Take flu shots for instance. How do you best ensure that you can reach the optimal percentage of staff? How about an attention-grabbing catch-phrase?
At Peninsula Regional Medical Center, Salisbury, MD, a new theme is introduced every year during flu season. For 2010, the organization said "Boo to the Flu."
"We had Halloween-themed costumes, and gave out candy and stickers saying 'I said Boo to the Flu'," says Tracy Daugherty of Peninsula Regional's Employee Health department. They also held a drawing for a $50 gift certificate. Special artwork was created specifically for the event's stickers and posters.
"The Employee Health program has grown to reach out to not only employees, but contractors, physicians, volunteers, students, everyone who is associated with the hospital," says Karen Mihalik, RN, CIC, infection preventionist and member of Peninsula Regional's Flu Team.
"Boo to the Flu" was a follow-up to last year's theme, "Tackle the Flu," which promoted awareness with similar giveaways as well as staff wearing their favorite football jerseys to work.
This year, Peninsula had a new level of support from upper management in the form of mandatory net learning.
"This allows the organization to poll staff to find out why they may or may not be receiving the flu shot," says Daugherty. "We can find out the employees' reasons behind it, and educate to those reasons."
The net learning polling system has been in place for years, but was not mandatory until now. While the non-mandatory version was helpful, it was nowhere near as beneficial or educational as receiving feedback from all employees.
"We can use the information we learned from it to develop the program in the future," says Daugherty.
The employee flu shot clinics are part of a larger outreach project spearheaded by Peninsula Regional's overall healthcare awareness program.
"It's a multidisciplinary team," says Mihalik. "It's a big effort and not limited to just employees."
The program also includes family nights for flu shots, and the incredibly popular Drive-Thru Flu Clinic for the community. "We've been doing the Drive-Thru clinic for 17 years," says Mihalik.
It began as an extension of the mall booth concept. "We expanded from the booth due to a distinct need for flu shots," she says.
At first, the drive-through clinic was set up outside the hospital using the facility's own parking lot. These days the clinic has moved down the road to Arthur W. Perdue Stadium in order to accommodate the number of patients who show up.
"Last year we were just a few patients short of seven thousand," said Mihalik. The team's multidisciplinary approach comes into play when pulling together this enormously popular event.
"We need staff to organize the lot, involve security, make sure supplies are ordered. [We need] people to handle the consent forms. We need staffing to support the clinicians who are on site," said Mihalik.
All of this has become a sixteen-hour event that served over 5,000 people this year."We've got it down to a science now," said Mihalik. As expected with any project of this scale, there were lessons learned along the way.
"Before we moved to the stadium, we encountered traffic issues when the popularity grew," says Mihalik. When issues grew, like cars parked in neighboring residential areas or blocking the street, they knew the clinic would need a larger venue more apt to handle the flow.
"We've figured out now how to arrange the number of shot givers and consent takers, people to answer questions from patients, security to direct traffic," said Mihalik.
Impressively, all of this happens with in-house staff and volunteers. A combination of security and facilities management direct traffic (local police are aware of the event, but are not on site). The clinic itself is staffed by ten nurses at a time on an availability-based schedule. They rotate in and out as needed, with a core group of leaders on site at all times.
No one is required to participate as part of their job—everyone who works on the clinic does so voluntarily.
Physically, the drive through is set up to do a volume business. Rows of cars literally drive up to a tent, under which nurses wait on each side of the car to administer shots. Typically there are four lanes of traffic with two nurses manning each lane. Support staff act as runners to keep the nurses administering the shots supplied in vaccines (the vaccine is temperature sensitive and thus needs to be kept cool). The runners also keep each station stocked in alcohol preps.
Additionally, the clinic provides an educational service to patients. Before passing through the tents, they are provided with information on the flu, why vaccination is important, and key product information about the vaccine used.
"It's phenomenal—our staff is able to give 300 shots an hour," said Milahik.
Shelia Hull, RN, Joint Commission specialist with Pikeville Medical Center, Pikeville, KY, was with the organization just a few months before the latest PPR was due to The Joint Commission. At that time, she and her supervisor discovered the organization had fallen out of compliance with its timing and dating of physician orders.
“We were trying to come up with ways to achieve better compliance in this area,” says Hull. “We already had reminders at the documentation areas on each floor.”
The organization also had a program for brightly colored reminders for all entries to remind physicians about timing and dating. And yet, they still were not meeting the organization’s expectations.
It was time to expand to other methods.
They began with the CMO: she listened to the expectations the organization was hoping to meet and began addressing it at staff meetings. But this was a stopgap measure. It was an idea from the stroke manager in Pikeville’s ED that brought the process up a notch.
“The ED stroke manager said we needed to give them something like a report card, show them how well they’re doing,” says Hull.
Pikeville went with a color-coded system for demonstrating compliance:
90-100%: green
70-89%: yellow
Under 70%: red
“We had it broken down into what components they were missing,” says Hull.
Hull worked to do 70 chart reviews each month, followed by report cards for each.
“When the program started we weren’t where we should have been,” says Hull. “I think this was effective in getting their attention—I had calls from physicians who wanted to talk with me to explain what they needed to do to improve on where they were falling out of compliance.”
This increased awareness has brought about a marked improvement in timing and dating compliance.
The improvements were palpable just in terms of percentages: Pikeville began at 40% compliance and climbed quickly to 78% compliance. The goal, says Hull, is 90% at a minimum.
“We aren’t where we want to be yet, but it’s a steady improvement,” says Hull.
Positive reinforcement
It’s one thing to tell physicians when they are out of compliance; it’s another to do so without recognizing good work as well. To counter this, Pikeville also instituted a recognition program for those who remain “in the green” with timing and dating.
“We call it the 90-Plus Compliance Club,” says Hull.
This list of top performers is posted throughout the facility and is published regularly in the organizational newsletter. It is also sent to the CMO directly.
“It’s just a chance to congratulate them,” says Hull.
Still, improving compliance is a slow process—getting the right combination of communication and motivation. Physicians seem to be reacting well to the process, though.
“I take it when they contact me that they are looking to improve, otherwise they wouldn’t reach out,” says Hull. “I’ve had some contact me to say they thought they were doing better than they are, and that this made them more aware.”
Of course there will always be those who fight the process and remain non-compliant, but the vast majority took the report cards to heart.
Developing the form
In order to create the report card, Hull listened to “listserv chatter,” she says, in places like AHAP Talk, and found a wide range of ideas. Pikeville’s director of stroke crafted a report card of her own which would serve as the basis for the form now used at the facility.
“I discussed it with my supervisor, then with the vice-president, and then talked it over with the CMO,” says Hull. “We then put out what we were developing to each director so everyone was aware, and then sent out a letter to every physician.”
To put some weight behind the decision, this letter quoted not only Joint Commission standards on timing and dating of physician orders but also CMS requirements.
“We wanted to explain ahead of time” so as not to catch them off-guard, says Hull.
Next step
The next course of action is to continue preparing for Pikeville’s upcoming survey—including timing and dating of orders.
“What we’re doing is having the unit secretaries or nurses pull their orders to see what has or hasn’t been timed. The challenge right now is timing, not dating—our physicians are very compliant with dates. Timing remains a challenge.”
When a unit sees they have an issue with failing to time and order, they attempt to catch the physician while he is still on the unit to rectify the issue. If the physician has already moved on, they flag the record.
Another area being worked on is the electric time and date stamp. Pikeville is in the process of converting over to a completely electronic order submission program.
“We haven’t got there yet, but it’s just a process of getting it into place,” says Hull. “It takes a lot of time and training.”
It’s really about perseverance more than anything, she says.
“Stick to your guns. When you audit and see that physicians aren’t complying we need to bring that to their attention,” says Hull.
Get the idea, the concept for communication, and work your way through each individual department. Find out what time physicians make the rounds, and try to meet them on their unit face to face.
“I like to do things in person,” says Hull. “But being in person with hundreds of physicians can be nearly impossible. Still, I make every effort to meet them one on one. I think they perceive me better when we speak face to face rather than receiving a letter.”
In the cases where a face to face just can’t happen, Hull will personalize the letter to the physician to make the importance of what she’s asking as clear as possible.
Tone matters too.
“I always talk to the physician like I would with a good colleague or good friend. I try not to point fingers or embarrass anyone,” says Hull. “As long as you’ve got your facts with you to explain why you’re having this discussion, you’ll be fine.”
Those facts are invaluable. Physicians are known to prefer hard data when being asked to change methods or behavior, and having percentages of timing and dating orders to back up your statements is a must.
The Joint Commission has announced that its long-time president and chief executive of Joint Commission Resources and Joint Commission International will be leaving the position on July 1, 2010.
Karen H. Timmons has headed up the organizations since 1999. Since that time Joint Commission International has developed a presence in 90 countries and currently accredits facilities in 41 countries.
Joint Commission International is also a part of the World Health Organization's Collaborating Centre for Patient Safety Solutions.
"Karen has provided excellent leadership for JCR and JCI and for The Joint Commission for the last 34 years," said Joint Commission President Mark R. Chassin, MD, in a prepared statement. "She and her team have guided JCR and JCI through dramatic growth that has helped these organizations earn reputations as worldwide leaders in helping healthcare organizations prosper by improving quality of care and patient safety. We are grateful for her service and her commitment."
The Joint Commission has brought in Paula Wilson to act as interim head of Joint Commission Resources and Joint Commission International. Wilson previously was vice president for policy at the United Hospital Fund. A member of the faculty at the Wagner School of Public Service at New York University, Wilson is also a member of the board of the New York City Health and Hospitals Corporation and serves on the finance committee of the Saint Mary's Center, Inc.
The Joint Commission's plan to implement CMS telemedicine standards for hospitals (both acute and critical access) has been pushed back until March 2011, according to an official announcement from the accrediting body.
Originally slated for implementation on July 15, 2010, The Joint Commission had intended to add new Elements of Performance (EP) that would bring the organization's requirements more in line with CMS standards for telemedicine services, specifically for the credentialing and privileging of telehealth providers. CMS issued an extension to The Joint Commission on the grounds that CMS has proposed changes to telemedicine requirements—which will in turn affect the organization's own standards and in turn change the requirements The Joint Commission intends to implement.
Hospitals can comment on the proposed CMS rule changes until July 26, 2010.
There has been back and forth between the two agencies over the past year regarding telemedicine. The Joint Commission had intended to include the CMS requirements in their own standards as a means of aligning with CMS following the accrediting organization's deeming authority application, though The Joint Commission felt that CMS requirements for telehealth put an excessive burden on hospitals.
The accrediting body has maintained a belief that the CMS version of telemedicine requirements did not provide sufficient improvement of quality or safety to warrant the amount of work they placed upon hospitals for compliance.
The Joint Commission has announced it has plans to expand its Heart Failure Advanced Certification Program. The program, which the accrediting organization conducts together with the American Heart Association, looks at the continuum of care for patients who experience heart failure in various healthcare settings.
The Joint Commission is seeking input from healthcare organizations and professionals involved in caring for patients with heart failure. Specifically, The Joint Commission seeks comments on proposed standards. They also seek participants for focus groups on how the standards will be implemented, locations willing to participate in pilot testing for assessing standards compliance, and sites willing to play host to Joint Commission representatives to look at compliance with the standards.
In related news, The Joint Commission continues to seek feedback on recent updates to its sentinel event statistics. The accrediting body released updated numbers related to sentinel events last week. For more information on both of these topics, accreditation professionals should visit www.jointcommission.org.
The Joint Commission has announced an official update to its ongoing tracking of sentinel event statistics.
The Joint Commission has investigated 6,782 of the sentinel events reported from January 1995 through March 31, 2010. A total of 6,920 patients have been affected by sentinel events during that time frame, with 67%—4,642 patients—resulting in patient death, the accrediting organization says in its official statement. (More information directly from The Joint Commission can be viewed on its official Web site.
The top ten most frequently reported were:
Wrong site surgery
Suicide
Operative/post-operative complication
Delay in treatment
Medical error
Patient fall
Unintended retention of foreign body
Assault, rape, or homicide
Perinatal death or loss of function
Patient death or injury in restraints
The Joint Commission is also seeking out additional feedback from those who have been directly effected by a sentinel event in the past, posting a survey on its Web site (also available through the link above).
The Joint Commission announced this week a clarification on Information Management standard IM.02.02.01. This standard deals with the area of abbreviations, acronyms, symbols, and dose designations.
Previously, this issue was dealt with under the National Patient Safety Goals addressing do-not-use abbreviations. However, during the course of the Standards Improvement Initiative, rules for compliance with this issue were moved under the IM standards, specifically Element of Performance (EP) 2 of MS.02.02.01.
This change also included changes in language to the standard, which subsequently led to some confusion on the part of Joint Commission-accredited organizations. According to The Joint Commission, the new language appeared to indicate that hospitals had to craft a list of approved abbreviations (including acronyms, symbols, and dose designations)—which was not the intent of the standard.
Thus The Joint Commission has issued an update (effective July 1, 2010) clarifying the language of the standard (or rather, converting the standard language back to its previous wording in the 2009 version of the standard).
The Joint Commission has announced it will reinstate an anti-discrimination requirement that had been removed.
As of July 1, 2010, this requirement—deleted originally in 2003 with the thought that it was covered under other, existing standards—will be reinstated because of research on who those requirements cover. In fact, existing requirements usually only effect employees, and thus physicians, who are most often not hospital employees, were not covered under the requirements.
The changes will impact two Elements of Performance (EP) in the medical staff standards: EP MS.06.01.07 and EP MS.07.01.01 (discussing gender, race, creed, national origin).
The decision follows a request by the American Medical Association's Women Physician's Congress that the requirement be put back into place.
A recent round of edits to the Centers for Medicare & Medicaid Services' (CMS) interpretive guidelines has caught the attention of experts in the field for its focus on anesthesia guidelines.
Any hospital that accepts Medicare and Medicaid reimbursement must follow these interpretive guidelines, explains Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for The Doctor's Company, in Columbus, OH.
These guidelines must be followed for all patients in the hospital, such as commercial payer or no pay patients, and not just Medicare and Medicaid patients. The guidelines do not apply to critical access hospitals, which have their own manual.
The final memo was 17 pages long and completely rewrites the CMS anesthesia section standards. Every anesthesiologist, certified registered nurse anesthetist (CRNA), or anesthesiology assistant that practices in a hospital, including surgery, post-anesthesia care unit (PACU), outpatient department, and obstetrics, should be aware of these new guidelines along with all Prospective Payment System hospitals.
These standards are also of interest to places where moderate sedation may be given, says Dill Calloway, such as in the emergency department or endoscopy unit. It is important to note that deep sedation is anesthesia, which can only be done by an anesthesiologist, qualified physician, CRNA, or anesthesiology assistant.
A dentist, oral surgeon, or podiatrist, who is qualified under state law, may also administer anesthesia. The hospital's policy must address the circumstances under which a doctor, who is not an anesthesiologist, is permitted to administer anesthesia and hospitals must follow accepted standards of anesthesia care when establishing their policy and procedure. The American Society of Anesthesiology (ASA) has a number of position statement and guidelines.
Anesthesia tags
The anesthesia standards start at tag number 1000. The CMS hospital manual is 370 pages long and has 1,163 tag or section numbers. The new standards go into detail on the differences between anesthesia and analgesia.
In analgesia, the patient does not lose consciousness and is given medication for pain relief by blocking pain receptors. Anesthesia is the administration of a medication to produce blunting or loss of pain perception, voluntary and involuntary movement, autonomic function, and memory or consciousness.
The anesthesia standards apply to general anesthesia, regional, Monitored Anesthesia Care (MAC), and deep sedation can be done by an anesthesiologist, qualified physician, CRNA, or anesthesiology assistant.
Topicals, locals, minimal sedation, and moderate sedation can be done by an appropriately trained medical practitioner within their scope of practice, such as an emergency department physician or gastroenterologist. Also, these four services (minimal, local, minimal sedation, and moderate sedation) are not subject to the anesthesia administration and supervision requirement.
"Often these are administered by a RN," says Dill Calloway. "The hospital must have a policy detailing who can administer these that is consistent with the state scope of practice."
Supervision of anesthesiology assistants
The guidelines also include the supervision of anesthesiology assistants (AA) for those states that recognized this category of healthcare workers. Some states have opted out of the supervision requirement meaning that the CRNA does not need any physician supervision.
In states that have not opted out, the CRNA must be supervised by the operating physician or by an anesthesiologist who is immediately available.
Immediately available, explains Dill Calloway, means the anesthesiologist is within the same area, such as in the OR or the labor and delivery unit, and is not occupied. In other words, they should not be prevented from immediately conducting hands-on intervention, if needed.
If the hospital allows the operating surgeon to supervise the CRNA, there must be medical staff bylaws or rules and regulations that specify for each category of operating practitioner, the type and complexity of procedures that category of practitioner may supervise. However, individual operating surgeons do not need to be granted specific privileges to supervise a CRNA.
A pre-anesthesia evaluation must be done within 48 hours prior to surgery and documented in the medical record, Dill Calloway explains. This must be done by a qualified person, like a CRNA, AA, physician, or anesthesiologist for patients under going anesthesia such as a general, regional, or MAC. It must be done within 48 hours prior to the delivery of the first dose of medication given for the purpose of inducing anesthesia. CMS sets forth what should be documented as part of the pre-anesthesia evaluation as does The Joint Commission and ASA.
CMS now requires a few items to be documented as part of the intraoperative anesthesia record. This includes:
Name and hospital identification number of the patient
Name of practitioner who administered anesthesia, and as applicable, the name and profession of the supervising anesthesiologist or operating practitioner
Name, dosage, route, and time of administration of drugs and anesthesia agents
Techniques used and patient position, including the insertion/use of any intravascular or airway devices;
Name and amounts of IV fluids, including blood or blood products if applicable
Time-based documentation of vital signs as well as oxygenation and ventilation parameters
Any complications, adverse reactions, or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient's response to treatment
Hospitals are sick and need our help. That is the message process improvement concepts like Lean and Six Sigma hope to address as they become more commonly used in healthcare.
The symptoms, like waste and blame, pile on like any human illness.
"Blame is like a virus," said Marshall. "But there are no bad people, only bad processes."
As for waste, people adjust to it and get used to it. It takes "new eyes"—another common concept in Lean and Six Sigma—to spot waste that hospitals may have become so used to living with that they no longer even notice it.
Without change management, Marshall said, lasting change can't happen.
Key elements to change management include:
Leadership buy-in, active participation, and long-term thinking
Regular communication with key stakeholders (via e-mail, reports, and meetings)
Employee motivation through incentives (such as recognition, promotion, and burning platform)
System of checks and balances (e.g., project reviews and scorecards)
Action plans at both the project and program levels that are updated on a regular basis
"Something as simple as an action plan can be incredibly effective—very simple and very powerful," said Marshall.
Change management can certainly be done wrong, however. Poor change management can have many variations of negative results:
Confusion
Anxiety
Anger
False starts
Chaos
Resentment
Burnout
A major component of making change management work is meeting management. Leaner processes involve fewer meetings, but meetings are still necessary—so do them right, said Marshall.
The following are tips for effective meeting management:
Communicate the agenda at the beginning of the meeting
Develop and enforce meeting rules
Prevent interrupting when someone else is talking, and maintain a level of respect among participants as well.
Roles are important. Know who is:
Leader
Facilitator
Timekeeper
Note taker
And know how precious time is. End every meeting five to 10 minutes early to allow people time to get to their next meeting, Marshall said.