More than 50% of chief information officers who participated in a recent poll are "extremely concerned" about security breaches of personal health information affecting their facility. And they should be, especially as more practices are moving toward utilizing electronic mediums to communicate with their patients, colleagues, and healthcare leaders.
Various ways to keep patient and other personal health information secure from those inside or outside the practice are being more widely used. Security breaches can be averted by enacting and following these simple steps.
Limit the number of staff members authorized to view personal health information
Require unauthorized personnel to apply for disclosure if they need access
Require patients to complete a release form to access their records
Require release forms between providers except in the case of a referral
Notify any patient older than 12 years of any request to access his or her information
Deny any provider request if the patient objects to disclosure
Encrypt data
A policy should be in place that outlines what information should be encrypted and how to do it.
This article was adapted from one that originally appeared in the October 2008 issue ofThe Doctor's Office, a HealthLeaders Media publication.
If a police officer pulls you over—and you both know full well you were speeding—he or she typically asks, "Do you know why I stopped you?" The officer is trying to elicit an admission of guilt from you, such as, "But officer, I was only going eight miles over the limit." That is self-incrimination, and as Miranda makes clear, you have the right to remain silent because what you say can and will be used against you.
Although medical malpractice lawsuits are civil and not criminal proceedings, sometimes admitting what you did wrong may prevent a medical malpractice claim.
But other times, such an admission could result in a slam-dunk malpractice case against you. So it's best to know what to say and how to say it.
The medical apology
Although some providers disagree with offering a medical apology after an adverse incident, hospitals, medical centers, risk managers, and malpractice insurers increasingly recommend it.
A study published in the Journal of the American Medical Association concluded that subsequent to committing medical mistakes that harmed patients, providers were not providing the information and emotional support those patients needed, and that failure resulted in an increased likelihood of a malpractice claim.
After any questionable event, try to be open, honest, communicative, and understanding while making yourself fully available to the patient and/or his or her family.
The medical apology has four components:
The acknowledgment includes details of the event, the persons involved, and the unacceptable nature of the behavior.
The explanation is the exact reasons for the event. (Stating there is no explanation yet is acceptable.)
Remorse is the genuine expression of contrition; if the expression is false or simply a pretense, the listener will sense it, and the apology will do more harm than good.
Reparation is an attempt to make things right, even in a small way.
In some states, such an apology is perfectly acceptable; in others, it's an admission against interest and evidence of malpractice. Your malpractice insurer or risk management department can provide guidance on your state's laws.
Real-world case study
An elderly patient presented to the hospital for major abdominal surgery performed by an attending surgeon. The procedure was successful. After seeing the patient on the first post-op day and noting recovery was progressing normally, the attending surgeon proceeded with a planned vacation.
On the second and third post-op days, the nurses observed a gradual deterioration of the patient's condition, which they recorded in their notes and verbally alerted the covering attending surgeon. On the fourth post-op day, the patient continued to deteriorate, and the covering attending surgeon finally called the vacationing attending surgeon, who made some general inquiries but did not further contribute to the patient's care. On the sixth day, the patient crashed and died the next day.
The attending surgeon returned home, met with the family, apologized, and said, "This never should have happened. It's my fault for not returning early to take care of her and for not ensuring she was in good hands when I left. This was a mistake that could have and should have been avoided."
The attending surgeon later told me he said these things to appease and comfort the family, although he did not believe he or any other healthcare provider committed malpractice. But in the resulting lawsuit, the attending surgeon, covering attending surgeon, nurses, and hospital were all forced to settle.
The attending surgeon's statements implicated the entire medical team caring for the patient; each healthcare provider involved in the patient's care was held legally responsible in some way. (This incident took place in Florida, where a physician's apologetic statements are considered an admission against interest and can be used as evidence of malpractice.)
Alan G. Williams, JD, is the author of Physician, Protect Thyself: 7 Simple Ways NOT to Get Sued for Medical Malpractice and an attorney with Physicians MedicaLegal Prevention in Orange Park, FL. This article originally ran in the September issue of Private Practice Success, a HealthLeader's Media publication.
Medical officials, researchers, and policymakers all debated how best to boost the number of physicians in Idaho during the last legislative session. As part of lawmakers' efforts to boost the state's doctor to patient ratio, they're digging into research that could help remedy the state's physician shortage. That research points toward a number of educational options that could help attract doctors to the state and push some to consider the feasibility of an Idaho medical school.
A New York Times reporter says she found out how unreliable MRIs can be after a scan missed a serious stress fracture in her foot. MRIs use powerful magnets and radio waves to manipulate protons in the body's hydrogen atoms. The idea is that protons in different types of tissue respond in distinctive ways to this pushing and prodding, and the differing responses reveal the characteristics of the tissue. Magnetic resonance machines, though, vary enormously. Even more important, radiologists say, is the quality of the imaging coils they put around the body part being scanned and the computer programs they use to control the imaging and to analyze the images. And there is a huge variability in skill among the technicians doing the scans, the reporter writes.
About 85% of MRSA infections can be traced back to a hospital stay and two-thirds occur after a patient has arrived back home. But 15% of the infections can't be linked to a hospitalization. These patients often show up first at a doctor's office for treatment, and Benjamin Brewer, MD, says this is why hand washing and disinfecting surfaces in physician practices is absolutely crucial.
A proposed rule from the U.S. Department of Health & Human Services requiring all physician practices and other providers to adopt a new ICD-10 code set by 2011 would dramatically increase costs for physician practices and clinical laboratories, according to a new cost study initiated by a broad group of provider organizations and conducted by Nachimson Advisors. These groups are now calling on HHS to carefully reassess its plan to rapidly adopt ICD-10 and extend the implementation time frame, according to a release from the Medical Group Management Association.
There has been a considerable amount of attention paid recently to "never events," serious medical errors that should not happen. The Centers for Medicare & Medicaid Services raised the visibility of these events by mandating that when such errors occur, CMS will not pay for additional expenses incurred. Hospitals are currently preparing for implementation of CMS' "no pay" plan and expending tremendous resources in the process.
Never events are relatively infrequent occurrences, but underlying the events are failures in patient-centered care that affect thousands of patients every day. Seven years after the Institute of Medicine identified patient-centered care as one of six aims of a quality healthcare system, hospitals still struggle to consistently deliver care that "is respectful of and responsive to individual patient preferences, needs, and values." The lapses in patient-centered care are documented in the HCAHPS survey results, which confirm that hospitals nationwide are not always listening to patients, communicating in a way that patients understand, being responsive to patient requests, or managing patients' pain.
The quantitative portrait offered by HCAHPS is supplemented by the qualitative stories of patients who experience humiliation, shame, hopelessness, and powerlessness in a system that is intended to help the patients it is inadvertently harming. A recent Picker Institute-funded analysis of more than 100 patient focus groups conducted by Planetree at 35 hospitals of all sizes and locations across the country found disturbing evidence of major failures in the provision of respectful and responsive care. Major themes emerging from the focus groups included lack of caring attitudes on the part of hospital staff, dismissal/trivialization of patients' knowledge and views about their own bodies and their health, and a troubling phenomenon of "reverse caring" in which patients witnessing the stress and strain on caregivers makes them reluctant to inconvenience or aggravate staff by asking for the care they need.
Ultimately patient-centered care is about culture change and must involve not only caring for patients, but also caring for staff members who often feel demoralized and shamed themselves by constant reminders of how they are falling short. In the safety movement, the focus has shifted from individual providers to system solutions, and the patient-centered care movement needs to evolve in the same direction. We need to advance beyond the amorphous public policy goal of patient-centered care to tangible operational objectives. These objectives must reflect and honor the good work done every day by passionate people who dedicate their professional lives to helping others, but work in a system that doesn't always honor that intention.
Expanding focus from never events to the patient-centered "ever events" is a significant step in the right direction. Never events focus on preventing horrific clinical outcomes for a small number of patients, while ever events focus on what should happen for all patients, every time they interact with the healthcare system. Never events are nationally standardized; ever events are customized by each institution. Never events highlight what goes wrong; ever events celebrate what is done right.
The Cleveland Clinic is one of several patient-centered hospitals that are making this leap. The Clinic's Office of Patient Experience is guiding teams of physician and nurse leaders who are defining what actions will create the ideal experience for patients. One initial ever event defined by the Cleveland Clinic is that prior to the induction of anesthesia, all staff members in the operating room should introduce themselves to the patient and explain their role in caring for the patient. This ever event was identified by a patient who called the Office of Patient Experience to report how amazed he was by this approach. In stark contrast to the ever event is the more frequent patient-centered never event of OR staff chatting about their weekend plans, ignoring the patient who is lying terrified on the table waiting for anesthesia. The patient-centered never event will be prohibited, while the ever event is celebrated.
Ironically, CMS' no-pay for never events policy became effective October 1, 2008; the same day marked the beginning of the second annual Patient-Centered Care Awareness Month. This month we call on all hospitals to broaden their focus from "never events" to "patient-centered ever events," and we ask each hospital to identify its own patient-centered ever events. Many patient-centered practices that promote an effective partnership between patients, families, and providers, as well as among all staff members, clinical and non-clinical, are described in a Patient-Centered Care Improvement Guide that Planetree and the Picker Institute will publicly release in late October. Together we can build a future where the never events are more rare than they are today and the patient-centered ever events are not simply something we do, but an inseparable part of who we are.
Susan B. Frampton, PhD, is president of Planetree. Patrick A. Charmel is president and chief executive officer of Griffin Hospital.
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Guidelines for reducing healthcare-associated infections are not hard to find. They're everywhere, in fact. But a new infection control compendium released last week is no ordinary guideline.
Myriad organizations have created specific recommendations for hand washing and inserting catheters and shaving the operative site and anything else you can think of (or might not want to think of, for that matter). Senior leaders are well aware of the numbers—roughly 2 million HAIs associated with nearly 100,000 deaths in U.S. hospitals every year, according to the Centers for Disease Control and Prevention—and have implemented all manner of prevention initiatives in an effort to reduce those figures. I have edited many stories for HealthLeaders magazine in which a hospital executive explains how his or her organization has made infection control a priority and is taking steps to make HAI prevention efforts part of the hospital's "culture."
The availability of recommendations isn't the problem—it's the adherence part of the equation that causes the trouble. Last year, a Leapfrog Group study found that 87% of hospitals don't consistently follow guidelines for preventing some of the most common HAIs. Only 35% of hospitals had full compliance with hand hygiene practices. A guideline is one thing, but following that guideline is quite another.
So when I first read about the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, the new HAI-prevention guidance released last week by The Joint Commission, the American Hospital Association, the Society for Healthcare Epidemiology of America, and the Infectious Diseases Society of America, I was skeptical. The new guidelines offer recommended practices for preventing methicillin-resistant Staphylococcus aureus, Clostridium difficile, central-line-associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, and surgical site infections. The compendium's authors don't claim that the guidelines are all that different from existing guidelines—they're just more concise and collected in a single source. So if the main problem with infection control has long been lack of adherence, not lack of recommendations, why should this latest attempt be any different?
The messengers, for one thing. The Joint Commission and the AHA uniting to create a singular infection control guidebook is quite different from a random organization offering its two cents on infection control. And by 2010, some of the new guidelines will show up in The Joint Commission's accrediting standards.
The format, for another. A consensus like this presented in relatively concise form should be much easier for healthcare workers to digest than the current volumes of infection control recommendations. Having a multitude of guidelines might seem like a good thing, but it's really not, says Robert A. Wise, MD, vice president of The Joint Commission's division of standards and survey methods. "One of the reasons hospitals are having difficulty now is that when they look at guidelines, they are drinking from a fire hose," Wise told The New York Times. "There are thousands of these things, and they don't quite know what to do with them."
So now we have a single playbook, backed by major organizations and organized in clear form, for preventing six of the most common HAIs. Practical advice on what to do and what not to do. No more excuses.
Will it work?
Personally, I think there's something to the theory that too much information from too many sources can cause paralysis. This compendium could genuinely help provider organizations take meaningful strides in the HAI fight. But infection control ultimately comes down to the individual. We've told you to wash your hands. You know the risks if you don't wash your hands. So wash your hands.
Will your people listen?
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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Like a lot of veteran physicians, Mark DeFrancesco, MD, MBA, began his career in a small practice with just one partner. Since his first days as an OB/GYN in 1984, however, his practice has grown organically and through mergers, and he now serves as chief medical officer for Physicians for Women's Health, a 155-physician group in Connecticut.
I spoke with DeFrancesco for this month's cover story about new business models for medical groups, and his career path in many ways mirrors a trend we're seeing across the industry: Small practices are struggling and dying out in a wave of medical practice consolidation.
The proportion of physicians in solo and two-physician practices dropped from 41% in 1997 to one-third in 2005, according to the Center for Studying Health System Change. Many older physicians are merging with other groups or selling to a hospital or health system. Newer physicians are skipping the small-business phase entirely and going to work directly for a larger organization.
There are many underlying reasons for the trend, but the tough financial climate physicians face—the one-two punch of skyrocketing costs and stagnant reimbursement—is probably most significant.
Practicing today isn't just about building relationships with patients and being a good doctor; it takes capital and technology and sophisticated management. Whether it's controlling costs, negotiating managed care contracts, or spearheading quality initiatives, larger practices have resources to succeed in today's environment that many mom-and-pop practices lack.
DeFrancesco thinks he could still make it in a two-person practice today, but he admits that it would be a much greater struggle in this environment.
I wrote the story less than two months ago, but since that time we've seen financial institutions collapse, a $700 billion federal bailout, and perhaps the beginning of a prolonged recession. As the overall economy turns for the worse, the financial squeeze on small practices will only become greater.
Yet we lose a lot if we lose our small practices. Mom-and-pop operations tend to have better relationships with patients (equaling higher satisfaction scores) and allow physicians the autonomy that many value highly.
The practices I spoke with that were most successful were striving to combine the best of both worlds—harness the strength of a larger group while maintaining the agility and personal connection of a smaller one. Although strategic decisions are made by centralized leadership, for example, they try to give formerly independent physician locations as much autonomy as possible to deal with patients on a daily basis.
That's essential going forward. As solo and two-physician practices become rarer, success in larger groups hinges on remembering why both patients and physicians have liked that model for so long.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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Medical helicopters transporting patients to the Indiana Heart Hospital and Community Hospital North now have a permanent landing site with the construction of a new helipad. The helipad's location provides access to both hospitals. "The helipad enhances our relationship with rural hospitals, allowing them to transfer heart patients to our facility in a timely manner using air transport," said Scott Lakin, clinical support director at the Indiana Heart Hospital.
