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PSQH: Patient Safety & Quality Healthcare, October 31, 2020
In general, SDoH go a long way in determining both the access and quality of care available to people.
This article was originally published October 30, 2020 on PSQH by Mark Stephan, MD
The World Health Organization (WHO) defines social determinants of health (SDoH) as “the conditions in which people are born, grow, live, work and age,” which are “shaped by the distribution of money, power and resources at global, national and local levels.” SDoH are “mostly responsible” for causing the health inequities that exist around the world, according to the WHO.
These social and economic factors, such as housing, healthy food, and income, can drive up to 80% of health outcomes, making them critical components in any “whole-person” approach to healthcare. In general, SDoH go a long way in determining both the access and quality of care available to people.
Three levels of clinician cultural preparedness
While it’s fairly easy for clinicians to agree that SDoH have a substantial impact on health, what—if anything—they should do about it is a more challenging question. Some physicians are apprehensive about wading into SDoH, well aware that these issues are not their domain of expertise. Others worry that SDoH are simply too large and all-encompassing of a societal issue for medical professionals to solve. Many recognize that the interventions the healthcare system has identified to address SDoH are inadequate. Adding complexity to the SDoH issues are cultural beliefs, preferences, and practices among ethnic minority groups that influence both health behaviors and the way in which people engage with healthcare services.
It is possible, however, for providers to deliver a positive impact to patients’ SDoH. In some cases, it may be as straightforward as connecting a patient with a smoking cessation program, though many SDoH issues are obviously more complex. Our experience has shown that most medical practices can be grouped into one of the following three levels of cultural competence when it comes to addressing patients’ SDoH:
Cultural awareness: This is the most basic level of SDoH recognition, in which clinicians have a basic understanding of the scope of sociocultural factors and the role they play in medical care. These clinicians appreciate that the world is a heterogenous place and that behavioral and cultural differences exist across different populations.
Cultural competence: At this level, clinicians not only realize that SDoH exist, but they have begun to investigate their own patient panel in attempt to determine how these factors impact well-being. It starts by medical practice personnel asking probing questions of patients without assuming they already know the answers. Culturally competent practices have taken active steps to gain a more intimate understanding of the social and economic factors as well as cultural beliefs and values that are contributing to patient outcomes.
Cultural care delivery: Building on the other two levels of cultural preparedness, cultural care delivery means that clinicians are taking some action to address SDoH. Medical practices that have achieved this level not only collect SDoH information from patients, but they are in a position to act on it, helping patients take steps or create connections to resolve issues related to SDoH.
How medical practices can start addressing SDoH
Admittedly, getting to the point of cultural care delivery can be a heavy lift for practices that are already overwhelmed with administrative burden. Many small, independent practices lack the time and resources necessary to serve as hubs of SDoH activity and may prefer to enlist the help of a partner. For practice leaders who are considering a more proactive approach to SDoH, here is a three-step process to lay the foundation for cultural care delivery:
Conduct SDoH surveys: The first step to alleviating SDoH issues is to recognize which problems are the most acute in the practice’s patient panel. Practices should conduct annual patient surveys, collecting demographic and personal information that will help reveal any challenges patients are facing. Ideally, this information would be collected with the assistance of staff prior to the clinician visit, perhaps via an online form in the waiting room. The goal of this step is to identify barriers that may prevent patients from following through on their care plans, such as a recent job loss compounded by health literacy issues that would make it difficult for a patient to afford a pricey new prescription and understand medications being prescribed.
Analyze the data to develop a full SDoH picture: After identifying via the survey the individual issues confronting each patient, practices should aggregate all individual survey data to create a holistic representation of the SDoH challenges patients face. Whether the most prevalent issues are food insecurity, housing insecurity, or transportation challenges, for example, clinicians can use this information to begin exploring ideas and having conversations about how the community can work together to solve them.
Build a network of vetted community partners: Clinicians certainly can’t do it alone, so it’s critical that practices establish networks of trusted community-based organizations to which they can refer patients for SDoH issues. These partners may include food banks, housing coordinators, job training centers, and similar organizations. All participants in this preferred community network should have a clear set of goals and expectations for the level of service they provide to patients.
Although the myriad societal problems contributing to health inequity can make the problem appear insurmountable, many medical practices can play an important part in improving the underlying social, cultural, or economic issues impacting their patients. By starting with cultural awareness and competence and then graduating to cultural care delivery, clinicians can make a difference in patients’ lives that goes far beyond the four walls of their practice.
Mark Stephan, MD, is chief medical officer at Equality Health, a whole-health delivery system.
PSQH: Patient Safety & Quality Healthcare, October 13, 2020
OSHA instructed compliance safety and health officers to exercise discretion in response to ongoing respirator shortages during the pandemic.
This article was originally published October 13, 2020 on PSQH by Guy Burdick
The Occupational Safety and Health Administration (OSHA) issued temporary guidance on enforcement of initial and annual fit-testing requirements in the Respiratory Protection standard for Powered Air Purifying Respirators (PAPR). Enforcement discretion is limited to healthcare personnel or other workers engaged in high- or very high-exposure-risk activities.
OSHA instructed compliance safety and health officers (CSHO) to exercise discretion in response to ongoing respirator shortages during the coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is a respiratory disease caused by infection with the SARS-CoV-2 virus.
The agency instructed CSHOs to exercise enforcement discretion when considering issuing citations for the fit-testing requirements when employers have:
Provided PAPRs using a high efficiency (HE) particulate cartridge or filter to protect personnel from SARS-CoV-2 when initial and/or annual fit testing is infeasible due to shortages of N95, N99, N100, R95, R99, R100, P95, P99, and P100 respirators or fit-testing supplies;
Monitored fit-testing supplies and made good-faith efforts to obtain fit-testing supplies;
Implemented engineering controls, work practices, or administrative controls that reduce the need for respiratory protection, such as using partitions, restricting access, and cohorting patients; and
Maintained all elements of a fully compliant respiratory protection other than fit-testing requirements.
The policy permits the use of tight-fitting PAPRs approved by the National Institute for Occupational Safety and Health (NIOSH) for protection against the coronavirus when initial and/or annual fit testing is infeasible due to respirator and fit-testing supply shortages.
The guidance does not apply to PAPRs:
That have not been approved by NIOSH;
Used by workers with low or medium exposure risk to the coronavirus or for protection against airborne hazards other than SARS-CoV-2, such as chemical hazards; or
That are loose-fitting and hooded and that do not require fit testing.
The agency’s rationale is that due to limited availability of N95 filtering facepiece respirators (FFR), many N95 FFRs are being used only under contingency and crisis-capacity strategies such as extended use and respirator decontamination and reuse.
As opposed to disposable N95 FFRs, tight-fitting PAPRs are designed to be cleaned and reused. If employers switch from N95 FFRs to tight-fitting PAPRs, it will reduce the demand for N95 FFRs, according to the agency, and the number of employees affected by the strategies that many employers are implementing to deal with N95 FFR shortages.
Officials are encouraging employers to take steps to prioritize the use of available fit-testing supplies to protect employees who must use respirators for high-risk procedures. OSHA also said that employers should reassess their engineering controls, work practices, and administrative controls to identify any changes they can make to decrease the need for N95 FFRs used for protection against hazardous dusts and airborne biological hazards. Employers also should consider whether it is feasible to increase the use of wet methods or portable local exhaust systems for dust-generating operations or to move operations outdoors so that N95 FFRs are not necessary. Employers also should consider taking steps to temporarily suspend certain nonessential tasks to limit potential exposure to the hazardous dust and other respiratory hazards, according to OSHA.
To address ongoing shortages of N95 FFRs, employers should consider the use of alternative classes of respirators that provide equal or greater protection compared with N95 respirators, such as N99, N100, R95, R99, R100, P95, P99, and P100 FFRs; NIOSH-approved, nondisposable elastomeric respirators; or loose-fitting or tight-fitting PAPRs.
PSQH: Patient Safety & Quality Healthcare, October 9, 2020
Hartford Hospital is sharing its experience as a road map for other facilities looking to improve their processes and quality of care for a procedure that impacts nearly every patient in the hospital.
This article was originally published October 8, 2020 on PSQH by Lee Steere, RN, CRNI, VA-BC
Introduction
Over the past decade, hospitals have shifted their care delivery focus from quantity to quality, a direct result of the value-based purchasing programs introduced as part of the Affordable Care Act. Using financial incentives, these programs encourage hospitals to improve quality, efficiency, patient experience, and safety of care.
Yet improving the quality of care cannot be done without addressing the issue of waste, which is endemic in healthcare, as the Institute for Healthcare Improvement (IHI) notes in its Call to Action for health system leaders. Waste must be proactively identified and eliminated to achieve the IHI’s Triple Aim, a framework to assist health systems in improving patient care and outcomes while reducing healthcare costs.
Perhaps one of the clearest examples of waste in hospitals today is also one of the most widely performed procedures—the insertion and maintenance of peripheral IV catheters (PIVC). So in 2015, Hartford Hospital’s vascular access specialty team (VAST) embarked on a quality improvement initiative to transform our facility’s infusion therapy practices.
The initiative was inspired by a hospitalwide effort to eliminate waste and improve safety, as well as a commitment to uphold the core values of the Hartford HealthCare System: caring, safety, excellence, and integrity.
As our experience shows, standardizing PIVC insertion practices can help an organization achieve the Triple Aim by improving patient safety and satisfaction, while significantly decreasing hospital costs.
More than five years after beginning this journey, we are sharing our experience as a road map for other facilities looking to improve their processes and quality of care for a procedure that impacts nearly every patient in the hospital.
PIVC: Waste, variability, and defects
As the most commonly performed invasive procedure in all of healthcare, approximately 90% of hospitalized patients receive a PIVC at some point during their stay, and the majority receive more than one. In fact, 350 million catheters are sold in the United States each year, a number that exceeds the total U.S. population.
Lack of training is a major contributing factor to the waste, variability, and defects that plague this routine procedure. Nursing students receive little to no training on appropriate PIVC selection criteria or insertion techniques. This leads to variable work processes that result in multiple insertion attempts and high failure rates. On average, the number of PIVC insertion attempts is 2.18 to 2.35 catheters per placement (Keleekai et al., 2016). Even after successful PIVC placement, it is estimated that approximately 50% of catheters fail because of preventable complications and must be replaced (Helm et al., 2015).
This explains why patients fear needles more than prognosis, according to a recent survey of hospitalized patients (Sweeney, 2016). The end result is patient dissatisfaction, potentially harmful adverse events, use of more invasive vascular access devices (VAD), and increased healthcare costs.
At Hartford (Connecticut) Hospital, an 867-bed acute care teaching hospital, we believed PIVCs could be inserted more effectively and efficiently using a Lean-based approach. We set out to develop a standard work process that applies best-practice approaches to reduce needlesticks and prevent premature catheter failure. The key to this process transformation was centralizing PIVC insertions within a team of experts who specialize in IV therapy—the VAST—using an evidence-based care model to reduce waste and variability.
A successful change in culture is a delicate equation that requires the right approach to get the right result. This approach includes a sufficient number of staff members who are properly trained in IV therapy; standard work processes, including bundled best practices and technology; and a high level of collaboration between frontline clinicians and nursing leadership who share the same vision.
The journey begins: Collecting the data
Anchoring change in an organization’s culture requires support from the top down. To get behind any kind of process transformation, hospital leadership will need metrics to prove that the proposed change will translate to better clinical outcomes and patient care.
The first step is collecting and presenting key data on the current state of PIVC insertion practices to establish baseline measures. In 2015, the VAST started the process by assessing our annual catheter and IV supply consumption. Based on hospital admission and supplies data, we calculated an average of 4.4 catheters were consumed per patient visit. Our team also developed a cost analysis to establish the cost basis per bed for IV therapy—a large cost that is widely unknown to hospital administrators. At an average cost of $28 per PIVC insertion, we estimated an annual cost of $4.1 million ($4,781 per bed) for PIVC insertions, which includes both supplies and nursing time.
Next, the VAST set about creating the vision for the ideal future state that would reduce variability and eliminate waste. We sought to increase PIVC dwell times while reducing adverse outcomes, with the ultimate goal of achieving 1 PIVC per patient stay (Gorski et al., 2016). Using principles of LEAN/Six Sigma methodology, we designed an evidence-based best-practice framework—called the PIV5Rights™ bundle—to address the most common reasons for PIVC failure: infiltrations, phlebitis, infection, occlusion, and accidental dislodgement.
A key element of the PIV5Rights bundle is having PIVC insertions performed by a dedicated VAST. IV insertion is both an art and a science, and we felt strongly that placing the procedure in the hands of specialists who have a thorough understanding of vascular access issues and their impact on patient safety would improve outcomes and lead to better patient care.
To collect the data, we designed a prospective, comparative multi-modal study that compared PIVC insertions by the VAST using the best-practice bundle to a generalist clinician using the standard-of-care process. The goal of the study was to show better patient outcomes, fewer IV-related complications, and overall cost savings by achieving 1 PIVC per patient stay with the PIV5Rights bundle.
The study included specific elements that would demonstrate the clinical and financial benefits of the bundled VAST approach, including photo documentation and standardized data collection and analysis. The VAST took photos during every assessment of every PIVC in the study to provide a side-by-side comparison between the two approaches. In addition, the team developed a HIPAA-compliant iPad® app used to uniformly collect data about PIVCs, and all study team personnel were trained on its functionality.
After obtaining IRB approval, the VAST conducted the study in a 47-bed medical unit from November 2016 to February 2018. The study included 125 patients with a total of 207 PIVCs. The data collected were validated and analyzed by a senior research scientist for the hospital. While we expected to see positive outcomes with the PIV5Rights best-practice model, the actual results far exceeded even our most optimistic expectations.
Phase 2: Presenting the data
Published in the Journal for the Association of Vascular Access, our study found that the PIV5Rights standard work process was associated with higher insertion success, longer dwell times with fewer complications, greater patient satisfaction, and significantly reduced IV therapy costs (Steere et al., 2019).
Using the best-practice bundle, the VAST successfully inserted 96% of PIVCs on the first attempt, and 89% of the catheters lasted until the end of treatment. In contrast, only 15% of catheters inserted with the generalist model lasted until therapy completion. In addition, the PIV5Rights approach led to fewer harmful complications, reducing the complication rate from 40% with the control group to just 11% with the VAST.
Overall, the standard work model reduced Hartford Hospital’s projected catheter consumption by 90%, which translates to a projected annual savings of $3,376 per bed, or $2.9 million overall. This includes both direct and indirect cost savings due to the reduction in IV supplies as well as nurse training and labor costs. Fewer central line–associated bloodstream infections, fewer treatment interruptions, and higher patient satisfaction scores may further increase the financial impact of this new model by contributing additional savings and/or increased reimbursement.
Based on these results, and the powerful clinical and economic benefits we were able to demonstrate, hospital leadership approved the proposal to centralize PIVC insertions within the VAST in late 2018.
Though we were already more than three years into the process, the real work was only just beginning. Now we faced the challenge of expanding the VAST and training the team members in the standard work processes in order to begin implementing this evidence-based approach throughout the entire hospital.
Phase 3: Building and training the team
Between selecting and training the right candidates, we knew the journey wouldn’t yield results overnight. After all, we weren’t only attempting to build a team; we were also trying to change the culture of an entire organization.
When this process started in 2015, our VAST consisted of seven RNs and two LPNs, equating to roughly seven full-time employees. In less than four years, the size of our team increased nearly threefold to 23 RNs (an equivalent of 20 FTEs) without adding to the hospital’s overall FTE headcount. As our analysis showed, implementation of the PIV5Rights model could save more than 37,000 hours of nursing time spent on PIVC insertions. This enabled us to reallocate full-time nursing staff from other departments to the VAST, while giving the floor nurses more time to focus on patient care and other quality improvement initiatives.
Choosing the right people meant not only focusing on their vascular access skills, but also their personality and how they would interact with the rest of the team. A standard workflow requires every team member to be on the same page, executing the process in the exact same way, every single day. Clinical skills, while important, can be taught over time; a “team player” mentality cannot.
Once the right people are selected, training them is a long, ongoing process. We averaged a minimum of four to six weeks of training per new team member. As a small department, we faced the added challenge of having a limited number of available preceptors to facilitate training at any given time. Our orientation focused on theory-based concepts to get the new team members up and running, knowing we could focus on refining the standard work process at a later time.
In July 2019, more than four years into the process, the VAST took over all PIVC insertions in the hospital’s inpatient units, with the exception of labor & delivery and critical care units.
Phase 4: Hardwiring the standard work process
After onboarding was complete, we could finally shift our focus to hardwiring the standard work process to better manage workflow. Essentially, this process provides the VAST members with a script to follow throughout their daily routine, and our standardized data forms enable uniform collection and reporting of critical information about every PIVC. Every morning at 7 a.m., the entire VAST assembles in a morning huddle, facilitating a successful handoff and ensuring that every team member is following the appropriate process.
The VAST is divided into four teams across the hospital. The teams proactively round on all new admits from 7 a.m. to 11 p.m., with the goal of having all patients assessed within 24 hours of admission. This early assessment ensures that every patient receives the most appropriate VAD. Our team is able to perform a daily review of all central lines for necessity, while increasing the use of midlines when appropriate.
As the months went by, we began to see a significant decrease in the amount of IV site requests. Instead of always racing to catch up, the proactive rounding and early assessment as part of the standard work process enables our team to stay ahead of the requests.
We’re seeing positive results on the other end as well, including an increase in patient satisfaction scores. Based on over 3,000 surveys, our average Press Ganey score increased by five points, from 68% at baseline to 73% after centralizing PIVC insertions within the VAST. These improved patient satisfaction scores are moving us closer to achieving the Hartford HealthCare balanced scorecard initiative of 75.6%.
With patient satisfaction potentially linked to millions of dollars in reimbursement funds, this improvement can have a significant financial impact on the hospital. In addition, the VAST model increased our billable IV services from $6 million to $7.4 million. With the VAST’s proactive approach to PIVC placement, we’ve been able to decrease the number of unsuccessful insertion attempts while increasing billable IV services.
In recognition of this significant effort, the VAST was named Hartford Hospital’s 2019 Clinical Team of the Year. Selected from a group of 27 teams by a committee made up of local community leaders, this award honored the team’s innovative approach to improving IV care at the bedside.
Looking ahead: Standard work observations and tracking real-time outcomes
Though we experienced some disruption due to the COVID-19 pandemic, the VAST members picked right up where they left off when normal hospital operations began to resume in May 2020. This is a testament to the power of the standard work process and how ingrained it has become for every single team member. As we continue to move forward, the next step is to begin standard work observations to ensure adherence to the PIV5Rights care model, which requires hiring a clinical nurse leader to assist with observations. This will enable us to identify and address any issues as soon as they arise and hopefully minimize their impact.
The last step will be implementing a system to track productivity and outcomes in real time. In addition, we’re also considering putting the VAST under the auspices of a medical director so we can increase oversight and track better quality data, as well as increase revenue.
The future of IV therapy for Hartford HealthCare and beyond
Currently, we’re helping other hospitals within the Hartford HealthCare network to facilitate the same process transformation. By working with one facility at a time to implement the PIV5Rights evidence-based care model, our eventual goal is to standardize how infusion therapy is managed across the Hartford HealthCare system.
As our experience shows, an effective quality improvement initiative requires significant time and effort. The right approach requires choosing the right team members, the ability to foster teamwork, and a mindset of continuous improvement, as well as the support of hospital leaders who share the same vision.
Was the reward worth the challenge? Absolutely. For an invasive procedure that affects nearly every single patient in the hospital, the journey to getting the right result is most certainly one worth taking.
Lee Steere, RN, CRNI, VA-BC, is the unit leader of IV therapy services at Hartford Hospital. He also chairs the Hartford HealthCare’s Clinical Value Team and is a member of their HAI Committee.
PSQH: Patient Safety & Quality Healthcare, October 9, 2020
The model presented sets out standards that push toward service excellence and focusing on the best interests of customers.
This article was originally published October 8, 2020 on PSQH by Benjamin E. Ruark
Introduction
Nursing homes are not unique when it comes to bandying the word quality around in their self-promotion literature. More likely than not, they’ll be found sorely wanting in how to epitomize such a claim.
The model presented herein admittedly constitutes a “respectable draft” only, since I’m no longer a training and management consultant; regardless, it sets out standards that push toward service excellence and focusing on the best interests of customers: the residents who’ve chosen a nursing facility to be their 24/7 care-based home for their remaining time in this world.
The model does not include specific standards referring to administrative offices, dining hall service, grievance handling, parking lots and facility grounds, physical therapy operation, resident care plans, and scheduled activities for resident entertainment and exercise.
Nonetheless, it puts forth 15 distinct categories, listed alphabetically.
Expectations for new hires & temporary contract personnel
o Cover the following points in a frank and sober discussion before any new/temporary staff person begins work:
Professional conduct
Major roles performed
A statement of what constitutes unacceptable conduct
A statement describing how misconduct will be handled
The requirement to seek guidance from their supervisor on any incident posing uncertainty
Their top priority, which is to think and act in each resident’s best interests—preferably as residents explicitly express them
The need to resist the temptation to perform routine actions reflexively—not to view the facility as human warehousing and their job as a daily grind, but to retain their full attention to detail and optimize actions taken according to each resident’s needs
2. Expectations for visiting student nurses
o Visiting student nurses should be assigned assistance tasks, as needed, and take direction from permanent staff in whichever units are visited.
o They should interact with residents on a work-related basis only.
o They should avoid huddling, conversing socially, and making a distraction around residents in public areas such as commons and dayrooms.
o Prepare beforehand to give every student nurse both learning and service opportunities, rather than allowing them to stand idly by.
Facility safety, security, and maintenance
o Institute, at minimum, instructions for:
Handling resident threats made about other residents
Setting/resetting exit alarms
Respectfully handling resident attempts to leave premises
Unvarying hours on facility lockup and opening for business
Handling troublesome situations instigated by visitors (include identified examples for practice drills)
o Adopt a comprehensive inspection and planned maintenance schedule of:
Operability of heaters, overhead lights, and toilets (and water pressure)—facilitywide (rather than waiting for malfunctions to occur)
Hot water volume in restrooms and shower rooms
Operability of public-area lighting and TVs
Cleanliness, function, and appearance of furniture
Various body-lifting/transporting equipment—cleaned, lubricated as needed, and tested for functionality
Operability of devices in residents’ rooms: remote controls, TVs, table lamps, and HVAC units (and thermostats)
4. Housekeeping
o Resident rooms: Avoid any cleaning that conflicts with a resident’s need for private time or aggravates their health condition. When otherwise deemed appropriate, sweep, mop, and empty wastebaskets daily, cleaning any dried spills and other floor stains. Periodically clean the inside windows.
o Public/resident restrooms: Thoroughly sweep and mop, along with emptying wastebaskets and replacing linings. Clean and disinfect outside toilet, toilet bowl, washbasin and counter, and mirror. Replenish room deodorizer and toilet paper on wall units, with a surplus roll set on toilet tanks. (In resident restrooms, especially, perform closer inspection of floor to ensure all “matter” has been scraped and swept away, then mop with bleach or other regulation-adherent additive to fight infection. Perform this same practice from floor to head level on interior walls and doors. Rather than strict utilitarianism and hospital drab, resident restrooms should have a home-like appearance.)
o Public areas: Periodically, lightly shampoo and/or disinfect chairs, sofas, picture frames, mirrors, windows, foot stools, benches, tables, TVs, computer stations, and bookcases.
o Shower rooms: Preferably, each shower room should be gone over by a night crew who perform floor-to-ceiling cleaning with a disinfectant soaping and rinsing. When this is done, the sinks, floor, and fixtures should be sparkling clean, giving an impressively orderly appearance for the start of the next day.
Individual resident vulnerability monitoring
o A resident’s BBPP proneness monitoring plan should be posted next to their care plan in clear, concise language. BBPP stands for biological, behavioral, physical, or psychological tendencies or vulnerabilities. Just as elderly people are susceptible to injurious falls, and still others are susceptible if certain foods are included in their diet, nursing home residents can be susceptible to gastrointestinal issues, headaches, nervous tics, etc. caused by factors such as stress.
o Thus, each resident’s specific vulnerabilities need to be identified, recorded, and memorized, then monitored daily for early onset as well as prevention through preemptive actions. For example, if a resident has severe back problems, staff should lift any of the resident’s items that exceed 5 pounds, make their bed, and retrieve items from floor level to prevent the resident from stooping low and minimize the risk of back injury.
Medication dispensing & administration
o Nurses and med techs will dispense all medications in accordance with the physician, PA, or nurse practitioner’s prescriptions.
o Nurse and med techs will double-check that they have the correct medication name and the correct dose for the time period stipulated.
o Nurses and med techs will repeat the name of each medication being administered and its dose to all cognitively functioning residents, and inquire whether the resident agrees on the medication names/doses and/or the number of items being handed over. This approach allows residents to disagree in the event they receive some medications that are only taken “as needed.” It’s doubly important that such distinctions are also made clear at resident intake. (Note: If oral medication requires a glass of water, use either tap or cool water—not ice-chilled, which can induce throat constriction.)
o Follow protocol for IV administrations and needle injections.
o All resident requests to increase, or terminate use of, a medication will be thoroughly explored and referred to higher authority. Resident requests to decrease a medication will also be explored before being granted. If the reason(s) given are not sound, the matter will be referred to the charge nurse or possibly also a facility social worker.
Overall facility appearance & setting
o All commons and dayrooms: Maintain casual, comfortable décor with stain-free carpeting, pleasant fragrances, color-coordinated settings, adequate activity tables and coffee/end tables, and nicely appointed wall hangings. Selected furniture should rest high and firm enough for elderly to rise without risk of falling. Rooms should be spacious enough to accommodate parked walkers and for wheelchair-bound persons to move about freely. TV/radio volumes should be low enough for residents and visitors to converse and socialize.
o Dining halls: Apply a standard spacing arrangement for wheelchair-bound diners and chairs for those entering by foot, with space to park walkers. The décor should be cafeteria style and spotless, and the space should be brightly but not excessively lit. Wall sanitizers should be mounted at all resident entry/exit points. Soft music should be playing; this music should be unobtrusive, not played to entertain service personnel.
o Equipment: Store large pieces of equipment in less-traveled hallways, at least 18 inches away from doorways for resident safety.
o Hallways: Air fresheners should routinely deodorize resident hallways with a semi-tropical scent (most widely accepted) whose chemicals are non-allergenic. (The customary condition of offensive odors emanating along hallways—often taken as an inescapable fact—is no longer acceptable, just as it would not be in residents’ former homes.) This can be done through piping, exterior nozzles and timing, or remotely triggered wall mounts (appearing as sconce-like ornaments). PA system announcements should be short, reserved for business purposes, and discontinued after 8 p.m.
Staff should make it standard practice to talk in low tones in hallways—not competing with noise within residents’ rooms. Every room should be furnished with noise-canceling wireless earphones. With many rooms’ doors left partway open for peek-in monitoring by passing staff, residents whose hearing is still intact will no longer be subjected to loud noise emanating from adjacent rooms in the event that residents (e.g., those suffering from dementia) resist use of earphones.
o Shower rooms: Use high-quality (non-leaking) hoses and spray nozzles. The heating and cooling apparatus installed should have plenty of capacity to perform given the size of the room itself. An overhead warming light outside the shower stall is recommended.
Washable bench seats should be sturdy, weight-bearing, and roomy enough to hold a person and toiletries. Wall hooks should be well placed for hanging clothes, gowns, towels, etc. Adequate-size shelves should be located at the sink, along with outlets for personal appliances and grooming devices. Ceiling-hung curtains should skirt both the toilet and the shower stall. Non-skid footpads should be fastened inside the shower stall for added safety.
Resident call-light requests
o Aides will learn the personal preferences of all residents with regard to lids with spouts positioned on water bottles for drinking, and on condiments, medical containers, etc., to alleviate residents with arthritic and weak hands from readjusting them based on handedness.
o For all other requests, aides will ask residents’ preferences for optimizing any task with an intent to provide a best way of performing it, such that its configuration or outcome is optimal for each resident (requiring listening skills and analytical thinking skills).
o For incoherent residents, aides will have been tutored to interpret residents’ likely requirements for most optimally performed tasks and then follow through with such actions, witnessing anticipated results as positive confirmation.
o Aides will respond to call lights within 12 minutes from their signal85% of the time (allowing for coded assistance interruptions, etc.). All promised actions made to residents—including implied follow-up actions—will be handled within one-half to one full business day.
Resident information handovers at shift change
o Staff will adhere to the SBAR or I-PASS method of conveying individual pertinent resident information to their counterparts at shift change. This handoff will include any resident requests that are set to take place during the next shift.
Resident in-room meal service
o All staff involved in meal tray delivery will work out an efficient system that moves trays to resident rooms at the fastest pace feasible. (This minimizes lukewarm resident meals and protracted hunger; contract food services, for example, may supply a skeletal staff who deliver food carts consecutively on one unit/ward at a time.)
o Tray servers will quickly inspect trays to ensure a complete silverware and napkin set is present, adequate condiments are provided, and the items on the tray match the preferred drink(s)/meal for each resident (on food ticket).
o Tray servers will tactfully explain to any residents wishing to chat, etc. that meal delivery fills an urgent need and that other requests will be handled after meal delivery is completed.
Residents’ quarterly satisfaction survey
o The satisfaction survey’s purpose is to routinely assess for levels of effectiveness across key facets of healthcare services, not to gather glowing ratings. It should identify specific weaknesses, omissions/neglects, and possible indications of where performance is slipping from its former level. Data gleaned from the quarterly assessment is then used to install organizational improvement interventions such as refresher training, peer coaching, supervisory spot checks, or job aids. As many as 18 to 24 categories of assessed service might be useful.
Residents requiring morning wake-up assistance
o Residents not requiring assistance are offered the option of being woken up at a pre-specified time.
o Residents requiring assistance will be courteously coaxed to start their day, given physical assistance as needed, and assisted with cleaning up and getting dressed. Incoherent residents are scheduled for earlier wake-up based on their likely need for extended assistance.
Residents requiring special handling—location & monitoring
o Cognitively “animated” residents suffering dementia (and emitting various loud, incoherent vocalizations, etc.) are to be contiguously sequestered in nooks/alcoves ideally located adjacent to nurses’ medication carts. Residents with special needs are thus prudently clustered together for closer monitoring; in addition, since these needs tend to correlate with louder noise levels, sequestering the residents helps avoid stress within the general population due to excess noise.
o Aides are to modulate voice level based on each resident’s hearing capability. An air vent will be turned on as well to minimize the chance of toileting conversations being heard by third parties who share the same restroom.
o Late evening/overnight toileting assistance should be held to whispers, or at least done with a restroom vent turned on. Avoid waking sleeping residents within close proximity.
o After assisting with toileting and returning an assisted resident to their quarters, the restroom is made relatively sterile—not just given an appearance of cleanliness. Allaffected surfaces are thoroughly cleaned with approved cleaners.
Staff demeanor around & communication with residents
o All frontline staff will comport themselves as caring, compassionate, and empathetic professionals; supervisors will coach staff a minimum of one or two times per week (depending on individual staff skill levels) on exemplary demonstration of actual service examples indicative of one, two, or all three of these attributes.
o Presumptive of residents’ dignity and integrity, everyresident will be shown respect, without exception—regardless of their current behavior. Staff will not adopt a surly attitude or use patronizing or condescending language like “dearie,” “honey,” “sweetie,” “sugar,” etc. (as is apparently still prevalent in rural locales).
o Residents will be given advance notice of planned procedures and other actions they’re targeted to receive, to be in effect in 95% of occasions. A staff person about to perform some task/procedure will explain to the resident why it is needed, in language the resident is able to comprehend. With cognitively impaired residents, staff will offer simpler explanations and resort to approved, tactful methods to achieve the task at hand.
Final words
Many of the italicized phrases found herein denote quality standards; a few of them denote quantity and timeliness standards. Performing all of them with consistency is indicative of another service standard: reliability. Staff competence is another critical area of focus—their requisite knowledge, technical ability, and soft skills (such as communication, listening, and interpersonal skills) need to be of the highest caliber.
It is recommended that skilled nursing homes budget for training workshops on soft skills, which generally are the most lacking. Supervision and top management both need to set impressive standards for being accessible (by phone and in person) and responsive. This translates into satisfying resident requests of all kinds and taking follow-up action in a manner that matches the customer service standard of other industries.
Benjamin E. Ruark is a former learning and development and continuous quality improvement professional. He now devotes his time to writing on important subjects for various industries, healthcare included.
PSQH: Patient Safety & Quality Healthcare, October 7, 2020
While we continue to refine our efforts to standardize the delivery of safe, efficient, and person-centered care to those facing serious illness or the end of life, more must be done to scale similar efforts across the healthcare system.
This article was originally published October 7, 2020 on PSQH by Kurt Merkelz, MD
When it comes to systemic improvement of our healthcare delivery system, there is no shortage of ideas. Yet, even as the conversation has evolved to include important drivers of health outcomes such as the use of real-time data to guide interventions and care plans that address housing, transportation, and other social determinants of health, very little of what is discussed is truly actionable and easily scalable.
That’s why the National Quality Forum’s (NQF) recent report, The Care We Need: Driving Better Health Outcomes for People and Communities, is significant. Much like the Institute of Medicine’s seminal report, To Err Is Human, which catalyzed healthcare around a systems approach to reducing preventable harm, the NQF report highlights actionable opportunities to scale efforts that have demonstrated the ability to improve quality, value, and safety.
One important difference is a new emphasis on delivering comprehensive, person-centered care. Recognizing that, too often, healthcare looks at a patient solely in terms of their debility, the NQF report is a call to re-orient the system around the patient and their unique goals and social, emotional, and spiritual needs.
With its focus on quality of life and interdisciplinary care teams of clinicians, social workers, and chaplains who are trained to understand the complex relationship between physical and emotional pain, the field of hospice and palliative care is uniquely suited for this new approach.
Yet, end-of-life care too often falls short of its promise to help a patient live fully—sacrificing quality of life for symptom management. When this happens, decisions are often based on assumptions rather than patient preferences.
This flawed approach extends to the measurement of quality and value. While the hospice industry has made significant strides in collecting data to track the delivery of care shown to produce better outcomes, there are still gaps. For example, Medicare-certified hospice providers are only required to assess a patient’s understanding of their Do Not Resuscitate (DNR) status. Simply asking the question checks the box—often resulting in a missed opportunity for meaningful dialogue around the patient’s goals for end-of-life care.
A new model of care
I believe we can do better. By identifying high-impact opportunities to support the delivery of consistent and predictable high-quality care and defining a series of actionable steps, hospice and palliative care providers can achieve many of the objectives outlined by the NQF.
My organization recently took the first step to heed this call. With input from a medical advisory board, interdisciplinary team members, patients, and families, we created a person-centered care model focused on seven key areas, including pain and symptom management, safety and autonomy, and quality of life.
The model, which has been implemented across a 159-location hospice community in 29 states, standardizes care around proven practices and provides a common framework for conversations with patients and family members. The goal is to create space to focus on the patient as an individual.
Rooted in the belief that listening is among the most transformative tools in healthcare, the model calls for each member of the interdisciplinary team to focus on understanding the patient’s greatest concern within their domain and address it in a way that supports the individual’s unique quality-of-life goals. These conversations allow team members a deeper understanding of the patient’s needs, priorities, and religious and cultural preferences—allowing them to tailor care accordingly.
Connecting the dots to address social and emotional barriers
This emphasis on whole-person care includes a focus on addressing the social determinants of health: another opportunity identified in the NQF report.
Sadly, social factors such as poverty, mobility challenges, and caregiver burnout often worsen as an individual nears the end of life. To achieve true person-centered care, providers must not only address the patient’s physical, social, or emotional deficit, but also connect it to their underlying needs.
For example, instead of simply identifying gaps in a person’s ability to manage activities of daily living, such as the ability to ambulate, our person-centered model of care examines the factors driving the need for mobility—such as the need to access food or medication. By hardwiring a framework to identify these needs and connect patients with the right social supports, the team can design a comprehensive care plan that considers the whole person.
Measuring quality of life
These and other steps outlined in the NQF report are critical to improving end-of-life care. Yet, true transformation will not happen without improved quality measures that align with the focus on safe, appropriate, and person-centered care.
While improved, existing measures still do not reflect the importance of educating and engaging the patient and family, they also do not reflect the need to provide coordinated care tailored to the patient’s goals and preferences.
To address this gap, we must embrace new performance metrics. Since implementing our care delivery model, we have created new measures to track performance across the domains of care, including pain intervention response, medication reconciliation, patient safety, and quality of life.
While we continue to refine our efforts to standardize the delivery of safe, efficient, and person-centered care to those facing serious illness or the end of life, more must be done to scale similar efforts across the healthcare system.
Until we have highly actionable and easily replicable models of care—and corresponding quality measures—that address the physical, emotional, social, and spiritual needs of patients and families, the vision of providing every person with consistent and predictable high-quality care will not be realized.
Kurt Merkelz, MD, is senior vice president and chief medical officer of Compassus, a provider of home health, palliative, and hospice care services across 29 states.
PSQH: Patient Safety & Quality Healthcare, October 7, 2020
What is not in question is the need to protect healthcare workers from contracting the disease—either from patients or colleagues.
This article was originally published October 7, 2020 on PSQH by John Palmer
A new study finds that, while voluntary testing of asymptomatic healthcare workers for COVID-19 may help identify positive cases, it’s not the best way to ensure the safety of workers dealing with COVID-19 patients.
The study, “SARS-CoV-2 Screening of Asymptomatic Healthcare Workers,” was published in the July issue of Infection Control & Hospital Epidemiology, the journal for the Society for Healthcare Epidemiology of America.
“Extensive testing of employees does not seem to be cost-effective or necessary when strong symptom screening and infection control policies are in place,” wrote lead author Andrew P. Jameson, MD, FACP, an infectious diseases physician with Mercy Health Saint Mary’s Hospital in Grand Rapids, Michigan. “As hospitals and communities prepare for the next phase of the pandemic, we recommend close monitoring of employee symptoms, rapid access to testing when symptoms develop, strong infection control practices, and broad testing of patients to effectively cohort patients as an alternative to testing asymptomatic employees.”
There is, of course, much debate over what the “next phase” of the COVID-19 pandemic will look like, and whether U.S. hospitals are already seeing a second phase or a continuation of the first wave.
Certain areas of the country are experiencing an increase in the number of COVID-19 cases, while other areas, including the Northeast, have been enjoying a lull in their positive case numbers. However, as colder weather sets in and the population is driven inside, the number of cases is expected to rise as indoor face-to-face interactions increase.
What is not in question is the need to protect healthcare workers from contracting the disease—either from patients or colleagues. After all, both asymptomatic and pre-symptomatic people can transmit COVID-19 without knowing it.
Jameson and his study team developed a protocol to screen asymptomatic workers at Saint Mary’s as a way to determine COVID-19 positivity rates among those who do not develop symptoms. Those tested (by nasopharyngeal swabs) included respiratory therapists, physicians, nurses, and patient care assistants.
Of 499 eligible staff members, 121 took part in the screening, representing about 25% of the eligible workers. All 121 workers were found to be negative for COVID-19.
“The negative results of all tested individuals allowed these personnel to return to work in confidence and also informed the hospital’s decision to not continue routine testing of employees,” Jameson wrote.
So, what did the study prove? While testing asymptomatic healthcare workers might determine positivity and increase confidence among staff, good luck getting them all to agree to be tested. The 25% of eligible staffers volunteering to be tested was much lower than the study authors expected, probably from a combination of people who did not want to get swabbed or who had low trust in the organization’s approach to infection control.
“Regardless, this relatively low uptake does not support routine testing as an effective method to improve workforce confidence or safety,” Jameson wrote.
In other words, there are many other more important things that hospitals should be focusing on to help protect their employees, and it starts with robust intake procedures, monitoring, and use of personal protective equipment (PPE). Consider the following precautionary measures that Jameson says were instituted at Saint Mary’s:
All patients admitted to the hospital, regardless of symptoms or reason for stay, are tested for SARS-CoV-2
All patients undergoing surgical procedures are tested 24–48 hours before the operation
All positive patients are isolated in designated COVID-19 care units
All COVID-19 care floors have negative-pressure ventilation systems in place
PPE is required, including surgical masks and universal precautions on all floors, plus gowns and eye protection on COVID-19 units
N95 mask or PAPR/CAPR use is mandatory for anyone performing aerosol-generating procedures in COVID-19 units
There is a “no visitors” policy throughout the hospital, absent exigent circumstances
Universal symptom screening of all staff arriving to work is in effect, and workers are sent home if they present with any symptoms including fever, cough, shortness of breath, chills, body aches, loss of taste, or loss of smell
“In the months since implementation, adherence to the listed protective measures has been central to the safety of the hospital community and has contributed to the lack of positive testing among asymptomatic HCWs,” Jameson wrote. “As statewide regulations and social distancing restrictions begin to relax, it is essential to adequately protect our healthcare workforce.”
The Saint Mary’s study gained the attention of former CDC director Thomas R. Frieden, MD, MPH, who co-authored a letter in Infection Control & Hospital Epidemiology supporting the study’s conclusion and championing the idea that “all healthcare facilities must rapidly and rigorously implement the full hierarchy of established infection controls.”
Frieden added that because many healthcare workers are contracting and dying from COVID-19, “the scale of this epidemic necessitates thinking beyond individual healthcare facilities.”
The full hierarchy of controls he suggested would include the following:
Source control, or the removal and mitigation of the source of infection. This includes advising patients with minor symptoms to stay home or seek treatment through telehealth. If they must be seen in person, they need to wear masks or be isolated in rooms separate from other patients.
Engineering and environmental controls. These include changes in airflow and filtration to remove virus particles from the air, as well as the use of UV light and better cleaning and sanitizing practices.
Administrative controls. These relate to training and the development, implementation, and enforcement of infection control policies and procedures that are written clearly, easily understood by all staff, and posted conspicuously throughout the facility.
Nothing new to the healthcare community, PPE includes face masks, respirators, face shields, goggles, gowns, and gloves.
“Especially in areas with many cases, most persons with known or suspected COVID-19 could ideally be channeled to designated facilities,” Frieden wrote. “Infection control procedures would still be needed in all facilities, but enhanced efforts could concentrate on COVID-19-designated facilities, and reusable PPE could be safely used, maintained, and disinfected.”
He also said that critical supplies, equipment, and treatments could be allocated to designated facilities more efficiently.
“This would require participation by most or all hospitals in a geographic area, with centralized coordination, but might ultimately reduce this epidemic’s toll on patients, healthcare workers, and society.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, October 6, 2020
The consolidation trend will demand strong leadership from physicians at the helm of these evolving models.
This article was originally published October 6, 2020 on PSQH by Megan Headley
Over the years, physicians have been frequently accused of resisting change. In the face of tremendous new pressures—ranging from explosive levels of new technology and data to changing regulatory burdens and expectations—it is understandable that care providers may struggle to keep up.
Now, Thomas H. Lee, MD, chief medical officer for Press Ganey and a physician at Brigham and Women’s Hospital in Boston, finds that this reluctance to change may itself be changing.
In recent years, Lee says, there’s been a promising “changing of the guard” that he believes may better support the new demands of leadership in healthcare’s future. “They’re different,” Lee says of the physicians coming out of medical school today. “They’re wired more to be part of teams as opposed to individuals raging about change.”
That’s a necessary evolution, as Lee sees the demands facing future leaders steadily increasing. The trends against which physicians have pushed back are not, as he puts it in a June article for NEJM Catalyst, “trends that can be ignored or reversed … physicians need leadership guidance to help them plunge into these trends.”
The changing of the guard
Lee’s article, “Six Tests for Physicians and Their Leaders for the Decade Ahead,” written with Toby Cosgrove, MD, executive advisor and former president and CEO of the Cleveland Clinic, highlights the traits needed of tomorrow’s physician leaders.
However, it also notes a change in how this leadership is organized. Citing the AMA’s 2019 Physician Practice Benchmark Survey, the pair point out that 2018 was the first year in the survey’s history that there were fewer physician practice owners (45.9%) than employees (47.4%).
Only 26% of physicians under age 40 had an ownership stake in their practice in 2018, hinting at the greater shift to come as physicians consolidate beneath the umbrellas of large practices or health systems.
This consolidation is a trend that supports the need for greater economies of scale, effectively meeting new consumer expectations and preventing physician burnout. As Lee and Cosgrove write, “Problems are emerging that can only be addressed through scale. For example, small groups and hospitals are simply unable to take on emerging cybersecurity challenges.”
The consolidation trend will demand strong leadership from physicians at the helm of these evolving models—as well as physician employees who want to drive their practice toward best practices for navigating future challenges.
As Lee and Cosgrove put it, there’s no retreating from challenges, which include:
An explosion in knowledge due to research advances—and increasing complexity that threatens to overwhelm physicians
Greater pressures to improve in order to meet regulatory burdens of the Affordable Care Act
A loss of autonomy for physicians, who are increasingly driven to work in groups
The need to improve interactions between physicians and their electronic medical records
Lee and Cosgrove have identified a set of six “tests” for physicians and their leaders that they predict will define effective healthcare leadership in the future.
Emphasizing transparency in all aspects of care
According to the NEJM article, “The idea that good care is good business seems obvious, but the notion that meeting patients’ needs should be the focus for every decision remains disruptive.”
Patient care may be the mission, but Lee finds that “distractions” keep physicians from focusing foremost on patient care. Reprioritizing patients is the first test for leaders, and this may mean rethinking payment and compensation.
By organizing around the fee-for-service system, the authors suggest, physicians prioritize performing procedures, tests, and operations rather than taking care of patients. “The organizational structure and the fee for service incentives behind it don’t incentivize bad care, but they don’t directly reward us for being at our best,” they write. The practice of coupling compensation with volume of services also gets in the way of excellent care.
Transparency, Lee suggests, can help drive these needed shifts. It’s already underway for some practices with online reviews. “Transparency tends to have its most dramatic effects on the parties who are being measured, even more than on the patients/consumers who might seem the targets for the information,” the authors write in the NEJM article. “Physicians want what is said about them on the Internet to be consistent with how they see themselves. And the most reliable way to make that happen is to be their best selves consistently.”
This shift toward prioritizing patients will continue with greater transparency around cost, a critical, if often overlooked, piece of the patient experience. As Lee and Cosgrove point out, many health systems are beginning to take steps in this direction. While groups such as Mayo Clinic, Cleveland Clinic, and Geisinger Health System see most of their revenue flow through fee-for-service contracts, they pay their physicians straight salary, without financial incentives for performing more services.
“The trend is in this direction, but we need to accelerate it,” Lee elaborates. He suggests that the groups that provide greater transparency and are more reliable in meeting these patient needs will prosper.
Embracing collaboration and competition
Physicians are becoming more collaborative, both with their peers in these growing practices as well as with colleagues across other areas of care. But Lee and Cosgrove encourage the creation of super-teams, with members who remain focused on the goal of excellent patient care above all else.
“The team members don’t worry about job descriptions; they do what it takes to help the team achieve its goal, and they know they can count on their colleagues to do the same. They are resilient individually and collectively, which enables them to deal with unexpected crises with effective aplomb.”
It’s a tricky demand at a time when physician burnout remains on the rise, but this push toward super-teams can actually help physicians work more efficiently. Super-teams proactively address complaints from both patients and physicians. They are made up of high-performing partners across care delivery: administrators, schedulers, scribes, and others who work to simplify the burdens that distract from patient care.
“Scheduling turns out to be one of the biggest causes of dissatisfaction,” Lee says by way of example. “So, in a really good team, the scheduler is sitting right there with the clinicians to make things work.”
With a focus on collaboration, it may seem counterintuitive to also focus on competition, but Lee and Cosgrove say actively thinking about—and ultimately embracing—competition is another critical test of leadership.
“Most physicians don’t think positively about the effects of competition in the health care marketplace,” the pair write. Physicians are often glad when their organization deflects competition through mergers with potential competitors. But this may not be the best strategy for improving patient care. Healthy competition can drive the lower prices, better care, and increased transparency that patients truly desire.
One such step, Lee says, is checking your online ratings and embracing the competition with other practices. You may already be the best, but it’s critical to ensure consumers see this. “Knowing that every patient can comment on my work, and anyone can see the comments, makes me want to be wonderful. That’s the way I want to be seen,” Lee says. “Creating an environment where people are trying to be at their best all the time is kind of stressful, but it’s necessary for plunging into competition.”
Driving change and innovation
As Lee mentions, change is coming more easily to many physicians, but the next step is to embrace innovation—pushing to introduce something new.
“The desire to be perfect creates a culture that has a way of smothering innovation,” Lee and Cosgrove write. “Physicians are afraid of failing. They and their colleagues get paralyzed by exceptions. They say something shouldn’t be tried unless there is evidence that it will make things better—and, as a result, it never gets tried.”
A strong first step toward embracing innovation, Lee suggests, is to start looking beyond the healthcare industry. “Healthcare is a decade or two behind other businesses,” he points out. “The idea of using balanced scorecards and having a clear strategy that helps you focus on what it is you’re trying to do so that you can be reliable about doing those things, that is 1990s insights for the rest of the business world, but it’s relatively new to healthcare.”
This is becoming somewhat easier as other industries begin to move into healthcare, particularly the technology industry. As new names offer entirely new service delivery concepts that compete with traditional models, innovation will become increasingly necessary for physician practices to survive.
And, with technology tackling diagnostics and other challenges, Lee says soft skills may become a more critical edge for leaders in the years ahead. Leadership training will need to support this and other shifts. Training more managers in the needs for physician leadership will encourage the collaborative, innovative processes that will help drive organizational success.
“When Toby and I started having this conversation, we could see that the decade ahead we were going to have to change. But we didn’t know how the new physician workforce would respond,” Lee says. Now? “We’re optimistic.”
PSQH: Patient Safety & Quality Healthcare, September 29, 2020
At least two hospitals were cited following what OSHA called coronavirus-related investigations.
By A.J. Plunkett
Ensure workers are trained on and fit-tested for using respirators and are not sharing protective gowns as they care for potentially infectious patients, or you may face fines from OSHA.
At least two hospitals were cited following what OSHA called coronavirus-related investigations.
Bergen New Bridge Medical Center is facing $9,639 in proposed penalties after OSHA inspectors citedthe hospital in Paramus, New Jersey, for “failing to fit test tight-fitting face piece respirators on employees who were required to use them. The hospital also failed to train employees on proper respirator use and ensure employees understood when to wear a respirator.”
Meanwhile, the Christus Shreveport-Bossier Health System in Shreveport, Louisiana, is facing $13,494 in proposed penalties — the maximum allowed by law — “for failing to ensure employees wore proper protective equipment.”
“OSHA opened a coronavirus-related investigation after receiving reports of employee exposure. The agency found that emergency facility employees often shared used protective gowns or did not have protective gowns to wear while treating patients,” according to the OSHA statementannouncing the penalties at the Louisiana facility.
Both facilities now have the chance to defend or mitigate the citations, which could then result in reduced fines.
In March, in recognition of the ongoing N95 respirator shortages, OSHA said it was relaxing annual fit testing requirements, but only under certain circumstances. OSHA said facilities had to be providing workers with respirators that provide equal or higher protection than the N95 medical respirators, and the facility still had to conduct initial fit testing to “determine if the respirator properly fits the worker and is capable of providing the expected level of protection.”
A.J. Plunkett is editor of Inside Accreditation and Quality, a Simplify Compliance publication.
PSQH: Patient Safety & Quality Healthcare, September 20, 2020
In normal times, healthcare staff are expected to do their jobs with competence while dealing with crisis situations that very few people in other industries experience.
This article was originally published September 18, 2020 on PSQH by John Palmer
Since the COVID-19 pandemic began in January, healthcare workers in U.S. hospitals have been working almost nonstop, often in high-stress environments without the proper support they need to do their jobs.
As usual, healthcare workers are asked to take on some of the hardest work during this pandemic, and many of them are doing so without taking enough breaks or getting enough sleep.
It’s taking a toll. You need only look at the nightly news to see photos and videos of exhausted healthcare workers working overlapping shifts to cover their colleagues—some of whom are getting sick themselves with the coronavirus.
It’s a given that work in the healthcare field is stressful. In normal times, healthcare staff are expected to do their jobs with competence while dealing with crisis situations that very few people in other industries experience.
Add to that things such as insufficient personal protective equipment, fears of infection, feelings of isolation from family members, and harassment from the community for enforcing strict infection control and prevention measures, and it’s not hard to imagine how staff can become overwhelmed both in their professional and private lives.
“The mental, emotional, and physical strain healthcare workers are experiencing during these unprecedented times of COVID-19 cannot be understated,” says Erin Lawler, MS, CPPS, human factors engineer at The Joint Commission (TJC)’s Office of Quality and Patient Safety.
The accreditor has joined the fight for protecting the mental and physical well-being of healthcare workers by releasing a guide designed to help staff support themselves, as well as help managers support them during the tough times of the pandemic, which is likely to stretch well into 2021 and perhaps beyond.
“The Quick Safety advisory serves to support individual healthcare workers and organizations alike by providing recommendations for protective strategies and ways in which to build individual and institutional resilience during crisis,” Lawler says. “It is critical that we ensure healthcare workers have access to psychosocial resources and support now and in the future.”
The strategies that TJC recommends for healthcare workers include the following:
Practice self-care and engage in healthy coping strategies. Eat healthy, exercise, and employ stress management strategies that work for you.
Practice good sleeping habits. Strive for no less than seven hours of sleep to combat fatigue.
Partner with colleagues to monitor each other’s well-being. Engage in a buddy system at work to provide support as needed.
Stay regularly connected with friends and family, while practicing social distancing, to mitigate isolation.
“While physicians and nurses are often the first members of a health care team that come to mind when picturing frontline staff, leaders must remember that all staff who keep their facilities running—including environmental and food service workers, imaging technicians, respiratory therapists, pharmacists, physical and occupational therapists, security personnel, social workers, and chaplains, among others—may be dealing with mental health conditions aggravated or brought on by the COVID-19 pandemic,” the document says.
In addition to being able to support themselves, staff leaders must also be ready to step up and help support workers.
“Some health care workers may believe that seeking support from a mental health professional will adversely affect their career,” according to the Quick Safety document. “The anxiety, stress, and other emotions brought on by these challenging circumstances are real and justifiable; they do not indicate weakness or incompetence.”
TJC’s guidance recommends the following strategies for leaders and managers:
Communicate regularly. Keep staff up to date about important information and announcements. Communicate honestly, sincerely, and empathetically. Ensure that communication reaches less visible service lines in an organization.
Model behaviors that promote self-monitoring. Encourage staff to focus on their well-being by doing things such as leading a three-minute reflection before each shift change.
Encourage sharing of concerns to build transparency and mutual trust. Create a safe environment that allows staff to openly share concerns with and ask questions of leadership. Acknowledge and listen to staff concerns even if answers to their questions are not known or readily available.
Orient staff to psychosocial resources and services, including how to access them, and offer the basics of psychosocial first aid.
Provide positive feedback. Share encouraging news and extend kudos to staff members. Consider sharing care recipient stories that are uplifting.
Adapt staffing. Monitor staff well-being and rotate staff from higher- to lower-stress functions when possible.
According to the Occupational Safety and Health Administration, excess stress can lead to loss of appetite, ulcers, mental disorders, migraines, difficulty in sleeping, emotional instability, disruption of social and family life, and increased use of cigarettes, alcohol, and drugs. Stress can also affect worker attitudes and behavior, which in turn can affect the way they do their jobs and lead to mistakes.
Some simple ways to help employees relax and take a quick break from the stress of the environment around them include the following:
Promote a sense of optimism and humor. In a profession where sickness and death are a part of the daily grind, it’s important to make sure your staff stays optimistic.
A quick joke or a positive quote written on the whiteboard in the staff room can be enough to raise spirits. Donations of food or coffee from the community can provide a needed lift during a busy afternoon of seeing patients. In some communities, healthcare workers have been greeted after their shifts with applause from first responders and cheering groups of residents in high-rises, or praised on social media. Whenever possible, expose your workers to these positive experiences so they know their work is not going unnoticed.
Institute a timeout policy. Sometimes the best way to relieve stress is to walk away from the situation, take a few breaths, and gain some perspective. A surgeon in the middle of a risky heart surgery can’t necessarily do this, but a nurse or front desk worker can probably take five minutes in the back for a quick break.
Next, make sure those breaks actually happen. Institute a policy where at least once an hour, employees get rotated out of the work environment for a 10-minute break. Whether employees use their break to take a quick walk outside, read in the break room, or grab a cool drink of water, they need to understand that these breaks are non-negotiable.
Teach breathing techniques. There will of course be times when it is impossible for your employees to walk away from their job responsibilities, but they can control their reaction to the stress they feel.
Some experts say that breathing exercises can help workers relax. Try teaching this technique for belly breathing from the University of Michigan Health System:
Sit or lie flat in a comfortable position.
Put one hand on your belly just below your ribs and the other hand on your chest.
Take a deep breath in through your nose, and let your belly push your hand out. Your chest should not move.
Breathe out through pursed lips as if you were whistling. Feel the hand on your belly go in, and use it to push all the air out.
Do this breathing three to 10 times. Take your time with each breath.
Notice how you feel at the end of the exercise.
Lend a listening ear. Hands down, one of the biggest complaints from healthcare workers is that they feel like no one is listening to them, that there is no process in place at work to report patient violence or safety problems, or that they simply need an avenue to talk about their feelings—after all, they are working in one of the most stressful career paths, and helping other people with health problems can take its toll.
Some healthcare facilities have counselors on call—if not on staff—to help their staff members deal with life’s issues. Others have peer groups consisting of fellow coworkers to give staff a relatable group to talk to.
Provide help with personal struggles. Financial troubles, family issues, and childcare challenges can be stressors that affect a person’s work performance. Give your employees a hand by offering childcare services, or invite a CPA to come in and give them a primer on personal finance.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, September 11, 2020
Some nurses will also leave extra infusions at the bedside so they can be spiked and hung by any nurse entering the room.
This article was originally published September 10, 2020 on PSQH by the Institute For Safe Medication Practices
ISMP recently spoke to a hospital nurse working in a location where the coronavirus (COVID-19) has again surged with a vengeance, causing a significant increase in patient admissions to the intensive care unit (ICU) and frequent, tragic fatalities.
He was particularly concerned about the many opportunities for serious medication errors when providing what he called “pandemic nursing” care—the rushed, physically overwhelming, and emotionally draining care provided to an onslaught of critically ill patients.
He acknowledged that serious medication errors were happening frequently at his hospital and was worried that frequent errors were occurring in other hospitals as well when attempting to handle another wave of COVID-19 patients.
The nurse also was concerned that healthcare providers in his hospital are, once again, resorting to finger pointing and blaming nurses when medication errors happen.
Overall, the nurse felt that few medication errors involving COVID-19 patients were being reported, given a significant and understandable lack of time, as well as a fear of retribution.
Environment of 'pandemic nursing'
The nurse works in a busy ICU treating about 20 COVID-19 patients daily, most of whom have multiple intravenous (IV) high-alert medication infusions (e.g., fentaNYL, propofol, norepinephrine, cisatracurium) administered via smart infusion pumps located inside their rooms.
Due to staffing shortages, each nurse has a taxing workload and is typically assigned three patients—two seriously ill, ventilated patients and one recovering patient. Nurses are constantly vigilant with infection control procedures and wear the usual personal protective equipment (PPE) (e.g., gown, mask, gloves) throughout their shift.
They can only change gloves between patient encounters due to PPE shortages. By the end of each shift, nurses are exhausted and overwhelmed, and sweating profusely under the PPE.
Nurses typically spend several hours in a patient’s isolation room and often bring in as many medications, infusions, and supplies as they think might be needed during this time. Any unused infusions and supplies are left in the patient’s room, stored in drawers and closets, before the nurse leaves.
If nurses realize they have not brought a necessary medication infusion into the patient’s room, they search the drawers and closets for stashed supplies because there may not be anyone available outside the room to bring them the needed infusion.
Also, when they are in a patient’s room, nurses cannot hear if a smart pump is alarming in another assigned patient’s room, often resulting in pumps alarming without a timely response. If a nurse outside a room happens to hear a smart pump alarm, they will typically enter the room and reprogram the pump and/or hang a new infusion if needed, looking for the medication in the patient’s drawers and closets.
Some nurses will also leave extra infusions at the bedside so they can be spiked and hung by any nurse entering the room.
Occasionally, a “resource” nurse is available to assist in the ICU. However, too often, the resource nurse is tasked with auditing activities to ensure proper nursing documentation rather than assisting with clinical patient care. Subsequently, nurses have been reprimanded for documentation failures and urged to document care they were unable to provide.
According to the nurse, a perfect storm for serious medication errors in the ICU is created in his hospital by:
The hectic pace and disorganization of pandemic nursing
The constantly under-resourced healthcare environment
High nurse-to-patient ratios due to staffing shortages
The exhausting and continuous donning of PPE
The criticality of patients who require multiple high-alert medication infusions
The stashes of medication infusions located in patients’ drawers and closets
The inability for timely response to smart pump alarms
The need for any available nurse, not necessarily the assigned nurse who is familiar with the patient, to manage critical infusions
The errors
Most of the medication errors described by the nurse occurred after retrieving the wrong concentration of an infusion from stashes left in patients’ rooms. Multiple concentrations of a drug may be available for one patient in response to required fluid restrictions due to renal and/or heart failure. Programming errors, titration errors, and mix-ups among the numerous infusions also occurred frequently. A few examples follow.
This hospital was utilizing two concentrations of fentaNYL infusions—the usual 10 mcg/mL concentration and a concentrated strength of 50 mcg/mL for fluid-restricted patients. Numerous errors occurred when the wrong concentration of fentaNYL was hung, which was often the result of administering a fentaNYL infusion bag left in a drawer or closet in the patient’s room.
Sometimes, the wrong concentration was selected when programming the smart pump. The nurse also mentioned that there were frequent errors associated with either prescribing and/or programming fentaNYL infusions in mg/hour instead of the intended mcg/kg/hour.
Because bedside barcode scanning technology was not available in the ICU, and the smart pump drug library (dose error-reduction system) was often not engaged, these errors were not detected and corrected.
Similarly, the hospital utilized two concentrations of norepinephrine infusions, with the more concentrated infusion for fluid-restricted patients. Again, numerous errors occurred when the wrong concentration of norepinephrine was found in a drawer or closet and was administered, or the wrong concentration was selected during pump programming.
The nurse also described titration errors. In one case, norepinephrine had been prescribed for titration to manage significant hypotension in a ventilated, critically ill COVID-19 patient. When the patient’s blood pressure dropped quickly, a physician at the bedside asked the nurse to progressively titrate up the norepinephrine.
As they watched helplessly, significant hypotension worsened despite repeated upward titrations of norepinephrine. The patient continued to spiral downward, with no response to the norepinephrine titration, and subsequently died. It was then discovered that the nurse had actually been titrating a fentaNYL infusion instead of the norepinephrine infusion. It appears that fentaNYL had been administered via a smart pump programmed for norepinephrine, and norepinephrine had been administered via a smart pump programmed for fentaNYL.
The blaming cycle
The nurse we spoke with confided that, when a medication error happens in his hospital, there is usually gossip about the event, along with speculation regarding who was involved in the error given that many different nurses may have entered a patient’s room to respond to an alarm, hang an infusion, or reprogram a smart pump.
Managers and other leaders are concerned about the frequency of medication errors and frustrated about their inability to do anything about it; thus, they have resorted to blaming those at the sharp end of the error—nurses in general if the individual nurse involved is unknown.
In turn, nurses feel targeted, isolated, frustrated, and fearful of being fired; however, they are also concerned about the frequency of medication errors and feel unsupported by leaders in minimizing the risk of errors. Their suggestions for improvement seem to fall on deaf ears, and therefore they blame managers and leaders for their inability to prevent medication errors. Thus, the blaming cycle comes back full circle.
Nurses and other healthcare professionals have also joined in the blaming and shaming of the public for not taking the pandemic seriously and not following scientific recommendations to wear masks in public and maintain social distancing. They are angry at the anti-maskers and resentful of members of the public who wear masks under their chins or attend large gatherings without the necessary precautions.
Recommendations
COVID-19 is proving to be a long, uphill battle, with an end that is barely visible on the horizon. Thus, it is critical for healthcare leaders to plan for recurring waves of this pandemic. During a pandemic surge, all healthcare workers, including nurses and leaders, will face unimaginable anxiety and stress caused by the burden of this pandemic. Of course, no one wants to contribute to needless patient suffering and potential harm. We all need to aspire to identify and prevent errors and to avoid blaming attitudes when medication errors happen—and they will!
Identifying errors during the pandemic. During a pandemic surge, hospital leaders and managers should anticipate medication errors given the altered workflow and hectic environment, and should make it easy and safe for practitioners to report errors.
To promote error reporting under the best of circumstances, leaders and managers must be trustworthy and credible, and the reporting system must be confidential, clear, and easy to use, as well as useful.
During the pandemic, those who receive and act on error reports must understand that the probability of human error is significantly increased given the many adverse performance shaping factors that impact workers. They must earn and maintain the trust of reporters and prove that reporting is safe, allaying all fears of blame and punishment.
They must also pay attention to the format and length of the required report, and provide rapid, useful, and understandable feedback to reporters, keeping them informed about how their reports are being used to improve systems and processes. Few things impede reporting more than perceived inaction and failure to use the information contained in a report to improve safety. During the pandemic, it is advisable to create a streamlined reporting process and build informal reporting pathways that promote communication and feedback, such as daily safety huddles.
Preventing errors during the pandemic. While time is a very precious commodity during a pandemic surge, certain steps can be taken to minimize the risk of a medication error once it has been reported and analyzed. For example, in the case of the hospital described above and the associated medication errors, the following steps could be taken, even during a surge, to minimize the risk of concentration errors, programming errors, titration errors, and other mixups among IV infusions:
Standardize to a single concentration of IV high-alert medication infusions whenever possible, taking into consideration the need for fluid restriction in COVID-19 patients
Standardize the dose-rate (mcg/kg/hour vs. mg/hour) for certain IV infusions, ensure that only these standard dose-rates are available as a choice in smart pump drug libraries, and require the use of standardized order sets that are in alignment with the standardized dose-rates when prescribing the infusions
For common infusions, use premixed, commercially available solutions that are visually distinct from each other (i.e., do not look alike), whenever possible
In the pharmacy, affix bold auxiliary labels to critical care infusions when dispensing a nonstandard concentration or a neuromuscular blocking agent (e.g., “Warning: Paralyzing Agent, Patient Must Be Ventilated”) to reduce the risk of mix-ups
Label all IV lines between the smart pump and source container, and close to the access into the patient’s body; trace the line from the source container to the smart pump, and to the patient prior to hanging a new source container or programming a pump
Establish a process for conducting independent double checks prior to administration of certain critical infusions
Conduct daily safety huddles with physicians, pharmacists, and nurses
When possible, schedule a “resource” nurse in the ICU with a light patient assignment to decrease the nurse-patient ratio and to help the team with other clinical activities
Plans should also be made to implement strategies that require more significant resources between waves of the pandemic, including:
Implement bedside barcode scanning technology in the ICU and plan a procedure for its use in isolation rooms
Increase and monitor compliance with engaging the smart pump drug library
Implement smart pump interoperability with the electronic health record (EHR)
Consider (and plan) the feasibility of locating smart pumps in hallways to facilitate timely management of pump alarms and infusion bag changes, and to prevent stashes of medications in COVID-19 patient rooms (please see our website for details on how to implement)
Avoiding blaming attitudes during the pandemic. ISMP believes everyone should follow the safeguards recommended by the Centers for Disease Control and Prevention (CDC) to prevent the spread of COVID-19 infection and to avoid endangering the lives of others. And, yes, we might respectfully coach others around us who may not be following these safeguards.
Nonetheless, the vitriol hurled towards the public from both sides—by anti-maskers towards those wearing masks, or by those following CDC guidelines towards those not wearing masks or not practicing social distancing—is spreading discord during an already distressing time. This growing culture of blame and shame has had tragic consequences (e.g., violence, injuries from physical altercations, suicide from online shaming) and has done little to effect change.
Perhaps this public finger pointing during the pandemic has contributed to the recurrent cycle of blaming and shaming in healthcare in the wake of an error?
Why is finger pointing happening during the pandemic? COVID-19 is an unseen, unpredictable, unknown, and horrific adversary. Because we feel powerless, it is natural to look to where we can find some sense of power, even if it is simply pointing the finger of blame at another.
However, healthcare leaders and workers should not regress to the seductive powers of blaming and shaming so they can feel as though they are “doing something” about the problem. Blaming and shaming is neither a noble nor productive way to reduce errors—the opposite is true, as we have abundantly learned in healthcare.
Instead, leaders and managers should set a good example and support workers through the turmoil of the pandemic. First and foremost, workers need to know that their leaders and managers have their backs during the pandemic. Leaders and managers need to be effective listeners and transparent communicators, make collective decisions that support workers’ needs and safety, and visibly demonstrate their trust, respect, and appreciation for the workforce.
They also need to make it very clear that blaming and shaming is not acceptable—for leaders, managers, and healthcare workers alike—particularly in the wake of an error.
Please see ISMP’s May 1, 2020 article, “Leadership Support Is Vital: If We Fail to Support Caregivers, There Will Be Few Left to Support Care,” for additional recommendations to support the workforce during the pandemic.
From the August 27, 2020 Edition of the ISMP Medication Safety Alert! Acute Care Edition – Volume 25, Issue 17.