Kaiser Permanente has agreed to pay $1 million to settle claims on behalf of five patients alleging that the HMO mishandled its kidney transplant program, endangering lives and causing deaths. The arbitration claims were filed shortly after a Los Angeles Times investigation found that Kaiser's Northern California kidney transplant program jeopardized hundreds of patients by forcing them into a new program unprepared to handle an enormous caseload. Kaiser released a brief statement confirming the settlements.
CMS released its fifth quarterly update of patient satisfaction data late last month, one year after the first Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospitals that participated in the pilot test were made available to the public. This time around, scores from all hospitals that receive reimbursement through the inpatient prospective payment system have been included.
After the first round of the survey was released in March 2008, hospital leaders and staff members were unsure of the extent to which consumers would use the data available. It's since been shown that although some consumers have been looking at the data, they have not been using those data to choose where they receive care.
"I think it created apprehension initially because it was the first time that this type of information would be public," says Deirdre Mylod, PhD, vice president of the acute business division at Press Ganey, a vendor for administering the HCAHPS survey. "I think we've moved from apprehension clearly through to acceptance. Although patients have gone to the site, a fair amount of the research suggests that patients are not using the publicly available data—not just HCAHPS, but any of what's out there—to truly make decisions about their care."
The March release of HCAHPS scores represents survey data collected from patients discharged between July 1, 2007, and June 30, 2008. Although the survey questions have not changed since the initial survey was released, CMS has translated the survey into Chinese, Russian, and Vietnamese for 2009.
In the past 18 months, CMS has also increased its oversight of the guidelines surrounding HCAHPS, specifically about communicating with patients. Hospitals should not communicate with patients about the HCAHPS survey in a way that might affect their responses or diminish their likelihood of completing the survey.
This spring, the Agency for Healthcare Research and Quality (AHRQ) and CMS are collaborating on an HCAHPS chart book, says Carrie Brady, MA, JD, vice president of quality at Planetree, Inc., a nonprofit consulting company that helps hospitals focus on delivering patient-centered care. The book will provide hospitals with national benchmarks for each question that is asked on the HCAHPS survey. This differs from the data available at the Hospital Compare Web site, which show composite scores for each topic covered on the survey. Although hospitals could ask their vendors for benchmarks for each question, having national data offers a more complete picture.
"It'll be nice to have the full set of national data and be able to drill down into individual questions," says Brady. "Your comparative performance compared to a vendor pool, depending on the size of that pool, can tell you a different story than the national data will tell you."
Although the intent of releasing HCAHPS scores and making them available to the public was to give patients more options for choosing their care, the public scores have had a greater effect on the quality of care at hospitals around the country on the whole, says Mylod.
"CMS intended [HCAHPS] to be a public report measure for consumers," she says. "They also hoped it might spur quality improvement because of the fact of transparency. I think that, actually, the second thing has happened more than the first because consumers aren't using it to drive choice, but executives know that how they're doing is public. Clearly, there have been differences in the way people behave."
Press Ganey, a company that works with 42% of U.S. hospitals to help them improve care, analyzed the data coming out of the hospitals with which they consult from January 2007 through July 2008. During that time, large statistical increases were seen in patient satisfaction from the year-over-year data reported in May and June 2008, following the first release of HCAHPS data in March 2008. Press Ganey reported that during the 23 years it has been analyzing these types of data, this jump in patient satisfaction with inpatient care was the largest it had ever seen.
Additionally, CMS ran a large public ad campaign in major national newspapers during May 2008, publicizing the first release of scores. This resulted in a huge spike in visitors to the Hospital Compare Web site. In March 2008, just after the scores were released, about 2 million people visited the Web site. In June 2008, that number jumped to 12 million.
"There were jumps in patient satisfaction scores that clearly said to me that executives were paying attention, boards were paying attention," says Mylod. "The fact of transparency and the public report clearly drove changes in how hospitals behaved."
Brady says the improvements in patient satisfaction that CMS had hoped for are occurring, even if not as many patients as expected are choosing where they receive care based on HCAHPS scores.
"What has been the most compelling effect is that hospitals are more focused on the data," she says.
Heather Comak is a Managing Editor atHCPro, 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.
At Geneva, IL-based Delnor Hospital, there is a patient-first philosophy. That focus on patient care and comfort led to recent construction of a new 52-bed addition and recognition for its focus on a holistic approach toward the healing of mind, body, and spirit. Delnor was recently designated as Planetree's first Patient Centered Hospital in Illinois and one of only six in the nation. Planetree emphasizes patient comfort, dignity and empowerment, along with top healthcare.
New Jersey seniors are readmitted to hospitals more often than those in most other states, often because of what experts say are preventable breakdowns in care. Now Virtua Health plans to launch an ambitious effort to tackle this problem by better educating its departing patients and reconnecting them to family doctors. The system hopes to ease the often treacherous transition period when medication errors often occur and follow-up care can be missed.
A hospital can be a frightening place for children, which in turn creates a barrier of distrust nurses must work through in order to provide them with adequate care. However, recently released research suggests nurses can do less scaring and more caring for their facility's pediatric patients by brightening up their wardrobe.
A study published in the April 2009 issue of the Journal of Clinical Nursing examining the effect of multicolored, nonconventional attire on hospitalized children found it improved children's and parents' perceptions of the nurses providing them care. These enhanced perceptions led to increased comfort for the pediatric patients and increased confidence among parents of the nurses' abilities.
"Our goal was to understand the perception of nurses," says Filippo Festini, BA, BSN, RN, lead author of the study and professor of nursing science at the University of Florence in Italy. "The importance of our findings is that the multicolored uniforms improve the relationship between the nurse and the child, and this helps obtain the child's compliance to the treatment and reduce anxiety and fear."
The study was conducted by Festini and his team of University of Florence researchers between July and September 2005 among children at Meyer Children's Hospital in Florence. The researchers surveyed 112 children—ranging from six to 16 years of age—before and after nurses on two pediatric hospital wards swapped their light blue, traditional scrub uniform for nonconventional attire inspired by children's drawings collected throughout the country (you can view a picture of both uniforms here).
In both instances, researchers asked the children to define the nurses using one word, discovering a higher percentage (96%) used positive words such as "pleasant," "friendly," and "helpful" for nurses wearing the new uniforms than when they wore the former (82%).
The study cites "the children also expected the nurses to be 'funny' and 'cheerful,' and to play with them" while wearing the new uniforms. Researchers concluded the children's perceptions regarding the hospital environment, however, did not improve.
While the nursing uniform has dramatically evolved over the past few decades, many nurses still shy away from those splashed with child-friendly prints for fear they detract from their professional image. Shelley Cohen, RN, BS, CEN, president of the Hohenwald, TN-based Health Resources Unlimited, LLC, recently conducted an anonymous, national survey among more than 1,000 nursing professionals to delve into the types of behaviors, attitudes, appearances, and circumstances they felt shaped their image. Respondents were asked to rate several factors based on how much they affected the image of nursing, choosing from "no effect," "little effect," or "great effect." How nurses present themselves to patients and families was reported to have the greatest effect on their image. How nurses' dress was found to have the fifth greatest effect.
Furthermore, respondents suggested individual nurses could shape a more realistic image of nursing by ridding cartoon scrubs from their wardrobe.
Still, peering back into the pediatric study, the multicolored scrubs did not worsen pediatric patients' and parents' perceptions of nurses' professionalism, yet seemed to improve it. For example, researchers asked parents to rate the nurses on a one-to-five scale. Of their findings, parents' perceptions of nurses':
Adequacy in their role increased from 4.0 to 4.7
Ability to be reassuring rose from 4.0 to 4.5
Ability to not frighten their child rose from 4.4 to 4.7
Ability to be fun improved from 2.3 to 4.6
"By wearing creative and child-friendly scrubs, nurses demonstrate respect for the patients they are caring for and send a message that they understand children and their developmental needs," says Jill Duncan, RN, MS, MPH, director of the IHI Open School for Health Professions in Cambridge, MA, who has more than 15 years of pediatric-related experience in a variety of acute care settings.
Duncan says nurses can even use their scrubs as a discussion starter with their young patients by pointing out drawings or characters and asking the child what he or she sees. "This helps engage the child as well as assure the parents that there is a confident and competent nurse caring for their child," she says.
When Rochester (NY) General Health System determined to cut down on Methicillin resistant Staphylococcus aureus (MRSA) in its cardiothoracic unit, the organization didn't just see the number of cases shrink—there has not been a MRSA case in the unit since January of 2008.
"It's all about execution," says Linda Greene, RN, MPS, CIC, director of infection prevention and control for the New York hospital system.
The organization pursued this goal as part of the Association for Professionals in Infection Control and Epidemiology's (APIC) Targeting Zero campaign.
"Since 2006, APIC has been promoting a Targeting Zero philosophy," says Liz Garman, the association's director of communications. "In keeping with APIC's mission and vision for 2012, Targeting Zero is the philosophy that every healthcare institution should be working toward a goal of zero (healthcare-associated infections) HAIs. While not all HAIs are preventable, APIC believes that all organizations should set the inspirational goal of elimination and strive for zero infections."
Why MRSA?
The primary reason behind targeting MRSA for a zero infection rate is and was patient safety. But the secondary factors are hard to ignore: Average length of stay jumps from 7.6 days to 25.6 days for a MRSA patient, and the average case costs $40,000 more to treat than a non-infected patient.
"That's not the driving force for from a quality perspective, but this information is important," says Greene. "When you're doing a risk assessment, you're looking at those things—what is the end result and what are opportunities for improvement."
The question was: Were these infections inevitable, or preventable? A large amount of infections are preventable, says Greene. In fact, targeting MRSA in one unit had an interesting fringe benefit.
"What we did in 2008 drove all our infection rates down," says Greene. Implementing and hardwiring improved practices caused an across-the-board lowering of infection rates in the cardiothoracic unit.
The facility looked at infections from the perspective of the science of epidemiology.
"Infections are preventable. We know they're not all preventable, but how many are? Have we done enough?" says Greene.
Bi-directional change
"One of the reasons we chose this population—which is a high risk population—is that the people working in this area are innovators," says Greene. "At the beginning it is important to engage key people."
Because MRSA is such a high-profile topic, it was also easier to engage and leverage administrative support.
"We needed some early wins," says Greene. "While it's a really high-performing unit anyway, we found that it's all about execution—incorporating changes into the routine standard of care."
This sort of change is bi-directional, Greene says.
"Top down and bottom up—we need the executives on our side but also the stakeholders," she says.
To this end, they made it a point to drive home individual consequences. For example, education was provided to environmental services staff to demonstrate how their actions could eventually have an effect on the patient.
Rochester's MRSA efforts fit in with its overall accreditation activities because Targeting Zero falls in line with the Joint Commission's National Patient Safety Goals and new governmental regulations (e.g., CMS regulations reducing reimbursement if an infection occurs during a hospital stay)
"There are institutions that have managed to greatly reduce and even eliminate certain infections—showing that zero is possible," Garman says. "It's changing a mindset that these are the inevitable consequence of more complicated care to one where these can be avoided in many cases."