Patient Safety & Quality Healthcare’s mission is to provide news, science, research, and a forum for opinion for clinicians, healthcare professionals, and everyone interested in improving quality in healthcare. Learn more .
PSQH: Patient Safety & Quality Healthcare, October 11, 2018
Concerned about discrepancies among accrediting organization surveys and its own findings, CMS plans to make deficiency reports more accessible to the public.
By A.J. Plunkett
Editor's note: This article originally appeared on PSQH.
Hospitals may find themselves directly in the line of fire as the Centers for Medicare & Medicaid Services ramps up its oversight of The Joint Commission and other accrediting organizations.
CMS wants to put a stronger spotlight on times when TJC and other AOs fail to find patient safety problems later discovered by CMS survey teams conducting performance checks referred to as validation surveys.
To do so, CMS has created a website that lists hospitals it says have "recent substantial deficient practices," according to the AO each uses for deeming authority to bill Medicare. It then posts a copy of the CMS deficiency report that outlines the patient safety problems government surveyors found, and notes if the problems posed an immediate jeopardy to patients.
A ruling of immediate jeopardy threatens the hospital’s ability to bill Medicare and, in many cases, to stay in operation.
Although the website talks about the disparity rate of deficiencies found on validation surveys, the reports posted are not from the validation surveys, but from inspections done after someone has filed a complaint against that hospital, according to a CMS news release touting its tough new stance. Those inspections can happen at any time. And each of the AOs also can revisit hospitals in response to complaints.
But the implication is that the AO missed critical patient safety problems later found by CMS. Accreditation consultants and other compliance experts note that CMS surveys can be done several weeks after an AO survey, and that deficiencies CMS finds may not have existed at the time of the initial survey. The validation surveys are done within 60 days of the AO visits, according to CMS.
CMS officials have also complained that deficiencies they found were critical enough for surveyors to rule immediate jeopardy, yet the AO’s online list of accredited facilities still showed the hospital fully accredited.
Earlier this summer, TJC updated its Accreditation Participation Requirements to specifically state that hospitals that use TJC for accreditation must notify the commission "immediately upon receiving notice from the Centers for Medicare & Medicaid Services (CMS) that its deemed status has been removed due to Medicare condition-level noncompliance identified during a recent CMS complaint or validation survey."
The website currently offers only information on hospitals and the four organizations approved to accredit hospitals: TJC, the Healthcare Facilities Accreditation Program (HFAP), DNV GL Healthcare (DNV), and the Center for Improvement in Healthcare Quality (CIHQ). (HFAP is listed on the site as the American Osteopathic Association, which was the original AO for osteopathic hospitals when Medicare was created in the 1960s. HFAP has since expanded to accredit all hospitals.)
CMS says the creation of the website and other moves to intensify oversight of the AOs are part of an effort to making hospitals safer and the accreditation process more transparent.
While the details of CMS deficiency reports on hospitals have been publicly available for a number of years, they were difficult to find on CMS’ website and were in a hard-to-read spreadsheet. The Association for Health Care Journalists worked with CMS to get the information in a searchable format that it now posts online at HospitalInspections.org.
However, those reports were only of CMS surveys at hospitals where government surveyors from CMS State Survey Agencies (SSA) were investigating a complaint. It does not have reports on routine surveys or validation surveys, and did not offer the hospital’s response to findings. Those responses, called plans of correction, were available through public information requests from the SSAs.
This new CMS website provides the summarized "Statement of Deficiencies and Plan of Correction" for each hospital, with this notation: "This website lists all hospitals who were found to be substantially out of compliance during a State Survey Agency survey in the last six months and provides the survey report for public review."
The site can be searched according to hospital AO or by state. However, the reports do not indicate what problem CMS identified that the AO might have missed. It just states at the top of the page for each AO the number of hospitals the AO accredits, and the percentage of those where CMS found a "substantial deficiency in the last six months."
For instance, the top of the webpage for TJC says: "The Joint Commission deems 3993 Hospitals. CMS cited 1.7% of them for a Substantial Deficiency in the last six months."
With the new website, the CMS deficiency reports are much easier to find and to read, note accreditation experts. Which means that hospitals should be prepared for the public relations ramifications.
"Hospitals should be concerned because this data is easier to read than other formats CMS already had publicly posted," says Kurt Patton, who served as TJC's director of accreditation services before starting his own compliance consulting company, Patton Healthcare Consulting.
"This is fast and easy to find the hospitals in any individual state," he says. "Consumers might read it, and attorneys who have litigation planned or pending might read it. Hospitals should be prepared with a communications strategy for each state survey report at the same time as they are working on their Plan of Correction. It appears that as soon as the POC is accepted this may be posted." Patton notes that some September data is already available on the site.
Hospitals already face funding challenges to meet fire code requirements after CMS finally adopted the 2012 NFPA Life Safety Code®, and it will get even worse as survey scrutiny increases, predicts Ernest E. Allen, a former TJC surveyor and current consultant and patient safety executive with The Doctor’s Company in Columbus, Ohio.
Having the survey findings on the Internet "could result in public relations issues for the facility," says Allen. But compliance officers might be able to use that to their advantage. "That is the argument I would use when asking for more funding" to meet requirements, he added.
"Additional staff and funds to replace any deficiencies as quickly as possible will be needed," says Allen.
In announcing the website, CMS also said it is changing how it will conduct validation surveys and will also post more information online about AO performance.
Instead of waiting until after an AO finishes its survey to do a follow-up survey, CMS inspectors will now show up at the same time and watch as the AO surveyors work.
CMS says the new process will be more effective.
"Historically, CMS has measured the effectiveness of AOs by choosing a sample of facilities, performing state-conducted assessment surveys within 60 days following AO surveys, and comparing results of the state surveys with the AO surveys," according to the CMS announcement.
"In a pilot test, CMS will eliminate the second state-conducted validation survey and instead use direct observation during the original AO-run survey to evaluate AOs’ ability to assess compliance with CMS's Conditions of Participation," said CMS.
“Direct observation will enable CMS not only to evaluate AO performance more effectively, but also to suggest improvements and address concerns with AOs immediately. This approach will relieve providers from having to undergo the burden of a state’s follow up assessment. The approach is another example of the wide-ranging effort at CMS to eliminate duplication and relieve burden, reducing the amount of time that healthcare facilities must spend on compliance activities.”
In addition, CMS says it will “analyze and incorporate State complaint investigations of accredited facilities as part of the agency’s strengthened validation program. This work will focus on identifying and monitoring accredited facilities that are out of compliance with Medicare health and safety requirements. CMS will use this information as an additional indicator of AO performance.”
"Today, the public relies on accreditation status as a way to gauge providers' and suppliers' quality of care. By posting more detail—accredited hospitals' complaint surveys, out-of-compliance information, and performance data for AOs themselves—CMS will offer the public more nuanced information than accreditation status alone provides. The agency is currently prohibited by law from disclosing the actual surveys done by AOs, except for surveys of home health agencies and surveys related to an enforcement action."
PSQH: Patient Safety & Quality Healthcare, October 3, 2018
Improper cleaning and disinfecting can expose patients to infectious materials on mattresses or mattress covers. Sponges retained inside patients after surgery can lead to infection. Other hazards abound.
This article was first published October 2, 2018, by PSQH.
By Jay Kumar
In its 2019 Top 10 Health Technology Hazards report, ECRI Institute highlighted potential sources of danger stemming from health technology, with cybersecurity attacks topping the list. Ranked by which risks should receive the highest priority, the list compiled by ECRI’s Health Devices Group positions the threat of hackers targeting remote access to healthcare systems as the most pressing.
"Cybersecurity attacks that infiltrate a network by exploiting remote access functionality on connected devices and systems—or by any other means—remain a significant threat to healthcare operations," according to the report’s executive brief. "Attacks can render devices or systems inoperative, degrade their performance, or expose or compromise the data they hold, all of which can severely hinder the delivery of patient care and put patients at risk."
Once hackers gain access to an organization’s network, they can move on to other connected devices or systems, installing ransomware, stealing data, or using computing resources for other purposes, according to ECRI. Organizations should identify, protect, and monitor all remote access points, as well as follow recommended cybersecurity practices like having a strong password policy, maintaining and patching systems, and logging system access.
Other hazards include the following:
"Clean" mattresses that retain blood and other body fluids after cleaning. Whether it’s the mattress or the mattress cover, improper cleaning and disinfecting can expose subsequent patients to infectious materials.
Retained surgical sponges that are unintentionally left inside a patient after the surgical site is closed. Surgical teams conduct manual counts of sponges as a matter of routine, but errors still occur, and retained sponges can lead to infection and other complications.
Errors in setting ventilator alarms can result in the risk of hypoxic brain injury or death. Ventilators are life-support devices that help patients breathe adequately, but loose connections, manufacturing defects, and other problems can put patients at risk. Properly set alarms can prevent these complications, but errors in setting the alarms can result in bad outcomes.
Improper handling and storage of flexible endoscopes can recontaminate previously disinfected scopes, leading to an increased risk of patient infections.
Confusing the dose rate with the flow rate can lead to dangerous infusion pump medication errors. This includes incorrectly programming so-called smart pumps.
Improper customization of the alarms on a physiologic monitoring system could result in missed alarms, which in turn could lead to serious patient injury or death if problems aren’t recognized and treated in time.
Overhead patient lift systems can cause injury or damage if the system is improperly designed, installed, used, or maintained.
Improper cleaning of electrical equipment can result in equipment malfunction, damage, or fire. The use of cleaning or disinfectant wipes that are dripping with excess fluid, or spraying liquids directly onto powered medical devices and equipment can cause fluid to enter electrical components such as plugs, sockets, or power supplies.
PSQH: Patient Safety & Quality Healthcare, September 21, 2018
Needles are a workplace hazard for nurses. New needleless technology may help improve RN safety and patient experience.
Editor's note: This article by John Palmer for PSQH has been adapted.
By John Palmer
The dreaded needlestick in the healthcare environment is a source of nightmares for many. People have dreamed about getting rid of needles for years, not only to help patients relax when getting their blood drawn, but also to keep healthcare workers safe.
But even though there is legislation on the books—the Needlestick Safety and Prevention Act of 2000 encourages the use of safety sheaths and retractable needles and requires healthcare facilities to evaluate new sharps safety devices annually—injuries from sharps and needlesticks continue to occur.
Worker safety watchdogs have been lobbying for safer ways to give injections and draw blood, but until recently the thought of doing away with the needlestick completely was only a pipe dream. But now, some forwarding thinking organizations are trying to make that dream a reality by using needle-free technology.
Needle-Free Blood Draws
University Hospitals in Cleveland, Ohio, announced in July that it has implemented the PIVO needle-free device from San Francisco–based Velano Vascular at UH Cleveland Medical Center for inpatient blood draws.
“As an institution, we continually look for innovative new technologies that improve the delivery and quality of care we provide,” Daniel I. Simon, MD, president of UH Cleveland Medical Center, says in a statement. “As caregivers, we strive to serve our patients in the most humane and personal way possible. This new procedure makes it possible for us to do both, eliminating the pain and anxiety associated with blood collection while advancing our own high standards and practices.”
Two other hospitals, Griffin Hospital in Derby, Connecticut and Brigham & Women’s Hospital in Boston, are also testing the PIVO device.
In typical practice, an IV needle is used to puncture the skin. That needle is then withdrawn and replaced with a plastic tube that becomes soft and almost noodle-like over time. While a “noodle” is fine for injecting fluids and medications into a patient, it’s bad for drawing fluids out of a patient, as the negative pressure of suction causes the tube’s soft walls to collapse. Also, clots that form at the ends of the IV catheter can disrupt the blood testing process.
The PIVO uses a narrower-gauge, stiffer tube inside the existing IV tube for collecting a blood draw. The device is used once and then thrown away, after which the IV catheter is reattached to the bag containing whatever fluids were being delivered to the patient prior to the blood draw. PIVO allows practitioners to extract high-quality blood samples from the vein, eliminating the need for multiple needlesticks.
The device was created by Velano Chief Executive and co-founder Eric M. Stone and President Pitou Devgon, MD. Velano won FDA approval for the PIVO in 2015; it has also obtained two U.S. patents for the device, according to published reports, with additional applications outstanding in the U.S. and abroad. Velano has publicly acknowledged receiving a total of $8.5 million in investments to improve the device.
The adoption of PIVO at UH’s flagship academic campus follows evaluation of the technology and the procedure in multiple UH Cleveland Medical Center inpatient units, the hospital said in a statement.
“Our evaluation and collaboration proved that PIVO delivers high-quality blood draws in an elegant manner that enhances the patient-practitioner relationship, reduces rejected blood samples, and provides an alternative to accessing central lines for blood collection,” said Cheryl O’Malley, vice president of patient care services and nursing at UH Cleveland Medical Center. “We are excited to bring this procedure and technology to our entire academic hospital, especially for our most vulnerable patients like those at UH Rainbow Babies & Children’s.”
Safer sharps slow to evolve
More than 400 million blood draws occur annually in hospitals in the U.S., informing as much as 70% of all clinical decisions. Many of these are conducted in a hospital setting on patients that receive as many as three blood draws daily. This number of daily draws can increase dramatically for the 30% of U.S. hospital patients that are classified as “difficult venous access,” or DVA, due to obesity, age, or disease.
Stone is a Northeast Ohio native and former UH Rainbow Babies & Children’s Hospital patient. “As a chronic disease sufferer and over the course of multiple hospitalizations as a teenager, I developed a clinical fear of needles,” said Stone. “My personal experience as a patient has informed our person-centered mission at Velano to enable more humane care. Coming full circle, back to UH and Rainbow, to make this technology a national standard of care will enable our children and their parents to have their blood drawn in a gentler fashion.”
It may have important benefits for healthcare staff, too.
In July 2017, the Houston-based group International Safety Center released surveillance data from hospitals in 2015 that showed a marked increase in injuries from sharps and needlesticks sustained by training physicians (i.e., residents and interns) compared to 2014, and an overall increase in injuries sustained in the operating room, along with an unexpected decrease in the use of safety-engineered medical devices.
And, according to OSHA, up to 5.6 million workers in the U.S. are at risk of exposure to bloodborne pathogens, such as HIV and hepatitis, because they use needles and other sharps like scalpels as part of their everyday job. In fact, every year, about 1 million workers in hospital and clinic settings suffer a needlestick or other sharps-related injury.
One well-known example of this is the experience of nurse Karen Daley. In 1998, she was working in the ED at a Boston-area hospital and was stuck by a needle protruding from a full sharps container. As a result, Daley contracted both HIV and Hepatitis and had to end her career in the ED. She has since become an advocate for needlestick safety and lobbied for the 2000 Needlestick Safety and Prevention Act. She is also former president of the American Nurses Association.
Safe in Common, a nonprofit organization based in York, Pennsylvania, issued a list of guidelines in 2013 that serves as a “wish list” of attributes for sharps safety. Established in 2010, SIC is an organization of healthcare professionals and advocates that work to raise awareness of needlestick injuries and save lives of healthcare workers.
The guidelines, titled “The Top Ten Golden Rules of Safety,” were released at the Association for Professionals in Infection Control and Epidemiology conference in Fort Lauderdale, Florida. Specifically, the guidelines seek to make needlestick injuries a “never event,” an incident so rare that it almost never happens, by lobbying for sharps that are easy to use in even the most distracting environments. In addition, safety devices should be activated automatically so that they’re safe and easy to use with one hand. Sharps should also be “rendered safe prior to removal or exposure to the environment,” should not cause additional harm or discomfort to the patient, and should not add to the already-high cost of medical waste.
PSQH: Patient Safety & Quality Healthcare, September 11, 2018
There are multiple ways to prevent nurse injuries from patient handling. Find out the pros and cons of various interventions.
By John Palmer
It's no secret that America's healthcare workers are in danger of injuries sustained from improperly lifting and moving the patients they tend to every day in U.S. hospitals. And if workers can't safely move patients, it places the patients at risk as well.
According to Occupational Safety and Health Administration statistics, worker injuries from slips, trips, and falls are one of the agency's biggest concerns, especially in hospitals. Injury and illness rates in healthcare, at 5.2 cases for every 100 workers, continue to be above the national average, which is 3.5 cases per 100.
In 2011, U.S. hospitals recorded 253,700 work-related injuries and illnesses, or 6.8 injuries and illnesses for every 100 full-time employees. This is almost twice the rate for private industry as a whole.
Despite this, says OSHA, hospitals still are not employing enough assistive devices to help move patients, and that's a major reason why healthcare workers have one of the highest rates of occupational musculoskeletal injuries in the U.S. A recent study found that such devices can help cut down on these injuries and improve patient care at the same time.
The National Institute for Occupational Safety and Health reports that there are 75 lifting-related injuries for every 10,000 full-time hospital workers, and 107 injuries for every 10,000 workers at nursing homes and residential facilities. Hospital rates are nearly twice the national average for all industries, and nursing home rates are nearly three times as high.
The problem has gotten so bad that OSHA was forced to create an entire website devoted to lifting injuries in hospitals and to solutions that facilities can employ, including training tips and advice. However, OSHA still does not have any published mandate or standards related to reducing patient-handling injuries, just a recommendation that hospitals take steps to reduce them.
Aging Patients Need Assistance
Now look at this issue from the patient's perspective. U.S. residents are getting older, and with that their mobility will become compromised. The number of people older than 65 in the United States is expected to grow significantly in the next 10 years. Consider the following:
One out of every eight U.S. residents is age 65 or older. One in four will be in that age group by 2030.
U.S. residents over the age of 85 are the fastest-growing segment of the population. Projected figures show them increasing from 3.3 million to 18.9 million—one in 20 people—by 2050.
People are living longer. The average life span today is 75 years compared to 47 years in 1900 and is projected to rise to 85 years by 2050.
According to a May 2016 study by Guy Fragala, PhD, PE, CSP, CSPHP, senior advisor for ergonomics at the Patient Safety Center of Inquiry in Tampa, Florida, 36.5% of U.S. adults are obese, and one out of five U.S. adults have a disability, which means they will likely wind up on a physician's exam table at some point in their lives. So will we all, but for individuals with mobility challenges, these exam tables can be major contributors to the injury statistics we've just discussed. (Fragala's study was sponsored by Midmark Corporation, an Ohio-based provider of medical, dental, and veterinary equipment and technologies, including exam tables and chairs.)
"In ambulatory care settings, assisting patients on and off of examination tables happens with each patient visit all day long," Fragala says. "The risks associated with these types of movement are similar to those associated with a bed-to-chair or chair-to-bed type transfer, one of the most difficult and high-risk activities for caregivers to perform because of the potential strain on a caregiver's shoulders, back, and neck. Even something as seemingly insignificant as extending a hand to help a patient ascend a fixed-height table can quickly become dangerous for caregivers if the patient stumbles."
By some estimates, populations in nursing homes and long-term care facilities will double in the not-so-far future, and this increase will require forethought and investment in equipment to help move patients safely and securely.
Lift Equipment
According to some reports, hospitals are trying to do their best by utilizing new technologies and installing patient lifts. However, many nurses and caregivers still prefer to lift and move patients themselves. The problem, of course, is that if they don't lift properly, or if the patient shifts during the process, it could cause the caregiver or the patient to be injured.
There is some controversy around when lift devices should be deployed. Some research says nurses and other caregivers should not lift more than 35 pounds without an assistive device. The American Nurses Association has advocated for hospitals to deploy equipment and adopt protocols so that no staffer ever moves a patient without device assistance. But most caregivers balk at these recommendations, noting that they regularly move children and adults of average weight without help.
Some hospitals in healthcare systems such as Kaiser Permanente and the Veterans Health Administration have begun to install overhead lifts in their facilities that consist of a motorized hoist that can lift a patient into the air while the patient is secured in a sling. An overhead rail system allows nurses to move patients around the room or between rooms.
Some models designed for obese patients have two motors and can lift as much as 1,000 pounds. They can be pricey, though. Permanent overhead lifts cost an average of $16,000 per room to install. In contrast, mobile devices cost an average of $6,000. A few mobile devices can service an entire hospital if workers take the time to find and use them, according to statistics from the ECRI Institute.
OSHA says that these devices are cost-effective and that the benefits far outweigh the costs, adding that the initial capital investment in policies and equipment can be recovered within two to five years. Consider the following benefits OSHA says can be enjoyed by facilities that use lift–assist equipment:
Reduced injuries
Decreases in lost time and workers' compensation claims
Increased productivity
Higher quality of work life and worker satisfaction
Increased staff retention
Better patient care and satisfaction
Some hospitals have success stories with this equipment. For instance, St. Joseph's/Candler Health System in Savannah, Georgia, installed ceiling lifts in 38 patient rooms in the critical care department, the 330-bed St. Joseph's Hospital and 384-bed Candler Hospital, where a troubling 78 patient-handling injuries per year occurred. St. Joseph's is the state's oldest continuously operating healthcare facility; Candler is the second oldest in the nation.
In 2011, the hospital installed the ceiling lifts along with a staff training program; within a year, with the program only partially in place, the number of annual injuries dropped to 37. That number has been maintained since.
Assistance in the Ambulatory Setting
Overhead lifts aren't the only devices that can help prevent patient and caregiver injury. Fragala says that patients can benefit from adjustable equipment such as height-adjustable examination chairs and tables. His study found that with adjustable chairs, the level of exertion required by a patient needing a minimal assist was reduced by 72%, the level of difficulty getting into the chair was reduced by 64%, and the feeling of safety improved by 42%.
"These reported results indicate that when a height-adjustable examination chair is provided to assist a patient who requires even a little bit of help to mount the chair, the process of getting up onto the examination chair is made much easier and requires less exertion," he says.
That's good, Fragala notes, because if a patient can't get onto an exam table or chair, the physician may be unable to examine the patient properly. That can have cascading effects—the patient might be misdiagnosed because the physician can't collect sufficient information, or the patient might miss the benefit of early detection of a serious condition.
"By providing accessible examination chairs, physicians improve the quality of care available to people with disabilities and activity limitations," he says. "In addition, the use of an accessible exam table may also reduce the frequency and time required in using a lift team, lift equipment, and/or providing transfer assistance from staff."
As ambulatory care settings expand throughout the healthcare delivery system, he says there will be pressure to reduce healthcare costs through shortened length of stay, meaning activity in these settings will only increase.
"It is likely that greater volumes of patients with high dependency levels, who require assistance with movement and mobility, will be seeking the services provided in ambulatory care settings," Fragala says. "As new ambulatory clinics are built and renovations are done to existing clinics, the benefits of height-adjustable examination tables should be recognized, and those making decisions on furnishings need to understand how height-adjustable examination tables can add to the quality of care provided."
It is part of Fragala's professional mission to be an advocate for equipment such as height-adjustable chairs and tables, which he says go a long way to reducing the risk of physical strain for both patients and providers.
Traditionally, he says examination tables have a height of about 33 inches. "Consider this height of 33 inches versus the height of a common chair seat, which is approximately 18 inches," he says. "That's nearly twice as high, making it all the more difficult for a patient with mobility limitations."
Fragala says when an examination table or diagnostic chair is high and not adjustable, wheelchair users and people with other activity limitations (especially elderly or obese populations) may need to be lifted or assisted. Even a patient who is relatively independent might encounter difficulty when attempting to get up onto a surface 33 inches high. This is where the possibility of injury rears its head.
Beyond facilitating access, he says adjustable-height equipment also enables healthcare providers to position the equipment at a comfortable height, letting the caregiver assume a better posture while conducting an examination or procedure and again enhancing the quality of care.
"The federal agency providing leadership and guidance for accessible design, the U.S. Access Board, recommends an exam chair with a low, uncompressed seat height of 17 to 19 inches," says Fragala.
PSQH: Patient Safety & Quality Healthcare, August 27, 2018
Patients feel shame, fear, and uncertainty when healthcare providers don't provide them with adequate education about HAIs.
Healthcare-associated infections can affect patients in ways beyond physical health, finds a new study. Dealing with HAIs can also lead to problems with social relationships and cause healthcare providers to distance themselves from patients, according to the study published in the American Journal of Infection Control.
Researchers at Glasgow Caledonian University in Scotland looked at 17 studies from five different countries that examined five different HAIs, with a focus on patient experiences of colonization and infection from bacteria that commonly cause HAIs.
Healthcare providers should look at the social circumstances that affect patient experiences, including feeling shameful and dirty, and the responses of those around the patients.
The study found that many patients who were diagnosed with HAIs described feeling dirty, “having the plague,” or “feeling like a leper.” Patients reported a fear of transmitting their infection to others, which affected their personal and workplace relationships. Patients who were able to speak to an infection preventionist reported receiving valuable information and getting reassurance about their condition; those who didn’t talk to an IP said they felt dismissed by staff members.
The report also found that concerns about interacting with a healthcare provider or restriction to healthcare treatment were prominent with patients who had infections caused by resistant organisms such as methicillin-resistant Staphylococcus aureus.
Many patients with HAIs reported changing personal hygiene behavior, including precautions to prevent infection transmission such as extensive cleaning at home and advising family members on hygiene measures.
Another finding was that patients reported interactions with healthcare providers led to fear and uncertainty, especially when the providers lacked knowledge of the causes and consequences of HAIs and couldn’t provide adequate information to the patient.
With a new flu season right around the corner, now is the time for hospitals and other healthcare facilities to consider implementing a mandatory vaccination program for seasonal influenza. Some employees may initially object, but most experts agree that flu shots are a necessity for healthcare workers.
"It’s really important for healthcare personnel to be vaccinated because they are in really close contact with the most vulnerable of our populations," says Terri Rebmann, PhD, RN, CIC, FAPIC,director of the Institute for Biosecurity at Saint Louis University. "If the healthcare personnel become infected, regardless of whether or not they have symptoms, when they shed the influenza virus during patient care activities, they can then expose those really high-risk patients."
Many healthcare workers already understand that getting a flu shot every fall helps protect not only themselves, but also coworkers, friends and family, and of course patients. Others, however, will require more than a reminder of the 2017–2018 flu season, which was the worst in nearly a decade, to go get vaccinated for the flu.
Mandatory Programs are Effective
The Centers for Disease Control and Prevention, which recommends annual flu vaccinations for all healthcare personnel, reported that during the 2015–2016 flu season, there was a vaccination rate of over 95% for healthcare workers whose employers required them to get vaccinated for seasonal influenza, compared to a 79% vaccination rate overall among healthcare workers.
"For many years, seasonal influenza vaccines have been offered to healthcare personnel and there have been a number of initiatives, educational campaigns, and other types of interventions that have been attempted in order to increase healthcare worker intake of seasonal influenza vaccine," says Rebmann. "But over and over again, the research has shown that themandatory vaccination policies are the strongest indicator of high vaccination rates among healthcare personnel."
Rebmann is quick to point out that a mandatory vaccination policy doesn’t mean that every single healthcare worker must be vaccinated against the flu; "there are legitimate reasons why some healthcare personnel cannot be vaccinated." Some are allergic to the vaccine or a component of the vaccine. Others have religious or philosophical objections to being vaccinated, which some healthcare organizations will respect if a worker submits proof.
In May, the Association of Occupational Health Professionals in Healthcare joined the club, releasing a position statement recommending flu shots, among other vaccinations, for healthcare workers. It also asks "administrators to consider a policy that makes annual influenza vaccination mandatory (with medical exemptions) or offer alternatives to vaccination such as requiring the use of surgical masks for patient care by healthcare workers who refuse the vaccine."
PSQH: Patient Safety & Quality Healthcare, July 23, 2018
Infrastructure changes from healthcare system mergers can challenge clinicians and cause risk to patients.
This article by John Palmer originally appeared on PSQH.
A new collaborative study by researchers from two Boston healthcare systems has unlocked findings about adverse risks to patients when hospitals go through mergers, acquisitions, and other organizational changes that are intended to improve the safety and quality of care.
The United States healthcare system is undergoing many transformative changes, among them the trend for smaller hospitals (usually located in rural areas) to be taken over by bigger hospitals that are part of larger healthcare systems; Memorial Sloan Kettering Cancer Centerand The Cleveland Clinic are just a couple of examples. Mergers in healthcare have been increasing: 31 deals were announced in the first quarter of 2018, compared with 30 during the same period in 2017 and 25 in 2016's first quarter, according to published reports.
Experts say healthcare mergers often make sense for many reasons. For one, the smaller hospitals gain the ability to attract customers by leveraging the brand visibility of a well-known health system. They also benefit from the infrastructure improvements that come from the deeper pockets of larger systems, from better equipment to recruitingbetter-trained physicians. In addition, because the hospitals can provide quality care closer to home, patients no longer have to travel long distances to get the treatment they need.
"Strategic partnerships allow smaller member hospitals to get access to specialists and consultants, and in many cases will send consultants to analyze, for instance, if you are a smaller hospital with high readmissions," says Allan Baumgarten, MA, JD, a Minneapolis-based healthcare market analyst. "Mergers are a good way to bring good treatment to parts of the country that in the past may have meant patients travel 40 miles to get the care they needed, and now it's closer to home."
However, the study found many risks that can come with mergers and acquisitions—and hospitals considering mergers should think about these factors when doing their due diligence.
New patient populations
The study's authors found that after system expansions, healthcare institutions may experience significant changes in patient populations, including increases in general volume and in patients with demographic characteristics or conditions that a given facility might not have previously served.
As a result, patient population changes can lead to unit-level adjustments such as training support staff. However, staff who interact with these patients elsewhere in the hospital may also need new knowledge, skills, practice patterns, and support, such as having the ability to recognize and promptly treat withdrawal symptoms in the case of substance abuse treatment. Further, the study found that these changes are often not anticipated. An increase in referrals may bring an influx of non-English-speaking patients, for instance; this will require more interpreters, institutional relationships with different community services, and increased awareness of the economic and social challenges these patients face in following care guidelines.
Baumgarten downplays these issues to a degree. "I don't disagree that mergers produce some risk, but the risks identified are not different than bringing on new staff, which hospitals are doing all the time," he notes. He points to Florida's Broward County as an example, where the Cleveland Clinic is taking over two community hospitals to form a "hub and spoke" model that will feed patients into major hospitals.
"Presumably, they are doing their due diligence because they will be putting the brand on these hospitals," he says. "It's in their best interest to make sure the standards are being upheld."
Unfamiliar infrastructure
Often, healthcare mergers result in a larger hospital offering financial incentives to a smaller hospital, including upgrades to supplies and equipment, protocols, and IT such as electronic patient records and security systems.
The downside, the study found, is that changes in infrastructure often create challenges for clinicians. Without planning, such changes can cause significant patient risk. Even with training, the authors noted, a learning curve can make routine tasks more time-consuming or prone to error. Consider, for instance, finding the correct form in an electronic health record for ordering a test, identifying the correct substitute medication and dose from a new formulary, or transferring a patient. The attention clinicians must now give to tasks that were previously "automatic" also distracts from other aspects of patient care.
Unless schedules and capacity, as well as training, are adjusted, such shifts in time and focus may result not only in dissatisfied patients, but also in increased likelihood of major errors, the study found.
On the other hand, says Baumgarten, investments in infrastructure to accommodate new technology and equipment often come with highly trained professionals that know how to use the new tech. Consider the IT experts who may be accessible along with a new computer records system, or easier (and safer) transfers and handoffs as a result of tapping the experience of veteran staff from a busier hospital.
"If you look at recent single-hospital acquisitions, smaller hospitals that are seeking to be acquired are having trouble gathering capital for electronic medical records, recruiting and retaining physicians," he says. "By joining the larger system, it can benefit the smaller, former independent hospitals."
New settings for physicians
Another major risk factor that mergers place on hospitals involves transitioning staff such as physicians and specialists. Proponents of mergers say that by combining forces, hospitals can attract higher-qualified doctors who can provide more office hours and availability for patients, as well as supply consultants for smaller facilities that need the know-how of longer-tenured experts.
"At each hospital with a separate CFO, now they can remove that layer of administration and instead have a senior systemwide CFO and have controllers at each hospital," says Baumgarten. "By increasing volume and increasing quality, with certain kinds of surgeries like transplants, there is a theory that practice does make perfect. So if you're dealing with higher volume, it will often be reported that the quality is higher, because you have teams of surgeons and support professionals. Now instead of doing 50 surgeries in one hospital and 50 in another, you are doing 100 in a year with a combined team [and] better safety and satisfaction."
The study found that out of 82 healthcare institutions that have undergone expansions, 87% required physicians to travel to new practice sites, the most common being specialists such as cardiologists, surgeons, oncologists, and obstetricians.
In many cases, healthcare systems offer attractive incentive packages to sweeten the pot for physicians, including travel and relocation costs, housing deals, and jobs for their spouses. But when clinicians travel, they often receive little systematic orientation to their new setting, leaving them to grapple with infrastructure, processes, teams, and a clinical culture that can vary from their home institution in significant and unexpected ways.
In some instances, the study found, some physicians adapted to these new circumstances through trial and error, which can put patients at risk. Imagine being a new physician at a hospital and having to guess which kinds of care can be provided in a given setting, or trying to understand an unfamiliar crash cart, electronic health record, or phone number list in the middle of an emergency.
The study found that some physicians, while they knew the right care to provide to patients, commonly encountered situations in which they did not know how to deliver the care—and, especially, how to do it quickly.
"I expect there is a learning curve to familiarize with the new facility and develop a good working relationship with staff," says Baumgarten. "But hospitals are constantly bringing on new residents and hiring specialists for training in machinery. If you're good at doing it, you should be able to minimize risks to patient safety."
To help providers better prepare to talk about safety when navigating a merger, the Harvard team built a free toolkit. It includes guides that healthcare organizations can use when holding crucial conversations during a merger. In addition to addressing high-priority issues such as internal culture and infrastructure, the toolkit offers specialty-specific guides for obstetrics, emergency care, and surgical care. It also offers guiding principles for more effective clinical integration and highlights some key steps that providers might not otherwise consider when planning a merger, such as conducting first meetings between major players off-site.
With the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers, The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers. About 75% of workplace assaults occur in the healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than in other kinds of industries.
Patient Safety Monitor Journal spoke with Victoria Fennel, of Compass Clinical Consulting, about the alert and healthcare's culture of violence.
Q: In your opinion, how much of the workplace violence (WPV) issues in healthcare is cultural (behaviors around WPV) vs. policy?
Fennel: When you think about violence, most of all let me say that it's a learned behavior. It comes from modeling or observing behaviors in which there was violence. From a cultural perspective, if violence can be a learned behavior, then I think responding to violent behavior must become a learned response.
You can have all the policies in the world, but if you don't have some things in place culturally that help leaders and staff understand how to respond to those situations, then it's not going to be real helpful. It has to be more than just policies and procedures. There has to be some kind of accountability in terms of leadership and how they won't tolerate certain types of behaviors so that the staff feels comfortable going to authority and expressing things that have occurred where they felt like there was the potential for them to be harmed, be it through verbal abuse or if they experienced physical abuse.
Q: How do you keep these alerts from just becoming white noise in the array of things that accreditation and patient safety people have to worry about?
Fennel: I think that in and of itself is part of the problem. The concept of workplace violence is more than something that only accreditation and patient safety facilitators need to be worried about. You have to have leadership involved.
I think if you have the leadership commitment, and I mean true commitment, that certain behaviors will not be tolerated, then I think it helps the organization. Because you'll have more satisfied staff, and they'll feel comfortable coming forward with these certain situations.
At one facility, I heard a chief medical officer say he'd spoken to a physician and said a certain behavior would not be tolerated, and that he could replace the physician faster than the organization could replace a nurse.
Also, the organization will need to provide the training on how to respond. There's not enough training that goes on.
Q: Would better restraint-and-seclusion training, to include de-escalation training, help hospital staffers dealing with abusive patients? And should that include security personnel?
Fennel: If an organization is looking at de-escalation in only terms of patients who need to be restrained, then they are not looking at a big enough picture.
There are many areas within an organization where employees are potentially exposed to violent behavior that has nothing to do with restraining a patient. Many times when we're looking at de-escalation training in organizations, we're looking at different areas of the hospital where this is being provided.
It may be that this training is provided to a limited number of people in the ED or people in the psychiatric department. But what about all the people who have the potential for dealing with this violent behavior all the time (for example, people at the front desk)? And they receive no training, don't know how to respond, and don't know what the organization's stance is in regards to violence. If they are experiencing something, they don't know if they have the freedom to come forward with what's going on.
For example, we know there's been a lot of violence that's happened in the surgery area over the years, where it gets to the point that someone is throwing a scalpel at a nurse or a chart that barely misses a nurse's head. Those are behaviors that cannot be tolerated, but at the same time not a lot of information has been provided to the staff on how to respond in those situations.
There's also the fear of retaliation if someone says something, that someone will come back at them because they brought this information forward. There are a lot of things that are involved, but it's far beyond the scope of just accreditation and safety people to be concerned.
Hospital readiness for managing health emergencies has improved over the last five years, according to a new report. The Robert Wood Johnson Foundation (RWJF) this week released the 2018 National Health Security Preparedness Index, which found that the U.S. scored a 7.1 out of 10 for preparedness, up 3% over the last year and almost 11% since the Index was begun in 2013.
The assessment found improvements in most states, but also noted serious inequities in health security across the country, according to a RWJF release. Maryland was the highest scoring state, 25% higher than the lowest-ranked states, Alaska and Nevada. The report found that states in the Deep South and Mountain West scored poorly compared to those in the Northeast and Pacific Coast.
“Five years of continuous gains in health security nationally is remarkable progress,” said Glen Mays, PhD, MPH, who led the University of Kentucky research team that developed the index, in the release. “But achieving equal protection across the U.S. population remains a critical unmet priority.”
The index found that 18 states had preparedness levels exceeding the national average, while 21 states fell below the average. Thirty-eight states and the District of Columbia increased their overall health security last year, with eight remaining steady and four declining.
Researchers collect, aggregate, and measure health security data from more than 50 sources. The final measures cover health security surveillance (2018 national average of 8.1., a 12.5% improvement since 2013), community planning and engagement (6.0, 22.4%), information and incident management (8.8, 7.3%), healthcare delivery (5.2, 2.0%), countermeasure management (7.7, 6.9%), and environmental and occupational health (6.6, 8.2%).
The Indexwas originally developed by the Centers for Disease Control and Prevention to help improve health security and preparedness and is funded by RWJF. State health officials, emergency management experts, business leaders, nonprofit groups, researchers, and others help shape the Index.
A Baltimore hospital was cited by the Centers for Medicare and Medicaid Services (CMS) in a report released this week for removing a mentally ill patient from its emergency room in January and leaving her at a bus stop wearing just a hospital gown.
The University of Maryland Medical Center (UMMC) was cited for failing to comply with the Emergency Medical Treatment and Labor Act (EMTALA), as The Washington Post reported. The hospital came under fire after a bystander filmed the incident as the woman was left by security guards at a bus stop on a cold night.
According to the Post, the patient was admitted to the hospital earlier that day after a fall from a motorized bike. She was cleared for discharge, but resisted and refused to dress, the report said. Security then dropped the patient off at a nearby bus stop, where the man who filmed the incident called for an ambulance.
The woman was brought back to the hospital and then taken to a homeless shelter in a taxi without an exam, and it was not registered that she returned to the facility, the Post reports.
According to the Baltimore Sun, CMS found that UMMC violated a federal law that hospitals must protect and promote each patient’s rights. The hospital also was found to have violated the woman’s right to receive care in a safe setting, to be free from all forms of abuse or harassment, and her right to confidentiality of records because non-clinical staff were given access to or made aware of part of the patient’s medical history. CMS also found that UMMC failed to meet data collection and analysis standards and failed to perform quality improvement activities.
The Sun reports that the hospital has now begun to record every time patients visit the ER. It also conducts audits of the patient log each month, provides additional staff training on federal requirements, and keeps ER doors unlocked. The staff bylaws were updated to specify who can perform medical screenings.
In a statement reported by the Post, a UMMC spokesperson admitted that mistakes were made. “We take responsibility for the combination of circumstances in January that failed to compassionately meet our patient’s needs beyond the initial medical care provided. While our own thorough self-examination revealed some shortcomings, the regulatory assessment punctuates the necessity to more firmly demonstrate our unwavering commitment to safety quality, compassionate patient care.”
EMTALA, in general, requires hospitals to care for patients with emergent conditions, regardless of their ability to pay. Violations of EMTALA are often cited by CMS surveyors under patients’ rights or failure to do an adequate medical screening exam. In addition to potentially impacting a hospital’s accreditation or ability to bill Medicare, EMTALA violations can also come with a civil penalty, which can reach nearly $105,000 for each citation. The newspaper reports did not mention whether the hospital was fined in relation to the CMS findings.