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.
The term "malpractice" often invokes images of courtrooms and spiraling insurance rates, but malpractice data can often be used for the purpose of fostering patient safety. In the surgical world, that information is increasingly more important as the amount and types of surgeries performed climb each year.
In its 2009 annual benchmarking report, CRICO/RMF (originally two companies, Controlled Risk Insurance Company and the Risk Management Foundation), the patient safety and medical malpractice company owned by and serving the Harvard medical community among others, analyzed malpractice claims and provided that information to its members as well as the public.
Not surprisingly, communication, disclosure, diagnosis, and technical performance were common reasons for claims. The report's authors hope the data analysis and benchmarking capabilities included in the report will influence patient safety initiatives at hospitals in the near future.
"We feel that malpractice activity is what I would term 'the tip of the iceberg,' " says Bob Hanscom, JD, vice president of loss prevention and patient safety for the Risk Management Foundation and RMF Strategies, a division of CRICO/RMF. "Malpractice activity is always above the surface of the water; it has the potential to be known to the public, it's always where something has really gone wrong. Our theory has always been if you analyze those malpractice cases as deeply as possible, they become a very rich, almost divining rod as far as where those vulnerabilities are in the real-time environment."
The report is based on data from 3,300 surgical malpractice cases that took place between 2003 and 2008. The data, collected through RMF Strategies' Comparative Benchmarking System, show that surgical errors occur during all three stages of surgery—pre, intra, and post—and that open communication is one of the main ways of preventing errors from occurring, in addition to clinicians possessing the cognitive and technical skills required for complicated procedures.
The malpractice data analysis included in the report has already helped some member hospitals examine how to change existing processes to improve patient safety.
"We have been able to use the report to more effectively engage our physicians in process improvement," says Pat Sullivan, PhD, vice president of quality and patient safety at the University of Pennsylvania Health System (UPHS). "I'm a big believer in peer processes, and some of our most successful initiatives are those that come from within and are not necessarily top-down."
Sullivan says that clinicians at her facility were interested to see how they compared with similar types of institutions in the areas of malpractice risk and patient safety, and doing so has motivated them to become involved.
It's also likely that the surgeons at UPHS and other hospitals are more apt to recognize the need to improve and get on board with any new initiatives because the data are evidence-based, says Hanscom.
"Physicians are by nature evidence-based, and a lot of the patient safety initiatives are not necessarily based on real evidence, which is why culturally they'll really push back," says Hanscom. "What we tried to do with the malpractice data ? because we analyze it as deeply as we do, it's rich in demonstrating where vulnerabilities are. It fulfills this yearning for evidence."
Technical skills
The malpractice data included in the report show that at academic medical centers, 27% of surgical cases have intraoperative complications and 9% have poor technique. At community hospitals, those figures are 29% and 17% respectively.
To strengthen technical skills, faculty at UPHS decided to use their simulation center to create a certification course around laparoscopic surgery technique. Unlike traditional programs that require something like this for residents and trainees, UPHS' program is for all staff, even those already trained and experienced in laparoscopic technique.
"That's not an easy thing to do. It takes strong clinical leadership, in addition to administrative leadership—the chairman of surgery and other clinical chiefs—to say, 'Yes, we believe we should do this because it's going to help us help our patients,' " says Sullivan.
It is this type of leadership that is necessary to create real change in the operating room (OR). The surgical culture is one of the most complex in healthcare, says Hanscom, and when leadership teams embrace programs such as the UPHS laparoscopic certification for all of their staff members, they set a standard.
To read more about the report and some ways that hospitals are increasing staff engagement and reducing the likelihood of error, see the August issue of Briefings on Patient Safety, a product of Patient Safety Monitor. To view the report in its entirety, click here.
Computer physician order entry systems (CPOES) can potentially miss half of routine medication orders and one third of potentially fatal medication orders, a report released by The Leapfrog Group shows. The report is based on a study of 214 hospitals that tested their CPOE systems using a web-based simulation tool between June 2008 and January 2010. The Leapfrog Group is a quality organization that uses the power of large purchasers to positively affect patient safety and quality in healthcare.
The simulation tool was used to see how often CPOE caught common medication errors. Adult hospitals involved in the study received ten sample patients and 50 medication orders and pediatric facilities received 10 sample patients and 51 medication orders. Most of the hospitals that adjusted their protocols and CPOE systems after using the tool improved their performance.
"Although this is a simulation using fictitious patients and medication orders, it should be a red flag for every hospital and information technology company in America," said Leah Binder, MA, MGA, CEO of The Leapfrog Group. "The belief that simply buying and installing health information technology will automatically lead to safer and better care is a myth. Hospitals and vendors must continue to work together over time to ensure the effectiveness and efficiency of CPOE."
As a result of this report, The Leapfrog Group is calling on the federal government to ensure that the definition of "meaningful use" require that CPOE systems be monitored on a regular basis. Meaningful use refers to a set of requirements regarding health information technology that hospitals and physicians must meet to receive incentive payments through Medicare and Medicaid. Leapfrog is also urging hospitals and vendors to work more closely in designing CPOE interfaces and incorporating the system into practice. It does believe that using CPOE correctly can save lives by catching potential medication errors.
All hospitals that voluntarily take part in The Leapfrog Group's Hospital Survey have the opportunity to use the web-based monitoring tool.
Last week The Joint Commission announced it had made revisions to four elements of performance (EP) included in its National Patient Safety Goals (NPSG). The revisions, announced in the June 23 Joint Commission Online reflect the most up-to-date practice. When the original EPs were written, they reflected evidence-based practice at that time, but because science continues to develop, The Joint Commission felt these revisions were necessary. There are no additions to existing NPSGs, and the revisions are effective immediately.
The specific revisions include changes to:
NPSG.03.05.01, EP 6: Related to anticoagulant therapy-required lab-tests.
NPSG.07.04.01, EP 11: Related to central line-associated bloodstream infections, specifically antiseptics for skin preparation.
NPSG.07.05.01, EP 7: Related to surgical site infections, specifically administration of antimicrobial agents for prophylaxis.
NPSG.07.05.01, EP 8: Also related to surgical site infections, specifically methods for hair removal.
The Joint Commission also announced last week that it would be categorizing its performance improvement measures into "accountability" measures and "non accountability" measures. This announcement is based on an article published in the June 23 New England Journal of Medicine. Mark Chassin, MD, MPP, MPH, president of The Joint Commission, was the lead author of the article.
Those quality measures that are considered to meet the standards for accountability will have to meet four criteria: Research, proximity, accuracy, and adverse effects. Taking these criteria into account will allow quality measures to positively affect patient outcomes. The hope is that those measures that offer more of a provision of good advice for patient care, and are not really measures of quality, will become less important as the "non accountability" measures. For example, two of these types of measures currently include smoking cessation counseling and providing discharge instructions for heart failure patients.
The Joint Commission has decided to separate its existing quality measures into these different categories to reflect to use performance measure data as a means of transparency, as well as to prepare for the future. You can find more about this announcement in a special issue of Joint Commission Online.
The Department of Health and Human Services and the Agency for Healthcare Research and Quality announced last Friday that they had awarded $23 million in grants in the name of a patient safety and medical liability initiative, as well as $2 million for final contract evaluation. The grants are the product of an announcement on patient safety that President Barack Obama made in September 2009 to a joint session of Congress.
The initiative includes grant money for both demonstration and planning grants in the realm of patient safety and medical malpractice, as well as funding to review existing reforms of the medical liability system.
"The goals of the HHS Patient Safety and Medical Liability initiative are widely supported throughout the healthcare system, and we solicited broad-based input to ensure that it reflects the needs of stakeholders," said Carolyn M. Clancy, MD, director of the AHRQ, in a statement. "The projects we have funded help create measurable differences in the safety of health care for patients and help bring rationality and fairness to our medical liability system."
The demonstration grants, which were awarded in allotments of up to $3 million and total $19.7 million, were given for projects that will be implementing and evaluating evidence-based patient safety and medical malpractice projects. To view the full list of recipients of demonstration grants, visit www.ahrq.gov/qual/liability/demogrants.
The planning grants, which were awarded in allotments of up to $300,000 and total $3.5 million, allow recipients to do some detailed planning around patient safety and medical liability reform. To view the full list of recipients of planning grants, visit www.ahrq.gov/qual/liability/planninggrants.
"This new research is the largest government investment connecting medical liability to quality and aims to improve the overall quality of health care," said Kathleen Sebelius, secretary of HHS, in a statement.
President Obama originally said that the initiative should award grants to programs that trial models for:
Focusing on patient safety by reducing preventable injuries
Encouraging better communication between doctors and patients
Compensating patients quickly and fairly for medical injuries, but also discouraging frivolous lawsuits
Collecting core measures data is a part of everyday life at most healthcare facilities, affecting various types of staff members and CMS reimbursement. Assessing whether your facility is managing those data well and using the information contained in your core measures data is vital to improvement, according to Ken Rohde, senior consultant in patient safety and process at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Rohde spoke on the topic at the 4th Annual Association for Healthcare Accreditation Professionals Conference in May.
"Data that do not validate or change our behaviors are not very useful," said Rohde. "It's important to consider control loops and to make sure your core measures are part of formal control loops."
A closed control loop is one in which data and responses are connected. For example, if your data collection surrounding the heart failure core measure is telling you that patients are not receiving appropriate discharge education on medications 100% of the time, your response should be to try to control that.
A broken control loop is one in which the data and the response are not connected, meaning that data are collected but there is no indication that behavior is changing as a result of what the data say.
Another key item to consider when looking at data measurement with respect to core measures is why things are occurring, said Rohde.
"Core measures tell us what's happening, but we need to analyze why it's happening. The key thing to do is convert data from 'what' into 'why,' " he said. Improvement on a specific core measure will only come after staff understand why goals for that core measure are not being reached.
Connecting core measures to processes
Ultimately, core measures are really looking at internal process measures, said Rohde. You have to connect your core measures data to your processes and thereby the people who use those processes. However, because the core measures are not organized by hospital process, it's easy to lose sight of which processes are ultimately in control.
"When we start looking at core measures, which is a relatively large burden, we really see that they break down into these processes," he said.
For example, throughout the entire set of core measures, a large majority fall into the medication process, with a significant amount of those being medication ordering process measures, said Rohde. If the facility is aware of which processes may be breaking down or not working properly, it might be able to fix the processes, thereby improving core measures.
However, core measures improvement requires change at a behavioral level. Looking at core measures data provides vitally important process and culture of safety information, said Rohde.
"We need to ask, 'What behaviors do we need to be connecting to make sure we're getting the right things done?' " he said.
A new study finds that an overwhelming majority of psychiatric patients treated at community hospitals are cared for in specialty units, as opposed to in general medical/surgical beds. "Nevertheless, we must continue to be vigilant and ensure that access to needed specialized treatment is provided as health reform shapes new care systems," said Pamela S. Hyde, JD, SAMHSA Administrator, in a press release.
The study, published in the June 2 issue of Psychiatric Services, was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Agency for Healthcare Research and Quality (AHRQ).
Researchers working on the study were interested in finding out how many patients at community hospitals (not freestanding psychiatric hospitals) are treated in separate psychiatric units and how many are treated in general medical/surgical beds, often known as "scatter beds," and examine the differences between the two populations. By utilizing data from the Healthcare Cost and Utilization Project State Inpatient Databases, the researchers found that only 6.8% of psychiatric patients are treated in scatter beds. Some notable comparisons include:
Patients in scatter beds were 50% less likely to also have a substance abuse disorder
Almost 40% of patients from scatter beds had a diagnosis of schizophrenia, episodic mood disorder, or depression
Patients in general psychiatric units were less likely to be elderly patients on Medicare
However, there was a wide variation between states' rates of psychiatric discharges, which could mean that a better assessment should be made of the need for psychiatric beds in certain regions.
Ultimately the researchers think that more work needs to be done to figure out what the optimal number of dedicated psychiatric beds in community hospitals is, and how to best use scatter beds to treat patients with psychiatric conditions.
More than two dozen hospitals are participating in the Maryland Patient Safety Center's (MPSC) SAFE from FALLS initiative. The project, based on a program by the same name being run through the Minnesota Hospital Association, has been providing facilities around the state with a road map for forming a comprehensive falls prevention program since July 2009.
The program is not mandatory, but is a valuable initiative in which to take part, says Susan D. McDonald, BSN, JD, director of risk management at Peninsula Regional Medical Center (PRMC) in Salisbury, MD. Her facility, a 375-bed acute care hospital, has been a part of the SAFE from FALLS program since its beginnings.
"We really already had many of the best practices in place," says McDonald. "Most hospitals have had falls programs in place for years, quite frankly. But what this forced you to do was really take a hard look at what your program consists of." For example, PRMC re-evaluated its method for flagging patients as fall risks. The organization has "moved away from the clever" and taken a more direct route to doing this, says McDonald. The hospital now places signs that say "risk of fall" on patients' doors, and prints orange arm bands with the words "fall risk" on them to place on the wrists of patients who are at risk of falling.
Developing a statewide initiative
MPSC was created through the Maryland legislature, with the Maryland Hospital Association and Delmarva Foundation selected as joint operators. The two organizations are involved in many of MPSC's initiatives, including SAFE from FALLS. Wendy Gary, MHA, vice president of healthcare quality and patient safety at the Delmarva Foundation, says that the state was looking for a way to standardize the way in which falls are measured to achieve a universal improvement.
"You really can't compare apples to oranges when you're looking at falls and looking at falls prevention and the severity of falls, especially if everyone is dividing them up in a different way," says Gary.
The falls road map was created with the help of workgroups for each of the three settings that the project addresses: Acute care, home health, and nursing homes. The next step was pilot testing in each of these settings during 2008 and 2009. Today there are about 30 hospitals using the road map, along with 50-60 nursing homes and 12 home health agencies, says Gary.
On a quarterly basis, the users report outcome and process measures. The outcome measures include things like falls, falls with injury, severity of falls, etc. The process measures are audit questions that align with the road maps, says Gary. The project also seeks to measure any cost savings that have been realized due to falls prevention.
"We can do a couple of things: We can look at the decrease in falls overall and a decrease in severity, but we can also take a look at what elements these folks are implementing off the road map on a progressive basis," says Gary. "We're looking to prevent the preventable and then make sure whoever falls has the least severe fall that they can possibly have."
One of the more important aspects to consider when using the road map is that because it is a guide, it's perhaps not necessary for each facility to implement all of the suggested prevention techniques; instead, finding the best combination of strategies is the goal. It is a comprehensive guide, but not prescriptive, says Gary.
"Maybe it's not about implementing all of the audit questions or all of the strategies—maybe there's a perfect recipe, that if you implement x, y, and z, you're going to get the best results, so that's really what we're looking for in each of the settings," says Gary. The goal is to provide each facility the option of creating its own personalized falls program.
That sentiment was taken to heart at PRMC, and the facility has seen a decrease in both the number of falls and the number of patients who had falls with significant injury from 2007 through 2009.
"We decided that there might be things [on the road map] that we were not going to try to do," says McDonald. "I don't think this is an exercise where you answer 'yes' to everything—some things might not work for you." For instance, PRMC has elected to not have a pharmacy consult with a fall risk because of staffing and technology issues.
The goal of the SAFE from FALLS initiative in the coming months is to continue to recruit more hospitals and gather more data, says Gary. Additionally, the program will roll out a best practice monitoring tool statewide in July. The program will continue to develop an outpatient module for acute care facilities to use as well.
One of the largest benefits of participating in the collaborative for PRMC has been improving staff engagement levels, says McDonald. When someone from the MPSC visits the facility to check in on how the facility is working with the road map, staff plan events to display efforts on fall prevention. One instance involved a contest with each nursing department's falls educational boards exhibited in the hospital's lobby.
"That got people in the spirit, and that prompted many other similar types of [efforts] with other educational boards."
Empowering nurses to become leaders in patient safety can have positive effects not only on the patient population's quality of care, but on staff satisfaction levels.
At The University of Kansas Hospital (KUMED) in Kansas City, KS, Liz Carlton, RN, MSN, CCRN, director of quality, safety, and regulatory compliance, helped design a Quality Safety Investigator program (QSI) as a way to better involve bedside nurses in championing quality and patient safety. There is a designated QSI on each unit and he or she is provided dedicated time to focus on initiatives specific to their unit, as well as education in a group setting on topics like medication safety, handoffs, and hand hygiene.
KUMED has been designated in the American Nurses Credentialing Center's Magnet Recognition Program® (MRP) since 2006, and will apply for redesignation in October of this year. KUMED's philosophy is that the patient always comes first, Carlton says.
"They're responsible for taking that back to their unit, partnering with their unit leadership, and really driving those initiatives that are happening on their unit," says Carlton. "That is a great example of the Magnet model, empowering staff in an innovative way to share knowledge, share data, and make changes."
There are currently 39 QSIs at KUMC. Nurses interested in becoming a QSI have to go through an application process, says Carlton.
"When you get selected, you have to sign a contract that says you are going to participate and be engaged, and your manager has to sign a contract also that says they're going to support you in being participative and engaging, so that you can't use the excuse of 'well my manager wouldn't let me off,'" says Carlton.
Not only has this program helped encourage some nurses to become leaders, it has brought about greater staff involvement across the organization. Peers are influenced to join the program, says Carlton. The QSIs get their own scrub tops, are sent to outside conferences for additional training, and receive the necessary tools to act as a QSI. When their nurse peers see many of the rewards that QSIs take advantage of, they too become interested in the program, says Carlton.
Additionally, the QSI program is a mentor opportunity for staff members in the quality and performance improvement world. Mentors share advice with QSIs from various departments about gathering and presenting data. Carlton says she is a mentor for a QSI in maternal and child health, even though she doesn't know as much about the clinical aspects for this unit. This helps the QSIs run their specific performance improvement projects.
“The message I give the staff is . . . you're the one that's taking care of the patient more than anyone else," says Carlton. “That patient—the quality, safety, and care that's provided to the patient—is owned by you. If you empower that nurse to be able to impact their practice, put input into changing a policy or protocol . . . that's all the more stronger because of it."
Engaged nurses who feel like they work in an organization that values their efforts and opinions have an incredibly positive effect on the quality of care patients receive. Studies have shown that organizational support for nursing leads to better quality of care, which can reduce mortality rates and improve rates for nursing-sensitive indicators, such as patient falls, pressure ulcers, and central line infections.
For the past 17 years, the American Nurses Credentialing Center's (ANCC) Magnet Recognition Program® (MRP) has given healthcare facilities a framework around which to structure their nursing programs to achieve quality patient outcomes. Those facilities that have been designated as MRP organizations say that their hospitals have been able to take improvement in quality and patient safety to new levels. Even those facilities that have not yet been recognized but are in the application process for becoming an MRP hospital say the exercise has been a positive one.
How can one program help elevate the standard of nursing care and, thereby, patient safety nationwide?
"[The MRP program] encourages us by way of their standards—they almost mandate it—to make sure we are on our journey towards quality and that we do embark on safety, and that we not just meet the standard, that we take it to higher levels," says Denise Occhiuzzo, MS, RNC, BC, administrative director of clinical education and nursing practice, and MRP program director in the Department of Patient Care at Hackensack (NJ) University Medical Center (HUMC). HUMC was the second facility to ever be MRP-designated and has been redesignated four times since 1995, most recently in 2008.
At its core, the MRP program requires hospitals to consider five model components: structural empowerment; exemplary professional practice; new knowledge, innovation, and improvements; transformational leadership; and empirical outcomes, the last of which really overlaps all of the other domains. These areas guide the development of many initiatives at MRP facilities. There are currently 371 MRP-designated facilities, and many more are in the process of becoming one.
No small undertaking
Becoming an MRP hospital requires years of preparation and data collection, as well as a binder of materials that can be hundreds to thousands of pages long. Additionally, the cost of being designated can be substantial, depending on the size of the organization. The cost of an appraisal by the ANCC ranges from around $14,000 for hospitals with fewer than 100 beds to nearly $58,000 for hospitals with 950 beds.
However, the investment, time, and resources required are generally found to be worthwhile by organizations that go through the process.
The road to empowerment
Because shared governance is one of the major components of designated organizations, nurses are more than simply encouraged to take part in hospital initiatives. MRP facilities give their nurses the tools and resources they need to create and lead new programs. That empowerment leads to better outcomes for patients and more satisfied staff members.
"[MRP] requires that we have a quality council and that it is staff led," says Theresa Colarusso, RN, BSN, MPA, administrative director for performance improvement and regulatory compliance in the Department of Patient Care at HUMC. "It's wonderful to see how bright, educated, and engaged they are. They really take this to heart, and it's good discussion at the table."
HUMC had success with a patient falls prevention initiative, which is led by a staff nurse. The nurse was part of a larger "champion" group, and through it found her passion for reducing falls, says Claudia Douglas, RN, MA, CNN, APN.C, supervisor of clinical practice affairs and MRP coordinator in the Department of Patient Care at HUMC. The nurse's program has been in place for the past four years, and many efforts around the organization can be attributed to her ability to identify a need and take hold of the resources available.
"Our organization's philosophy from the nursing department of patient care services is to encourage nurses to be leaders, because we're all leaders at the bedside," says Douglas. "Staff nurses in particular are encouraged to be leaders, and the support, resources, education, and time are provided, and the nurse was able to take this to a great level."
The Joint Commission will be releasing new standards for hospitals surrounding language, culture, and communication in the January 2011 hospital manual.
The standards, announced in the January 2010 Perspectives on The Joint Commission, will be accompanied by a Web-based, downloadable guide, which will be released in late May. Hospitals will be able to view the standards at this time, and although they will be included in the 2011 hospital manual and part of a survey, they will not be factored into a hospital's accreditation at that time, said Paul Schyve, MD, senior vice president at The Joint Commission, who spoke on a Webcast entitled New Joint Commission Standards to Improve Patient-Provider Communication on April 16.
"We realized that there were more barriers to effective, safe care and communication than just culture, and just language," said Schyve.
To develop the standards, The Joint Commission put together a technical expert panel (TEP) of people involved in many different areas of healthcare, as well as other areas of society. The panel addressed three areas:
Effective communication—Identifying needs and providing language services for those patients who need them.
Data collection and use—How to collect demographic data of patients and using it for performance improvement.
Address specific patient needs—Ensuring patient and family involvement, equitable treatment, and addressing cultural and spiritual beliefs.
Specifically, new to the standards will be requirements involving identification and documentation of oral and written communication needs of a patient, and the patient's preferred language for discussing healthcare. This goes beyond language, and includes glasses, hearing aids, and communication boards for intubated patients. Additionally, the patient's and his or her advocate's preferred language should also be documented in the medical record.
"Think broadly about the different barriers to communication and how you might need to address them for any specific patient, and be prepared with any equipment and so on for patients with that particular kind of problem," said Schyve.
Other additions include the need to formally train interpreters, as not all people who are bilingual are trained in medical terminology. These qualifications must be evaluated and met through assessment, education, training, and experience, as deemed acceptable by the facility.
The new standards also heavily emphasize the effect on a patient's well-being that having a family member, close friend, or other individual present during care can have. The hospital will be required to allow this type of person, regardless of relationship to the patient, to stay at a patient's side for emotional support throughout his or her care. This will align with President Obama's memorandum last week stipulating that hospitals that participate in Medicaid or Medicare afford patients the right to have visitors of their choice, regardless of their relationship (familial or not).
"Those that were on the TEP pointed out that in patient-centered care, it's become clear that patients are much more comfortable when they're in the hospital if they can have a friend of family member with them on a much more continuous basis," said Schyve.
Many of the new requirements are additions to some existing standards in the Rights and Responsibilities of Individuals, Record of Care, Treatment, and Services, and Human Resources chapters.
The road map will help guide facilities in complying with these standards and incorporating their concepts and intent into everyday care, said Amy Wilson-Stronks, MPP, CPHQ, project director in the Division of Standards and Survey Methods at The Joint Commission and principal investigator on the Hospitals, Language, and Culture study.
"I think it's really important for folks to think about this in a broader context," said Wilson-Stronks. "In order to address disparities, there really needs to be an integrated effort at multiple levels, and it needs to be an ongoing process, integrated into both patient safety and quality improvement initiatives."