All Entries Tagged With: "transparency"
NQF President steps down
The National Quality Forum (NQF) Board of Directors today announced that NQF’s President and CEO Janet Corrigan has submitted her resignation, effective late June 2012. Corrigan has served as NQF’s President and CEO for more than six years.
“Reflecting on our accomplishments over the last six years, I am deeply proud of NQF’s contributions to the overall healthcare quality movement,” said Corrigan. “Working with NQF leadership, our dedicated members, our scores of volunteer experts, and our committed partners at HHS, we have accelerated the critical work of achieving a healthcare system that provides safer, better, and more affordable care. I am eternally grateful for this experience to steer NQF during an unprecedented time of change in healthcare. Sustained, systemic change that benefits patients is within our reach. The strength of the NQF Board of Directors and executive team, coupled with our organizational stability and future possibility to meet our mission gives me the confidence to take the leap to my next chapter in life.”
The NQF Board of Directors has created a search committee to immediately launch a national search for a new President and CEO. John Tooker, MD, MBA, MACP, CEO Emeritus, American College of Physicians will lead the search committee. More details will be available on the NQF website.
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.
Apologies and action for famous actors only?
Hospital chief Sandra Coletta is making waves throughout the healthcare community after being frank with her audience of hundreds at the 10th annual dinner of Medically Induced Trauma Support Services (MITSS), a widely respected group that aims to support patients, families, and staffs after things go medically wrong.
She spoke about the death of James Woods’ brother in the emergency department at Kent Hospital in Warwick, RI, after orders were not carried out in a timely manner.
“Quite honestly, I did nothing other than what my mother taught me,” Coletta said of apologizing.
James Woods and the hospital settled the suit, in the process created a foundation, the Michael J. Woods Institute, in honor of his brother. The institute aims to recreate healthcare from a human factors perspective.
Similar action was taken after Dennis Quaid’s twins were put in peril because of a medication administration mistake. (According to an April 2010 USA Today story, Quaid said Cedars-Sinai hospital in LA “stepped up to the plate and spent millions of dollars on bedside bar codes.” He and his wife also created the Quaid Foundation, which has merged with the Texas Medical Institute of Technology.) Do you think these cases are addressed more swiftly, and more apologetically, because of their high-profile nature? Or do you think the tides are turning?
Of course, Sorrel King, without being famous (at least then), spurred plenty of action on her own. But are hospitals finally reacting with action and apologies, even without fame and publicity?
Share your thoughts on the blog.
Is it time to stop duplicating reporting efforts?
Interesting turn of events this week. The Cleveland Clinic, Henry Ford Hospital in Detroit, and Parkview Health in Fort Wayne, IN, have all ceased to report hospital-acquired infections to the Leapfrog Group, a nonprofit organization in Washington, D.C.
According to Consumer Reports, the three health systems fall in different spots for bloodstream infections—something Consumer Reports previously analyzed. One did better than average, one about average, on under average.
The hospitals’ reason for the end to Leapfrog reporting was that they now report to CMS on the same or similar measures, and must end duplicate efforts to reduce waste of resources.
What do you think? Do you think the private nonprofit reporting group will soon be a thing of the past?
Rewarding near-miss reporting
By now, most of us involved in patient safety understand the importance of reporting, collecting, and analyzing near misses. More and more, healthcare providers are beginning to understand that more often than not, a systematic problem—not an individual—is behind potentially dangerous errors.
But how do you get staff to report them? No really—actually report them? Including physicians? Many healthcare providers have been working in the field for decades, and for many of those decades, mistakes were swept under the rug—especially mistakes that luckily did not reach the patient. No harm, no foul, no reporting–this was a common way of thinking for many years. When providers have learned and worked in an environment where reporting errors often meant severe individual punishment, how do get them to trust you that reporting is okay?
It’s critical to show staff the positive effects of near miss reporting. It’s also a good idea to publicly and consistently reward those who “see/experience something and say something.” A good example is one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards. After 24 months, the health center provided a table of 27 good catches that shows how systems were changed in response to the catch, including one that led to a national recall of an improperly labeled drug that lead to look-alike medication errors.
Clinicians honored with an award receive public recognition with wall boards on the surgical suite. The system is not yet implemented hospital-wide, but continues at the Weinberg OR Suite at Johns Hopkins Hospital.
Do you have a near-miss reporting system? Is it used? Do staff receive public recognition for their efforts? Have you had trouble getting staff to trust that reporting is benefits all? Post your comments below.
When quality data reaches the public
Most of you who read this blog are likely aware of common adverse events that occur in hospitals, but what about the average Joe? “Never events” and “HACs” are terms the public is becoming more and more aware of. News stories are focusing on such events, mostly due to The Centers for Medicare & Medicaid Services (CMS) March 31, 2011 release of Medicare data on certain measures, such as patient falls and central line infections. Before, only measures concerning heart attack and pneumonia patients were made public.
One thing you learn as a reporter is that all news is local—in other words, what’s happening in your own community usually takes precedent. It’s one thing to have the federal data on Hospital Compare, a site that is a bit cumbersome for average people to explore and find information that is meaningful to them, even if they know of the site in the first place; it’s another to read it in your local newspaper.
For example, if you live in Louiseville, KY, an article in yesterday’s paper explains which “never events” are occurring in your hospitals. The Post Crescent reports that hospitals in Fox Cities, Wisconsin suffer from a higher rate of pressure ulcers. Connecticut residents read last month that collectively, the state’s hospital had a higher level of objects left after surgery than the national average. In April, The Chicago Tribune reported on the newly available data and in Georgia, a state that does not publicly post such data, the Atlantic-Journal Constitution headline announces that Georgia residents have been kept in the dark on hospital infections. A simple Google news search shows many more city newspapers are reporting on the new data.
Of course, this is what transparency is all about. However, not all reports explain that the AHA is against the release of such raw data, and why. (The AHA is concerned the data are too raw and do not account for sickliness of patients. The organization has other concerns, including the fact that the measures have not been reviewed by an organization such as the National Quality Forum.)
What do you think? Is this ultimately good? Will this lead to more quality efforts in healthcare? Will it lead to more funding, more public awareness? Will more news coverage lead consumers to use Hospital Compare more regularly? Have you seen your hospital in the news? Has the media had an effect on your quality efforts?
A new proposed rule would allow more Medicare data to be available, as I posted last week. The new link to the proposed rule can be found here.
New CMS final and proposed rules address HACs, transparency
Last week, The Centers for Medicare & Medicaid Services (CMS) issued the final rule on reducing or prohibiting payments to providers for hospital-acquired conditions (HAC). The new rule will better align Medicare and Medicaid payment policy and give states flexibility to add to the federal list of HACs. This rule specifically prohibits states from making payments to providers under the Medicaid program for HACs, using the current list of HACs under the no-payment Medicare rule already in place.
The final rule is effective July 1, 2011 and gives states the option to implement its effective date July 1, 2012.
View the press release and the list of reduce or no-pay HACs.
In other CMS news, a new proposed rule would allow Medicare and private sector claims data to be used to produce public reports that evaluate the performance of physicians, other healthcare providers, and suppliers. Organizations seeking such Medicare information would have to undergo an application process and be continually monitored by CMS.
To prevent mistakes, the proposed rule requires that any reports generated from the Medicare data be shared confidentially with providers and suppliers before being released to the public. Publicly released reports would contain aggregated information only, meaning that no individual patient/beneficiary data.
“Performance reports that include Medicare data will result in higher quality and more cost effective care,” CMS administrator Donald M. Berwick, MD, said in a statement.
For more analysis, visit HealthLeaders Media.
The proposed rule will be published in the Federal Register on June 8, and the CMS will accept public comments for 60 days. Until June 8 the proposed rule is available here.
New Michigan law allows healthcare providers to say sorry
A bill signed on April 19 by Gov. Rick Snyder allows healthcare providers to apologize to patients for adverse events without the fear that their apologies might be used against them in malpractice cases, reports the Detroit Free Press. (Also of interest to our readers might be an article in the November, 2010 issue of Patient Safety Monitor Journal that discusses The University of Michigan Health System’s disclosure policy with long-time disclosure proponent Richard Boothman, JD, UMHS’ chief risk officer.)
The law does not apply, however, to admissions of medical fault or negligence. Michigan is not the first state to pass such a bill. Thirty-five other states have similar laws and see fewer and smaller malpractice claims as a result.
What do you think? Does your state have a law like this? Is it important to have a law like this? How does it affect patient care and safety?
Stories, not data, have most influence for change
Editor’s note: The following is an excerpt of a Patient Safety Monitor Journal
column that explores patient safety from the perspective of a newcomer to the patient safety field. Columnist Catherine Hinz, MHA, currently works at PatientSafe Solutions, Inc. Previously, she was the patient safety lead at HealthEast Care System in St. Paul, MN, worked for seven years as an ED health unit coordinator, and has completed a patient safety internship with the Agency for Healthcare Research and Quality.
In patient safety and quality, there is no shortage of data and information that needs to be gathered from an inpatient stay. Data are collected for compliance with federal quality-of-care measures, federal and state patient safety indicator and event tracking, accreditation, professional organizations, public disclosure, and internal monitoring and analysis—eliciting a response of “good grief.” That’s a lot of stakeholders to satisfy. What is more incredible is the melting pot of automatic sorting and manual chart abstraction it takes to pull everything together to deliver patient safety data to regulators in neatly wrapped electronic packages.
It gets overwhelming rather quickly—especially when the hospitals might be in disarray because of all the paper and electronic sources from which to abstract and pull data. At the end of the day, all data, statistics, rates, and other information are collected in an overall attempt to inform the acceleration of improvement and performance. However, one has to ask: What are the most important data to collect, or more accurately, the most important data to pay attention to? This is a question I struggled with while working in the operational setting and now struggle with as I examine data from hospitals all over the country. What are our best and most effective impactful indicators of patient safety and quality?
To read Catherine’s full column on just culture, see the November issue of Patient Safety Monitor Journal (a part of your Patient Safety Monitor subscription for those blog readers out there who are also subscribers.)
