Swine flu could shine a glaring light on the best and worst about American-style healthcare, according to this article from the Associated Press. In a country where one in seven people lack medical insurance, doctors worry that some individuals won't get needed protection because of cost. In a flu epidemic, the uninsured face the worst options, the article notes: They flood emergency rooms or self-medicate with cold preparations and hoping for the best. Many might not be aware they can also go to a federally-funded community health center and see a doctor or nurse for little or no cost.
A survey conducted for the Michigan Department of Community Health found that 62% of the state's doctors say their practices are full or nearly full, compared with 60% in 2007. The 2008 physicians' survey also shows that the number of Michigan doctors accepting Medicaid patients is declining. About 85% said they provide care to some Medicaid patients, down from 87% in 2007.
Boston-based Beth Israel Deaconess Medical Center, which earlier this year said it might lay off 600 workers because of a projected operating loss of up to $20 million, has shed about 70 employees in a round of job cuts. The layoffs took place last month, but about 100 early retirements that are helping to offset the number of layoffs needed are continuing through this week, said spokesman Jerry Berger.
An article in the Annals of Internal Medicine examines press releases that academic medical centers sent out about their research, examining such details as whether they gave information on the studies’ size, hard results numbers, and cautions about how solid the results are and what they mean. The conclusion: The press releases “often promote research that has uncertain relevance to human health and do not provide key facts or acknowledge important limitations.”
The Agency for Healthcare Research and Quality has launched a campaign aimed at getting Americans to research and ask questions of their healthcare providers. The public service announcements are meant to prompt people not only to ask questions but also to think about what those questions might be ahead of time, says Carolyn Clancy, director of AHRQ.
Several theories have emerged as to why all but one of the confirmed deaths from swine flu have occurred in Mexico. But a critical factor, according to specialists in the country, is that flu victims have delayed checking into hospitals until their condition has deteriorated so much they cannot be saved. While medicines are plentiful and cheap at Mexican pharmacies, swine flu antiviral medication was often not available or prohibitively expensive.
Boston's Beth Israel Deaconess Medical Center is using peer pressure and the threat of humiliation in a playful game of "Tag, You're It!" in hopes of reducing hand-washing lapses among the busy emergency staff.
Last Friday, hospital ED chief Richard Wolfe, MD, persuaded his physicians, nurses, techs, and attendings to bravely accept the challenge. When any team member espies a colleague failing to wash hands between patient encounters, they get tagged. The words, "Tag. So-and-so is it" appear on the dashboard banner of all monitors throughout the hospital.
Wolfe says staff also can be marked for failing to write legibly in patient charts, writing prohibited abbreviations that can be misunderstood, or failing to correctly sign, date, and time all orders. Having coffee in a clinical area is a big tag-able no-no as well.
But hand-washing is the biggest bête noir at the Harvard teaching hospital. "It is by far the hardest not to trip up on in the ED," he says. "If you have just washed your hands after seeing one patient, you still are expected to wash again before entering the next patient's room, even if you haven't touched anything. Between the initial evaluation, re-eval, and the discharge, each patient can require six separate episodes of handwashing."
Beth Israel Deaconess sees on average 150 ED patients a day.
Wolfe isn't quite ready to write up the experiment in a medical journal, but that may come.
"We really are into a proof of concept phase for now rather that measuring the outcome of the intervention," Wolfe says. "We want to see if the game will be adopted and run continuously or if it requires regular pushes from leadership to keep it going."
As far as determining whether it works by reducing infections, that's tough in a setting where patient stays are relatively short. "The easiest measure to track compliance will be in the amount of Cal Stat (a brand of hand sanitizer) used," he says.
In his blog "Running A Hospital," Beth Israel Deaconess CEO Paul Levy calls the experiment "A fun game, for serious purposes," and "a good humored use of peer pressure among a group of doctors who tend to be really good at noticing things. Let's see how it works!"
Game rules are simple.
During each shift, a staff member who is caught violating any mandate, has his or her name placed on the banner until that staffer fingers another scofflaw. If at the end of the shift, the "tagee" has been unable to tag another violator, the banner is cleared and the game starts anew the next shift.
There is no punishment for getting tagged, but a monthly award for the one who tag the most frequently.
Wolfe says that at least on the first day, the staff embraced the game even though "a number" of care providers were tagged.
Adding to comments on his CEO's blog, he jokingly wrote, "There is healthy competition developing between the categories of providers: attendings vs. residents vs. nurses vs. techs. So far we have not knocked over any elderly patients, but no promises.
"I agree that proof of the validity of the exercise will depend on this exercise leading to providers adopting compulsive habits once we are beyond the first few days. It will be some time before we can assess this. But, so far, so good."
He also says staff members do not see this as "ratting someone out," but a sense that "we're all in this together."
Wolfe said there was the drive for "a culture of transparency" and "perfection in hand hygiene."
"The drive to eliminate harm, recent DPH citations in other areas, and our culture of transparency was causing us to strive for perfection in hand hygiene. Considerable training, daily e-mail communications, and town hall discussions, along with random audits were performed to try and achieve compliance.
"However, the ED has such a rapid flow of patient-provider contacts (any provider to be in compliance in the ED may need to wash hands up to eight-12 times/hour) that it is much harder than one might think to get there. With all the distractions that trip up providers from being 100% compliant, we were far from eliminating the problem," says Wolfe.
To prevent central line–associated bloodstream infections (CLABSI), Swedish Medical Center (SMC) in Seattle has found sharing information with staff members and simplifying techniques has made all the difference.
SMC is a participant of Institute for Healthcare Improvement's (IHI) campaigns, which has featured CLABSI prevention as a part of its past two campaigns. Its efforts have spread beyond ICUs and now include central lines placed by anesthesiologists and interventional radiologists.
By incorporating the following four techniques into its practice, SMC has at one time gone 12 months without reporting a CLABSI in some of its ICUs, and has currently not had a CLABSI in four months.
Staff education
Before 2005, when the more organized effort to prevent CLABSI began, the facility would often fail to keep up with educating staff members, says Will Shelton, M(ASCP), CIC, director of epidemiology and employee health at Swedish Medical.
"As the education wore off, our compliance would go down and the rate [of infection] would go back up, and so the rates were constantly this yo-yo up and down," says Shelton.
Learning from the IHI's model, which involved bundling education with several prevention techniques, such as hand hygiene, optimal catheter selection, clorhexadine antiseptic, and, in SMC's case, an antimicrobial bio patch on the site, it was able to post weekly infection and compliance rates for staff members to see.
In addition, the facility implemented one-on-one meetings with nurse managers for those staff members whose patients were not in compliance.
The graphs were very powerful, says Caroline Truong, RN, BSN, critical care clinical supervisor, because staff members could clearly see the efforts' effects.
"We've seen tremendous dedication from the managers, nurses, the charge nurses, and the physician champions," says Shelton about the one-on-one education of complying with the bundle of actions recommended by the IHI.
Use of bundles to create a checklist
Like many efforts to prevent CLABSI, SMC created a checklist that used the recommended techniques from the IHI. However, it went a step further and had a manufacturer create all of the supplies necessary for inserting a central line in one package so whoever was completing the insertion did not have to search in different places for these supplies.
Additionally, SMC empowered the ICU nurses to speak up when they saw a physician not completing the checklist in the required manner by enlisting a physician sponsor so they felt more secure.
"There's only so much that nursing can do by themselves," says Truong. "We needed to partner with the physicians and let them know that nurses would be giving them that feedback to stop the procedure if the checklist was not followed."
The director of infectious disease wrote a letter to all staff members informing them that the facility was instituting the central line bundle insertion and that nurses would be intervening if steps were not followed.
"We gave the nurses a script too so it wouldn't be uncomfortable," says Truong. "Basically, we made all the obstacles in the past; we tried to make things easier so there'd be no excuse for not having it done unless someone was being a silent partner and seeing something go wrong but not say anything."
To further the nurses' commitment to stepping in when a checklist was not being followed, Truong had the nurses sign an "Act Boldly" statement during annual evaluations to reinforce the message.
"Act Boldly" is a slogan that the American Association of Critical-Care Nurses created as a means of empowering critical care nurses to "act deliberately and powerfully" to give better patient care.
"We have a discussion with our staff to speak up and act boldly if they see an opportunity for improvement, especially if they witness a potential or actual risk to patients or staff," says Truong.
Recognize the need for flexibility
To come up with the best policy to outline SMC's CLABSI prevention tactics, Shelton and Truong's team received permission to have a rogue policy that could be changed instantly at the suggestion of staff members.
This practice is contrary to how policies and forms are normally approved and signed off on at the facility since most forms are dated and approved by a higher committee, says Shelton.
As staff members gave feedback about the policies and checklists being created to prevent CLABSI, Shelton and Truong could instantly make changes, especially if staff members thought something on a policy or checklist was not working.
Leadership support and collaboration
Shelton says SMC' leaders are quality-focused. Support for joining the IHI's initiative always came from the top down. His team had convinced leadership earlier that taking on these types of quality initiatives was a step in the right direction by improving the quality of life for ventilator-associated pneumonia patients, which also saved the facility a significant amount of money.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals.Contact Heather by e-mailing hcomak@hcpro.com.
The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is out, and with it comes good and bad news for hospitals.
Although there aren't a whole slew of changes related to Medicare Severity DRGs (MS-DRG), hospital acquired conditions (HAC), and the present on admission (POA) indicator, hospitals will see historically low payment updates with a phased-in documentation and coding adjustment (DCA) to take place over time.
A slow rate of economic inflation and an increase in aggregate payments due to changes in hospital coding practices that do not reflect increases in patient severity of illness (SOI) are the reasons for the low updates, according to a CMS press release announcing the rule late Friday afternoon.
"We understand hospitals will be concerned about lower than historical payment update amounts," said Charlene Frizzera, CMS acting administrator in a CMS press release. "However, we are proposing an adjustment that minimizes the effects on FY 2010 payments while still meeting the requirements of the law, which may mean larger reductions in the next two years."
Payment updates
The proposed update for acute care hospitals means an update of 2.1% for inflation minus a DCA of 1.9 percentage points. Long-term care hospitals will see a proposed update of 2.4% for inflation minus a DCA of 1.8 percentage points. These DCA adjustments reflect the differences between the changes in documentation and coding that do not reflect real changes in case-mix for discharges occurring during FY 2008, according to CMS.
Experts agree that these low rates won't help hospitals struggling to keep their doors open in the midst of a worsening economy. "Hospitals that are counting on some sort of increase won't really see anything this year," says Kimberly Hoy, JD, CPC, director of Medicare compliance for HCPro, Inc. in Marblehead, MA. "Payments are going to stay flat, and that's going to be tough for a lot of hospitals."
"The increase was practically eliminated by CMS' contention that improved documentation and coding for MS-DRGs resulted in an underserved 2.5% improvement in reimbursement," says James Kennedy, MD, CCS, director of FTI Healthcare in Atlanta.
The Medicare Actuary found based on analysis of 2008 data that additional coding did not reflect actual changes in patients' SOI. The analysis also found that additional coding increased total payments under IPPS by 2.5% in FY 2008 and will further increase total payments in FY 2009.
Still, it's as though CMS is penalizing hospitals for documentation and coding improvement, Kennedy says. "It's as if no good deed goes unpunished," he says. "Hospitals that took care of these sick patients and had rigorous clinical documentation and coding integrity processes in place in 2007 will see their reimbursement decline. CMS is penalizing their ethical and compliance efforts to improve disease definition, documentation, and reporting."
Clinical documentation improvement programs as well as more diligent efforts by HIM are most likely the reasons behind more accurate coding that led to higher payments, agrees Shannon McCall, RHIA, CCS, CCS-P, CPC-I, director of HIM and coding for HCPro, Inc. in Marblehead, MA. "CMS may have underestimated that facilities would create such effective clinical documentation improvement programs," she says. "I think those programs were an integral part of all of this."
And in light of decreased payment updates, hospitals that don't currently have a clinical documentation program will need to think seriously about implementing one, says Gloryanne Bryant, RHIA, CCS, CHW, senior director of corporate coding and HIM compliance in San Francisco. "Hospitals will need to assess their current efforts to capture patient severity and acuity through documentation and coding to see if opportunities remain," she says.
To view the rule, click here. CMS will accept comments until June 30.
Lisa Eramo, CPC, is a senior managing editor in the health information management division of HCPro, Inc.She is located in Rhode Island and writes content for the company's flagship newsletter,Medical Records Briefing. Contact her at leramo@hcpro.com.
A new federal report says rural Americans pay a lot more for healthcare that is tougher to find and less specialized than for citizens in urban areas. And, the report said, the situation is exacerbated by the recession.
The challenge, said Nancy-Ann DeParle, the director of the White House Office of Health Reform, is for the Obama administration to find reform remedies that will be effective in towns with only one or two stoplights.
The report, entitled "Hard Times in the Heartland" shows us why we must pass comprehensive health reform this year," said U.S. Health and Human Services spokeswoman Jenny Backus.
"The problems of a thin provider workforce can be expected to worsen if action is not taken," the report said. Physicians in rural areas are also older, and more likely retirement age than in urban areas.
All such issues can lead to worsening health. For example, people with diabetes receive recommended exams less frequently in rural areas, and thus have a higher rate of hospital admissions than diabetes patients in urban areas. Rural women don't get mammograms or have pap smears as frequently as urban women. And both male and female rural residents are more likely to report they are in poorer health. More patients in rural areas also meet the definition of being obese.
Highlights of the report include:
1. Rates of poverty are higher with 15% of people in rural areas living below the poverty level, compared with 12% in urban settings.
2.Rural areas are losing jobs at a faster rate than the rest of the country, which means they are also losing health insurance. Rural areas dependent on manufacturing have lost nearly 5% of their jobs since the recession began.
3. There were 72 primary care physicians per 100,000 residents in urban areas in 2005 compared with 55 per 100,000 in rural areas, and 36 per 100,000 in small rural areas. Also, there were half as many specialists in rural areas and a third as many psychiatrists as in urban areas.
4. Rural residents have many part-time, seasonal workers or are self-employed, which makes it less likely they will have private, employer-sponsored healthcare benefits.
5. According to one survey of farm and ranch operators, while 90% have insurance coverage, one-third purchased it directly from an agent, compared to the national average of 8%.
6. Rural residents spend more out-of-pocket on healthcare than their urban counterparts. And 20% of rural residents spends more than $1,000 out-of pocket for medical expenses in a year. Rural citizens pay 40% of their healthcare costs out of pocket, compared with only 30% among urban residents.
7. One in five farmers has medical debt, and in one state, farmers who purchased an individual health plan spent $2,117 on average more than colleagues who purchased insurance through a group plan.
8. Rural residents report higher rates of postponing care because of cost than urban residents. This problem is worse among rural minority populations, who are twice as likely to have deferred care in the past year as whites who live in rural areas.
"Perhaps nowhere is the economic downturn felt more than in rural America," the report said.
