Hartford Hospital, which was placed on a one-year probation last February, remains on probation, and a Connecticut official said a new end date has not been determined. Earlier this year, state regulators identified a number of new healthcare violations at the hospital.
Some of the newly reported violations occurred before the hospital implemented policy changes or staff training programs to address problems that gave rise to the initial probation. Others occurred more recently.
As immigrant communities swell around the country, hospitals, clinics, and other healthcare providers are increasingly confronted with language and cultural challenges that can discourage people from seeking care and lead to calamitous errors in diagnoses and treatment regimens. Hospitals and doctors, however, are wary of the cost of interpretation services, which can run up to $190 an hour. They say the government, not them, should pay these costs.
Reports from the field indicate that validation surveys by state surveyors on behalf of the CMS are happening with greater frequency in 2009.
Validation surveys are unannounced surveys used to validate an organization's accreditation process. These surveys are conducted on a representative sample basis, or in response to substantial allegations of noncompliance. Unlike in the case of a for-cause survey, hospitals are selected at random for validation surveys. It could be that CMS is requesting more validation surveys to be ready to review the Joint Commission's soon-to-be-submitted applications for continued deeming authority.
Central Maine Medical Center in Lewiston, ME, faced a slightly different challenge than the average hospital—the facility is a 250-bed hospital but is interconnected with 30 outpatient practices as part of the hospital's license.
"CMS goes to all sites," says Patricia Roy, RN, director of professional quality services at Central Maine. "We had to have multiple surveyors out to every physical location we have."
The five-day survey, which took place five weeks after the close of the Joint Commission survey, involved up to 11 surveyors each day.
"The [CMS] visit was a surprise—when they came to the door I thought, 'You've got to be kidding!'" says Roy.
On the upside, however, the entire facility was still very much in survey mode.
"We still had binders we hadn't put away from the Joint Commission visit," says Roy. "As soon as they came in, we went right into response mode. They let us do an opening presentation, and we had it updated and ready."
Again, the surveyors did not arrive together as they would in a Joint Commission survey.
"They sort of staggered in on the first day rather than arriving en masse," says Roy. "The lead surveyor showed up first, then a few more, then we had the rest arrive a few hours later."
This allowed for even more prep time to get escorts ready for surveyors and prepare staff. The pharmacist surveyor arrived on day four, while the engineer surveyor arrived on day two.
"The amount of resources and people needed as opposed to a Joint Commission survey just to play host is quite a bit more," says Roy. "Managers and directors always want to be back in their departments to help them get ready, but we really had to have eight or nine people playing host."
With so many outpatient facilities, transportation was a unique problem as well.
"Just to have enough people to drive them around was tough," says Roy. "We had two fire marshals for all of the days as well who also had to go to every physical site. It was an awful lot of traveling."
To help keep things streamlined and organized, Central Maine developed in preparation for its most recent survey a command center concept.
"This worked very well for us, so we did the same for the CMS survey," says Roy.
Staff were dedicated to the command center, passing out information to survey hosts, and were the repository for information coming in from staff regarding what surveyors were looking for and which files they wanted.
"It helped us coordinate who was with who, where they were going, printing out the right schedules," says Roy. "We had a managers briefing every night after the surveyors left with notes about what they were seeing, what their concerns were, so that the managers and staff could be prepared and calm."
Roy found the focuses varied between surveys.
"Compared to the Joint Commission survey, the CMS team focused tremendously on performance improvement and quality," says Roy. "Hours and hours and hours spent discussing minutes, when did [a certain decision go] to the board, details around one chapter of the regulations."
For the Joint Commission survey, these things were discussed but not highlighted in such a key way.
"I spent three days with two surveyors talking about quality," she says. "What are you working to improve upon, what are your safety items?"
The survey team pulled out the regulations and went through it line by line.
"The Joint Commission are much more trying to get the gestalt of the standard," says Roy. "In the CMS survey, it's much more black and white—they pull out a chapter of the CMS regulations and check off yes or no."
In the end the survey was very positive, with no recommendations from the survey team.
Although the general principles of what goes into creating a culture of safety are the same at small and large hospitals, both types of facilities face different hurdles when addressing the topic.
"I think that there is not a substantive distinction," says Jennifer Lundblad, PhD, MBA, CEO of Stratis Health in Bloomington, MN, about the culture of safety in the two settings. "You can focus all you want on clinical change, but if you are not also simultaneously focusing on issues of the culture in a hospital, those changes are probably not sustainable, because culture drives so much of what occurs in terms of adverse events."
The Agency for Healthcare Research and Quality (AHRQ) recently published its annual Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. The report compiles data from hospitals utilizing its Hospital Survey on Patient Safety Culture, originally released in 2004. Stratis Health, a nonprofit organization that works with hospitals on national and local levels to improve quality, helped implement this survey tool in Minnesota's hospitals as that state's Medicare Quality Improvement Organization. Karla Weng, MPH, CPHQ, program manager at Stratis Health, says that generally, small rural hospital score higher on the AHRQ survey.
"In particular, the biggest gap was on handoffs and transitions, they were 22% higher than their urban counterparts," says Weng.
Communication and Openness
Handoffs, in particular, highlight one of the areas in which small and large facilities have unique sets of problems. Coordination and communication between different departments are often the lowest scored domains when measuring the culture of safety.
"I think those are especially problematic in large organizations, just because of the complexity in dealing with different departments," says Marilyn Szekendi, RN, PhD, Patient Safety Leader at Northwestern Memorial Hospital (NMH) in Chicago. Szekendi cites a greater number of departments and less familiarity among staff members as one of the barriers that her large urban facility faces on a daily basis.
"At some large hospitals, transferring someone from one unit to another can take going to another building." Not only do transitions occur less smoothly than they do in rural facilities, staff members at large urban hospitals are often more stressed as a result of having to connect with staff members with whom they are not familiar and worry about keeping patients safe, says Szekendi.
From a small rural hospitals' perspective, communication and coordination present a whole different set of challenges. The close, personal atmosphere that many small hospitals foster plays well for handoff communication.
"Where rural health can really be a leader is because [the setting] is close and personal, those handoffs and transitions are managed so much better in that smaller environment," says Lundblad. "I think that's some of the reason we see those generally higher scores when looking at an urban and rural comparison around safety culture." She gives the example of a part time nurse in the emergency room who may also work in the medical unit, "They transition to themselves in some cases. There's not that lost information about the patient, that missed opportunity about medication reconciliation."
It's this same closeness that can also inhibit open communication among hospital employees. "There's a particular unique rural challenge in communication because you know these people personally as well as professionally," says Lundblad.
The role of leadership
Leadership plays an important and vital role in effecting culture change in small and large hospitals. In both settings, any culture change initiatives must come from the top-down to be successful.
The difference may be that in large settings, hospital leaders are more in tune with what quality and patient safety issues exist. At NMH, many of their culture of safety initiatives have come from the leadership team, says Szekendi. In a rural setting, this might not be true, especially with boards of directors, says Lundblad. At the board or trustee level, in small communities these people are often local business leaders.
"I think they have fewer opportunities than their urban counterparts to be exposed to or have the kinds of orientation and training that is specific to quality and patient safety," says Lundblad."
Additionally, if rural hospital leaders embrace a culture of safety, the effects can be seen quickly. Because of the closer environment, one leader can have much more influence than one leader in a large hospital, simply because he or she has more visibility and more influence over the entire facility.
"If leadership at a small facility really gets it, and really embraces the culture of safety, they can make things happen so quickly with such amazing results because it has the ability to so quickly infuse itself across the whole facility," says Lundblad.
Hospital leaders at large urban facilities have to make more of an effort to connect with staff and show that they are supportive of culture change, says Szekendi. Having hospital leaders take part in patient safety Walkrounds, or showing a presence in patient care areas in some other way can help staff members at a large hospital understand that their leaders stand behind a culture of safety.
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-mailinghcomak@hcpro.com.
Hospitals in Dallas will not accept organ donations from people who aren't friends or relatives. They fear under-the-table payments—it is a federal offense to buy or sell organs in the United States—and the growth of an Internet-induced organ exchange industry preying on the sick and poor.
Five Iowa residents filed a class-action lawsuit against a South Dakota urology clinic that might have exposed patients to blood-borne infections such as hepatitis and HIV. The federal complaint was filed in Sioux Falls against Siouxland Urology Center in Dakota Dunes and its six owners. The South Dakota Department of Health put out a news release stating that a routine survey of the center identified the potential for infection during cystoscopy procedures because single-use products such as saline solution bags and tubing were used on more than one patient before being discarded.