In new survey, 68% of clinicians reported frequent incidents of catheter dislodgement.
Dislodgement of venous access devices such as catheters is widespread and underreported, a survey of 1,500 clinicians shows.
There are several negative impacts from dislodgement of peripheral and central catheters including interrupted treatment, supply waste with catheter replacement, phlebitis, and infection.
Dislodgement is a significant source of wasteful spending at health systems and hospitals, the author of the survey, Nancy Moureau, RN, PhD, of Hartwell Georgia-based PICC Excellence Inc., told HealthLeaders last week.
"Accidental dislodgement may be a much bigger problem than central line associated blood stream infections. It contributes to the increasing cost of healthcare. When we look at the estimates of dislodged catheters, there are more than five million incidents. If you put dollars and cents to that, it's more than a billion dollars that is lost every year," she said.
The survey found high rates of catheter dislodgement.
68% of clinicians surveyed said accidental dislodgement occurred often, daily, or multiple times daily
The top three reasons for dislodgement were confused patient (80%), patients removing catheters (74%), and loose IV catheter tape or securement (65%)
Audits essential step
Auditing incidences of catheter dislodgement and other vascular access device failures is crucial to managing care, Moureau said.
"With value-based purchasing and pay-for-performance, everyone is on alert to reduce complications with these devices whether they are peripheral or central. By auditing complications—specifically dislodgement—we can identify causes and incidents. Then you can look to the solutions."
The electronic medical record should account for discontinuation of vascular access devices for a patient including dislodgement, Moureau said.
"The EMR should have appropriate choices that include dislodgement and whether it was associated with securement, the dressing, or a patient dislodgement or a staff dislodgement. Looking at the reasons helps us to reach what the solutions may be."
Health systems and hospitals also should encourage reporting of catheter dislodgements, she said.
"Hospitals can stress compliance with documentation and work on electronic medical record documentation in order to provide clear choices that are consistent with the reasons for catheter failure with dislodgement. Making a more accurate notation is one of the best ways hospitals can move forward with managing dislodgement."
Auditing is foundational to improving vascular access device care, Moureau said. "Audit can help you achieve two key results: increasing education and helping to recognize where there are safety issues."
Shared decision-making about health conditions is linked to lower likelihood of patient legal action.
Shared decision-making can significantly lower the probability that patients will file lawsuits and complaints, recent research indicates.
Multiple benefits have been associated with shared decision-making such as facilitating patient-centered care and managing overutilization of lab tests as informed patients forego invasive exams.
Shared decision-making provides clinicians with a measure of legal relief, the research team wrote in the Annals of Emergency Medicine. "Although intent as reported on a survey does not always predict behavior, our results suggest that the use of shared decision-making confers medicolegal protection in the event of an adverse outcome."
The researchers used a Web-based research recruitment platform to enlist 800 study participants. The participants were surveyed after completing decision-making vignettes for an appendicitis scenario.
Study participants who engaged in brief or thorough shared decision-making were 80% less likely to want a lawyer than participants who did not engage in shared decision-making.
"Participants exposed to either level of shared decision-making reported higher trust, rated their physicians more highly, and were less likely to fault their physicians for the adverse outcome compared with those exposed to the no shared decision-making vignette," the researchers wrote.
There are three primary barriers to shared decision-making, the lead author of the research, Elizabeth Schoenfeld, MD, MS, assistant professor, Department of Emergency Medicine at UMass Medical School-Baystate, and adjunct faculty at Tufts University School of Medicine, told HealthLeaders recently.
1. Finding the time
"Clinicians feel that shared decision-making takes up too much time," Schoenfeld said.
It takes organizational commitment to include patient preferences in decision-making, she said.
"We can't just create work-arounds, like sending patients decision aids in the mail, or having a non-clinician start the shared decision-making process. We have to actually commit to giving clinicians time to have these conversations. Clinicians, for their part, can get better at having these conversations efficiently, but a conversation will always take longer than a directive," Schoenfeld said.
2. Weighing options
Clinicians often feel shared decision-making is inappropriate because the options are not equally advisable, she said.
"The clinician thinks that option A is probably better for the patient than option B, and therefore doesn't want to discuss the options. The problem with this is that many of our 'medically reasonable' decisions have consequences to patients that we have either not considered or have not given sufficient weight."
Clinicians need to commit to shared decision-making even when they think one option makes more sense, Schoenfeld said. "We need to remember that decisions that seem straightforward to us may be less so when the patient's preferences are considered."
3. Encouraging patient participation
Many clinicians assume that some of their patients do not want to be involved in shared decision-making, but patients want to be involved in decisions when they understand the consequences, she said.
"This means that clinicians should err on the side of thoroughly explaining options and consequences before they seek patient feedback. It also probably reflects that we could all be better at communicating medical decision-making."
The crisis declaration includes a call for three interventions to help physicians and their employers address burnout.
The Massachusetts Medical Society and three other Bay State healthcare organizations have declared physician burnout a public health crisis.
Recent research indicates that nearly half of physicians 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.
"We need our healthcare institutions to recognize burnout at the highest level, and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us," Alain Chaoui, MD, president of the Massachusetts Medical Society and a practicing family physician, said in a prepared statement.
In a report released today, the medical society calls for urgent action in tandem with the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, and the Massachusetts Health and Hospital Association.
In addition to alarmingly high physician burnout rates, the report lists several dire consequences associated with the phenomenon.
Burnout reduces the work effort of physicians about 1%, which is equivalent to losing the graduates of seven medical schools each year
Burnout-related departures from the medical profession are worsening the country's physician shortage, which is estimated to reach 120,000 by 2030
The Massachusetts report's call to action includes three interventions to reduce physician burnout.
1. Addressing mental health
Efforts should be initiated immediately to stop stigmatizing physicians with burnout, the report says.
"Physicians face stigma and professional obstacles to seeking appropriate care and treatment for burnout and related mental health concerns. Physician institutions — including physician associations, hospitals, and licensing bodies — should take deliberate steps to facilitate appropriate treatment and support without stigma or unnecessary constraints on physicians' ability to practice."
In addition, statewide physician health programs are needed to help encourage physicians to seek help for symptoms of burnout, the report says.
2. Improving electronic health records
in a recent survey, EHRs were the top "pain point" at physician practices.
The report makes four recommendations to ease the EHR burden on physicians.
Involve physicians in efforts to develop user-friendly EHR technology
Allow software developers to craft apps for certified EHR systems to boost functionality and usability
Establish application programming interfaces that enable third parties to develop apps for EHRs
Develop artificial intelligence capabilities such as analyzing physician narratives and clinical documentation
3. Appointing chief wellness officers
Research shows effective leadership can have a significant impact on physician burnout. The report calls on health systems and hospitals to have chief wellness officers with five primary responsibilities.
Assess the organization's levels and extent of burnout
Establish quality improvement goals and processes as well as report findings about key areas such as wellness and physician satisfaction
Report findings, trends, and strategies to C-suite leadership and boards of directors as a dashboard metric
Develop technological and staffing approaches to easing physician work and administrative burden such as scribes and EHR improvements
Propagate successful approaches to curbing physician burnout
Skeptical perspective
While there is widespread concern in the medical community over physician burnout, alarm over the condition is not unanimous.
In September, a JAMAeditorial claimed there is insufficient data about physician burnout to guide an effective response to the phenomenon.
"The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome. The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic," the editorial says.
Focusing on physician burnout, which is a relatively new diagnosis, could be dangerously misguided, a co-author of the editorial, Thomas Schwenk, MD, professor of family medicine and dean of the school of medicine at the University of Nevada in Reno, told HealthLeaders in September.
"What is more important to note is the high level of depression as a criterion-based diagnosis, with a more clear understanding of pathophysiology and consequences including student, resident, and physician suicide. This would be a more worthy area of focus. It is possible that the use of the term 'burnout' has increased as a sort of more acceptable substitute for a diagnosis that still carries considerable stigma, namely depression," he said.
The University of Pennsylvania Health System reduced hospital readmissions in one year by joining forces with a payer and using value-based approaches.
A relationship between the University of Pennsylvania Health System (UPHS) and Independence Blue Cross has generated a remarkable reduction in hospital readmissions.
For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital’s readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.
After the first year of a five-year contract with Philadelphia-based Independence, UPHS achieved a 25% reduction in hospital readmissions. Hospitals that intervene to reduce readmissions typically achieve 1% reductions.
The new contract took effect July 1, 2017.
Patrick Brennan, MD, chief medical officer and senior vice president of UPHS, says the health system expects further readmission reductions this year and into the future.
"We have already achieved a dramatic reduction through our relationship with Independence, and we can expand on that. In the current fiscal year, we are improving on what we did last year. There are aspects of our work that will be refined and become second nature over time," he says.
Three value-based and innovative approaches are largely responsible for the readmission reductions at UPHS.
1. Embracing value-based partnership
Data sharing between UPHS and Independence has been essential to reduce readmissions and redesign care, Brennan said.
"We have a data exchange with them. It was born out of earlier iterations of their pay-for-value program. We weren't getting information in anywhere near real-time—we really couldn’t manage. For example, we would be held accountable for readmissions and go through an entire year and into the next fiscal year without a sense of our performance," he says.
The five-year contract with Independence has a trio of value-based programs.
The readmissions program, which puts UPHS at financial risk for 30-day readmissions
Reducing the total cost of care for the health system's attributed population, such as establishing preferred provider relationships with skilled nursing facilities
Expanding episodes of care to about a dozen bundles, which include sepsis, hysterectomy, hip and knee replacement, heart failure, and back surgery
UPHS and Independence have invested considerable time and effort to build a mutually beneficial relationship, Brennan says. "This partnership did not happen overnight—it's been developing over years. A mutual trust has developed between the organizations. The fact that we are able to share information has been the foundation."
The Independence contract has prompted UPHS to improve clinical care broadly, he says. For example, patients at high risk for readmission now receive a call from a scheduler who assists in arranging follow-up outpatient appointments.
"This contract galvanized our interest in redesigning care. The trigger was the readmission program; but as we got deeper into the contract, we realized we were going to have to redesign our whole process of care. We could not have done that without the information systems we have enterprise-wide. All of our practices and all of our hospitals are on the same information system," Brennan says.
2. Upgrading information systems
UPHS has installed readmission scoring systems in the electronic health record that clinicians can access. "Every discharge gets scored, and we can see who is at risk," Brennan says.
Risk stratification allows UPHS clinicians to focus resources on patients who are at highest risk of readmission. Patients classified at high risk of readmission return to the hospital 16% of the time. Patients classified at low risk of readmission return to the hospital less than 1% of the time.
Redesigning care has necessitated different behaviors among physicians, nurses, and social workers, which has prompted the health system to leverage technology to monitor new metrics, he says.
"We are working hand-in-glove with our informatics folks to enable us to measure our performance. The beauty of the changes we have made to our information system is we can tell how often people are using order sets and we can tell whether the after-visit summary and the discharge plan are fully complete at the time of discharge," Brennan says.
UPHS is planning to roll out more information system upgrades that will help drive down readmissions.
"We're also moving toward the adoption of other systems that will give us predictive information about the best services that would be best-suited for patients at discharge. Other systems will give us insight into the patient records when they are at other facilities. We really want to know how patients who have left us are performing," Brennan said.
3. Avoiding seven-day readmissions
UPHS has focused on reducing readmission seven days after discharge.
"We think 30% to 40% of our readmissions occur within seven days—that has been a consistent number over the past 10 years," Brennan says.
Avoiding readmissions within seven days of discharge has become an organizational imperative at UPHS.
"Seven days—we really own that. If we can't keep someone at the next level of care for seven days, something happened in our processes. That gets back to what we call system of care design and how we are getting patients ready for discharge and providing information to the next level of care," he says.
A pair of work groups is focused on readmissions within seven days.
One work group accurately identifies patient diagnosis at time of admission and adjusts the diagnosis through the course of the hospitalization to ensure that care teams have accurate information on patient status. For example, a patient might be admitted with a diagnosis of stroke but leave with a diagnosis of seizure disorder.
The other work group is focused on discharge—establishing a discharge work plan that includes a readiness assessment for discharge, the risk score for readmission, and tools that provide the patient with an after-visit summary.
UPHS has taken a proactive approach to addressing shortcomings that lead to readmissions within seven days, Brennan says.
"For patients who have seven-day readmissions, they are patients with acute issues that aren't being addressed in a timely fashion, or patients who show up somewhere for follow-up care and there is inadequate information available to the clinician," he says.
Physicians who do not counsel patients about lifestyle factors that impact health are missing an opportunity.
A longtime advocate of lifestyle medicine is calling on his fellow physicians to step up efforts to counsel patients about the benefits of healthier lifestyles such as good nutrition and smoking cessation.
A mounting body of evidence shows lifestyle factors are linked to serious health conditions such as obesity causing more than a dozen forms cancer and cigarettes' link to multiple diseases including cardiovascular disease, lung cancer, and stroke.
In an article published this month in The American Journal of Medicine, James Rippe, MD, founder and director of the Rippe Lifestyle Institute, says more widespread adoption of lifestyle medicine is needed to maximize clinical care and financial benefits.
"Employing the principles of lifestyle medicine in the daily practice of medicine represents a substantial opportunity to enhance the value equation in medicine by improving outcomes for our patients and simultaneously controlling costs," wrote Rippe, who serves as editor-in-chief of the American Journal of Lifestyle Medicine.
Rippe cited data from the Nurses' Health Study to demonstrate the effectiveness of lifestyle medicine. The study found that more than 80% of heart disease and more than 91% of diabetes in women could be averted with attention to several lifestyle factors such as healthy body weight, physical activity, and avoiding tobacco use.
Despite indications of lifestyle medicine's potential, many physicians have not embraced it, Rippe wrote. "Unfortunately, less than 40% of physicians routinely counsel their patients on lifestyle issues. This represents a squandered opportunity, because more than 70% of adults see a primary care physician on at least an annual basis."
Getting past barriers
Time is the biggest obstacle blocking physicians from discussing lifestyle factors with their patients, Rippe told HealthLeaders last week.
"The first barrier to overcome is to make sure that these topics are at least talked about to some degree despite the lack of time. If you don't talk about these topics, the message that goes out is that the physician—who is an authority figure to some degree—doesn't care about them," he said.
To overcome the lack of time, physicians should have the ability to alert patients about lifestyle factors then make referrals for further counseling with another clinician such as a nurse practitioner, Rippe said. "The clinician can use the authority of the white coat but not have to take the time to provide the counseling."
There also is a gap in medical education that needs to be filled, he said.
"Physicians tend to get focused on their education. I went to Harvard Medical School many years ago, and we didn't have a single lecture on nutrition or physical activity. Many physicians focus so much of their effort on not missing a disease state that they don't see the enormous body of evidence that daily habits and practices probably drives more disease than anything else."
Lifestyle medicine should be included in clinician training, Rippe said.
"Even though there is a mantra about practicing evidence-based medicine, there is an enormous field of evidence-based medicine related to nutrition and other habits that physicians ignore. It's partly because physicians are not trained to see lifestyle factors as key drivers of either good health or bad health."
Easing physician burnout
Clinicians can benefit from applying lifestyle medicine to their own lives, Rippe told Healthleaders. "Physicians are human beings; so, all of the lifestyle medicine we talk about for our patients apply equally well to physicians."
Adopting healthy habits can help avoid physician burnout, he said. "Physicians should be using all of the principles of lifestyle medicine to enhance their own health—both physical and mental. A lot of lifestyle factors like physical activity are potent stress reducers."
Clinicians can benefit both professionally and personally from healthy habits, Rippe said.
"Research has shown about 50% of physicians are showing signs of burnout. We need to get physicians to understand that the same things they talk to their patients about will make their practices more enjoyable and should be applied to their own lives."
Pharmaceutical company marketing to healthcare professionals accounted for the largest portion of spending, set at $20.3 billion in 2016.
Spending on healthcare industry marketing has increased sharply over the past two decades, rising from $17.7 billion in 1997 to $29.9 billion in 2016, research published this week shows.
In healthcare, marketing often raises ethical and professional concerns such as "detailing visits" by company marketing representatives to physician offices that can include gifts for doctors and staff.
Growth in spending on advertising mirrors expansion of medical services and therapies, the researchers wrote.
"Increased medical marketing reflects a convergence of scientific, economic, legal, and social forces. As more drugs and devices and medical advances convert once-fatal diseases into chronic illnesses and with renewed interest in prevention for some diseases, the marketing of tests, treatments, and services has expanded," they wrote.
The research published in Journal of the American Medical Association has several key findings.
The steepest increase in marketing expenditures was in direct-to-consumer advertising, which increased from $2.1 billion in 1997 to $9.6 billion in 2016.
Drug maker marketing to healthcare professionals accounted for the largest portion of spending, increasing from $15.6 billion in 1997 to $20.3 billion in 2016. The expenditures included $13.5 billion for free samples, $5.6 billion for prescriber detailing visits, and $979 million for direct payments to physicians such as speaking fees and meals.
Advertising of health services rose from $542 million in 1997 to $2.89 billion in 2016. Health systems and hospitals accounted for the highest portion of direct-to-consumer health services advertising, with direct-to-consumer advertising expenditures for cancer centers rising from $18 million to $200 million.
"Although spending on DTC advertising for prescription drugs and health services increased the fastest, spending on pharmaceutical marketing to professionals consistently accounted for most promotional spending, despite efforts to limit industry entanglements," the researchers wrote.
Curbing unscrupulous marketing
The research article's supplement includes a list of recommendations to limit unscrupulous marketing techniques in the healthcare sector. For health services, three recommendations are proposed.
Replicate the Food and Drug Administration's Bad Ad program to encourage clinicians and consumers to report misleading health service ads to the Federal Trade Commission and state attorneys general
Have the Joint Commission conduct proactive review of hospital ads
Encourage health system and hospital marketing departments to take "truth in advertising" pledges and mandate submission of ads to a third-party reviewer for independent assessment prior to distribution
Several other recommendations directly involve health systems, hospitals, and physicians.
Healthcare organizations should discourage physicians from accepting payment to prescribe advertised tests and require physicians identified through companies to tell patients how they are being paid
At the state and healthcare organization level, restrictions or bans should be established on pharmaceutical company detailing visits and gifts to clinicians
Health systems and hospitals should forbid faculty participation on pharmaceutical company speaker bureaus
Public reporting of pharmaceutical industry payments to physician assistants, nurse practitioners, nurses, pharmacists and patient assistance charities—set to start in 2022—should be expedited.
Johns Hopkins Department of Medicine shares successful managerial and organizational strategies.
Academic Departments of Medicine are most effective with a mission-focused leadership structure, a thoroughly engaged workforce including nurses and administrators, and supporting faculty in scholarship achievements, recent research shows.
There are inherent leadership challenges at academic Departments of Medicine such as managing a diverse workforce and balancing the clinical and scholarly responsibilities of faculty.
Research published last month in The American Journal of Medicine shares how Johns Hopkins University School of Medicine has risen to these challenges.
The lead author of the research, who serves in a top role at Johns Hopkins, told HealthLeaders that the leadership recruitment process is crucial.
"Have a transparent process for leadership selection to develop a team with diverse experience and expertise. It is often easy to select individuals for leadership roles with whom we have a comfortable, pre-existing relationship; however, that may or may not be the best individual for the job," said Sherita Hill Golden, MD, MHS, professor of endocrinology and metabolism; executive vice-chair, Department of Medicine; at Johns Hopkins University School of Medicine.
At Johns Hopkins, all faculty members can vie for open leadership positions, she said. "A request for applications process that is disseminated to the entire faculty allows individuals with leadership aspirations and unique skills who may not be as well known to departmental leaders to be considered for important opportunities."
The Johns Hopkins Department of Medicine has more than 1,800 faculty, 900 nurses, about 900 trainees, and more than 1,000 non-clinical staff members.
The department's leadership structure features a vice-chair hierarchy. As executive vice-chair, Golden serves directly subordinate to the director of the department. There are four primary vice-chair leaders, who manage education, clinical care, research, and human resources.
Golden said there are three elements to attaining the best performance from a vice-chair leadership team.
Develop clear job descriptions for each role so that the scope of responsibility is clear.
To foster innovative programming across the academic mission, require vice-chairs to develop annual metrics and goals that are reported to the top leadership.
Empower vice-chairs to lead within their mission area by entrusting them with responsibility. If the right leaders are in place, they should be given latitude to innovate without being micromanaged.
The Johns Hopkins Department of Medicine has developed sophisticated approaches to all four primary vice-chair mission areas, Golden and her coauthors wrote.
1. Managing human resources
The Faculty Development and Promotions Office supports all faculty in the pursuit of academic achievements in several fields such as biomedical research, medical education, clinical care, program building, innovation, quality, and safety.
There are several recognitions for clinical excellence, including enrollment in the Miller-Coulson Academy for Clinical Excellence at Johns Hopkins Bayview Medical Center in Baltimore.
Two associate vice-chairs promote retention and advancement of women and faculty who are underrepresented in medicine. Services offered include enhanced mentorship, access to career development opportunities specific to women and minorities, and leadership training.
2. Excelling at clinical care
The Clinical Affairs Office is split into two main divisions—overall clinical affairs and quality, safety, and service. Inpatient and ambulatory operations groups are also part of the leadership structure.
The quality team focuses on four areas: patient safety; externally reported quality metrics such as hospital acquired condition rates; patient experience; and value-based initiatives that cut costs without compromising quality.
The inpatient team monitors and manages hospital throughput, inter-hospital transfer processes, length of stay, readmissions, and inpatient care policies. The ambulatory team has responsibility for clinical practices on both of Johns Hopkins' academic campuses and more than 30 satellite locations.
3. Driving research and innovation
A key feature of the Research Office is an innovation-to-market program called Innovation and Commercialization in Medicine (InCMed). The program is led by two Department of Medicine vice chairs in collaboration with the Johns Hopkins Carey School of Business.
The main goal of InCMed is to generate marketable healthcare products from discoveries in biomedical science and clinical care delivery. The program provides innovation networking opportunities across the medical campus and the applied physics laboratory.
4. Embracing education
The Education Office currently has four primary goals.
All learners such as medical students and house staff have excellent clinical skills. Clinical learning experiences are encouraged—particularly bedside rounding.
Multiple educational pathways and accelerated training foster careers in a wide range of healthcare fields.
Faculty are incentivized to teach such as a compensation model incentive.
Ambulatory medicine leaders are developed through measures such as enhanced curriculum and engagement of ambulatory subspecialists.
Learn how one health system launched systematic initiatives to improve its quality and safety rankings and is pursuing a zero-harm environment.
Nearly two decades after the Institute of Medicine published its groundbreaking healthcare safety report "To Err Is Human," medical errors remain a leading cause of death in this country.
To rise to this challenge, hospitals from coast to coast are engaged in efforts to boost quality and safety such as initiatives aimed at hospital-acquired infections.
For one hospital in particular, a poor Leapfrog Hospital Safety Grade rating in 2014 became a launching pad for improved quality and safety.
"When we got a 'D' from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn't the fanatic level that we have now," says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia.
Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.
In November 2018, six of Piedmont's 11 hospitals received "A" grades in The Leapfrog Group's Fall 2018 Hospital Safety Grade ratings
From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%
One Piedmont hospital has not reported a hospital-acquired infection for more than a year
Hamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.
1. Reallocate staff’s time and focus
One of the first quality and safety initiatives that Piedmont started was reforming quality and safety staff allocation. Hamby says about 80% of the staff's time was dedicated to surveillance such as chart reviews, rather than improvement projects.
He says the department, which has a staff of about 75, had to change.
"When I started looking at our hospitals and who was charged with quality and safety, they were not working on infections and other elements of the Leapfrog grades. When Leapfrog says hospital-acquired infections are important and people are working on something else, that told me we were working on the wrong things."
The department's functions were split into three branches: surveillance, analysis, and improvement. The improvement branch was divided into design and implementation segments.
"We took most of the folks doing the work—most of whom were clinicians reviewing charts—and put people on the design and implementation sides.
Our original resource allocation was about 80% looking for problems and maybe 20% trying to fix problems. We [have now] put it at 50-50," Hamby says.
2. Commit to a scientific approach
Piedmont's approach to clinical care is rooted in best scientific practices, Hamby says. "What we have done is to be fanatical about making sure every patient gets every component of the things we know scientifically they should be getting."
Central lines and other implantable devices are infection risks and hospitals can lower risk through a science-based approach to care, he says.
Hamby says the clinical team only inserts devices when needed and then removes them as soon as it is safe to do so. "You follow all of the procedures that science calls for while the devices are in to prevent an infection, and we measure performance on a patient-by-patient and hour-by-hour basis."
To prompt clinicians and nurses about care steps, reminders have been built into Piedmont's EMR, Hamby says. "We are giving frontline caregivers real-time tools that help them remember the things they are supposed to do for the patient."
3. Standardize care into'promise packages'
Piedmont has adopted an expanded approach to clinical care order sets that the health system calls promise packages. Catheter-associated urinary tract infection (CAUTI) is a prime example, Hamby says.
"The promise package is literally everything that you would do. For CAUTI, it's a policy, it's a training program, it's a documentation element in the EMR, and it's all the dashboards and reporting. You take all that up and call it a promise package," he says.
When new expanded order sets are rolled out, many members of the quality and safety staff are enlisted to assist in implementation, Hamby says. "We provide elbow-to-elbow support anywhere from seven to 14 days, depending on the complexity of the promise package. We get in the field and sort through the bugs in software or questions the nurses have."
After a 60-day trial period, effective promise packages become order sets for the entire health system and responsibility for order set compliance is shifted to hospital CEOs.
Compliance to promise packages and other order sets is crucial to quality and safety, Hamby says. "In the old days, we would be happy with 80% compliance," he says, but Piedmont found it needed to be within the 95%–99% compliance range, especially because of medical departments such as the ICU with significant utilization of implanted devices.
Regular reporting of compliance rates can avert safety events, he says. "It gives you the ability to identify problems in the process measure before it becomes an outcome problem. If I've got 10 doctors doing colon surgery and I know who is not compliant to the order set, I can intervene before it leads to an infection."
4. Reach for zero harm
Piedmont embraced a zero-harm strategy as part of the fallout from the "D" Leapfrog grade in 2014, Hamby says.
"We look at our harm count every month. Our harm count is comprised of four components: hospital-acquired infections, serious safety events, hospital-acquired conditions, and patient safety indicators as described by AHRQ. Every month, we know how many harms we have, and we have programs to address them," he says.
Benchmarking has no value in the pursuit of zero harm, Hamby says.
"I don't care if we are the best in the country. If we're not at zero, we're not done. I think benchmarking is an excuse for when you can stop working on something. We're going to keep on working until we get to zero harm," he says.
Piedmont's goal is to attain zero harm by 2024, and Hamby says the 10-year time frame is realistic.
"Ten years is a long time, but this is a pretty complicated business. Sick patients, by their very nature, require lots of complicated treatment. Since the IOM report in 1999, as a nation, we have not gotten all that much better."
If health systems and hospitals can create high-reliability organizations, there should be significant economic and operational gains, he says.
"Let's just say we woke up tomorrow and no more harm ever happened. One of the things we would realize almost immediately is an increased capacity of the healthcare system to accommodate more people. We would reduce wait times for service," Hamby says.
In adults, shortened length of stay has been linked to higher readmission rates for some conditions.
Shortening hospital length of stay does not increase readmission rates for pediatric patients, recent research shows.
For adults, length of stay has become a key metric for hospital readmissions, with concerns about the quality of discharge care such as patients discharged before they are ready to leave the hospital. Shortening hospitalization length of stay for adults is associated with a higher risk of readmission for some conditions.
The authors of the recent research, which was published in JAMA Pediatrics, say their finding likely reflects well-managed length of stay for pediatric patients.
"In children's hospitals, the majority of children may already be staying in the hospital for the appropriate amount of time. As a result, efforts to avoid readmissions should focus on other aspects of hospital discharge care," the researchers wrote.
The lead author of the research told HealthLeaders that most adults and children have fundamentally different length of stay experiences.
"When compared with adults, more pediatric hospitalizations are due to acute illnesses that are either self-limited or require interventions that can improve health with a short LOS. Adults with more chronic conditions may get more benefit from some additional time for improvement as well as discharge planning," said James Gay, MD, professor of pediatrics and medical director for utilization and case management, Monroe Carell Jr. Children's Hospital at Vanderbilt in Tennessee.
Gay and his team found little benefit from extending length of stay for pediatric patients.
"Keeping all children in the hospital longer may prevent some readmissions—as our study showed—but the cost is just too great for the relatively few readmissions prevented," Gay said.
Evaluating length of stay impact
Gay and his colleagues examined data from the Children's Hospital Association, including clinical and billing information from 49 children's hospitals.
The research team reviewed more than 950,000 pediatric hospitalizations.
There were 314 potential reasons for an admission and only six (1.9%) conditions had higher readmission rates with a shortened length of stay
The outlier conditions included asthma, cellulitis, and nephritis and nephrosis
The time estimated to prevent a single readmission ranged from 18 hospital-bed days for nephritis and nephrosis, to 148 days for newborns
The cost of preventing a single readmission through length of stay was prohibitive, ranging from $41,000 for nephritis and nephrosis to $1.4 million for dorsal and lumbar spinal fusion.
Rising to readmissions challenge
As they seek effective strategies to reduce readmissions, children's hospitals should be able to adopt some approaches from acute care hospitals, Gay said.
"In adults, improved discharge planning, follow-up telephone calls, and home visits have been shown to reduce readmissions for some patient populations. So, it seems logical that improved discharge planning and follow-up are potential targets for reducing preventable pediatric readmissions, too," he said.
Children's Hospitals will have to move cautiously, Gay said.
"Mounting evidence suggests that some post-discharge interventions such as follow-up home or office visits may actually be associated with more frequent readmissions in children. Is it just that the sicker patients—who are more likely to need readmission in the first place—are more likely to seek post-discharge care? Perhaps, but at this point, it's not clear and we continue to seek effective means of reducing pediatric readmissions."
Following length of stay best practices
Length of stay for individual patients should not be set rigidly, and providing efficient treatment in the hospital and effective discharge planning with the patient can safely shorten hospital stays, Gay said.
"We can shorten the LOS to the greatest extent possible while providing the patient with the best means to return to their previous health baseline," he said.
Some patients can go home earlier than others, Gay said. "We must remember that patients often do not require complete return to baseline while in the hospital and it may be appropriate for the recovery period to extend beyond the discharge date."
Federal and state rules have enabled spending on nonmedical services that have health benefits such as food security.
Managed care organizations (MCOs) are on the leading edge of efforts to strike a better balance between health and social service expenditures, a recent article in JAMA says.
Evidence is mounting that countries with higher social services spending such as disability, unemployment, and housing have better population health outcomes. Among Organization for Economic Co-Operation and Development (OECD) countries, higher social services spending is associated with higher life expectancy, lower infant mortality, lower prevalence of chronic diseases, and lower all-cause mortality.
MCOs are taking a leading role in addressing social determinants of health, the JAMA article authors wrote.
"By expanding the scope of service delivery as part of managing population health risk, managed care companies can invest in services and supports that meet their members' health-related needs, benefit from reduced spending on medical care, and leverage business principles to justify resource reallocation," they wrote.
The Centers for Medicare & Medicaid Services (CMS) have enabled MCO expenditures for social services.
In 2016, CMS amended the Medicaid managed care rule to prompt Medicaid MCOs to help patients with nonmedical expenses that were considered crucial to achieving health outcomes and cutting costs.
Under the CMS Accountable Health Communities Initiative, many Medicaid MCOs assess patients' unmet social needs, including housing instability, food insecurity, utility needs, interpersonal violence, and transportation requirements.
An increasing number of states are requiring Medicaid MCOs to address social determinants of health as part of contractual agreements. In New York, The Empire State's Value Based Payment Roadmap requires MCOs to offer startup funds for partners in Value Based Payment agreements who are conducting social determinant of health interventions.
Berwick's perspective
MCOs cannot take on social determinants of health single-handedly.
"Even if all MCOs were appropriately incentivized to invest in upstream social services for their members, the sum of these investments would be insufficient to create the system for providing social services and blending them with medical services to optimally serve all U.S. residents," the JAMA article authors wrote.
Healthcare organizations must build partnerships to address social determinants of health in the communities they serve, Don Berwick, MD, former CMS administrator, told HealthLeaders at last month's IHI Forum.
"Cincinnati Children's Hospital Medical Center is working with dozens of organizations in the city with the shared goal of improving outcomes for 60,000 disadvantaged kids in Cincinnati. They are not trying to do it alone," he said.
Hospitals can also look for economic opportunities to engage distressed communities, Berwick said. "Hospitals account for about $750 billion of economic activity—employment, construction activity, and supply chain."
Opportunities to generate partners through economic activity include hiring from those communities, using construction firms from those communities, purchasing products in those communities, and investing in community infrastructure such as housing.
"We're going to spend the money anyway. Why don’t we spend it where we can work on progressive income redistribution and opportunities?" he said.