Previously, the U.S. Department of Health and Human Services shut down a study at Michigan Hospitals that used checklists to prevent errors in the intensive care unit. At the time, HHS's Office for Human Research Protections said the study violated federal ethics requirements. Now however, the acting director of the agency said that the HHS should not have inhibited the activity and encouraged the hospitals to continue using checklists to improve patient safety.
Pay-for-performance bonus payments from health plans to California medical groups totaled $65 million for 2007, $10 million more than the bonuses distributed in 2006, according to the Integrated Healthcare Association. The quality bonuses typically average about 2 percent of annual reimbursements to the participating groups, which critics say is not significant enough to give medical groups a financial incentive to improve quality.
Rhode Island lawmakers have proposed a system to investigate and track medical mistakes and so-called "near misses" after brain surgeons at Rhode Island Hospital operated on the wrong side of patients' heads on three separate occasions in 2007. New bills introduced in the House and Senate would create a Rhode Island Patient Safety Organization designed to determine the potential causes of medical errors and fix them at healthcare providers statewide before patients are hurt.
A story about Medicare's looming deadline for "never events" traveled around the Associated Press wire earlier this week, informing the general public about what those of us who work every day in quality and infection control already know: As of October, Medicare has declared that it won't pay for certain hospital-acquired conditions and happenings and others--including state governments and private insurers--are following suit.
The article presents several examples of hospitals that are instituting new policies and procedures that will help their institutions avoid these "never events." At the University of Michigan Health System, the article says, surgeons are using sponges tagged with radio frequency identification (RFID) chips to make sure that a stray sponge doesn't get left in a patient during surgery. In Tennessee, Wellmont Hospital is using a portable machine that releases sterilizing vapors to help eliminate germs in patient rooms, the article says.
These examples--and the hundreds of others that my colleagues and I have written about--show what we already know: by examining their processes, hospitals have been able to improve their infection rates, prevent staff errors and other "never events." Sure, we can improve our statistics, but will we ever get to a point where there are no errors, no falls, and no infections? The reality is no. Only eternal optimists will tell you that someday we might have a healthcare system that provides care with zero chance of errors. Humans aren't perfect, and as long as humans are caring for humans there are bound to be mistakes. Still, Steven Gordon, MD, infectious disease chief at the Cleveland Clinic Foundation, tells the Associated Press that it isn't stopping hospitals from wanting to get to zero.
Some might question whether an unattainable goal has value. Much thought on leadership goes to the notion that goals should be realistic and manageable, and indeed at the hospital unit level, quality goals are meant to be measured and met. As an industry, reaching zero must continue to be the motivating goal behind the work we do at our hospitals. It should be the underlying message in our staff meetings, training sessions and quality improvement meetings. We must evaluate the steps we're taking to prevent infections, falls and errors and among our caregivers, stress the processes that will give us the best return on our investment. The questions coming in quality are not what gets us to zero, but what initiatives get us closer than the others.
Lake Regional Health System (LRHS) announced that it has joined hospitals across Missouri to adopt new standards to prevent medical confusion. More than 90 percent of Missouri hospitals use colored wristbands as a means of quickly identifying important information about patients. A statewide survey by the Missouri Center for Patient Safety (MOCPS) found wristbands are commonly used for alerts such as allergy warnings, fall risks or do-not-resuscitate orders.
As the total annual cost of obesity continues to rise in the United States, the National Committee for Quality Assurance said it will apply two new standards to the Healthcare Effectiveness Data and Information Set, focusing on obesity in children and adults. The total annual cost of obesity in the United States is an estimated $117 billion. Further, studies have shown that overweight children and teenagers are more likely to become obese adults, which is why NCQA is adding assessments of body mass index-the ratio between a person's weight and height-and how consistently physicians perform BMI assessments to HEDIS.