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July 2003

Dear Colleague:

We have enhanced our archives and search engine so you can find a story by its date, topic, or search the entire Safety Web site. Please encourage your colleagues to subscribe so they won't miss any issues.

Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute

News

Safety tools

 

Premier, HHS Medicare demonstration project offers hospitals incentives to provide high quality care

Premier and the Centers for Medicare & Medicaid Services (CMS) are undertaking a demonstration project that will use financial incentives to encourage hospitals to continuously improve the quality of their inpatient care.

Hospitals participating in the project will be eligible for increased Medicare payments for delivering high-quality care, as well as identifying new ways to continuously improve the care provided patients, focused on specific clinical conditions.

“At Premier, we have spent years building databases and the related reporting systems that allow our members to accomplish the first of these tasks. But financially rewarding superior outcomes is beyond the reach of Premier and its members. Yet, that is what’s necessary to complete the performance improvement process,” said Richard A. Norling, Premier’s chairman and chief executive officer. “The ability to reward superior outcomes truly closes the loop.”

Hospitals’ performance will be tracked through their subscription to Premier’s Perspective database, the most comprehensive clinical data repository in the nation. Participation will be voluntary and Premier anticipates that many Perspective users will be part of this voluntary effort to participate in the demonstration project.

"This project will give additional recognition and incentives for hospitals that achieve the highest standards of quality," said HHS Secretary Tommy G. Thompson. "But we expect it will result in improvements in quality of care for patients in all the participating hospitals, not just those who rank at the top and receive incentives."

Bonuses to hospitals will be based on quality measures associated with specific clinical conditions: heart attack, heart failure, hip and knee replacement, pneumonia, and coronary artery bypass graft. CMS will determine hospitals’ performance on such measures as prescription of aspirin for heart attack and bypass graft patients, and timely administration of antibiotics for pneumonia patients. Measures such as these are commonly accepted as linked with more favorable outcomes.

Hospitals will be scored on the quality measures related to each condition. Hospitals in the top 10 percent for a given condition will be provided a two percent bonus on their Medicare payments. Hospitals in the second 10 percent will be given a one percent bonus. All hospitals performing in the top 50 percent will be publicly recognized for their quality but will receive no bonus.

"What we hope to see is that the additional incentive payments through this demonstration project will be offset by reductions in costs," said CMS Administrator Tom Scully, "especially in reductions of unnecessary hospital readmissions because of better care in the initial inpatient stay. At the same time we expect patients will get better care, so everybody wins, the patients, the hospitals, the Medicare program and the taxpayers.”

Data on the quality of care at the participating hospitals will be published on the CMS Web site and made available to healthcare professionals and consumers. The demonstration is a pilot program. If successful, such a structure could be become a permanent Medicare program and applied to all hospitals.

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Funding, lack of clinical data standards are top barriers to implementing IT for safety

Information technology can reduce the risk of errors and patient harm by streamlining care, catching and correcting errors, assisting with decisions, and providing feedback on performance. In a special article in the New England Journal of Medicine (June 19, 2003), Dr. David Bates at Boston’s Brigham and Women’s Hospital outlines the barriers for development, testing, and adoption of information technology, including financial, cultural, and lack of standards for key clinical data.

The main class of strategies for preventing errors and adverse events includes tools that can improve communication (e.g., handoffs between clinicians), make knowledge more readily accessible, require key pieces of information (such as the dose of a drug), assist with calculations, perform checks in real time, assist with monitoring, and provide decision support. Bates notes that implementing computerized physician order entry, which includes appropriate constraints on choice of drugs, routes, frequencies, and doses, helps with calculations, performs real time checks, and assists with monitoring. The result: a 55 percent reduction in serious medication errors in Brigham and Women’s Hospital.

Barriers to implementation of information technology are financial and cultural, and often stem from a lack of standards, Bates adds. Financial issues include lack of ready-made products, high price tags, and limited funding. Progress is hindered by the lack of a single standard for most types of key clinical data, including conditions, procedures, medications, and laboratory data, resulting in high interface costs and many applications that do not communicate well, even within organizations. In an accompanying editorial, Donald Berwick, president of the Institute for Healthcare Improvement, asks, “How many patients will die in U.S. hospitals tomorrow because of injuries? I think it will still be about 100 the day after tomorrow and 100 the day after that … and so it will continue until the will and ideas … are translated into actions…”

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First-time bans on mercury blood pressure devices

In late May 2003, Maine and Washington became the first states to ban the sale of mercury-containing blood pressure devices, signaling the next major step toward the elimination of mercury from healthcare. Although other states and municipalities have banned the sale of mercury thermometers, these laws are the first statewide bans to include mercury-containing blood pressure devices, which today represent the largest use of mercury in healthcare.

With some exceptions, Washington’s Mercury Education and Reduction Act will reduce mercury in schools, hospitals and homes by banning the sale of certain mercury consumer products, such as thermometers, thermostats and mercury-containing blood pressure devices. Maine’s Act to Reduce Mercury Use in Measuring Devices and Switches also bans the sale of mercury-containing blood pressure devices. More information on past mercury reduction legislation can be found at the Healthcare Without Harm Web site.

To assist facilities with mercury reduction efforts, Premier provides information about and contracts for a variety of mercury-free products alternatives. See Premier Safety Institute’s Mercury Pollution Prevention module, which includes a list of mercury-free products and pharmaceuticals.

Downloads and links

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RAND Survey: 50 percent of Americans receive optimal care for common conditions

In its recent survey of 12 large metropolitan areas (> 7,000 adults), RAND Corp. found that only half of the adults received appropriate care (screening, diagnosis, treatment and follow up) for the leading acute and chronic medical conditions as recommended by national guidelines. The results were part of RAND’s study published in the June 26, 2003, issue of the New England Journal of Medicine. The quality indicators used in the study were derived from RAND’s Quality Assessment Tools system and represent the leading causes of illness, death, and utilization of healthcare, as well as preventive services related to these causes. These indicators represented activities that physicians control most directly, because they do not require risk adjustment and are consistent with national guidelines. The participants in the study received 54.9 percent of the recommended care; moreover, there was little difference between the proportion of recommended care provided for acute care conditions (53.5 percent) and chronic conditions (56.1 percent). Quality varied substantially for particular medical conditions, ranging from 78.7 percent of recommended care for senile cataracts to 10.5 percent of recommended care for alcohol dependence.

Researchers agree that deficits in care are associated with preventable deaths. For coronary artery disease more than 68.0 percent of the recommended care was provided. However, only 45 percent of the patients with a myocardial infarct received beta-blockers, which is known to reduce the risk of death by 13 percent during the first week of treatment and 23 percent over the long term. Among elderly participants, only 64 percent had received or been offered a pneumococcal vaccine. Nearly 10,000 deaths from pneumonia could be prevented annually by appropriate vaccinations.

The RAND study assessed the quality of care delivered to a representative sample of the U.S. population for a broad spectrum of conditions. In contrast, other national studies have been limited to a specific segment of the population, such as Medicare beneficiaries.

The study authors conclude that there will be no simple solution to correct these deficits given the complexity and diversity of the healthcare system. However, establishing a national baseline for performance makes it possible to assess the effect of policy changes and to evaluate large-scale national, regional, state, or local efforts to improve quality.

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JCAHO news: early release of standards, surgical fires alert, and surgical site marking protocol

Standards revision

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made the 2004-accreditation standards for most of its programs available for electronic downloading prior to publishing the manuals in September 2003. The standards become effective January 1, 2004, for the accreditation programs in ambulatory care, behavioral healthcare, home care, hospital, laboratory and long-term care. Crosswalks also are available to help users navigate between current and new requirements prior to publication of the manuals. The standards for assisted living, critical access hospitals, healthcare networks, and office-based surgery will be revised in 2005. Although the number of standards has been halved, the requirements are essentially the same. The revisions are the result of deletions, consolidations or clarifications of existing standards, though some elements that existed in one accreditation manual may now be applicable across all manuals. The new manuals integrate the assessment, care, education and continuum of care chapters into a single chapter, while a new chapter on medication management consists of revised standards extracted from the care chapter. Although the pre-publication standards are not yet edited, formatted, nor include scoring information, there will be no changes in the published version of standards and elements of performance requirements.

Sentinel event - surgical fires

JCAHO has issued a sentinel alert event (SEA) #29 focusing on a rare event that leads to serious consequences. Estimates based on data from the Food and Drug Administration and ECRI, an independent nonprofit health services research agency, indicate that there are approximately 100 surgical fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually. However, these estimates are drawn from more than 23 million inpatient surgeries and 27 million outpatient surgeries performed each year. ECRI's recent analysis of case reports reveals that the most common ignition sources are electrosurgical or electrocautery units (68 percent) and lasers (13 percent). The most common fire location is the airway (34 percent), head or face (28 percent), and elsewhere on or inside the patient (38 percent). An oxygen-enriched atmosphere was a contributing factor in 74 percent of all cases.

Surgical site - universal protocol

During May 2003, JCAHO hosted a Wrong Site Surgery Summit, with the goal of obtaining consensus on the adoption of a "universal protocol" for preventing wrong site, wrong procedure and wrong person surgery. Leaders of more than 20 professional organizations, including the American Medical Association, American Hospital Association, American College of Physicians, American College of Surgeons, American Dental Association, and American Association of Orthopaedic Surgeons agreed that a universal protocol would help prevent the occurrence of wrong site, wrong procedure and wrong person surgery. They also agreed that the protocol should be specific to eliminate confusion about site marking and facilitate communication among surgical team members, and that it should provide the flexibility needed for unique surgical situations. JCAHO sought additional input on the protocol and appendix through a public survey completed in early July. The final version will be forwarded to the JCAHO Board for approval.

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Smallpox vaccine OK’d for monkeypox prevention as broader plan slows

Update on smallpox and monkeypox

As of July 2, a total of 81 cases of monkeypox have been reported to the Centers for Disease Control and Prevention (CDC) from Wisconsin (39), Indiana (22), Illinois (16), Missouri (2), Kansas (1), and Ohio (1), including 32 (40 per cent) laboratory-confirmed cases at CDC and 49 (60 percent) suspect and probable cases under investigation. To prevent transmission of monkeypox, 28 residents of six states have received the smallpox vaccine since June 13; recipients included 26 adults and two children. Vaccine was administered to two laboratory workers and two healthcare workers pre-exposure and to 24 persons post-exposure (10 healthcare workers, seven household contacts, three laboratory workers, two public health veterinarians, one public health worker, and one work contact). For more on monkeypox, see the MMWR July 2 update on monkeypox and a CDC fact sheet on monkeypox and smallpox.

ACIP recommendations

The Advisory Committee on Immunization Practices (ACIP) has advised the Bush administration to not follow through on plans to offer smallpox vaccinations to 10 million emergency workers (phase two). Because of concerns for previously unknown and potentially dangerous cardiac side effects, ACIP recommended that CDC continue the first phase of the smallpox vaccination program, which seeks to inoculate 450,000 civilian healthcare workers.

In response to ACIP’s recommendations, CDC Director Dr. Julie Gerberding noted that the committee’s advisory role is to provide advice to CDC and the Secretary about issues related to immunization. Although ACIP’s advice is held in very high regard, it is not the only source of advice CDC must consider, and it is attending to the question of program breadth. Smallpox was declared eradicated from the world in 1980, but U.S. officials believe it still could be used as a bioterror weapon. CDC's national immunization program staff plans to discuss ACIP’s recommendations in light of national security concerns, along with all aspects of the program, which, in addition to vaccination, includes rapid isolation of identified cases of smallpox, better education, training and disease surveillance.

Civilian healthcare workers

Less than 10 percent of the smallpox immunization goal planned for civilian healthcare workers has been reached under the federal program that began in January 2003. Of those, there have been four probable and 18 suspected cases of heart inflammation or myopericarditis reported, according to the advisory committee.

Military vaccinations

The June 25, 2003, edition of the Journal of the American Medical Association (JAMA) published the “U.S. Military Smallpox Vaccination Program Experience” (JAMA 2003;289:3278-3282). This summary characterizes the more than 450,000 smallpox vaccinations conducted between December 2002 and May 2003. The single case of encephalitis and 37 cases of acute myopericarditis that developed all recovered, and there were no attributed deaths. The authors concluded that mass smallpox vaccination can be conducted safely with lower rates of serious adverse events than previously anticipated. A summary of the military experience may be located on the Department of Defense Web site.

Federal officials said recently that many states have accomplished the first phase of the Bush plan and are reviewing the steps needed for the next phase that would include the first responders.

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Back injuries cut by 57 percent, costs by 71 percent through lifting equipment, teamwork

The National Institute of Occupational Safety and Health (NIOSH) has recognized St. Louis-based BJC HealthCare for its involvement in a successful project to reduce work-related back injuries in its nursing homes through a combination of lifting equipment and teamwork. NIOSH awarded its 2003 Partnering Award to the project partners, including BJC HealthCare, BJC Occupational Health Nurse Council, Washington University and West Virginia University. NIOSH said over a three-year period, the project reduced the frequency of back injuries in six BJC facilities by 57 percent, lowered injury rates by 58 percent and decreased worker compensation expenses by 71 percent.

The project identified movements and postures that put nursing assistants at risk for back strain, stress and injury in lifting and moving patients. It also evaluated mechanical lifting devices for reducing those stresses and strains, and implemented a "best practices" program based on those results and employee input. The project partners received the award during the National Occupational Research Agenda (NORA) Symposium 2003, co-sponsored by NIOSH on June 23-24 in Arlington, VA. More information, resources and tools are available from Premier Safety Institute’s Back Injury Prevention module.

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American Hospital Association Quest for Quality Prize honors leadership

The American Hospital Association’s Quest for Quality Prize honors hospital leadership and innovation in quality, safety, and commitment to patient care, and is supported by grants from McKesson Corporation and the McKesson Foundation.

Nominations for 2004 are now being accepted. All U.S. hospitals and multi-hospital systems are invited to apply for the prize. Hospitals must show they have:

  • Implemented and are sustaining a culture of safety.
  • An ability to demonstrate significant improvements and results in patient safety through systematic use of information and data to improve care processes and overall patient care.

The recipient will receive $75,000 and a symbol of the award at the American Hospital Association Health Forum Summit, July 2004, in San Diego. Two finalists will receive $12,500 each. Applications for the 2004 Award are due October 18, 2003. See below for additional information on award criteria, an application or 2003 recipients, or call 312.422.2700.

Downloads and links

For information and application go to www.aha.org/questforquality, or questforquality@aha.org

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Healthcare Quality Colloquium at Harvard highlights patient safety and quality initiatives

Patient safety professionals and other healthcare executives who want to gain practical insights into healthcare quality improvement and medical error reduction should plan on attending the Healthcare Quality Colloquium at Harvard University, August 24-27, 2003, in Cambridge, MA.

Premier is a co-sponsor of the Colloquium, along with other prestigious organizations that include the Agency for Healthcare Research and Quality (AHRQ), the Joint Commission on Accreditation of Healthcare Organizations, (JCAHO), the Institute for Safe Medication Practices (ISMP), and the National Patient Safety Foundation (NPSF).

The Colloquium will feature a special pre-conference session on patient safety officer training, along with general conference sessions on error reduction and quality enhancements and the role of technology, informatics, competition for quality, and six sigma. Cases studies of successful programs, as well as practical initiatives for plans and providers, will be presented.

Faculty for this year’s event include:

  • Molly Joel Coye, M.D., M.P.H., founder and president, Health Technology Center.
  • Harvey V. Fineberg, M.D., Ph.D., president, Institute of Medicine, National Academy of Sciences.
  • George C. Halvorson, chairman and CEO, Kaiser Foundation Health Plan and Hospitals.
  • John Iglehart, editor, health affairs and national editor, New England Journal of Medicine.
  • George Isham, M.D., MS, medical director and chief health officer, HealthPartners.
  • Arthur Miller, Esq, M.A.
  • Dennis S. O'Leary, M.D., president; JCAHO.
  • David Shulkin, M.D., president, Patient Safety Officers Society.

Classes will be held on the Harvard University campus. For registration information and exhibit/sponsorship opportunities, visit the Colloquium Web site.

Downloads and links

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Safety tools

 

Slides - Hand hygiene educational resource

Educational materials promoting hand hygiene in healthcare facilities are now available from the Centers for Disease Control and Prevention (CDC). The educational slide sets are available as both core and supplemental slides, with or without speaker notes and in different formats. Additional materials include a poster that shows how “bugs” can lead to infection and may be found on healthcare worker's unclean hands. Pin-on buttons are also available for purchase.

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Safety climate survey - IHI

Organizations working to develop or improve a culture of safety need a reliable measure to monitor the success of their initiatives. Using the Institute for Healthcare Improvement’s (IHI) “Safety Climate Survey” tool, an organization can gain information about the perceptions about safety among front-line clinical staff in their clinical area, as well as management’s commitment to safety. The survey also provides information about how perceptions vary across different departments and disciplines. As the team tests and implements changes to improve the culture, it can repeat this survey periodically to assess the impact of those changes. Organizations using this tool successfully first collect a baseline measurement and then re-survey periodically (semi-annually or annually) to assess the impact of changes they are making. Improvement in staff perceptions of the safety climate has been linked to decreases in actual errors, patient length of stay, and employee turnover.

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Surgical site infection tools - IHI/CMS and others

A national Surgical Infection Prevention Collaborative (March 2002-April 2003) was led by Qualis Health and sponsored by the Centers for Medicare & Medicaid Services (CMS). As a result of this collaborative, the Institute for Healthcare Improvement (IHI) developed the Collaborative learning methodology with colleagues from Associates in Process Improvement (API). IHI, API, and Qualis Health worked with a panel of experts, including representatives from the Centers for Disease Control and Prevention and the Oklahoma Foundation for Medical Quality, to develop the charter, change package, and measurement strategy for the Collaborative. After the conclusion of the Collaborative, Qualis Health updated the charter, change package, and measurement strategy to reflect the learning from the 56 participating teams.

QHC requires free registration to access all tools. The site will include results from teams that participated in the collaborative, as well as tools, such as forms, policies and order sets.

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Tips - Implementing CPOE in community hospitals

Community hospitals implementing computerized physician order entry are succeeding in gaining physician participation and addressing the gaps in safety and quality they were targeting, according to a new report by the California HealthCare Foundation and First Consulting Group. The study is based on interviews with CPOE software vendors and key staff at 10 community hospitals that have made significant progress in implementing CPOE. Successful projects require the organization's CEO and medical, nursing, and pharmacy leadership to be "on board," according to physicians and project leaders interviewed in the study. Other keys to success included sufficient resources; a collaborative spirit; hospital and physician experience with computer systems; and a physician champion and cohesive medical staff.

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Computer staffing model - Bioterrorism response

A new computer model is available to help hospitals and health systems plan antibiotic dispensing and vaccination campaigns to respond to bioterrorism or large-scale natural disease outbreaks. The model was funded by the Agency for Healthcare Research and Quality (AHRQ) and developed by researchers at Weill Medical College of Cornell University after testing a variety of patient triage and drug dispensing plans. This project is part of a larger initiative of the U.S. Department of Health and Human Services to develop public health programs to address bioterrorism concerns. This new resource is the nation's first computerized staffing model that is downloadable as a spreadsheet or accessible as a Web-based version. It can be used to calculate the specific needs of local healthcare systems based on the number of staff they have and the number of patients they would need to treat quickly in a bioterrorism event. The model allows healthcare systems planners to estimate the number and type of staff required to operate these clinics in order to provide an entire community with critical medical supplies in an efficient and timely fashion. The model can be downloaded to run on common spreadsheet software and customized for use by health officials at all levels of government, hospital administration, and emergency medical planning.

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AHRQ and AONE reports address staffing, work environment and safety

Increasing nurse-staffing levels and reducing interruption are among the strategies that may lead to improved patient safety, according to an Agency for Healthcare Research and Quality (AHRQ) evidence report. Based on a review of 115 existing studies conducted in healthcare and non-healthcare settings, the report concluded that there is enough evidence in the scientific literature to make specific recommendations about these strategies for improving patient safety. The report, “The Effect of Health Care Working Conditions on Patient Safety,” created by the Oregon Health & Science University Evidence-Based Practice Center, describes additional workplace-related steps that show evidence of increasing patient safety.

AONE also has released a survey report addressing staffing in the work environment. The report is volume II of “Health Work Environments: Striving for Excellence,” and is entitled “Insights from a Key Informant Survey on Nursing Work Environment Improvement and Innovation.” Highlights cover leadership development and effectiveness, empowered collaborative decision-making, work design and service delivery innovation, values-driven organization culture, recognition and rewards systems, and professional growth and accountability.

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Editorial team

Gina Pugliese, RN, MS editor
Judene Bartley, MS, MPH, associate editor
Donna Bernstein, MPH, marketing consultant
John Hall, BSJ, contributor
Derek Kleckner, BA, Web master
Judith Luca, RN, BSN, contributor

About Premier

Premier, Inc. is a national strategic alliance of leading hospitals and healthcare systems representing more than 200 not-for-profit owners that own, operate, or are affiliated with approximately 1,600 facilities. Premier  members  have access to a wealth of resources that support them as they evolve into integrated delivery systems and improve community health across the continuum of care.  Premier maintains corporate offices in San Diego, CA; Charlotte, NC; Chicago, IL; and Washington, DC. For information, visit www.premierinc.com.

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