Hartford Hospital's ADAPT program has decreased length of stay and readmissions attributable to delirium.
Hartford Hospital has developed a comprehensive approach to addressing delirium in the hospital setting.
In-hospital delirium has been associated with several negative patient outcomes, including increased risk of death, increased risk of a prolonged or permanent cognitive impairment, increased readmissions, and increased risk of developing dementia after hospitalization.
"We know the more severe the delirium is and the longer it lasts, the worse the outcome," says Christine Waszynski, DNP, APRN, coordinator of inpatient geriatric services at Hartford Hospital, which is based in Hartford, Connecticut.
Patients who experience delirium during a hospitalization also can develop a form of post-traumatic stress disorder, she says.
"They have recurrent or unresolved issues related to their experience during a delirium episode. It can have an extremely negative impact on their life. They "remember" bad things that happened to them during their hospitalization and have to reconcile that it is really their perception of what happened—people really were not attacking them and aliens were not abducting them for testing."
In 2011, Hartford Hospital launched Actions for Delirium Assessment, Prevention, and Treatment. The ADAPT program has achieved impressive results. From 2013 to 2018, delirium-attributable days at the hospital decreased 40%. From 2012 to 2019, readmissions have fallen 14% for patients who experience delirium during a hospitalization.
The ADAPT program has three key components: screening, prevention, and treatment and management.
1. Screening for delirium
The ADAPT program features delirium screening in the inpatient and the emergency department settings.
For the inpatient setting, nurses screen all patients for delirium using the Confusion Assessment Method. When a patient is identified at high-risk for delirium, a care pathway is triggered, says Robert Dicks, MD, chief of geriatric medicine at Hartford Hospital.
"When a nurse identifies a patient who screens as abnormal, the clinicians are notified on the spot that they have a patient who is at high risk for delirium and they are engaged at that point. Then the preventive measures kick in," he says.
In the emergency department setting, nurses screen every patient over age 65 with a Single Question in Delirium (SQID) screening technique. These patients are asked whether they have been more confused lately. If a patient has a family member or someone else with them, that individual also is asked the question about the patient.
If the answer to the SQID question is "yes," a patient gets an intentional test—counting backward from 20 to one. "Attentional deficit is the key element of delirium. You must be inattentive to be delirious," Waszynski says.
2. Preventing delirium
Once a patient has been identified at high-risk for delirium, the ADAPT program calls for a range of preventive measures by clinicians, nurses, and hospital volunteers.
Clinicians focus on three kinds of preventive measures: avoiding administration of deliriogenic medications such as Ativan and fentanyl, avoiding the abrupt discontinuation of medications such as opioids and steroids, and avoiding several medical interventions when they are deemed unnecessary such as telemetry and urinary catheters.
Most nursing preventive measures are basic best practices such as moving the patient around, ensuring patients get as much uninterrupted sleep at night as possible, making sure patients have their sensory aids such as glasses, and providing assistance for eating and drinking.
Volunteers provide several preventive services to patients at high-risk for delirium, including socializing with patients, encouraging cognitive activities such as word searches, and assisting patients with walking.
Other preventive measures include an "all about me" poster placed in a patient's room. "It has basic information about patients such as what they like to be called, what they like to eat, the important people in their life, their dog's name, and what activities they enjoy," Waszynski says.
3. Treating and managing delirium
"When a nurse screens a patient as abnormal, it is an urgent situation," Dicks says.
The first step in treating delirium is determining the cause of the condition, he says. "It may be a drug-induced delirium. It may be a medication that was inappropriately stopped. It may be drug interactions. There's always the risk that infection and an abnormality in the blood can cause delirium. A new injury or stress can cause delirium. All of those factors are dealt with based on a systematic review."
Once clinicians feel secure that they have an explanation for delirium or the patient is responding in an expected way, there is a consult with one of three specialties—geriatrics, neurology, or psychiatry—for a second opinion. "Providers want to make sure that they are not dealing with something atypical, that there is not some other workup that is justified, and that the treatment they have approved is appropriate," Dicks says.
Clinicians apply best practices "across the board" related to treatment strategy, he says. "There are certain medications that we believe are more effective and better tolerated than other medications, and we guide clinicians to those medications in our protocol. When those medications are ineffective or contraindicated, we have second-line and third-line treatment strategies."
Cost-effectiveness of ADAPT
An Institute for Healthcare Improvement blog post highlights the cost-effectiveness of Hartford Hospital's ADAPT program.
Accounting for longer lengths of stay and higher costs of care per day, delirium adds more than $22,000 to an inpatient stay at Hartford Hospital. The total costs of the ADAPT program are about $50 per patient.
"From the Hartford Hospital data and analysis applied to it, one might reasonably conclude that even under the most conservative scenarios, ADAPT should at least break even and probably perform far better than that," the IHI blog post says.
Earlier research has shown that decreases in hospital competition have a negative impact on quality and increase prices of medical services. In theory, as insurers consolidate hospitals may view boosting quality as a key bargaining strategy because patients could pressure payers to keep hospitals in-network.
An article published recently in Health Services Research found evidence in support of the theory about insurer consolidation. "Changes in patient satisfaction are positively associated with increases in insurance concentration and negatively associated with increases in hospital concentration," the HSR researchers wrote.
The HSR article, which features information collected at more than 3,000 hospitals, generated two primary data points:
1. Patient rating of hospitals: Compared to a market with 20th percentile insurance concentration and 80th percentile hospital concentration, a market with 80th percentile insurance concentration and 20th percentile hospital concentration increases the number of patients who rate hospitals highly from 66.9% to 67.9%.
2. Patient recommendation of hospitals: Compared to a market with 20th percentile insurance concentration and 80th percentile hospital concentration, a market with 80th percentile insurance concentration and 20th percentile hospital concentration increases the number of patients who definitely recommend hospitals from 69.7% to 70.8%.
Interpreting the data
The lead author of the HSR research told HealthLeaders that the impact of shifting market concentration is modest but significant.
"We find that a large but not implausible change in market structure causes a 4 percentage point movement in the distribution of patient experience scores, which we don't view as trivial. In more human terms, an additional 1% of hospital inpatients in that market would report having a positive experience," said Caroline Hanson, who recently earned her PhD from the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health in Baltimore.
Hanson and her coauthors also found that insurance market consolidation has a relatively higher beneficial impact on care quality in markets where the hospital market is more concentrated. "This suggests that when a hospital market is not concentrated, other hospitals exert enough competitive pressure that insurance concentration has no additional impact on quality," the researchers wrote.
A children's hospital chief executive becomes the first leader of New Jersey health system's pediatrics service line.
RWJBarnabas Health has named the president and CEO of one of the health systems three children's hospitals to lead the organization's newly created pediatrics service line.
Warren Moore, MA, FACHE, will serve as senior vice president of pediatric services at the West Orange, New Jersey–based health system. Moore, who has worked in the organization for two decades, will continue serving as president and CEO of Children's Specialized Hospital.
HealthLeaders recently spoke with Moore to get his perspectives on managing the systemwide pediatric service line. Following is a lightly edited transcript of that conversation.
HealthLeaders: Why did you pick pediatrics as your main field of interest?
Moore: In some ways, pediatrics picked me. In 1998, I was about eight years into my healthcare career, which had all been on the adult side, and I was asked to work at Children's Specialized Hospital. I was a relatively new father—I had a 1-year-old and a 4-year-old. Once I toured Children's Specialized and watched the wonderful care that was given to kids, there was an immediate emotional connection for me as a new dad.
HL: For a health system or a hospital, what are the benefits of establishing a pediatrics service line?
Moore: From the perspective at RWJBarnabas Health, we have many places throughout the system where we are providing excellent care for children. For example, there's the Children's Hospital of New Jersey, Children's Specialized Hospital, and NICUs throughout the system. We have incredible services for kids, and what we have now is an opportunity to bring these great but disparate services into one system of care. We want to focus on our overall population and how we can get to the point where we can effectively care for more than a half million children in our service area.
HL:Limiting clinical care variation is a primary objective in prominent services lines such as cardiology. Is limiting variation a primary objective in pediatric service lines?
Moore: Absolutely. One of the challenges in pediatrics is it involves a large group of services—there are multiple service lines within pediatrics. We have cancer care, we have cardiac care, and we have care for medically complex children. From that standpoint, we have an opportunity with a pediatrics service line to look at best practices and how we can bring those best practices to children across our health system.
HL: Conversations about care variation can be difficult—particularly in pediatrics given the intense emotional connection that many clinicians have with their patients and their patients' families. How do you have that conversation?
Moore: In my 21 years in pediatrics, I have found that when you bring the conversation down to what is best for the kids, everyone pays attention. When we have sound data, and when we can show that we can treat patients better, very few clinicians push back. You must focus the conversation on the child and what is best for the child. You need the hard data that shows the best care for particular situations.
HL: What are your goals for the pediatrics service line at RWJBarnabas?
Moore: For us, it's similar to what we look at for adult care. Our goal is to promote health in the communities that we serve. There are about a million children in our health system's geographic area. In the next five years, we are focused on how we can provide coordinated, safe, high-quality, compassionate, and family-centered care. That means we need to develop a network of primary care, subspecialty care, and ambulatory care for approximately half of the market—about 500,000 kids.
HL: How do you think pediatric care at RWJBarnabas will look different five years from now?
Moore: The big thing that will look different is we will have a large ambulatory and primary care network. Right now, we work with informal relationships in pediatrics across New Jersey. I believe formalized networks of care are important in our future as we move away from fee-for-service to value-based care, which involves generating the best outcomes for children.
HL: What is one of the most significant challenges in pediatric care?
Moore: It's the funding. Traditionally, pediatrics has not been fully funded across the spectrum of healthcare compared to the adult side.
Typically, our reimbursement for care is less than you see on the adult side. And when you are dealing with kids, 50% or more of your patients are going to be on Medicaid as the insurance. So, Medicaid funding is always at the forefront of what we are thinking about financially. In graduate medical education, typically per slot on the pediatric side we get about 50% of what Medicare pays for graduate medical education. The same is true for cancer research—pediatrics is negatively proportionate to the adult side.
For the past 20 years, a big focus for me has been how do we keep moving the dial toward adequate funding to make sure we ensure the future for kids and make sure they all reach their full potential.
HL: How is operating a children's hospital different from operating a general acute care hospital?
Moore: To have a good outcome for a child, we need to engage the family and treat the entire family. Obviously, a child is dependent on parents or other caregivers or siblings. Without a healthy home environment, a child does not have a good chance of a positive outcome.
I realized early in my career at Children's Specialized the need to completely and holistically engage a family in the care of a child. We must make sure that the caregivers are in the right mindset and have the supports they need to take on the challenges of caring for their child. One of the most gratifying things for me working in pediatric care is watching our team wrap its arms around a family and truly make sure that we have them set up for success with their child.
HL: How do you fully engage family members and other caregivers?
Moore: We have focused on getting the voice of families into everything we do. So, we have "family faculty." We hire parents and caregivers of current or former patients, and we engage them in two broad categories.
One category is to give them an actual job function to help bridge the communication between families and our clinical team—they broker the space and help build the trust we need to build. The other category is to utilize them from a policy and operations standpoint. We have a member of either our family faculty or our voluntary family advisory council on every committee in our organization—from the board of trustees, to the patient safety committee, to our operating committees, to our performance improvement committee. So, the voice of families is literally in everything that we do.
In a recent survey, out-of-pockets costs and wait times had a limited impact on patient choice of care settings.
When patients choose a care setting, the main drivers are the nature of medical conditions and patient characteristics, new survey data indicates.
In recent decades, healthcare providers have developed several alternatives to traditional physician office and emergency room visits, including urgent care centers, retail clinics, telemedicine, and app-driven home health visits.
Survey data collected from more than 5,000 University of California-Irvine employees shows patients make rational choices of care settings based largely on medical condition severity and patient characteristics, a journal article published in Health Services Research shows.
"Out‐of‐pocket costs and wait time had minimal impact on patient preference for site of care. Choices were driven primarily by the clinical scenario and patient characteristics," the HSR researchers wrote.
Survey participants were given 10 clinical scenarios of varying severity, then they were asked to pick a preferred care setting. The survey generated several key data points:
Most survey participants chose physician office visits for chronic conditions and child well-visits.
For clinically severe and time-sensitive scenarios, survey participants were inclined to choose the ER or urgent care. For example, 68.9% chose the ER for chest pain, and 41.9% chose urgent care for a deep cut.
In non-time-sensitive scenarios, physician office visits were highly preferred. For example, 45.4% preferred physician office visits for immunizations.
For diarrhea, parents were much more likely to "wait and see" for themselves (29.9%) than for their children (5.8%). For most parents, a physician office or urgent care center was the preferred setting to take children for treatment of diarrhea.
Increases in out-of-pocket expenses generated single-digit percentage point changes in patient preferences for care settings. For physician office visits, a 20% increase in out-of-pocket costs decreased the likelihood of a survey respondent picking that setting by 3.6 percentage points. For urgent care, a 20% hike in out-of-pocket costs decreased selection of that care setting by 1.5 percentage points.
Interpreting the data
The survey results for out-of-pocket costs indicate payers would have to make significant changes to benefit structures to increase utilization of alternatives to tradition physician office visits and ERs. The lead author of the HSR article told HealthLeaders that payers could make substantial hikes in out-of-pocket costs to influence care setting preferences.
"If the insurer wanted to encourage virtual physicians visits, rather than having virtual visits at equal cost to an actual physician office, which it is now for most University of California-Irvine employees, the insurer could lower the cost of virtual visits to a few dollars and increase the cost of an actual office visit," said Dana Mukamel, PhD, a professor of medicine, public health, and nursing at UCI.
In addition to medical condition severity and patient characteristics, patient familiarity with a care setting was a significant preference driver, she said. "In general, we found that people were more likely to choose those providers that they had an experience with in the previous 12 months."
Telemedicine visits were a recent offering to UCI employees, which worked against their selection in the survey's care scenarios, but this preference pattern will likely change over time, Mukamel said. "I expect that as more people gain experience with this option, we will see more people making this choice."
To reduce patient harm, BJC HealthCare focused on pressure ulcers, adverse drug events, healthcare-associated infections, falls, and venous thromboembolisms.
A health system can not only slash patient harm incidents but also sustain the reduction efforts over time.
Medical errors are a leading cause of death in the United States, with estimates of the lives lost annually ranging as high as 440,000. Nonlethal but serious errors such as incidents that lead to permanent harm are estimated to impact as many as 4 million patients annually.
In 2008, St. Louis-based BJC HealthCare launched a patient safety and quality improvement initiative that was designed to dramatically reduce patient harm events over a five-year period and sustain the reductions for an additional five years.
"A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress," BJC staff members wrote this month in The Joint Commission Journal on Quality and Patient Safety.
The initiative achieved eye-popping results. During the intervention period from 2009 to 2012, total harm events fell 51.6%. An additional 2,600 harm events were avoided from 2013 to 2017, realizing a 74.9% reduction in harmful incidents through the entire course of the initiative.
BJC, which features 15 nonprofit hospitals, focused on five classes of harm events to garner these gains, according to The Joint Commission journal article.
1. Pressure ulcers
Before the initiative was launched, the top cause of patient harm at BJC was pressure ulcers.
To help reduce the incidence of pressure ulcers, BJC developed an electronic health record-based surveillance system for the condition that tapped data in nursing documentation. Best practices were adopted across the health system, including pressure redistribution and patient turning, skin care and moisture management, listing of pressure ulcer events on medical unit display boards, and educational efforts to enlist patients and families in detection and prevention.
2. Adverse drug events
At BJC, hypoglycemia accounted for 75% of adverse drug events, with over-sedation accounting for the next highest percentage of ADEs at 16%.
The health system investigated the causes of severe hypoglycemia through examination of nursing data collected on an online portal after adverse events. The investigative effort led to the development of a pioneering benchmark for severe hypoglycemia.
Hypoglycemia interventions included limiting bedtime snacks, which data analysis showed increased risk of early morning hypoglycemia. The health system also used a locally developed clinical decision support tool—the Pharmacy Expert System—to deploy an algorithm that identified patients at high risk for severe hypoglycemia. When patients were identified at high risk, a diabetes nurse educator, charge nurse, or pharmacist would adjust diet and medication as necessary.
Efforts to avoid over-sedation followed a similar roadmap, with initial efforts aimed at identifying causes such as inappropriate dosing based on a patient's health history or condition. Interventions included changing narcotic dosages in order sets and engaging clinicians who were prescribing medications in excess of guidelines.
3. Healthcare-associated infections
Before launching its harm reduction initiative, BJC had conducted a decade-long effort to reduce healthcare-associated infections (HAIs), but there were still gains to be made. The health system focused on the three most common HAIs at the organization's hospitals: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI).
For CLABSI, a standardized central line insertion kit and insertion checklist was deployed throughout the health system. For CAUTI, efforts focused on removing indwelling urinary catheters as soon as medically possible.
For CDI, housekeeping procedures were developed for cleaning isolation rooms as well as daily and discharge patient rooms. When CDI was detected, an intervention was conducted featuring core cleaning standards, hand hygiene, and presumptive isolation.
From 2009 to 2017, BJC achieved a 40.6% reduction in HAIs.
4. Falls with injury
Surveillance for falls with injury was conducted with an online reporting tool crafted at BJC. The surveillance data revealed variation in falls, with some medical units showing significantly higher rates of falls than others. The high-fall units were targeted for interventions such as increased use of electronic health record-based fall risk assessment tools and deployment of core prevention standards.
5. Venous thromboembolism
Efforts to prevent venous thromboembolism centered on making sure patients got appropriate VTE prophylaxis. The primary intervention was mandatory order sets in the EHR, including alerts when VTE prophylaxis was not ordered.
Keys to success
Sustaining harm reduction after the five-year intervention period required concerted effort, the BJC staff members wrote in The Joint Commission Journal on Quality and Patient Safety article.
"Each subteam developed a transition plan that designated a specific system-level group to oversee ongoing improvements in that area (for example, the system chief nursing officers' council provided ongoing oversight for falls with injury and pressure ulcers). Surveillance for each harm event continued, and detailed reports were available to the hospitals and responsible groups. Overall reporting of preventable harms was moved to the system quality best-in-class report card, with progressive reduction targets set each year."
Several elements contributed to the overall initiative's success, they wrote. "A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress."
Misidentifying depression as burnout can have deadly consequences.
The response to physician burnout often overlooks a potentially life-threatening condition: major depressive disorder, physicians say in a new journal article.
Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. It is estimated that a physician commits suicide every day.
In a journal article published this month in JAMA Psychiatry, a trio of physicians wrote that the widespread focus on burnout could lead to missed diagnoses of serious mental illnesses among clinicians.
"It is critical that burnout not become the catchall term for emotional distress experienced by physicians. Identifying psychiatric disorders appropriately will enhance the likelihood that the correct treatment is sought. However, as long as stigma and shame are associated with psychiatric disorders, and we have a convenient, ready-made psychosocial formulation to explain away distress in the medical profession, there is a risk that psychiatric illnesses will be less likely to be acknowledged, recognized, and treated appropriately," the physicians wrote.
Symptoms of burnout such as exhaustion overlap with symptoms of major depressive disorder, and signs of MDD in clinicians such as suicidal ideation should prompt a thorough psychiatric evaluation, they wrote.
"Erroneously labeling a physician's distress as burnout may prevent or delay appropriate treatment of MDD, a serious and sometimes life-threatening mental disorder. … Given risks associated with suicidal ideation, it is imperative that the presence of suicidal ideation lead to an evaluation to rule out MDD."
Prejudice is a significant risk factor for distressed clinicians, the physicians wrote.
"Given the robust stigma around psychiatric conditions, the physician may be much more likely to conceptualize her or his problem as burnout rather than a psychiatric disorder. In this scenario, the physician might not seek effective pharmacologic or psychotherapeutic interventions for her or his MDD, but pursue commonly recommended stress reduction and relaxation strategies for burnout, such as yoga, mindfulness classes, or time off from work."
There are several approaches to help ensure that MDD is not mistaken as burnout, they wrote.
"Robust, evidence-based screening tools for depression exist, and many are brief. Complementing any screening for burnout with screens for depression, anxiety, and substance use disorders could mitigate the risk of conflating psychiatric diagnoses and burnout. Creating confidential psychiatric services that are easily accessible to physicians, especially trainees, might make a difference. Web-based and telepsychiatry platforms make this easier than ever. Ultimately, the biggest challenge is rolling back the corrosive effects of stigma."
Rising to the challenge
The lead author of the JAMA Psychiatry article told HealthLeaders that prejudice against medical staff with mental illness should be openly challenged.
"Educating people that it is not about weakness or moral failings is important. Calling out stigma also is key. As we understand more about the biology of MDD, it becomes more and more difficult to distinguish it from other medical conditions," said Maria Oquendo, MD, PhD, chair of psychiatry at the University of Pennsylvania's Perelman School of Medicine in Philadelphia.
Research shows that a substantial portion of clinicians experience MDD, Oquendo said. "Studies of physicians in training suggest that MDD might be present in as many as 25%. An Austrian study of physicians suggested a 10% prevalence of MDD, and that burnout increased the odds of MDD significantly. For those with mild burnout, the risk of MDD was three times greater; for moderate burnout, the risk was 10 times greater; and for severe burnout, the risk it was 47 times greater."
It is possible to achieve diagnostic clarity between burnout and MDD, she said. "MDD has clear diagnostic criteria. Burnout does not. However, whenever an individual meets the criteria for MDD, the diagnosis should be the focus of treatment, even if there are elements in the clinical picture that resemble burnout."
The nonprofit's expanded Never Event Policy is designed to hold hospitals accountable to their patients and attain high reliability in healthcare.
Hospitals need to hold themselves accountable when errors lead to catastrophic consequences for patients, the leader of a national quality and safety organization says.
Preventable adverse events in hospitals are one of the leading causes of death in the United States, with estimates of lives lost ranging from 210,000 to 440,000 annually. Serious harm is as high as 20 times more common than fatal harm.
"This is really about the hospital industry declaring itself as accountable as any other industry in the country," Leah Binder, MA, MGA, president and CEO of The Leapfrog Group in Washington, D.C., tells HealthLeaders.
Leapfrog is promoting a nine-point Never Event Policy to help health systems and hospitals address catastrophic medical errors. The nonprofit group defines a never event as egregious mistakes such as surgery performed on the wrong patient or foreign objects left inside a patient after surgery.
The Never Event Policy includes apologizing to patients, reporting adverse events internally when they occur, performing root cause analyses, waiving costs directly related to an adverse event, and providing a hospital's adverse event policy to patients and payers upon request.
"If an airline did not adhere to a policy like this in the event of a crash, they would be out of business. No one would tolerate it," Binder says.
Never Event Policy adoption
Leapfrog recently published a survey report on adoption and adherence to the group's Never Event Policy, which was expanded from five points to nine points in 2018. The report features several key recommendations and data points:
100% of U.S. hospitals should adopt the Never Event Policy.
In 2018, 74.6% of hospitals met all nine elements of the Never Event Policy.
After the Never Events Policy was expanded to nine points, performance on the policy dropped at both rural and urban hospitals. Performance dropped more significantly at rural hospitals (9.9%) than at urban hospitals (5.1%).
Human nature is the most daunting barrier to hospital adoption of the Never Event Policy, Binder says. "As human beings, when we make mistakes, we are loath to admit it. We certainly don't want to have to apologize to someone or admit a mistake when we have made a catastrophic error."
Establishing protocols to respond to never events is essential, she says. "You need to move beyond human nature—that's why you need to have a policy. The policy must be enforced and monitored carefully by leadership because it is a critical part of running a hospital that is committed to what is best for patients."
Never Event Policy serves interests of hospitals and patients
Adoption of the Never Event Policy is good for hospitals and their patients, Binder says. "It's in the interest of hospital patients because it is the right thing to do. It treats patients with the dignity and the respect that they deserve. It's in the interest of hospitals because it has been tested; and where the nine elements have been used, they reduce overall risk for the hospital."
The Never Event Policy is based on the Communication and Optimal Resolution (CANDOR) program developed at the federal Agency for Healthcare Research and Quality. AHRQ initially tested and applied CANDOR at three health systems. "They have seen a reduction in malpractice claims. We know from literature that people who get an apology and get treated with respect are less litigious in the long run," Binder says.
When the Never Event Policy was expanded to nine points, calling on hospitals to care for medical staff was a pivotal addition, she says.
"Hospitals need to recognize how difficult and sometimes devastating never events can be to the individuals who lead to a catastrophe for a patient. It's difficult for them to move on after an error, and they need help and protocols. The protocols need to be public, so everybody who works in a hospital knows the hospital will take care of you if you make an error."
Caring for healthcare workers when never events occur sends an important message to staff members and patients that medical errors will be addressed, Binder says. "The hospital owns up to the error, stands up for its people, and does what is right."
Quest for high reliability
Leapfrog's Never Event Policy is part of a national effort to achieve the same level of high reliability in healthcare that has been achieved in other high-risk industries such as aviation, Binder says. "I expect hospitals to achieve that level of high reliability. People place their lives in the hands of healthcare providers every day, and our lives are worth the same when we walk into a hospital as when we board a plane."
The healthcare sector has completed about 20% of its high-reliability journey, she says. "We are not at the very beginning—a lot of hospitals have embarked on the journey. But we have a very long way to go. The data and statistics on errors in hospitals are extremely disturbing."
The next big step is for the healthcare sector to commit to attaining the highest possible standards for transparency, Binder says.
Boosting transparency features two components, she says:
Hospitals must hold themselves accountable to their patients.
Hospitals must fully accept the shift from fee-for-service medicine to value-based medicine. "They can embrace transparency, hold themselves accountable for results, and demand payment for results. They can sit down at the table with payers and ask for rewards when they achieve better outcomes," Binder says.
Leadership will play a decisive role in the quest for high reliability in healthcare, she says. "If hospitals can reach a new level of leadership, we would see major transformation in our healthcare system. The pathway to get there is through high reliability—it's with leaders who undertake the journey to high reliability and with leaders who are willing to hold themselves accountable."
Advice for effective quality improvement includes devoting time and resources, gauging patient experience, and taking a persistent approach.
At primary care practices, clinician-led quality improvement efforts not only boost the value of patient care but also elevate meaning in providing care, according to a recent journal article.
Primary care quality in the United States compares poorly to other industrialized countries on several measures, including timeliness of appointments when patients are sick as well as access to care on weekends and holidays. In addition, nearly half of physicians are experiencing symptoms of burnout, which can be eased through quality improvement (QI).
Quality improvement benefits primary care practices and their patients, Canadian clinicians wrote this month in the journal BMJ Quality and Safety. "Primary care professionals in North America are trained to provide excellent care to the patient in front of them. Few have been trained to measure and improve the care they provide to a population of patients. Fewer still are familiar with improvement science or QI tools."
The clinicians generated 10 tips to help guide QI efforts at primary care practices:
1. Time and resources: Enlist a dedicated cadre of clinicians and other staff members to lead QI work, including redistribution of clinical income to pay for physicians to lead the effort. Training should also be provided to QI team members.
2. Intrinsic motivation: QI efforts should capitalize on the natural desire among caregivers to improve clinical care such as clinician passion for teaching and developing expertise.
3. Patient experience: A patient experience survey can play a pivotal role in driving QI efforts. At their primary care practice, the BMJ Quality and Safety clinicians garnered a 20% response rate to the patient experience survey administered at their Toronto, Canada-based primary care practice. "Patient feedback has helped us identify and prioritize improvement opportunities," they wrote.
4. Early win: One way to promote QI success is to identify an early win. The BMJ Quality and Safety clinicians initially focused on boosting cancer screening rates for cervical, breast, and colorectal cancer.
5. Flexibility: Leaders of a successful QI effort are open to learning and adjusting course when necessary. In addition to ramping up cancer screening at the start of their QI initiative, the Toronto-based primary care practice also sought to improve influenza immunization among patients over 65, but positive results were difficult to achieve. Interventions to increase flu shots at clinics such as mass media campaigns were eventually dropped so resources could be diverted to more promising areas.
6. Persistence: Some priorities such as timely access to care require sustained commitment even if there are daunting obstacles such as resistance from some staff members.
7. Patient engagement: The Toronto QI team generated several gains based on involvement of patients in the improvement work, including increased access on evenings, weekends, and holidays. For example, patient surveys revealed the need to promote awareness about the availability of urgent care.
8. Openness to criticism and imperfection: QI teams should be transparent about their efforts and open to critiques. "Our QI leaders have tried to welcome criticism, suppress our own defensive reactions, and have made changes to how we collect, analyze or present data based on staff feedback," the clinicians wrote.
9. Ongoing improvement: Successful QI initiatives feature a strategy aimed at ongoing improvement rather than time-limited projects. "Concerted efforts to enable change may be time-limited, but the commitment to monitor and sustain improvement in a core set of performance indicators should be ongoing," the clinicians wrote.
10. Embed QI organizationally: To help ensure success, a primary care practice's leadership team should be heavily invested in QI efforts. The chief of the Toronto-based practice made sure QI was consistently included on the medical staff's meeting agenda and featured in the organization's strategic plan.
Applying quality improvement tips
Although these QI tips were developed at a Canadian-based primary care practice, they are widely applicable to practices in the United States, the lead author of the BMJ Quality and Safety article told HealthLeaders.
"All of the tips are suited to U.S. primary care. I think the payment and measurement context are different, so galvanizing intrinsic motivation and measures that are meaningful to the local practice may be more challenging," said Tara Kiran, MD, MSc, a physician in the Department of Family and Community Medicine at St. Michael's Hospital, Toronto, Canada.
Involving patients in QI efforts is crucial, she said. "This was a turning point for us. Clinicians want to improve the health and lives of our patients—we want to provide them with excellent care. Sometimes though, we aren't aware that what we are doing is not meeting patient needs. Hearing praise, concerns, and potential solutions directly from patients is helpful to motivate care teams to improve."
Opportunities and risks abound as healthcare organizations adopt new digital technologies and seek to manage disruption.
The digital future of healthcare is now.
More than 40 top executives from healthcare organizations across the country attended last week's HealthLeaders Innovation Exchange in Ojai, California, to share success stories and cautionary tales from the frontlines of digital invention and population health initiatives.
1. Clinical decision support adoption
An informal poll of Exchange participants found that 94% of the healthcare organizations present at the event were either actively using or developing computer-based clinical decision support tools.
Diana Rhyne, MHA, executive director of research and innovation at WakeMed Health & Hospitals in Raleigh, North Carolina, said clinical decision support tools are harnessing a wealth of digital data in clinical settings.
"Ultimately, all the tools, tech, and innovations we use in healthcare are embraced for their ability to impact the care we provide to our patients and families. We're in an era now where we have a tremendous amount of data: clinical data, social determinants of health data, evidence-based care guideline data, never ending data! Impactful clinical decision support tools enable clinicians to translate this data into actionable results," Rhyne said.
Clinical decision support has a wide range of applications, she said. "We see these tools across the spectrum in healthcare: from managing a patient's pain while avoiding harmful addictions, to intervening before a patient decompensates in the ICU."
2. 'Re-humanizing healthcare'
Digital technology has the potential to elevate healthcare to a higher plain, said Chris DeRienzo, MD, CMO at Palo Alto, California-based Cardinal Analytx Solutions and an adjunct professor at Stanford University.
"It's incumbent upon us as leaders to ensure our people spend as much of their professional time as possible doing work that brings them joy. And whenever I ask clinicians, 'What brings you professional joy?' the answer is inevitably 'spending time with my patients.' As a result, when we point the incredibly powerful engine of artificial intelligence and machine learning toward solutions that maximize the time clinicians spend with the patients who need them most, we not only help reduce burnout, but also simultaneously and systematically begin re-humanizing healthcare."
3. Leading disruption from the top
In managing disruption, healthcare leaders can learn a valuable lesson from Facebook's acquisition of Instagram, said Neil Carpenter, vice president of strategic planning at Array Advisors.
Facebook CEO Mark Zuckerberg orchestrated the billion-dollar acquisition of Instagram mainly to ensure that Facebook would not be disrupted by the upstart social media platform, which at the time was generating no revenue.
"Today in healthcare, a lot of the disruption has been delegated from the CEO down. In other industries, the CEO owns disruption. That's part of their bread and butter. So, Mark Zuckerberg is out there looking for the next Instagram—how to buy them, how to build them into his business model, and how to avoid becoming obsolete," Carpenter said.
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Photo credit: Pictured above: Chris DeRienzo, MD, CMO at Palo Alto, California-based Cardinal Analytx Solutions and an adjunct professor at Stanford University, makes a point at last week's HealthLeaders Innovation Exchange. (Photo: David Hartig)
Amazon Web Services is focusing on services that are not at the core of healthcare organization operations such as data centers.
The biggest impact that Seattle-based Amazon Web Services makes in healthcare may receive little notice.
AWS is a separate business inside Amazon that focuses on cloud computing. AWS has more than 165 featured services including Amazon Comprehend Medical that are used by healthcare companies.
At this week's HealthLeaders Innovation Exchange, a top AWS executive said the company is primarily focused on providing services to healthcare organizations in areas outside of their core operations.
"For many healthcare organizations, you are doing things that you probably shouldn't be doing that do not help to differentiate you in the market. If you are running a data center in healthcare, a data center is probably not a core part of your business. AWS can do the undifferentiated heavy-lifting in healthcare so our customers can focus on differentiators," said Shez Partovi, MD, senior leader of global business development for healthcare, life sciences, and genomics at AWS.
Partovi gave three examples of operational areas in healthcare where AWS has supported customers:
1. Access: AWS has developed machine learning services that help its customers remove the "friction" in making a medical appointment online. For example, Zocdoc uses Amazon Rekognition to simplify insurance eligibility verification. Patients can hold up an insurance card to an iPhone, which determines health plan coverage and matches the patient to appropriate clinicians.
2. Patient activation: AWS has services that allow companies to stream IoT data on the cloud. For example, digital health companies are using services to help remotely monitor patients with asthma. Every time a patient presses the button on the inhaler, it sends a signal to the cloud.
The technology has three primary benefits: helping to boost medication adherence, alerting clinicians when patients are using their rescue inhaler at an increasing frequency and are at risk of hospital admission, and providing the capability to build personal prediction models for patients. If a patient consents to it, the prediction model is built based on GPS location, with includes features such as air pollution index and temperature that can be used to predict asthma-attack risk.
3. Automation: AWS is working with customers to develop predictive analytics to forecast medical-related events. For example, Beth Israel Deaconess Medical Center is using AWS machine learning services to develop technology that can predict operating room cancellations and no-show rates at medical clinics.
Making a splash
While most of AWS' healthcare team is focused on undifferentiated services, the company also is resolving vexing problems, Partovi said. "About 90% to 95% of what we build is driven by what customers tell us matters. The other 5% to 10% of the time, we invent solutions on our customers' behalf."
For example, a cancer research center approached AWS with a challenge—finding a way to quickly read through patient charts to see who was eligible to participate in clinical trials.
"AWS invented on their behalf," Partovi said.
"We created a service called Amazon Comprehend Medical . It's like when you would read a book in high school and highlight key words. Amazon Comprehend Medical can read medical notes and extract key concepts, entities, and relationships, and it is HIPAA compliant. This means that it can quickly identify protected health information (PHI), such as name, age, and medical record number, and can be used to create applications that securely process, maintain, and transmit PHI. So, it can help providers better determine whether you have a condition, or whether you are taking a medication at a particular dosage, or some other key information. It generates discrete data that can be matched to inclusion or exclusion criteria."
Amazon Comprehend Medical also generated front-page media coverage, he said. "That was a groundbreaking machine learning service. But we didn't do it to be splashy. We did it because a customer came to us and needed to solve a problem."
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Photo credit: Pictured above: Shez Partovi, MD, senior leader of global business development for healthcare, life sciences, and genomics at AWS. (Photo: David Hartig)
