Those who want to extend the time some Texas hospital patients may live before their life support is cut off are worried that their proposal is running into a wall at the Capitol. Legislation by Texas Rep. Bryan Hughes would require life-sustaining treatment to continue for patients whose condition is deemed futile by doctors until a transfer to another medical facility can be arranged, if their family requests it. Currently, hospitals can stop life support after 10 days in certain cases if the patient is terminally or irreversibly ill and cannot express treatment wishes.
Two annual government reports show that progress in improving the quality of healthcare and narrowing health disparities among ethnic groups remains agonizingly slow, and that patient safety may actually be declining. One of the reports, compiled by the Agency for Healthcare Research and Quality, found measurable improvement in fewer than half of the 38 patient safety measures examined. The agency concluded that one of every seven hospitalized adults on Medicare had experienced at least one adverse event, calling the finding "disturbing." A separate report on healthcare disparities noted some improvements in closing the gaps between ethnic groups but found little progress in addressing the most glaring differences.
Four years after the Patient Safety and Quality Improvement Act of 2005 authorized the creation of Patient Safety Organizations (PSO), hospitals can now join a PSO of their choice. Ultimately, what this provides hospitals around the country is a chance to receive stronger data analysis and solutions surrounding quality- and patient safety-related errors, enabling them to create better systems for patient care.
Many hospitals already have event reporting systems, allowing data analysis at a hospital or hospital system level to occur, and some states also have reporting systems. But PSOs allow for data aggregation and trending to occur at a broader level.
"Once PSOs receive [patient safety work product (PSWP)], it's not just holding it, but really beginning to do some analysis and providing information back to the hospital or provider so that they can use the information to implement new solutions," says Amy Helwig, MD, MS, medical officer at the Agency for Healthcare Research and Quality (AHRQ), which oversees the PSO system. "The PSO can provide the expertise in looking at different types of patient safety event information and help guide the hospital."
The final rule, which was issued November 21, 2008, and went into effect January 19, 2009, stipulates which types of organizations can become PSOs and details the system that must be set up between the PSO and the facilities with which it has contracted. Those hospitals and hospital systems that have contracts with PSOs can provide data to PSOs in the form of PSWP. Data considered PSWP must be identified as such by the facility.
PSWP can be collected or translated by a hospital or PSO into what the AHRQ has termed "Common Formats" so that all data a PSO receives are standardized and can be easily compared.
Those data can then be aggregated, analyzed, and sent back to the provider. In addition, if the data are made nonidentifiable, they can be sent to the Network of Patient Safety Databases, a central location where PSOs around the country will share data. PSOs supply analyzed data and solutions to individual providers based on their own data, as well as the pool of data shared across organizations with which the PSO has contracted.
Data protections offer many benefits
In addition to aggregation of PSWP, the PSO system affords PSWP certain protections. These legal protections allow any adverse event–related data identified by providers as PSWP to be sent to a PSO, making the data flow confidential. These protections were set up to encourage organizations to share data from more serious events and near misses so the industry as a whole can benefit, says Helwig. The Office for Civil Rights is responsible for enforcing the final rule.
One of the things that has prevented this data flow in the past was the lack of protections given to data surrounding adverse events, says Ken Rohde, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, which has partnered with Peminic, Inc., to create the Peminic-Greeley PSO.
"People from one hospital were not real comfortable sharing their problems with people from another hospital because of the risk of liability, discovery, and litigation," says Rohde. "As part of the PSO process, there is increased confidentiality and protection of the data to help facilitate people's willingness to share the data, and once we share that data and aggregate it, it reduces our cost of learning. This approach is really not new; many other industries, even competitive industries, have shared their occurrences and problems in order to help them move forward more effectively."
San Francisco General Hospital's long waits for mammograms have been significantly shortened, and women needing appointments are now getting them within a week or two. In February, it was reported that the average wait time for a diagnostic mammogram at SF General after a woman had found a lump in her breast was 128 days, enough time for a very aggressive tumor to grow and affect the survival rate. Now, those women can get mammograms within seven to 14 days. The wait time for a precautionary screening mammogram has also been shortened, from 300 days to 90.
For the first time, there are three separate entities that hospitals can turn to for accreditation—the ubiquitous Joint Commission, the Healthcare Facilities Accreditation Program (HFAP), and newcomer Det Norske Veritas' (DNV) National Integrated Accreditation for Healthcare Organizations (NIAHO) program. With the option to move from one accreditation organization (AO) to another comes concerns of process and Medicare reimbursement.
"One of the issues that keeps coming up is, if I switch AOs, will that impact my Medicare reimbursement?" says Darrel Scott, senior vice president for regulatory and legal affairs for DNV.
To address this concern, DNV recently updated its FAQs to describe the process of switching accreditors.
"This applies regardless of which AO you are changing from or going to," says Scott. "We wanted to try to address in our FAQs the exact mechanic that occurs when a move is made."
So here's the process: when a hospital or hospital system decides to switch accreditation organizations, it can notify its current AO right away. The next step could go one of two different ways. First, the hospital and the AO can work out a plan for withdrawal and transition to the new AO. If this does not happen—that is, if the hospital and the AO cannot work out a transition strategy, the current AO may immediately withdraw the hospital's accreditation.
This is not as problematic as it may seem, however. The hospital's Medicare provider agreement is not affected should the current AO withdraw its accreditation before it is accredited by another AO. The current AO will, after removing the hospital's accreditation, notify the CMS Central Office and the applicable CMS Regional Office of its action. The AO will also provide those offices with an effective date of termination.
Again, there are two ways this next step can go. The simpler way is if the termination of one accreditation organization's accreditation is concurrent with a new recommendation for accredited, deemed status by the AO the hospital is transferring to. In that case, the hospital is simply transferred under the umbrella of the new AO.
However, if the current AO withdraws its accreditation and the hospital has not yet received accreditation from the new AO, the hospital is placed under the State Survey Agency (SA) jurisdiction. The hospital will remain under SA jurisdiction until it receives accredited, deemed status from the new organization. This new accreditation and deemed status must, of course, be approved by the CMS Central Office and the applicable CMS Regional Office as well.
"If the current AO informs the hospital that it is terminating its accreditation immediately and the AO notifies CMS, the hospital is moved over to the jurisdiction of the State Survey Agency," says Scott. "The hospital is then subject to a state survey until it is accredited by the new AO."
Throughout this process, the hospital's Medicare provider agreement and reimbursement is uninterrupted even though the hospital may be in transition from one AO to another. During this transition, there is always oversight from one of these entities and Medicare reimbursement is not affected.
To prevent central line–associated bloodstream infections (CLABSI), Swedish Medical Center (SMC) in Seattle has found sharing information with staff members and simplifying techniques has made all the difference.
SMC is a participant of Institute for Healthcare Improvement's (IHI) campaigns, which has featured CLABSI prevention as a part of its past two campaigns. Its efforts have spread beyond ICUs and now include central lines placed by anesthesiologists and interventional radiologists.
By incorporating the following four techniques into its practice, SMC has at one time gone 12 months without reporting a CLABSI in some of its ICUs, and has currently not had a CLABSI in four months.
Staff education
Before 2005, when the more organized effort to prevent CLABSI began, the facility would often fail to keep up with educating staff members, says Will Shelton, M(ASCP), CIC, director of epidemiology and employee health at Swedish Medical.
"As the education wore off, our compliance would go down and the rate [of infection] would go back up, and so the rates were constantly this yo-yo up and down," says Shelton.
Learning from the IHI's model, which involved bundling education with several prevention techniques, such as hand hygiene, optimal catheter selection, clorhexadine antiseptic, and, in SMC's case, an antimicrobial bio patch on the site, it was able to post weekly infection and compliance rates for staff members to see.
In addition, the facility implemented one-on-one meetings with nurse managers for those staff members whose patients were not in compliance.
The graphs were very powerful, says Caroline Truong, RN, BSN, critical care clinical supervisor, because staff members could clearly see the efforts' effects.
"We've seen tremendous dedication from the managers, nurses, the charge nurses, and the physician champions," says Shelton about the one-on-one education of complying with the bundle of actions recommended by the IHI.
Use of bundles to create a checklist
Like many efforts to prevent CLABSI, SMC created a checklist that used the recommended techniques from the IHI. However, it went a step further and had a manufacturer create all of the supplies necessary for inserting a central line in one package so whoever was completing the insertion did not have to search in different places for these supplies.
Additionally, SMC empowered the ICU nurses to speak up when they saw a physician not completing the checklist in the required manner by enlisting a physician sponsor so they felt more secure.
"There's only so much that nursing can do by themselves," says Truong. "We needed to partner with the physicians and let them know that nurses would be giving them that feedback to stop the procedure if the checklist was not followed."
The director of infectious disease wrote a letter to all staff members informing them that the facility was instituting the central line bundle insertion and that nurses would be intervening if steps were not followed.
"We gave the nurses a script too so it wouldn't be uncomfortable," says Truong. "Basically, we made all the obstacles in the past; we tried to make things easier so there'd be no excuse for not having it done unless someone was being a silent partner and seeing something go wrong but not say anything."
To further the nurses' commitment to stepping in when a checklist was not being followed, Truong had the nurses sign an "Act Boldly" statement during annual evaluations to reinforce the message.
"Act Boldly" is a slogan that the American Association of Critical-Care Nurses created as a means of empowering critical care nurses to "act deliberately and powerfully" to give better patient care.
"We have a discussion with our staff to speak up and act boldly if they see an opportunity for improvement, especially if they witness a potential or actual risk to patients or staff," says Truong.
Recognize the need for flexibility
To come up with the best policy to outline SMC's CLABSI prevention tactics, Shelton and Truong's team received permission to have a rogue policy that could be changed instantly at the suggestion of staff members.
This practice is contrary to how policies and forms are normally approved and signed off on at the facility since most forms are dated and approved by a higher committee, says Shelton.
As staff members gave feedback about the policies and checklists being created to prevent CLABSI, Shelton and Truong could instantly make changes, especially if staff members thought something on a policy or checklist was not working.
Leadership support and collaboration
Shelton says SMC' leaders are quality-focused. Support for joining the IHI's initiative always came from the top down. His team had convinced leadership earlier that taking on these types of quality initiatives was a step in the right direction by improving the quality of life for ventilator-associated pneumonia patients, which also saved the facility a significant amount of money.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals.Contact Heather by e-mailing hcomak@hcpro.com.