There are a several areas where hospitals can manage ED malpractice risk, including medical condition diagnosis and opioid prescribing.
There are dozens of actions that health systems and hospitals can take to manage malpractice risk in their emergency departments, a new report published today says.
Emergency departments (EDs) are a crucial frontline healthcare setting, with more than 138 million visits to emergency rooms annually. EDs are the fourth most common healthcare setting for malpractice claims, according to Coverys, a medical liability firm that insures 42,000 medical professionals and 800 healthcare organizations.
A Coverys report published today on malpractice claims in EDs is based on an analysis of more than 1,300 medical liability claims from 2014 to 2018. The report features several key data points:
EDs accounted for about 13% of all medical liability claims. Surgery was the top target for medical liability claims, accounting for about 26% of claims.
Failure or delay in making a diagnosis accounted for 56% of ED claims.
Cardiac and vascular illnesses were the most common conditions identified on ED claims, accounting for 23% of the total, followed by infections (18%) and neurological conditions (8%).
More than one-third of ED claims involved the death of a patient.
The top risk management issues in EDs were clinical judgment (44%), clinical systems (10%), and documentation including electronic health records (10%).
The Coverys report provides risk management recommendations for 11 areas of ED operations and concerns:
Given that most ED malpractice claims involved failure or delay in making diagnoses, Coverys' Top 5 risk management recommendations are designed to improve diagnostic accuracy, Ann Burke, RN, director of risk management at the Boston-based company, told HealthLeaders.
1. Care transitions: EDs should commit to enhancing communication handoffs at all transitions of care based on a policy and structure for communication of patient information.
"Committing to improve communication is a first step to improving patient safety. Using standardized handoff processes to ensure crucial information is clearly communicated and transferred during care transitions is essential to safely moving the patient through the ED episode of care," Burke said.
2. Patient evaluation: EDs should ensure that patient evaluation occurs on an ongoing basis during the ED episode of care by requiring documentation of patient status at prescribed intervals, she said. "Concise and timely documentation cannot be understated as a critical communication component in patient safety."
3. Decision support: EDs should implement clinical decision support tools to assist clinicians in the diagnostic process, such as practice guidelines for high-risk presentation, clinical decision applications, and providing access to a dedicated radiologist and pharmacist to assist with diagnosis and treatment, Burke said.
"Because of the nature of the environment—fast paced, limited ability to elicit medical history, and high acuity—in which they work, ED providers should consider using additional resources that can help them arrive at an accurate and timely diagnosis."
4. Team effort: ED clinicians should communicate clearly and efficiently with laboratory and radiology professionals, as well as other relevant healthcare providers, she said. "Communication between diagnostic departments, other providers, and ED providers is an area where patient safety can be improved with the implementation and standardization of communication protocols."
5. Test results: EDs should develop a protocol to manage communication of outstanding test results for the patient, primary care provider, and consultants. The protocol should be hardwired into everyday routines such as customizing an electronic system that supports the protocol and its objectives, Burke said.
"Without a strong system in place, test results that are outstanding when a patient is discharged or transferred from the ED may place the patient at risk. It is important that a follow-up system is in place to ensure patients and providers receive timely notification."
Senior healthcare leaders from health systems and hospital across the country are set to share their technology adoption experiences and success stories.
Automation adoption and tapping the potential of technology to seize patient and clinician engagement opportunities are the dominant themes of next month's HealthLeaders Innovation Exchange in Ojai, California.
The event features four dozen top healthcare executives from health systems and hospitals across the country, including Intermountain Healthcare, OhioHealth, and Sutter Health. Here's a preview of the topics participants will address in roundtable discussions.
Automation
From clinical care, to workflow, to back-office operations, several automated technologies have taken hold in the healthcare sector, including artificial intelligence, predictive analytics, the Internet of Medical Things (IoMT), natural language processing, and robotic process automation.
Innovation Exchange participants are set to discuss a half-dozen automation adoption challenges and success stories:
Innovative approaches to automation as well as business and operational impacts
Processes for health systems in selecting innovation pilots, the role of information technology departments, and achieving scale
Automation partnerships and collaborations with third parties such as other health systems and nontraditional healthcare organizations
Executives who attend the Exchange plan to explore AI and predictive modeling that can help anticipate patient needs associated with social determinants of health, and understand how social determinants of health interact with chronic conditions and impact risk.
In addition, healthcare leaders will discuss how to scale innovation initiatives from pilots and prototypes.
Technological approaches to engagement
Patient engagement is a priority for health systems, not only in guiding patients to choose providers, but also in devising ways to involve patients in their own care. Examples of technology revolutionizing patient engagement include wearable sensor devices, online review platforms such as Google and Facebook, and chronic disease management apps.
Innovation Exchange participants are slated to explore technology solutions that can impact a wide range of engagement activity, including telemedicine, artificial intelligence, predictive modeling, and remote sensing:
Remote monitoring to serve vulnerable populations and address social determinants of health
Technology to manage population health initiatives
Generating and impacting online ratings on review websites such as Leapfrog
Technology that shapes the involvement of patients in their care such as navigating hospital services
AI and predictive analytics to allocate clinical resources and manage negative outcomes such as readmissions
Technology to boost clinician engagement such as monitoring adherence to evidence-based care
Technology that engages patients outside the hospital walls, including telehealth initiatives
Predictive tools to target high utilizers of healthcare services and help manage their care
Exchange participants also plan to discuss methods to elevate patient involvement in care with technology, navigators, educators, and motivational interviewing.
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.
Over a three-year period, NYU Langone Health was able to cut costs while maintaining clinical quality.
A value transformation initiative at NYU Langone Health (NYULH) in New York generated net cost savings estimated at $53.9 million over three years, according to a new medical journal article.
The new journal article, which was published in BMJ Quality & Safety, provides insights and direction for other health systems seeking to boost the value of care, the article authors wrote.
"Overall, we were able to achieve and sustain substantive cost savings at a major academic medical center while maintaining quality of care, thereby increasing the value of care provided. In an era of increasing value consciousness, our program provides a template for effective conduct of similar work at other institutions," they wrote.
The value-based initiative featured 74 projects in four primary areas:
Supply chain management such as surgical trays
Operational efficiency including improvement of discharge processes
Care of outlier patients such as individuals at the end of life
Resource utilization including blood management
The initiative has several key differences compared to value-based efforts at other health systems, the journal article authors wrote. "It integrates the cost-accounting strengths of some initiatives with the clinician-led and front-line-driven agenda of others. It does not consist of a few high-profile, major projects, but rather dozens of smaller ones. Moreover, unlike most other published programs, this initiative was institution-wide, not limited to a particular department."
Value-based initiative results
The value initiative was launched in April 2014, and examination of the effort's impact collected data from more than 160,000 hospitalizations through December 2017. Several positive impacts were generated:
Adjusted variable costs fell 7.7%
Admissions with medical diagnosis related groups (DRGs) were reduced an average of 0.2% per month compared to pre-initiative levels
In comparison to other teaching hospitals, expense per hospitalization improved from 13% above median to 2% above median
Total cost savings were estimated at $59.3 million, with about $10.3 million in savings for medical patients and $49.0 million for surgery patients
Annual intervention costs were about $1.5 million, so net savings were estimated at $53.9 million
Initiative leadership and shared savings incentive
In 2014, NYULH formed a value-based management task force to lead the initiative.
The health system's chief medical officer served as chairman of the task force. Two deputies reported directly to the task force chairman—a project leader with an MBA degree and a clinical leader who was a practicing hospitalist. The deputies' responsibilities included project prioritization and oversight as well as meeting with stakeholders for new projects. The task force leadership also including all hospital-based vice deans and senior vice presidents.
Health system departments that posted costs below projection received shared savings averaging 25%. The level of shared savings was determined based on performance metrics such as length of stay. Shared savings funding was expected to be used for department-specific value improvement programs such as supporting physician salary time that was dedicated to value-based efforts.
Keys to success
According to the journal article, there were eight contributing factors to the value initiative's success:
The effort was launched by the dean and CEO, and it was sponsored by the chief operating officer, which demonstrated institutional commitment
The program was data-driven, including urgency to address unsustainable Medicare losses, robust cost-accounting, and a centralized performance dashboard
To motivate clinicians, performance improvement was compared to other high-quality but lower cost academic medical centers
The focus of the initiative was value rather than cost reduction—every effort accounted for both quality and cost
Most projects had significant information technology elements, and there was vigorous support from the health system's chief information officer and information technology staff
The deputies to the task force chairman were a clinician and an MBA-degree holder, which helped ensure that clinical and business considerations were at play in every project
The initiative's shared savings program boosted alignment between individual departments and the health system
High-quality project managers were "the lifeblood" of the initiative
Emergency medicine pharmacists increase guideline-concordant prescribing at hospitals with both new and established antibiotic stewardship programs.
Employing emergency medicine pharmacists improves empiric antibiotic prescribing for pneumonia and intra-abdominal infections, recent research shows.
Appropriate prescribing of antibiotics is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. Antibiotics also have been linked to negative patient impacts such as Clostridium difficile infections.
The recent research published in the American Journal of Emergency Medicine found that employing emergency medicine pharmacists (EMPs) not only boosted guideline-concordant empiric antibiotic prescribing but also increased the likelihood that appropriate therapy would be ordered after patients were admitted for hospitalization.
The research, which featured 185 patients treated when EMPs were present and 135 patients treated when EMPs were not present, generated several key results:
The overall likelihood of empiric antibiotic prescribing was higher when an EMP was present than when an EMP was not present: 78% vs. 61%.
For community-acquired pneumonia, the rate of guideline-concordant prescribing was 95% when an EMP was present compared to 79% when an EMP was absent.
For community-acquired intra-abdominal infections, the rate of guideline-concordant prescribing was 62% when an EMP was present compared to 44% when an EMP was absent.
More than 80% of patients who received guideline-concordant antibiotics in the emergency room continued to receive appropriate therapy after hospital admission, compared to only 18.8% of admitted patients who received inappropriate therapy in the ER.
The presence of an EMP improved empiric antibiotic prescribing for hospitals with both new and established antimicrobial stewardship programs (ASPs).
"This study shows the importance of coupling ED clinical pharmacist activities with ASP initiatives. Total guideline-concordant prescribing significantly increased over time, with improved prescribing adherence demonstrated in both the early-ASP and established-ASP groups when an EMP was present," the researchers wrote.
EMPs can play a unique role in boosting guideline-concordant prescribing, the researchers found. "EMPs are in an ideal position to encourage appropriate empiric prescribing as they can make real-time recommendations for antibiotic selection or intervene and suggest alternatives when inappropriate antibiotics are ordered."
A healthcare system is pioneering provision of palliative care and supportive services to oncology patients receiving curative treatment.
A new initiative called Supportive Care of Oncology Patients (SCOOP) pathway has helped a health system generate gains in clinical outcomes and cost reductions by improving nurse navigation as well as providing palliative care and supportive services for oncology patients in curative treatment.
Studies have shown positive results from high-quality nurse navigation and the early introduction of supportive care services for advanced cancer patients.
Wilmington, Delaware–based Christiana Care Health System hypothesized that similar gains could be generated at its healthcare organization and it launched SCOOP in November 2016.
The program generated several positive impacts in its first two years, according to a research article published recently in Journal of Clinical Pathways:
Nurse navigator compliance with assigned tasks increased from 94% to 98%
Emergency room visits for targeted patients dropped from 54% to 35%
Hospital admissions for targeted patients dropped from 34% to 22%
Direct cost saving per patient was more than $1,500
"The biggest message is that you can provide a better experience, probably lower costs, and decrease hospital admissions if you take this kind of intensive navigation and supportive care approach to patients who are being treated for cure if their acuity is high enough," says Christopher Koprowski, MD, MBA, associate cancer service line leader at Christiana Care.
Initially, participants in SCOOP were limited to patients with esophagus and lung cancers, colorectal and anal malignancies, and head and neck cancers. The pathway was expanded to include patients with hepatobiliary and pancreatic malignancies as well as brain tumors.
The SCOOP pathway initiative features four interventions: a nurse navigation electronic checklist; mandatory screening of curative patients for suitability to receive supportive and palliative care services; flags in the inpatient EHR when participating patients visit an emergency room, are admitted to a hospital, and are discharged; and an improved educational brochure for patients.
1. Nurse navigation electronic checklist
According to the Journal of Clinical Pathways article, the nurse navigation electronic checklist includes several key features:
The checklist is integrated into Christiana Care's EHR
The checklist is displayed automatically and updated daily as nurse navigators complete checklist tasks
After a nurse navigator fills out required fields, a patient-specific and time-driven set of tasks is generated for the navigators to complete
Tasks stay on the checklist until they have been completed
"Before, the nurse navigators had no daily electronic task list. They were writing things in steno pads; and there was no systematic, constant reminder to them to get these tasks done. So, a lot of the tasks were falling below the radar," Koprowski says.
For example, the electronic checklists include tasks such as trying to ensure that patients attend medical appointments and receive nutrition support.
2. Mandatory screening of patients
A pivotal component of SCOOP was adding palliative care and supportive services staff to Christiana Care's multidisciplinary oncology clinics, which was made possible with newly allocated financial resources, Koprowski says. Before SCOOP was launched, referrals from the clinics for palliative care and supportive services were made on an ad hoc basis.
"Now, supportive care staff review the records; and if the patient appears to have imminent problems, supportive care will see them immediately at a multidisciplinary clinic. Otherwise, supportive care provides patients with contact information to make a non-urgent referral to see them in the supportive and palliative care office," he says.
Palliative care and supportive services provided to patients include dentistry, nutrition, hydration, and psychosocial oncology.
3. Electronic alerts
EHR alerts for emergency room visits and inpatient stays have been helpful to the nurse navigators and their patients, Koprowski says.
"When a patient has visited an emergency room, a nurse navigator can immediately contact the medical or radiation oncology nurses to let them know that the patient may not be in for treatment. They may also let the medical or radiation oncology nurses know that it may be appropriate for the attending physicians to contact the inpatient physicians. Finally, the alerts enable the nurse navigators to communicate with the discharge planning staff in the hospital, so there is a seamless transfer from inpatient to outpatient care," he says.
4. Revised patient brochure
Elements of Christiana Care's new educational brochure for oncology patients include:
A map and directions for how to navigate the healthcare campus
Insights about how multidisciplinary clinic visits are conducted
Care information about radiation, chemotherapy and medications, surgery, palliative care and supportive services, and primary care
Emotional and coping options
Nutrition and well-being
Symptoms and side effects patients should expect
How to make and follow through on appointments
Post-treatment considerations
With SCOOP's success in the treatment of high-acuity oncology patients who are in curative care, the pathway may be extended to Christiana Care's high-acuity cardiology patients, Koprowski says.
"Cardiology already has similar clinical pathways for outpatients. It's quite possible that by enhancing navigation and providing more supportive care resources that they can get the same results we have generated. It could make it less likely that people will slip through the cracks," he says.
Online reviews reveal opportunities to improve patient experience at emergency departments and urgent care centers.
Studying online review platforms such as Yelp can help healthcare organizations understand and improve the patient experience at emergency departments and urgent care centers, new research shows.
In most areas of the country, urgent care centers have become an alternative to emergency rooms for acute medical needs. Both nonprofit healthcare organizations and private companies have opened freestanding urgent care centers in pharmacies, grocery stores, and other retail locations.
Yelp and other online review platforms are a golden opportunity for healthcare organizations to assess patient experience at emergency departments and urgent care centers, according to the new research published in Annals of Emergency Medicine.
"Studying differences in the patient experience between the ED and urgent care centers can provide insight into patients' needs and perceptions of these services. Furthermore, understanding differences in the patient experience may help health systems improve the allocation of, and investment in, alternative acute care settings," the researchers wrote.
Yelp data for emergency departments and urgent care centers
The Annals of Emergency Medicine research examined more than 100,000 Yelp reviews: 16,447 ED reviews and 84,502 urgent care center reviews. Yelp users pick ratings ranging from 1 star for the lowest rating to 5 stars for the highest rating.
The researchers' analysis of Yelp reviews of emergency departments and urgent care centers generated several key data points:
Ratings of urgent care centers were generally higher than ED ratings. More than 60% of ED reviews were 3 stars or fewer, and 60% of urgent care reviews were 4 stars or more.
There were five primary similar themes in 5-star reviews for EDs and urgent care centers—comfort and overall experience, professionalism, clean facilities, pediatric care, and friendly staff interactions.
There were six primary similar themes in 1-star reviews for EDs and urgent care centers—poor communication, telephone or reception experience, excessive wait times, billing or insurance problems, pain management, and diagnostic testing.
Unique themes in 5-star ED reviews included bedside manner, care for family members, and nighttime and weekend care access.
Unique themes in 5-star urgent care center reviews included pharmacy refills and prescriptions.
Unique themes in 1-star ED reviews included overall service and speed of care.
Unique themes in 1-star urgent care center reviews included lack of confidence in care and reception experience.
"Although in general strengths in ED and urgent care center reviews suggest patients perceive better clinical care in EDs and service in urgent care centers, the deficiencies in these reviews suggest [patients] expect both elements from both settings. Lessons learned from patient reviews in these clinical settings may help improve care delivery and the patient experience as the acute care markets emerge, grow, and change," the researchers wrote.
'Improving negative experiences and reinforcing positive ones'
The lead author of the research told HealthLeaders that patients posting Yelp reviews have differing drivers that set apart low and high ratings for EDs and urgent care centers.
"This suggests that people may seek different types of care from the two settings and that the expectations may be different. Additionally, there are components of urgent care centers that approach the patient experience in a much different way as compared to ERs," said Anish Agarwal, MD, MPH, a national clinician scholars fellow in the Department of Emergency Medicine at Penn Medicine in Philadelphia.
Although the researchers did not examine why patients are more likely to post reviews for urgent care centers than for EDs, Agarwal said he believes there are two reasons. "One, there are many more urgent care centers, and, two, a 'better' experience likely leads to a higher likelihood for an individual to post a review," he said.
A crucial lesson learned from the research is that healthcare organizations should pay attention to online reviews, Agarwal said.
"Patients and their families are using online platforms to rate, review, and research healthcare. These reviews are organic and free-form, so they can offer a lot of insights as compared to structured surveys that are randomly sent out. Obviously, these reviews come with selection bias and multiple other forms of bias, but the themes that emerge from them can provide important areas to focus on for both improving negative experiences and reinforcing positive ones."
At North Shore Medical Center in Massachusetts, antibiotics stewardship was the most effective intervention in reducing C. diff infections.
Resource-challenged community hospitals with high levels of Clostridium difficile (C. diff) infections among patients should focus on four contributing factors of the potentially deadly illness, recent research shows.
C. diff is the most common hospital-acquired infection at U.S. hospitals, the Centers for Disease Control and Prevention reported in 2015. Patients infected with C. diff shed millions of clostridial spores with every bowel movement, and the spores have been shown to survive for as long as five months on hospital surfaces.
In the hospital setting, there are multiple contributing factors that can drive C. diff infections. The lead author of the recent research, which was published in The Joint Commission Journal on Quality and Patient Safety, told HealthLeaders the main drivers of C. diff infections are likely to vary from hospital to hospital.
"There are many contributing factors, and they may carry different weights at different hospitals," said Barbara Lambl, MD, MPH, an infectious disease specialist and the hospital epidemiologist at North Shore Medical Center in Salem, Massachusetts. The medical center, which is an affiliate of Boston-based Partners HealthCare, features two community hospitals.
Systematic interventions
Starting in November 2013, North Shore Medical Center launched a systematic, four-pronged effort to reduce C. diff infections, according to the journal article:
1. Environmental services: Housekeeping efforts included cleaning of high-touch surfaces as well as terminal cleaning with bleach and ultraviolet disinfection.
2. Infection prevention: Several measures were introduced to increase staff hand washing with soap and water after caring for C. diff patients, including colorful signs posted on hand sanitizers outside patient rooms and anonymous observers to monitor hygiene compliance. When staff members raised concern that there were not enough sinks for hand washing, nine sinks were installed on five nursing units in two hospitals.
3. Antibiotic stewardship: In 2014, the medical center launched an effort to reduce use of clindamycin and fluoroquinolones. Studies have shown that clindamycin increases C. diff infection rates 20-fold, and fluoroquinolones increase risk 6-fold. A key component of the antibiotic stewardship initiative was an electronic decision support tool that encouraged clinicians to use alternative agents as substitutes for clindamycin and fluoroquinolones.
4. Emergency department processes: The ED staff developed an algorithm to identify and isolate patients with diarrhea or a recent C. diff infection. Inpatient nursing units were notified of patients who had been placed in isolation. Infection prevention practices in the ED were increased such as "SWAT teams" that properly cleaned and disinfected emergency room bays.
Interventions by the numbers
North Shore Medical Center's C. diff reduction efforts generated significant results over a four-year period:
Hospital-acquired C. diff infections fell 55.5%, from 12.2 cases per 10,000 patient-days to 5.4 cases
Antibiotics stewardship had the biggest impact, accounting for a 20.6% reduction in hospital-acquired C. diff infections
Use of high-risk antibiotics fell 88.1%
Infection prevention measures were the second-most effective intervention, accounting for a 13.0% reduction in hospital-acquired C. diff
Appropriate use of antibiotics
To craft the electronic decision support tool for antibiotics stewardship, North Shore Medical Center drew upon three of David Bates' "ten commandments," Lambl told HealthLeaders. "The decision support was speedy. It was timely. And it offered alternative antibiotics."
Staff pharmacists played a crucial role in securing physician compliance with antibiotics stewardship, she said.
"Getting the support of our pharmacist leaders and pharmacists was probably the most important factor in allaying clinician discomfort or unease about switching antibiotics. They would speak with the doctors and reassure anxious clinicians. Without the pharmacists, the whole thing might have failed. Electronic decision support can only get you so far. Having face-to-face interactions is critical."
Improving C. diff diagnostics to target only actively infected patients was also essential, Lambl said. "There's a difference between being colonized with a germ and being sick with the germ. People can be colonized with viruses and bacteria but not get sick. Whereas, other people who have the same germ will get very sick. That's the way it is with C. diff."
Testing needs to be able to distinguish between colonization and active infection, she said. "We believe that people who are just colonized are not transmitting infection to other patients. They certainly do not transmit at the same rate as people who are shedding millions and millions of spores with each diarrheal bowel movement."
Intermountain Healthcare has adopted a four-part strategy to establishing time and distance between people in crisis and firearms.
Intermountain Healthcare is tackling a daunting suicide prevention challenge—limiting access to guns for people in crisis.
In 2017, suicide was the 10th leading cause of death in the United States, with more than 47,000 lives claimed, according to the Centers for Disease Control and Prevention (CDC). In that year, there were more than twice as many suicides than homicides, the CDC found.
Visits to healthcare providers are a significant suicide prevention opportunity. One study found that 38% of people who attempted suicide made some type of healthcare visit in the week before the attempt.
To rise to the challenge and seize opportunity, Intermountain adopted the Zero Suicide initiative in June 2018.
"The Zero Suicide program is both a commitment to suicide prevention—acknowledging that these deaths are preventable—and a recognition that all of us in healthcare have a role to play, whether we are clinicians, administrators, or facility staff," says Morissa Henn, DPH, MPH, community health program director at the Salt Lake City, Utah-based health system.
Intermountain has made gun safety the centerpiece of the health system's approach to the Zero Suicide initiative, she says. "At Intermountain, we are proud to be developing our own version of Zero Suicide. Here in Utah, the strategy we developed recognizes some of the unique risks and protective factors in our communities. One of the key elements is understanding how important access to firearms is as a driver of Utah's high suicide rate."
Utah is an outlier for suicides involving firearms, Henn says, noting that 85% of all gun-related deaths are suicides. In the United States as a whole, about two-thirds of gun deaths are suicides.
"Firearms are widely accessible in Utah. Half of homes here have at least one firearm. Gun ownership ranges from 35% of homes in Salt Lake City to about 70% of homes in more rural areas," Henn says.
There are four primary components of Intermountain's approach to promoting gun safety: partnering with gun owners, holding structured conversations with patients, waging a social norms campaign, and offering gun-locking devices to patients.
1. Working with gun owners
"We focus explicitly on issues related to firearms access, and we are doing so in deep collaboration with Utah gun owners and gun advocates. We know that if we are going to move the dial on this problem here in Utah, the issues of access to firearms and suicide are inseparable," Henn says.
For example, Intermountain has developed public service announcements targeted at gun owners, she says. "These announcements make it clear that we are not trying to ban guns, which are part of our cultural heritage and recreational identity in Utah."
2. Structured patient conversations
In coordination with the Harvard School of Public Health, Intermountain has developed a course for healthcare professionals called Counseling on Access to Lethal Means (CALM). The one-hour course trains medical staff to have effective, sensitive, evidence-based conversations with patients about reducing access to lethal means for high-risk people.
The key elements of CALM include training about how to raise the topic of suicide prevention with patients, holding conversations about gun safety, and follow-up efforts, Henn says.
"CALM helps healthcare professionals to understand the rationale for having these conversations, provides some specific language to practice using, and makes these conversations part of a regular dialogue between healthcare providers and patients in a way that is prevention-oriented. We don't want to wait until people are in crisis. CALM develops plans to help patients and healthcare professionals navigate the dark times safely," she says.
3. Social norms campaign
Intermountain is developing a social norms campaign focused on social media and traditional media such as radio and billboards. The campaign will include encouraging help-seeking behaviors for people in crisis and promoting positive messages of hope and recovery.
"In consultation with many community stakeholders, we are in the process of developing what we hope will be a first-of-its-kind major, comprehensive, and evidence-based social norms campaign modeled on a successful underage drinking prevention campaign in Utah called Parents Empowered. … We also want to encourage a means-reduction approach—ensuring that there is always time and distance between someone in crisis and a lethal method such as firearms," Henn says.
4. Providing gun locks
To improve gun safety in people's homes, Intermountain plans to offer gun locks to patients who may be a high-risk for suicide imminently or in the future.
"As the largest provider of health services in Utah, we are looking at how Intermountain can distribute gun locks in our clinics and our hospitals. Oftentimes, gun locks are an important way to open the conversation and to encourage safe-storage behavior," she says.
Measuring progress
Intermountain has set four goals to help gauge the impact of the health system's gun safety efforts and other suicide prevention initiatives:
In conjunction with state-based efforts, Intermountain wants to achieve a 10% reduction in suicide rates among patients and in the health system's overall geographic region by the end of 2021.
Intermountain wants to get 5% of key caregivers—healthcare providers who interact with high-risk patients—to get CALM training by the end of this year.
After at-risk patients receive care at an Intermountain facility, the health system wants at least 40% of them to schedule and attend a behavioral health appointment within seven days.
The last goal is process-oriented such as identifying patient resources and triggers for suicidal thoughts, Henn says. "We want to develop brief, evidence-based interventions for safety planning—a collaboratively developed plan for someone who is identified as high-risk."
An oncologist who pioneered immunotherapy cancer treatments at Johns Hopkins Medicine is now pursuing novel cancer care at Baylor Scott & White in Texas.
Ronan Kelly, MD, MBA, is right where he wants to be—on the cutting edge of cancer care.
Kelly recently joined Baylor Scott & White (BS&W) as the chief of oncology for the Dallas-based health system's North Texas division and director of oncology for the Charles A. Sammons Cancer Center.
He came to BS&W from Baltimore-based Johns Hopkins Medicine, where Kelly served as director of the Gastroesophageal Cancer Therapeutics Program and medical director of Global Oncology Johns Hopkins International.
"I was there at the ground level when we were determining why patients were responding to PD-1 inhibitors, and why some patients whose tumors possessed more mutations were responding better than patients who had less mutations," he says.
HealthLeaders recently spoke with Kelly to discuss his new role at BS&W and the advances and challenges in cancer care. Following is a lightly edited transcript of that conversation.
HL: Why did you choose oncology as your specialty?
No. 1, I felt I had the right makeup as a doctor to be able to help cancer patients, not just in the short term but over a long period of time and to act as their primary physician for many months or years. No. 2, I was interested in the huge scientific and technological breakthroughs that I knew were going to emerge over the lifetime of my career as a cancer doctor.
When I was coming out of medical school in the late 1990s, the Human Genome Project was coming to a close, and I knew we had reached a new era in cancer treatment because the Human Genome Project was unraveling who we are as human beings. By unraveling the human genome, we can understand what normal DNA should look like; and, as a result of that, we can identify where the mutations are developing that cause people to have cancer.
The first whole genome sequencing cost $2.7 billion in 2003. In 2006, the cost to sequence a human genome dropped to about $300,000. In 2016, we were down to $1,000, which is an example of the huge technological advances that we have made in the past 15 to 20 years that today are improving our understanding of why patients develop cancer and why they develop resistance to some of the medications we prescribe. I wanted to be involved right from the start of this new era of cutting edge human science, where we can develop new molecular and immunotherapeutics to help cancer patients in a much more meaningful way than ever before.
HL: Can you provide examples of novel cancer treatments that you hope to pursue at BS&W?
BS&W's Baylor University Medical Center is one of the largest cancer centers in the United States. If you look across the whole family of Baylor Scott & White cancer hospitals, we have 16 Charles A. Sammons Cancer Centers located throughout Texas. So, I am looking at harnessing the power of population medicine by inviting the thousands of men and women who are receiving FDA-approved immunotherapy drugs every day in our clinics to help us improve our understanding of what is happening in their immune cells throughout the duration of their journey with cancer. By utilizing biosamples from real-world patients, we will gain a greater understanding of mechanisms of resistance so that more patients can benefit in the future.
My hope for Baylor Scott & White oncology is that we can position ourselves not just as an immunotherapy center of excellence in Dallas but also the whole Baylor Scott & White health system will become an immunotherapy system of excellence. We want to learn from every patient who comes in for treatment. We will be taking samples of blood and other biospecimens from patients during their whole journey with cancer to try to understand at every step of the way what's happening to their immune system. We want to understand why some people stop responding and why some people have a phenomenal response rate.
The other thing we are looking to do is to continue to grow our immunotherapy clinical trial portfolios. We have a huge volume of novel and exciting immuno-oncology trials here at the Baylor University Medical Center. We have some of the most novel cellular therapy trials in the country. We have numerous CAR T-cell, T cell receptor gene therapies, bi-specific T-cell engager, and Natural Killer cell studies. Some of these trials are first in humans and not available anywhere else in the world. By utilizing our good manufacturing practice (GMP) laboratory, which is located at the Baylor University Medical Center campus, we can take blood from a patient, isolate the strongest tumor fighting immune cells, and genetically alter those cells prior to growing them in huge numbers in our lab. Then we give the cells back to the patient as an infusion of their own "supercharged" immune cells in an attempt to overwhelm a tumor.
HL: Based on the advances in cancer care over the past 15 years, what kind of advances do you expect over the next 15 years?
Every person who develops cancer has within them the ability to control cancer. We have an immune system that should be programmed to kill cancer cells. However, cancer has a series of defensive mechanisms that can protect itself from immunological attack. Now, most of the emphasis in cancer research is turning on the patient's inherent cancer-fighting ability by overcoming a tumor's ability to resist immunological attack.
We have seen incredible advances in the past five to 10 years with the PD-1 inhibitors; but now, we have a whole new generation of immunotherapies emerging from cellular therapies or so called “living drugs” to new checkpoint inhibitor combinations. We need to understand how to personalize immunotherapy so that every patient can benefit. Our ambition is to turn cancer into a chronic disease, it's going to be based on turning on the patient's immune system to wage a war between the bad cells and the good cells at the microscopic level.
HL: What is the biggest barrier in cancer care and how can it be overcome?
On a macro level, the biggest challenge now is the escalating cost of cancer care. The cost of cancer care is increasing at a faster rate than many other areas in medicine.
One of the most important things that we have to do as doctors is to become involved in national organizations that are tackling this challenge. I am involved with several task forces at the American Society of Clinical Oncology that are looking at how we can improve quality of care and bend the cost curve. I'm also involved in the International Association for the Study of Lung Cancer, where I chair the quality and value task force to make sure that we can continue to improve the quality of care given to all lung cancer patients in the world while also improving the value and the cost effectiveness of our care.
There's only so much that individual doctors can do, but we can come together in large organizations like ASCO to work with government to ensure that we can continue to not only help every patient who gets cancer but also do it in the most cost-effective manner for our country.
The impact of medical errors on patients and families can be multi-dimensional and prolonged.
For patients, the physical, psychological, and financial impact of medical errors can last long after an adverse event.
In 1999, the Institute of Medicine published "To Err Is Human: Building a Safer Health System," which found that as many as 98,000 Americans were dying annually because of medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which would make medical errors the country's third-leading cause of death.
To gauge the long-term impact of medical errors and how healthcare providers can mitigate the harm, HealthLeaders recently spoke with Sigall Bell, MD, director of patient safety and quality initiatives at the Institute for Professionalism and Ethical Practice in Boston. Bell is also director of patient safety and discovery, OpenNotes, at Beth Israel Deaconess Medical Center in Boston. Following is a lightly edited transcript of that conversation.
HL: What are the primary considerations of long-term emotional harm?
Bell: Mounting data suggest that the impact of medical errors on patients and families can be multi-dimensional and prolonged. Patients and families describe physical, financial, emotional, psychological, and socio-behavioral impacts. In a study led by Madelene Ottosen, such impacts were found to last 10 years or longer in some cases.
Emotional harm is gaining accelerated attention in healthcare. It is a critical consideration because unlike the physical injury from medical error and adverse events, it can be much harder to see, and it may further unfold long after patients and families leave the healthcare setting. Patients and families may suffer profoundly from feelings of betrayal, sadness or depression, fear, anxiety or post-traumatic stress disorder, self-blame about the error, and other emotions related to the event.
HL: What are the essential elements of effective communication with a patient and family after a medical error?
Bell: To date, principles of effective communication after medical errors include acknowledging the error, discussing implications for the patient's health, a sincere apology, plans to prevent recurrences, and discussion of compensation when appropriate. Because some of this information may not be known at the time of the first conversation, it is important to remember that communication after harmful events is a process, not an isolated event.
Disclosure guidelines often emphasize what to say, or at least what topics to cover. It is equally important to think about how to communicate, focusing on genuine empathy, compassion, body language, and making space for emotion. Communication is a two-way street. Although healthcare professionals understandably focus on what they should say, it is crucial to also emphasize listening—making sure that patients feel heard.
HL: What are the most promising ways to support a patient and family after a medical error?
Bell: The growth of Communication and Resolution Programs (CRPs) nationwide offers a promising way to support patients and families after medical errors. CRPs are principled, comprehensive, and systematic approaches to responding to harmful events that help to support all involved stakeholders including patients, families, and clinicians.
In addition to open, honest, and timely communication, CRPs also address financial compensation in appropriate cases, peer support, and improving patient safety as a core mission. This is critical because robust organizational learning and safety improvements are likely limited in a "deny and defend" culture that does not adopt transparent communication.
Optimizing organizational responses to adverse events and medical errors can be challenging. CRPs provide a thoughtful structure, disciplined expectations related to transparency, and coordination of various stakeholders including clinicians, insurers, and risk managers. This helps keep everyone on track and coordinated on the primary goal of supporting patients and families. Further research about the experiences of patients and families over time is needed to guide long-term support after medical error.
HL: What are the most promising ways to address long-term emotional harm?
Bell: We are just beginning to understand the nature and impact of long-term emotional harm and far more work is needed to develop and test best practices to better support patients and families, and ideally prevent such events. As a first step, avoiding factors that can exacerbate emotional harm, such as organizational secrecy, silence, or hidden information is key.
We need to start from the beginning, rethinking taxonomy to define terms such as "harm" and "resolution" in ways that make sense and matter to patients and families. We should also expand the definition of harm to include the many dimensions patients and families experience, such as physical, financial, emotional, psychological, and socio-behavioral effects. Then we can modify existing safety tools to measure, track, and work toward more comprehensive harm prevention. We should focus clinician training on communication and relational skills that respectfully address emotion.
Finally, we need to also extend the timeline with which we consider harm and healing well beyond the event, longitudinally over years. This will have important implications for communication practices and accountability over longer arcs. Most importantly, it will help us better understand how to more fully help patients and families who are harmed by medical care.
