When Kathleen Mikos, RN, MSN, vice president of patient care, chief nursing officer, came to Ingalls Memorial Hospital in Harvey, IL, she couldn't shake the sense of déjà vu when she found that patient handoffs took an hour to 90 minutes to complete.
At her previous hospital, Mikos had dealt with a similar issue. The lengthy amount of time became an issue with incremental overtime and also got in the way of patient care.
Drawing on her past experience, in May 2008 Mikos began to develop a new, efficient method for patient handoffs that allowed for more patient/nurse interaction and reduced nurse overtime at Ingalls.
For years, nurses nationwide have used different methods for handling handoff reports. One technology was the use of taped records. This caused problems because if an interruption occurred while the nurse was reporting, the nurse had to make a note on the recorder where the tape left off, causing confusion later on.
There were also instances when the tape recorder broke or someone had recorded over a report, causing the nurses to take more time to re-record each patient report.
More recently, handoffs involved nurse-to-nurse interaction between shifts. As the nightshift was coming on and the day shift was leaving, and vice versa, the nurses discussed each patient and how the shift went.
Although effective, this process takes a lot of time, and many nurses went into overtime at Ingalls.
"Between shifts, as 10 nurses are coming on and 10 nurses are leaving, I can have up to 20 nurses tied up," says Mikos. "Having that many nurses tied up, trying to get reports, cuts into the patient care."
Much of the delay occurred because not all nurses shared the same patients. Most of the time, those nurses who were starting their shifts had to track down the nurses who had their patients during the previous shifts.
To solve this problem, Mikos turned to The White Stone Group, Inc., for a technological solution to facilitate a new handoff process. This company provides healthcare organizations with software to help improve the management of healthcare communication events.
Having had experience with The White Stone Group in the past, Mikos was confident in setting up OptiVox, a voice technology program for handoffs, and made the program accessible to all staff members through any telephone in the hospital system.
Other similar programs that facilitate the patient handoff process include the PatientKeeper Sign-Out technology and Vocera's communication systems. Physicians use the PatientKeeper program as a continuity of care tool and enter patient care details that the next shift's physician will need. Vocera's wireless devices enable instant communication among staff members.
OptiVox is a computer-based voice platform technology that is built into the phone system, says Mikos. Nurses can dial into OptiVox and record their patient reports, or listen to the patient reports from any phone in the health system.
Nurses coming off a shift and needing to report on their patients dial in an individual access code, pull up each patient's medical record number, and begin recording a report on that patient.
In addition to using OptiVox to record their reports, the nurses are also encouraged to use the SBAR format. The SBAR technique helps guide communication between staff members on a patient's condition.
To identify each patient in the system, Ingalls uses the patient's medical record number to prevent confusion, says Mikos.
"You are always up against potential patient safety issues, and some patients may have the same name or date of birth, but medical record numbers are always going to be unique," says Mikos.
When nurses arrive to start their shifts, they can access the reports from the previous shift the same way nurses record them. Using any phone in the health system, the nurse dials in with an individual access code and using his or her patients' medical record number; the nurse can then listen to the reports.
"To receive reports on five or six patients should take about 15-20 minutes of shift report time," says Mikos.
Now, with extra time, the nurse can find the previous shift nurse, clear up any unanswered questions, and visit his or her patients for brief assessments and introductions.
"Here at Ingalls, we believe there is a need for face-to-face, or bedside rounding," says Mikos. "After the nurses [listen to the] handoff report, they should immediately go out to their patients, introduce themselves, and have a brief discussion on how the previous shift went."
If a pilot program underway in New Jersey is a success, no newborns at participating hospitals will leave the facility without health insurance coverage.
Under the "Insured for Sure" Hospital Newborn Pilot Program, staff from the participating hospitals will verify if newborns have insurance coverage. The hospital will then submit data to the NJ Department of Health and Senior Services to confirm that the child is covered by their parents insurance. If the child is not, a NJ FamilyCare application is immediately submitted online to the state Department of Human Services.
"There's been a big push in the state of New Jersey to get every child some form of health insurance, and we now cover all children with either low-cost or no-cost care," says Eliot Fishman, director of policy for the New Jersey Department of Health and Senior Services. "There should be no reason for any child to go without health insurance."
NJ FamilyCare is administered by DHS as a free or low-cost program for income-eligible families. It covers children in families earning up to 350% of the Federal Poverty Level and parents earning up to 200% of the FPL.
The Insured for Sure program is designed to make it easy for parents to enroll their children, officials say. Parents receive assistance filling out the one-page application and the state will use the database system to monitor the process to ensure enrollment is complete.
If the six-month pilot program is successful, it may be implemented at hospitals across New Jersey, Fishman says.
"The point of the pilot is just to make sure the systems are working the way we anticipate they will work, but we absolutely see that as the first step in a statewide rollout," Fishman says. "We are very optimistic."
Organizations participating in the program include Saint Peters University Hospital in New Brunswick, AtlantiCare Regional Medical Center in Atlantic City, Capital Health System in Trenton, Cooper Health System in Camden, Monmouth Medical Center in Long Branch, Palisades Medical Center in North Bergen, Shore Memorial Hospital in Somers Point, and the Voorhees campus of the Virta-West Jersey Hospital.
The program is the latest effort by the state to identify uninsured children and provide them insurance coverage. For example, in June the state rolled out the "Express Lane Eligibility" program that uses information from tax forms to determine whether children have health insurance, and helps parents enroll them in the FamilyCare program if they are not.
Officials say Insured for Sure provides the tools necessary for hospitals to expedite coverage to newborns and eliminate delays that might otherwise result in costly healthcare charges.
"In these participating hospitals, we can now guarantee that no New Jersey newborn leaves the hospital without health insurance," said Health and Senior Services Commissioner Heather Howard in a statement. "Having health insurance is the first step in ensuring the youngest New Jerseyans have a healthy start in life."
In a statement, New Jersey Hospital Association President and CEO Elizabeth A. Ryan, Esq. said, the Insured for Sure program will take away obstacles families without insurance encounter in getting healthcare coverage, and help them enroll their children in a health plan.
"NJ FamilyCare can give New Jersey's children a healthy start in life, but there remain a number of families that fail to enroll," Ryan said. "What better place to reach out to these families than the very hospitals they turn to when in need?"
The Centers for Medicare & Medicaid Services has announced final changes to policies and payment rates for services to be furnished during 2010 by over 1 million physicians and nonphysician practitioners who are paid under the Medicare Physician Fee Schedule. The 2010 Medicare Physician Fee Schedule will recalculate estimated utilization rates for imaging equipment—raising it from 50% to 90%—which will lead to significant reimbursement cuts for cardiologists, radiologists, and other specialists. The money CMS saves will be used to boost payments to primary care doctors by 5%-8%.
Once again, news about a partnership between physicians and private industry has sparked controversy in the medical community. I'm not referring to the physician who claims he was fired for raising concerns about an inappropriate relationship between Lahey Clinic and Medtronic; or the 15 states that are suing Amgen, Inc. because they think the biotech giant provided kickbacks to medical providers to boost sales.
In fact, this time the controversy isn't related to drug or device companies at all.
A number of family practice physicians are upset with the American Academy of Family Physicians for partnering with Coca-Cola Co., the world's No.1 soft-drink maker, to develop consumer education content about beverage sweeteners and other health topics.
The health information will appear on familydoctor.org, and the AAFP will retain complete control over developing the content, says Douglas E. Henley, M.D, FAAFP, executive vice president and CEO for AAFP. That content will be pulled from evidence-based guidelines, and when appropriate will point out the health hazards of sugary beverages, he says.
"We've been asking members to not rush to judgment and hold us accountable for content we develop, understanding that's two or three months away. We believe that we can manage this relationship appropriately," he adds.
But it's not necessarily the content development that has drawn physicians' ire. Coca-Cola provided a six-figure grant to the AAFP, and not for nothing. The soft-drink company can brand itself, within strict limits, as a partner with familydoctor.org, and that association with a physician organization will be good for its image at a time when sodas and surgery beverages are under fire for contributing to America's obesity epidemic.
The AAFP insists that the alliance does not equate to an endorsement of Coca-Cola products (and Henley reminded me that the company makes more than just sugary beverages). But will patients be able to see the distinction? Some may be a little confused by the mixed messages when physicians are telling them to avoid too many sugary beverages for health reasons.
The dust up was serious enough that more than 20 physicians from Contra Costa Health Services in Martinez, CA, made a public show of resigning from AAFP in protest of the deal, and a handful of doctors have started a Facebook petition to end the partnership.
"I am appalled and ashamed of this partnership between Coca-Cola and the AAFP," said William Walker, MD, who had been an AAFP member for 25 years, in a press release. "How can any organization that claims to promote public health join forces with a company that promotes products that put our children at risk for obesity, heart disease and early death?"
What I find interesting about this controversy is what it says about the changes in medical priorities and physician culture. Physicians have always been conscious about corporate influences on public health, and there has always been a line that most doctor organizations won't cross. For instance, Henley says the AAFP wouldn't have had a similar partnership with companies that produce tobacco products or alcoholic beverages.
It appears that there is now disagreement about where that line should be drawn; or perhaps the line has already moved and the AAFP hasn't realized it yet. For many providers, obesity has become priority number one when it comes to improving the overall health of their patients.
On the surface, the AAFP partnership is harmless enough, and they'll probably produce quality health content, particularly after the initial pressure from members. But in the near future, the alliance may be viewed with the same bewilderment and disappointment as the partnerships between physicians and tobacco companies from way back, when doctors hawked mild cigarettes before knowing the true health consequences.
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Employment discrimination lawsuits have doubled in the past 10 years, due largely to provisions of the 1991 Civil Rights Act that give juries a say in financial settlements. Among the headlines: Publix supermarkets got slapped with an $82.5 million class-action sex discrimination settlement and Coca Cola paid nearly $192.5 million in 2000 to settle a class action.
We could cite many examples, but the point is that juries are ready and eager to shower aggrieved litigious former employees with millions of dollars at your business' expense.
"Plaintiffs don't win a huge percentage of lawsuits, but that percentage goes up a lot if there is a jury trial," says Michael D. Malfitano, attorney at Florida-based Constangy, Brooks & Smith, LLP (CBS). "After 1991, when jury trials came into play, the percentage of plaintiffs' wins increased and the dollar amounts increased."
"Most jurors are working people with family members who may have had problems with employers at some point," Malfitano says. "So there is a natural empathy with the working person who is the plaintiff."
The good news is that because of their relatively small size and close working relationships, physician practices are less likely than larger healthcare entities, such as hospitals and nursing homes, to find themselves in an employment suit, he says.
So what can you do to reduce your potential liability? Malfitano and his colleague, CBS attorney Cherie L. Silberman, have identified three pre-employment mistakes, errors committed during the recruiting and hiring process:
1. Failure to conduct an adequate background check on potential employees. Did you conduct a criminal background check, contact the references, ask about previous convictions, but not arrests, and check his or her driver's license?
2. Inconsistent recruiting and hiring practices. Are you thorough in the hiring process with some employees but not others? "When employers don't apply policies consistently, it looks to a juror like they may be discriminating," Silberman says.
3. Inappropriate interview questions and comments. This is a real minefield. Although you want to be thorough in your hiring process, you also have to be careful about what questions you ask. For example, you can ask about criminal convictions, but not arrests. You cannot ask about the status of military discharge, and questions about education must be thoroughly screened. Avoid questions related to religious or social issues, as well as those related to physical or mental health.
"Where employers get in trouble is where it may not seem so harmful, say in casual chatter," Silberman says. "[For example], if someone says they're moving into town and you ask if it's so they can be closer to their husband. The intent doesn't matter."
This article was adapted from one that originally appeared in the November 2009 issue of The Doctor's Office, a HealthLeaders Media publication.
When it comes to paying for healthcare, the United States—when compared with 10 other industrialized countries—tops the list as having the highest spending per capita ($7,290), while lagging behind those nations in access, quality, and use of health information technology, according to the Commonwealth Fund's 12th annual international health policy survey.
The spending per capita was 50% more than the next highest country, Norway ($4,762), and triple the rate of the lowest country compared with in the study, New Zealand ($2,510), according to the survey that appears Thursday in an online issue of Health Affairs. More than 10,000 primary care physicians were surveyed this year in the countries that also include: Australia, Canada, France, Germany, Italy, the Netherlands, Sweden, and the United Kingdom.
"An overriding message of this survey ... is that access barriers, lack of information, inadequate financial support for preventive and chronic care undermine primary care doctors' efforts to provide timely high quality care," said Karen Davis, the Commonwealth Fund's president, at a telebriefing discussing the findings. This puts "the U.S. far behind what other countries are achieving."
"The concept of the patient-centered chronic care model using teams [and] engaging patients to help prevent complications originated in the U.S. But we find such efforts are spreading faster in other countries," said Commonwealth Fund Senior Vice President Cathy Schoen, a lead author of the article. "We need to close the performance gap for the health of the nation."
Among the areas examined in the survey are:
Access and Barriers to Care. More than half of American physicians (58%) reported their patients had difficulties paying for medications or other out of pocket costs, compared to between 5% and 37% in the other countries.
U.S. physicians also were four times or more as likely as physicians in some other countries—Australia, Netherlands, Sweden, and the U.K.—to report major problems with the time they or their staffs spent in getting patients needed medication or treatment because of insurance coverage restrictions.
After hours care outside the emergency room. Many American primary care physicians (71%) said they had no arrangement for access to care after normal office hours—except for directing patients to a hospital emergency room. This was a drop from 40% in the 2006 international health policy survey, Schoen said.
On the other hand, nearly all physicians in the Netherlands (97%), and many in New Zealand (89%) and the U.K (89%) report after-hour provision, as do more than three of four doctors in France (78%) and Italy (77%).
Health information technology. While about half (46%) of U.S. primary care physicians reported using electronic medical records (EMR)—up from 28% in 2006—American primary care practices, along with those in Canada, continued to lag behind other leading countries. EMRs were found in nearly all practices in the Netherlands (99%), New Zealand (97%), the U.K. (96%), Australia (95%), Italy (94%), Norway (97%), and Sweden (94%).
Use of care teams and systems to care for patients with chronic Illness. Teams that include health professionals, such as nurses, served an important role in managing care—especially for chronic conditions. The survey found that the use of teams was widespread in Sweden (98%), the U.K, (98%), the Netherlands (91%), Australia (88%), New Zealand (88%), Germany (73%), and Norway (73%). The use of teams was less frequent in the U.S. (59%), Canada (52%), and France (11%) based on physician reports.
Tracking medical errors. The study found that half or more primary care physicians in Canada, France, Germany, Italy and the Netherlands report not yet having a process to identify "adverse events" and take action. About 20% of American primary care physicians said they have a process that works well to identify risks and take follow up actions, while a third said they have no process.
Financial incentives to improve quality. Every country in the survey used financial incentives to improve primary care, preventive care, or disease management. However, primary care physicians in the U.S. were among the least likely to report that they received financial incentives for quality improvement efforts, such as bonuses for achieving high patient satisfaction ratings or managing patients with chronic disease or complex needs.
The American College of Surgeons, a group representing 200,000 doctors in 20 surgical specialties, says it will fight health reform as proposed by the Senate Finance Committee, because "it will make an already-flawed system worse" in six ways.
A. Brent Eastman, MD, chairman of the ACS Board of Regents, emphasizes that the doctors are not opposed to health reform per se, and supports changes to provide cost-effective, high-quality care.
But "too many of the provisions that the Senate Finance Committee considered put patient access and quality improvement at risk," says Eastman, who also a trauma surgeon and chief medical officer at Scripps Health in San Diego.
He made the statement yesterday on behalf of 19 other professional societies, including anesthesiology, colon and rectal, endoscopic, gastrointestinal, neurology, obstetrics and gynecology, ophthalmology, orthopaedic, osteopathic, plastic, urology, and vascular surgeons. Their objections were sent in a letter yesterday to Senate Majority Leader Harry Reid.
"This is the first time you're seeing a large group of physicians, surgical organizations stand up" to oppose this, says Christian Shalgian, ACS' director of advocacy and health policy. Though ACS has sent six or seven letters over the last year expressing objections as health reform language began to take shape, "our concerns have been quite frankly ignored."
Eastman stresses that the doctors are not opposed to health reform, and favor the recently released proposals in H.R. 3962, the Affordable Healthcare for America Act, as well as the Sustained Growth Rate formula fix, H.R. 3961.
But the groups are opposed to the Senate proposals because they contain the following six provisions:
1. It would mandate that all physicians participate in Medicare's "seriously flawed," Physician Quality Reporting Initiative, and penalize those who decline. The PQRI program, which was launched for voluntary physician participants in 2006, calls for doctors to submit quality data on how they provided 100 types of care, such as whether appropriate antibiotics were administered prior to surgery.
In exchange for volunteering the information, the doctors were to receive bonuses in their reimbursement.
However, after CMS told doctors to send in their quality data, and after doctors faithfully followed the instructions, CMS "acknowledged that the instructions were wrong; that they had made mistakes, and that they would fix the problem and come back to doctors with a clear set of instructions," Eastman says.
"That was in 2007—we are now almost to 2010—and we still haven't heard from them what that clear set of instructions are supposed to be. And now the Senate want to mandate that we participate in the program?" says Eastman.
He adds, "This doesn't make any sense, and it certainly won't improve quality."
"They would go the whole year submitting their data, but never got the bonus payments," adds Shalgian. "They'd contact CMS, which said the doctor 'didn't participate appropriately, didn't send in the right information or sent it in on the wrong form.'"
Additionally, Eastman and Shalgian, say that participating physicians have received little, if any, of the bonus payments that were promised.
Officials for CMS were asked to respond Wednesday, but press officer Joe Kuchler says they could not comment on the accusations on such short notice.
2. Under the Senate plan, Medicare would give 10% bonus payments to primary care and family physicians as a workforce incentive, but half of that bonus would be financed by cuts in surgeons' pay. This would have an especially discouraging impact on the workforce of surgeons in underserved and rural areas.
3. The Senate plan would reduce payments to doctors who have the highest utilization of procedures "without regard for patient acuity or complexity."
4. The Senate proposal would establish an independent Medicare Commission whose decisions would become law without a separate vote of Congress. These individuals would not be elected, and would have no accountability to the public, yet would get to decide what treatments or procedures would be reimbursed under Medicare and which ones would be categorically denied, Eastman says.
5. The Senate plan would establish a budget-neutral value-based payment modifier, which CMS does not currently have the capability to implement. It also would place the provision on an unrealistic and unachievable timeline.
6. Under the Senate proposal, physicians would pay a fee to cover a background check in order to participate in Medicare, despite the fact that doctors already pay fees for training, licensure, and board certification.
Eastman sums up the groups' adamant objections, saying: "We are 100% behind quality improvement—it is our heritage and a constant focal point for surgeons—but it is foolhardy to mandate an unsuccessful program."
Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program Integrity Contractor (ZPIC), has begun requesting medical records for review.
The ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. According to the CMS Program Integrity Manual, ZPICs may "take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped."
During HCPro's November 3 audio conference, Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.
This information came as a mild surprise to Robert Wade, partner at Baker and Daniels, LLP, in South Bend, IN. Wade said ZPICs have the authority to start reviews as soon as they are awarded the contract, and Health Integrity was awarded the zone four contract in February.
Facilities should be aware that ZPICs could notify the facility via fax a mere hour before the visit. This can leave little time for the facility to prepare. Wade said in situations where ZPICs give short notice, facilities are within their rights to supplement any requested records with supporting documentation even after the visit is complete.
So far CMS has awarded only three of the seven ZPIC contracts:
Zone 4: Colorado, New Mexico, Oklahoma, and Texas—Health Integrity LLC
Zone 5: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia—Advance Med
Zone 7: Florida, Puerto Rico, and Virgin Islands—SafeGuard Services LLC
So what does this information mean for providers that are within one of these zones?
"They can come knocking at any time," Wade said.
Consequences of a ZPIC review include payment denials, recoupment of overpayments, and referral to other law enforcement agencies. Because ZPICs can refer cases to the Department of Justice, Office of Inspector General, or other law enforcement agencies, a ZPIC review may only be the first step in a long legal battle.
If anyone needs more evidence that healthcare spending is concentrated at the end of life, here's another raft of confirming statistics from the federal government for 2007.
The statistics were released by the federal Agency or Healthcare Research and Quality, which analyzed 765,651 hospital patient deaths in 2007. The statistical brief issued yesterday is the first analysis of the cost of death for payers other than Medicare.
One of every three people, who died in the U.S. in 2007, died in a hospital, or 765,651 of 2,423,995 deaths. Although 1.9% of hospital admissions resulted in death, their care cost 5.2% of all spending for hospital inpatient care by all payers, or $20 billion.
The average hospital cost for a stay ending in death was nearly three times higher, about $26,000, than the cost of a patient who was discharged alive, which was $9,447. The cost for patients who died was higher because their stays were 8.8 days vs. 4.5 days for those who lived.
Adding fuel to hospital concerns about preventing hospital-acquired infections, the leading principal diagnosis for patients who died while receiving inpatient care was septicemia, or infection of the bloodstream.
Those infections were responsible for 15% of all deaths, the leading principal diagnosis in hospital mortality. Of all patients diagnosed with septicemia in the hospital, 17% died in the hospital.
Other causes of death in the hospital included respiratory failure, aspiration pneumonitis, cancer of the bronchus, acute cerebrovascular disease or stroke, pneumonia, heart attack, congestive heart failure, secondary cancers, and acute and unspecified renal failure.
Of the patients who died in a hospital, 73% had one or more procedures while 27% had no procedures. Those with procedures were more likely to die than those who did not. One in four patients who died had a respiratory intubation and mechanical ventilation. Other procedures in people who died included vascular catheterizations other than the heart.
Twelve percent of patients, or one in eight patients who died in a hospital, was admitted for an elective procedure or other non-urgent reason while 72% came through the emergency room. Only 7% of patients who died in a hospital were admitted to hospitals because of unintentional or intentional injuries, and 2% were newborn infants.
Medicare was the coverage source for 67% of all inpatients who died in a hospital, at a cost of more than $12 billion. That accounted for 7% of all Medicare inpatient costs.
If you are in a hospital, you are more likely to die in the Northeast than in the Midwest, which had the lowest inpatient death rate, 1.8%, compared to 2.13% in the Northeast, 1.96% in the South, and 1.89% in the West.
House leaders will hold a rare Saturday vote on the expansion of the U.S. healthcare system. Democrats are still locking down support among a handful of holdouts, with the biggest bloc dissatisfied with the measure's handling of abortion. In other news, a bill that Republicans expect to offer as an alternative to the Democratic package received its assessment from congressional budget analysts, who concluded that the proposal would barely dent the ranks of the uninsured.
