ones they are?
You can’t improve without knowing what’s wrong
In the healthcare quality improvement field, there has been much talk about reporting errors, about a just culture, about using occurrence reporting data to implement quality improvement initiatives, and sharing results with staff. But it seems, according the latest Office of the Inspector General (OIG) report that many of you have probably seen, that hospitals aren’t cutting it.
In summary, the report concludes:
Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).
So, the majority of events go unreported because staff didn’t think the event qualified for the reporting system.
A list of common events is coming (via AHRQ and CMS), and it’s sure to be helpful. Until then, hospitals should work on what Occurrence Reporting: Building a Robust Problem Identification and Resolution Process author Ken Rohde calls this a reporting threshold.
“If your staff question whether they should report something, they are asking themselves a threshold question,” says Rohde. He advises the threshold to be either low or nonexistent.
“A good way to communicate a lower threshold is to tell staff: ‘If it was important enough for you to think about it or if it disrupted your day, then report it,’” says Rohde.
Though a higher reporting volume may require a more efficient screening process, more information about adverse events is usually better.
Here’s a quick tip sheet from Rohde’s best-selling book for improving your error reporting in your system: http://patientsafetymonitor.com/tools-library (starred, at the bottom, free for download).
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.
