Two years of training on team communication, leadership, and decision-making practices raised the perception of a culture of safety among employees of one Ohio medical center.
As the saying goes, "It's only a mistake if you don't learn from it." This philosophy of continual improvement is key in creating an organizational culture of safety to help reduce medical errors.
Organizations with strong safety cultures are places where individuals can report errors or near misses without punishment, where interprofessional collaboration to find solutions to patient safety problems is encouraged, and where there are dedicated resources to address safety concerns, according to the Agency for Healthcare Research and Quality.
A study, published in the American Journal of Medical Quality, has found that crew resource management (CRM) is one way to improve the perception of a culture of safety by hospital employees.
CRM is a training program that came from the airline industry and focuses on team communication, leadership, and decision-making practices.
The Ohio State University Wexner Medical Center is an academic medical center with more than 1,300 beds. Two years after implemented CRM at its six hospitals and two campuses, employees' perceptions of the organization's patient safety culture showed improvement.
Training consisted of day-long retreats where leaders and staff developed CRM safety tools such as checklists and standard protocols.
There was also role-playing around conflict management, respectful cross-checking, and assertive statements. System-wide internal monitoring processes were developed to evaluate adoption and use of safety tools as well as the occurrence of avoidable events.
Results
In 2011, the AHRQ's Hospital Survey on Patient Safety Culture was given to all employees before CRM implementation. In 2013, after receiving CRM training and using its concepts for about 2 years, employees were reassessed and reported:
A 9% increase in organizational learning/continuous improvement
A 9% increase in frequency of mistakes reported, enabling employees to address potential safety issues
An 8% increase in communication openness
A 6% increase in teamwork within departments
A 4% increase in teamwork across departments
Based on these results, "cultural transformation is possible," write the study's authors, but it takes dedication from an organization's leaders.
"To be ultimately successful with a large-scale program of patient safety culture transformation, continual leadership engagement and endorsement is needed," the study concluded.
Drug monitoring laws are on the rise, but their effectiveness in curbing the prescribed use of hydromorphone, oxycodone, and other opioids for pain is unclear.
States are increasingly implementing laws that aim to curb opioid abuse, addiction, and overdose, but their effectiveness is unclear, judging by two studies with conflicting results.
One study, published in Health Affairs, finds that state prescription drug monitoring programs may help curb opioid overdoses because they help to reduce prescribing.
Weill Cornell Medicine researchers analyzed 10 years of data from the National Ambulatory Medical Care Survey, which collects information on patients, office visits, and clinicians.
They analyzed 26,275 ambulatory care office visits for pain that occurred in 24 states that had upgraded or implemented drug monitoring programs during the 2001-2010 study period.
What they found was that "the implementation of a prescription drug monitoring program was associated with more than a 30% reduction in the rate of prescribing of Schedule II opioids."
This reduction immediately followed the launch of the program "and was maintained in the second and third years afterward," according to the study abstract.
Schedule II opioids, which include hydromorphone, meperidine, oxycodone, and fentanyl, are the most-addictive painkillers. The study also found that the programs' effects on "overall opioid prescribing and prescribing of non-opioid analgesics were limited."
Contradictory Findings
When it comes to the most vulnerable populations, however, these laws may have little effect, finds a different study in the New England Journal of Medicine.
Researchers from UCLA School of Law and the Dartmouth Institute of Health Policy and Clinical Practice examined a national population of 2.2 million disabled Medicare beneficiaries ages 21 to 64.
They found no significant association between state laws and hazardous prescribing patterns, such as very high daily opioid doses and the rate of nonfatal overdose.
Although states added 81 controlled-substance laws from 2006 through 2012, in "2012 alone, 47% of beneficiaries filled opioid prescriptions [and] 8% had four or more opioid prescribers," the study abstract said.
In fact, the researchers observed no "significant associations between opioid outcomes and specific types of laws or the number of types enacted.
The percentage of beneficiaries with a prescription yielding a daily [morphine-equivalent dose] of more than 120 mg did not decline after adoption of a prescription-drug monitoring program."
Researchers studying data from 37 major nonprofit U.S. children's hospitals found that ICU usage was 254% higher when comparing the lower eighth to the upper eighth of hospitals.
Hospital costs for pediatric patients with asthma can vary by as much as 87%.
Researchers who analyzed hospital records in a large national database found that even when patients were grouped by characteristics like age or severity of illness, hospitals differed significantly in inpatient costs, length of stay, and time spent in the ICU.
"As the most prevalent chronic illness in children, asthma imposes a major financial burden on many healthcare systems," said study leader Jeffrey H. Silber, M.D., Ph.D., director of the Center for Outcomes Research at The Children's Hospital of Philadelphia, in a press release.
Silber and colleagues from CHOP and the Perelman School of Medicine at the University of Pennsylvania co-authored the study, published in JAMA Pediatrics.
For patients with a similar set of characteristics, researchers found that the median hospital costs varied by 87%, total length of stay varied by 47%, and ICU usage was 254% higher, all when comparing the lower eighth to the upper eighth of hospitals.
The research team analyzed data from nearly 49,000 children hospitalized for asthma at 37 major nonprofit U.S. children's hospitals in the Pediatric Health Information dataset. All the children were hospitalized between 2011 and 2014.
The study team used an analytical tool it developed called "template matching." The tool grouped patients by different characteristics to create templates that could be compared to matched patient templates derived from each hospital.
This matching system, according to Silber, allows hospital to audit their costs and resource use in a more refined way than simply reporting whether a hospital is more or less expensive in an aggregate fashion for a given diagnosis.
Patterns of resource use differed significantly across hospitals when classified by patient risk.
In some hospitals, costs for higher-risk patients were significantly higher compared to matched controls, while in other hospitals, those costs decreased as patient risk increased.
"If hospitals can better understand if their care practices are disproportionately expensive and inefficient compared to other hospitals, they may be better able to pinpoint opportunities for quality improvements," said Silber.
By implementing guidelines for the perioperative handling of blood, researchers have successfully reduced blood use and waste.
An evidence-based blood management initiative devised by a multidisciplinary team at Vanderbilt University Medical Center in Nashville, TN has saved $2 million and reduced blood use by 30% at the academic medical center.
The program, which focuses on improving the processes around ordering, transporting and storing blood, was presented this week at the 2016 American College of Surgeons National Surgical Quality Improvement Program Conference in San Diego.
In a media release detailing the initiative, VUMC researchers noted that many hospitals reflexively order a transfusion based on habit, rather than assessment.
With that in mind, the first step for the initiative was to change the standard process of initially ordering two units of blood, which is not always needed.
Instead, researchers used an enhanced Computerized Provider Order Entry (CPOE) to support a single unit, based on a specific assessment of each case, and then followed up and ordered more blood when necessary.
That step allowed VUMC to reduce red blood cell transfusions by more than 30%—from 675 units per 1,000 discharges in 2011 down to 432 units per 1,000 discharges in 2015.
Study lead author Barbara J. Martin, MBA, RN, said that reducing the numbers of blood transfusions also reduces the risk of complications—including transfusion reaction, infection, volume overload, increased length of stay, and death.
"The data on restrictive transfusion has been out for years documenting that patients have better outcomes with a more restrictive transfusion strategy," Martin said in remarks accompanying the presentation.
"We were looking at whether we could guide providers to treat symptomatic anemia with a single unit of blood rather than the usual two units."
For general and vascular surgery patients who underwent NSQIP targeted procedures—including colectomy, proctectomy, ventral hernia, and appendectomy—between 5% and 6% were transfused with an average of 2.4 units of blood per patient in 2015, compared with 11% transfused with an average of 4.6 units of blood per patient in 2011.
Reduced Blood Waste
"We found that in that particular population, many of whom are transfused for acute blood loss, we still saw a significant decrease in the number of units transfused into the patient," Martin said.
The VUMC team also reduced blood wastage correcting inefficiencies in the ordering, transport, and storage of blood, such as:
When more than one unit of blood is ordered, it is sent in a cooler rather than the pneumatic tube.
Coolers were reconfigured to optimize temperature management.
A specific member of the staff is tasked with "ownership" of the blood products, including returning unused product to the blood bank.
Individual unit wastage is reported to clinical leaders for review; aggregate data are reported monthly.
The improvements resulted in fewer than 80 units of blood being wasted in 2015, down from 300 in 2011.
Martin said that the guidelines developed at VUMC could easily be implemented at other hospitals. "You have to prioritize what your initiatives are. At Vanderbilt, we had a lot of opportunities with blood transfusion and blood wastage and we made huge gains," she said. "Any incremental improvement would take additional resources."
The initiative also addresses broader implications for the way blood donations are viewed, Martin said.
"Blood is a limited resource and we have a responsibility as a healthcare provider to optimize the use of a resource that is difficult to get and only available through altruistic donations," she said.
The next two years will be decisive in determining the financial impact of the government-operated health insurance exchanges, says Moody's Investors Service.
There is light at the end of the financial-outlook tunnel for nonprofit hospitals as the performance of the Patient Protection and Affordable Care Act's health plan exchanges matures, according to Moody's Investors Service.
The financial uncertainty unleashed by the launch of the PPACA exchanges in 2014 should ease significantly over the next two years, Moody's says.
"Since their introduction in 2014, health insurance exchanges have benefited hospitals by facilitating gains in insurance coverage, particularly in states that did not expand Medicaid coverage," the report says.
"However, despite the improved insurance coverage, the long-term credit impact of the exchanges is not yet settled. A significant share of insurance gains nationally is due to people obtaining coverage under expanded Medicaid eligibility while the exchanges themselves have experienced stress with most insurers losing money on exchange-sold plans."
The report, released last week, identifies three factors that Moody's says will determine whether the public exchanges will have a net positive or net negative financial impact on nonprofit hospitals:
The profitability of HIX health plans: "Insurer losses on the exchanges are credit negative for not-for-profit and public hospitals because they threaten the long-term viability of the exchanges by reducing the number of insurers that are willing to participate."
The impact of HIX health plans on the financial operating margins and market share of nonprofit hospitals: "The exchanges present hospitals with the opportunity to gain market share, but also present risk through lower reimbursement or growing bad debt."
The status of Medicaid expansion under the PPACA in the state where nonprofit hospitals are based: "The exchanges have a more important role in states that did not expand Medicaid such as Texas and Florida."
Several factors are cited as contributing to uncertainty over whether commercial insurers can manage HIX health plans profitably:
"Most insurers have incurred losses selling individual insurance products on health exchanges owing to a number of reasons. These include last-minute rule changes which allowed individuals to maintain pre-Affordable Care Act polices, thereby removing a large component of healthier individuals from the risk pool, the non-payment of the risk corridor funds due to insurers (these payments were intended to protect insurers from excessive losses in the first three years of the exchange's operation), as well leniency that allowed individuals to obtain coverage mid-year without providing evidence of qualified life events."
The ability of nonprofit hospitals to consistently achieve a net-positive operating margin on medical services provided to HIX health plan beneficiaries has yet to be determined, the Moody's report says.
"Hospitals' ability to maintain adequate profitability through their reimbursement contracts with insurers under the exchange products is a key credit factor when assessing the overall impact of the exchanges; lower payment levels on these contracts would result in lower profitability and be credit negative. Although the contracts are currently profitable, not all contracts are as profitable as hospitals' existing commercial contracts, putting pressure on margins."
Moody's reports that uncertainty persists regarding the HIX impact on the market share of nonprofit hospitals.
"An additional factor we will monitor is what effect high deductibles have on patient behavior. Having greater financial responsibility may lead patients to shop for value, which would benefit high performing hospitals that could gain market share."
Finally, market conditions at the state level, such as whether a state has expanded Medicaid under the PPACA also are playing a determinative role in the HIX impact on nonprofit hospitals.
"Medicaid expansion is responsible for a larger share of the reduction in the national uninsured rate. However, in non-expansion states, increases in insurance coverage are due to people purchasing coverage on the exchange."
The proliferation of freestanding emergency departments is marked by the duplication of services and little improvement in access for the underserved, research shows.
Vast differences in the composition, location, and patient mix of freestanding emergency departments are the result of a patchwork of state regulations governing such facilities, researchers have discovered.
A study conducted by Brigham and Women's Hospital researchers and published in the Annals of Emergency Medicine shows that nationwide:
54.2% of freestanding EDs are owned by or affiliated with hospitals
36.6% are independently run by physician groups or other entrepreneurs
45.3% of freestanding EDs were for-profit entities, and
43.9% non-profit entities
Researchers conducted ZIP code-level geographic analyses on the three states with the highest number of freestanding EDs: Texas, Ohio, and Colorado.
They found 360 freestanding EDs nationwide, up sharply from 222 in 2009—a 62% increase during the study period.
Generally, freestanding EDs are located in areas with population growth, higher incomes and a higher proportion of the population with private insurance.
That's not surprising—businesses go where the money is—but could also be skewed by the fact that many hospital-based EDs are already in areas with higher proportion of the population on Medicaid or uninsured.
Of the almost 200 freestanding EDs in Texas, most were highly concentrated around several metropolitan areas and were located in ZIP codes that had fewer Hispanics, a greater number of hospital-based EDs and physician offices, and more physician visits and medical spending per year than ZIP codes without a freestanding ED.
In Texas, only 22.1% were owned by, or affiliated with hospitals, 71.3% of freestanding EDs were for-profit, and they are more likely to be located in ZIP codes with existing hospital EDs.
In Ohio, with 34 freestanding EDs, all but one were affiliated with hospitals, while only 5.8% were for-profit, and they were more likely to be located in areas without hospital EDs.
In Colorado, which had 24 freestanding EDs, 45.8% were affiliated with hospitals, and 61.9% were for-profit.
Researchers say their findings should help inform states on the effects their regulations have on the development of such facilities.
"Our findings, which addressed the distribution of freestanding EDs in relation to underserved populations and populations with fewer health services, can help inform ongoing policy discussions on how to regulate and pay freestanding EDs, said Jeremiah Schuur, MD, MHS, vice chair, Clinical Affairs at the Department of Emergency Medicine at Brigham and Women's Hospital, and corresponding author of the study. His remarks were in a press release accompanying the report's publication.
"Policymakers should review state regulations and payment policies to encourage the expansion of freestanding EDs in ways that will improve access and reduce cost, not duplicate services."
The CMS chief tells the Senate Finance Committee that 'multiple approaches' are being considered to ensure a smooth launch of the reporting period for the sweeping physician payment reforms put forward in the Medicare Access and CHIP Reauthorization Act.
Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt said Wednesday that the federal government could delay the Jan. 1, 2017 start of the reporting period for physician payment reforms put forward under the Medicare Access and CHIP Reauthorization Act.
"We need to launch this program so that it begins on the right foot. That means that every physician in the country needs to feel like they are set up for success," Slavitt told Senate Finance Committee Chairman Orrin Hatch, (R-UT).
Hatch opened a question-and-answer session with Slavitt by relaying the concerns of payers and providers that "they won't have enough time to prepare to effectively participate in the new MACRA incentive payment program when it starts on Jan. 1, 2017."
"Assuming that CMS releases its final incentive program rules around Nov. 1, physicians are only going to have about two months before the program goes live," Hatch said.
"Considering that the MACRA law does give CMS flexibility as to the start of the physician reporting period, what options are CMS considering to ensure that this program gets started on the right foot?"
Slavitt acknowledged that the Jan. 1 startup date for the 856-page proposed rule "has been a significant source of feedback" for CMS.
"We remain open to multiple approaches," he said. "Some of the things that are on the table that we are considering include alternate start dates, looking at whether shorter periods could be used, and finding other ways that physicians could get experience with the program before the impact of it really hits them."
Representatives of the American Medical Association, Trinity Health, and Blue Cross Blue Shield pressed for a postponement to the proposed MACRA rule at a panel Monday hosted by the Alliance for Health Reform, and sponsored by the AMA and the BCBS Association, MedPage Today reported this week.
The MACRA reporting period is slated to begin in January 2017, with payments adjustments based on those metrics to begin in January 2019. The AMA has recommended pushing back the rollout to July 2017.
Spending is projected to rise at a rate faster than growth in the country's gross domestic product. Contributing factors include economic growth, rising costs, and rising volume.
For the 10-year period between 2015 and 2025, national healthcare spending is projected to grow at a 5.8% annual rate, according to federal research released on Wednesday.
The 2016 National Health Expenditures Report, produced by the Office of the Actuary at the Centers for Medicare & Medicaid Services, projects annual healthcare spending to rise at a rate 1.3% faster than growth in the country's gross domestic product.
If the projection is accurate, healthcare spending as a share of the U.S. economy will rise from 17.5% in 2014 to 20.1% in 2025.
The lead author of the expenditures report, Sean P. Keenan, an economist at the CMS Office of the Actuary, highlighted the findings of the federal research during a conference call Wednesday afternoon.
The expected drivers of healthcare spending growth are similar to those identified in last year's expenditures report, he said.
Growth of health spending is expected to be influenced by changes in economic growth, faster growth in medical prices, and population aging. By the end of the 10-year period, it is projected that federal, state, and local governments will finance 47% of national health spending, up from 45% in 2014.
Projected national health spending growth "is faster than observed in recent history, but slower than in the two decades before The Great Recession, in part because of trends such as increasing cost sharing in private health insurance plans and various Medicare payment update provisions," Keenan said.
Two key provisions of the Patient Protection and Affordable Care Act that are designed to reduce the number of uninsured Americans—Medicaid expansion and public exchange "marketplaces" where individuals and families can purchase healthcare coverage—fueled a spike in medical service spending in 2014 and last year, the expenditures report says.
Health spending growth rose from 2.9% in 2013 to 5.3% in 2014, according to the report. For 2015, continued enrollment growth in Medicaid and the marketplaces, and projected increases in enrollment in employer-sponsored plans, is expected to have resulted in "a slight acceleration in spending growth (5.5%) and a further substantial reduction in the number of uninsured" (7.2 million).
The upward pressure on healthcare spending linked to Medicaid expansion and marketplace health plan enrollment is expected to ease this year, the report says.
"By 2016 the transition of consumers into Medicaid and Marketplace plans and the associated declines in the number of uninsured people are expected to slow significantly, contributing to a lower rate of growth in health spending (4.8%)."
The fastest rate of spending growth is expected to occur between 2020 and 2025, as the result of ballooning enrollment in Medicare linked to the aging baby-boomer population.
By 2025, one in five Americans is expected to received health coverage through Medicare, the expenditure report says.
Drug Spending Uncertain
Developments in the prescription drug market could have a major impact on the accuracy of the expenditure report's projections, Keenan said.
"There is uncertainty in a lot of our projections, and that is especially true with prescription drug spending. With the new drugs, as you saw with hepatitis C, they can significantly impact spending if a high-priced drug comes on and has high use."
It is difficult to predict the development of new drugs in a 10-year timeframe.
Researchers at the Office of the Actuary consulted with pharmaceutical experts, and the consensus was that "there is no new Sovaldi coming out in the near future that is going to have an impact like that drug and similar drugs had in 2014 and 2015," said Keenan.
"But there certainly is the potential that [a new drug] could be approved and have high use and high spend that could impact the projections."
Dispelling a common notion, the agency says HIPAA breach disclosure rules usually apply to ransomware.
Since ransomware attacks healthcare organizations do not necessarily result in data being exfiltrated from the breached systems, it has been assumed by some that the usual Health Insurance Portability and Accountability Act breach notification rules do not apply.
It clarifies that a ransomware attack usually results in a breach of healthcare information under the HIPAA Breach Notification Rule.
Healthcare organizations and other covered entities must notify individuals whose information is involved in a breach, as well as the media in some cases, unless the breached entity can document that there is low probability that the information was compromised.
The OCR guidelines list some of the activities required by HIPAA, which apply to ransomware attacks:
Conducting a risk analysis to identify threats and vulnerabilities to electronic protected health information, as well as establishing ways to mitigate or remediate these identified risks.
Implementing procedures to take precautions against malware.
Training users to detect malware and report such detections.
Limiting access to protected health information to people and software requiring such access.
Maintaining disaster recovery, emergency operations, frequent data backups, and practice restorations.
The guidance also discusses ways to spot the signs of ransomware, as well as how to understand what it is and how it works.
Through ransomware, attackers encrypt data with a key known only to the attacker, making the data inaccessible to that data's authorized users. Attackers typically demand a ransom be paid before they will supply the key to decrypt the data.
HHS Secretary Sylvia Burwell recently highlighted ransomware in a June 20 letter she sent to chief executive officers of companies in the healthcare sector.
Earlier this month , ahead of the release of the new guidance, a pair of Congressmen asked for different HIPAA rules for malware and ransomware attacks.
A Florida pediatric hospital's partnership with John Hopkins and resulting name change yields an immediate positive effect on its finances.
The St. Petersburg, FL-based All Children's Hospital officially added "Johns Hopkins" to its name in April, outwardly aligning itself with the organization it has been medically affiliated with since 2011.
Leadership for the now Johns Hopkins All Children's Hospital said they decided to go ahead with the name change in order to reap the benefits of an internationally known brand, which they expect will improve everything from recruiting to patient care to brand recognition, the Business Observer reported last week.
"Our name is very well recognized on the west coast of the state and in Florida," hospital board chairman Mark Stroud told the paper. "But Johns Hopkins is a worldwide brand."
To evaluate All Children's ahead of the name change, Johns Hopkins put the 256-bed hospital through several rigorous quality-of-care tests from 2011 through this year.
"The change signifies we met the rigorous standards set by Johns Hopkins Medical Center," said Sylvia Ameen, the hospital's vice president of marketing and communications. "You have to go through a process. It doesn't just happen."
Results
And it appears the name change is already netting results—according to Ameen, a couple from Sarasota, FL, pledged a multimillion-dollar donation when they heard of the Johns Hopkins relationship. The funding will go toward a new CT scanner and other equipment.
"This is a milestone moment," Ameen said. "It's not often a hospital system changes its name, especially to Johns Hopkins."
The name change represents the affiliation between the health systems. The member substitution agreement details a partnership that allows the All Children's board to remain locally controlled, with all assets remaining part of the St. Petersburg facility.
"There's a lot to a name, especially when that name is a world leader in healthcare," the hospital said in a statement when the name change was announced.
"Our new name honors our longstanding tradition of excellence in pediatric care and directly connects us to Johns Hopkins, a globally respected name in healthcare. The timing of our 90th year of service makes this a perfect time to make the announcement."