Connecticut is receiving more than $1.2 million in federal stimulus money to help fight illnesses and infections contracted during hospital stays. The funds are designed to assist the state to help hospitals better monitor and prevent such infections.
As a small fraction of the nasal spray version of the new swine flu vaccine began arriving at local health departments, plans for limited distribution were being formulated or revisited from earlier in the decade, when fears of an avian flu pandemic sparked a rush of emergency preparedness. But health officials are struggling to communicate information to the public and make the general population aware that the first doses were not being widely distributed, the New York Times reports.
Six members of the House of Representatives signed a letter written to HHS Secretary Kathleen Sebelius that urges HHS to repeal or revise the harm standard provision in HHS' interim final rule on breach notification.
The rule was published in the Federal Register August 24 and took effect September 23.
HHS added a provision that says an unauthorized use or disclosure of PHI is considered a breach only if the use or disclosure poses some harm to the individual. Part of the goal is to eliminate notification on incidental breaches, such as a fax to the wrong department within an organization.
The Congressmen, all but one of whom are Democrats, wrote they are "deeply concerned" about the harm provision because it gives covered entities and business associates (BAs) a "breadth of discretion" as they determine the level of harm to an individual whose PHI was inappropriately disclosed.
Congress explicitly rejected a harm standard when it crafted the American Recovery and Reinvestment Act of 2009 (ARRA), which includes tougher HIPAA enforcement and greater breach notification requirements.
Prior to ARRA becoming law, the Committee on Energy and Commerce proposed a similar definition of a breach. It required patients to be notified if the unauthorized use of PHI could "reasonably result in substantial harm, embarrassment, inconvenience or unfairness to the individual," according to the letter to Sebelius.
However, Congress rejected and passed a "black and white" standard on breach notification that "makes implementation and enforcement simpler," the Congressmen wrote.
The legislation includes a "safe harbor for information that is rendered unusable, unreadable, or indecipherable to unauthorized individuals, and other specific exceptions," the letter continued. "The primary purpose for mandatory breach notification is to provide incentives for healthcare entities to protect data, such as through strong encryption or destruction methodologies, and to allow individuals to assess the level of unauthorized use or disclosure of their information."
Chris Simons, RHIA, director of UM & HIM and the privacy officer at Spring Harbor Hospital in Westbrook, ME, says the harm threshold provision in the interim final rule leaves the rule "nowhere near as strict as I was expecting."
"Privacy officers should be breathing a sigh of relief that those faxes sent by mistake to one doctor instead of another, for instance, will not be required to be reported," Simons adds.
Covered entities and BAs may get off the hook on some breaches with good reason. But at other times the harm threshold may lead them down the wrong road, misjudging or underrating the impact of the breach.
Kate Borten, CISSP, CISM, president of The Marblehead Group in Marblehead, MA, says, "The bad news from a privacy compliance perspective is that while the harm threshold approach requires organizations to perform and document a risk assessment in every instance, introducing the concept of a subjective harm threshold can be seen as a big loophole that some organizations will stretch."
The letter to Sebelius was signed by:
Henry A. Waxman (D-CA)
Chairman
Committee on Energy and Commerce
Charles B. Rangel (D-NY)
Chairman
Committee on Ways and Means
John D. Dingell (D-MI)
Chairman Emeritus
Committee on Energy and Finance
Frank Pallone Jr. (D-NJ)
Chairman
Subcommittee on Health Committee and Energy and Commerce
Pete Fortney Stark (D-CA)
Chairman
Subcommittee on Health
Committee on Ways and Means
Joe Barton (R-TX)
Ranking Member
Committee on Energy and Commerce
After learning about the above-average hospital-acquired infection (HAI) rates, SUNY Upstate University Hospital in Syracuse, NY, kick-started a fast-paced improvement program to reduce central line infections in all ICUs throughout the facility. A year later, the hospital has reduced its rate to zero, says David Duggan, MD, medical director and quality officer at University Hospital.
"We have tried to look for solutions that make it easy for people to do the right thing, and I think that's the key," Duggan says.
Duggan explains that although infection prevention improvements have helped lower the HAI rate in the med-surge ICU, one of the primary reasons this particular six-bed unit was so high was because it was part burn unit and part general ICU.
"Burn units, when they are standalone units, are actually excluded from this measure because infections are so common in patients with burns," Duggan says. "This unit was included because it did not have the majority of patients with severe burns, but still there was a component of the population there that was extraordinarily susceptible to infections."
Shelley Gilroy, MD, the hospital epidemiologist at University, explains that burn patients can easily become infected with an indigenous flora.
"That's why they are considered a high-risk group and why we might have had an increase in the rate," she says.
The unit was included on the report because it was technically a general ICU, but the numbers didn't account for these susceptible burn patients, Duggan says. Still, a published infection rate that was more than three times the state average elicited a primary focus on infection control.
Implementing the bundle
At the beginning of the year, University formed a multidisciplinary group made of roughly 12 people with the task of implementing the Institute for Healthcare Improvement's (IHI) central line bundle. The group developed forms and documentation that included a checklist, one of the major parts of the bundle.
The group also implemented procedure carts for maximum barrier precautions so that all the required equipment was present at the bedside at the time of the procedure.
Duggan says a very important reason the hospital was able to reduce infection so quickly was because they joined the University HealthSystem Consortium, a membership organization of 103 academic medical centers and 219 affiliated hospitals created to improve the clinical, operational, and financial performance of healthcare facilities.
University joined a group sponsored by the Consortium, which dictated the time frame to implement change, Duggan says. The hospital organized weekly conference calls with the group that assisted University in educating staff members about the bundle and instituting revamped IC policies quickly and effectively.
"They said if you want to join this group get ready to run," Duggan says. "So we put on our track shoes and ran with them and really implemented change in a very short period for a large institution."
Continuing improvement
Although implementing the IHI bundle and improving staff education helped dramatically reduce infections, the quality team at University Hospital has taken additional steps to make IC compliance even simpler.
The hospital recently integrated an electronic data-mining system that pulls in IC information from the laboratory, the pharmacy, and the units so IPs can easily sift through pertinent data.
The hospital has also invested $250,000 to purchase ultrasound technology to use with central line insertion. This device makes it much easier for the physician to correctly insert the line. Duggan says the hospital wanted to implement this technology with the bundle, but the cost delayed the process so it elected to implement the bundle first, and incorporate the ultrasound later.
"We didn't want to delay the IHI bundle so we implemented that, and now we are going to retrain everyone in the hospital on how to place central lines with ultrasound guidance," Duggan says.
As hospitals across the country feel pressure to cut costs and improve operational efficiencies, the role of the hospital supply chain becomes increasingly important. Hospital supply chain issues are no longer just the concern of materials management departments and service line VPs. C-suite executives are also getting heavily involved. When they do, they should first know five critical points when it comes to supply chain management.
Disconnects in supply chain and revenue cycle lead to financial loss
Many hospitals don't realize that cash is leaking out of their organization due to a lack of coordination between their supply chain and revenue cycle areas. The financial impact of this fragmentation can be substantial—millions of dollars each year for some providers-- particularly associated with costly medical devices, such as implantable items. It's essential that hospitals connect the revenue and spend management sides of their organizations in order to gain a true understanding of their financial issues and needs.
Traditional supply chain metrics are failing hospitals
Expense performance metrics have been traditionally based on a percentage of hospitals' revenue, expense or Medicare Case Mix Index. What's missing from these metrics is a way to account for the supply intensity for the specific patient population of a particular hospital. Without this information, hospitals cannot accurately predict supply costs. Today there are new ways for hospitals to answer the questions of: "What should my level of supply chain spending be given the numbers and types of patients I treat?"; "How are we doing on our supply expenses?"; "How do we compare to other facilities?" and "What can we do better?" Executives should ensure that the methods they are using to predict supply costs can truly answer these questions.
Business intelligence tools are essential for controlling supply costs
When supply costs are not managed well, savings erosion can accumulate quickly and can be as high as 60% on any key supply contract within as little as six months after execution. That's why it's critical for hospitals to have access to the right metrics for managing supply costs. Business intelligence tools today can accurately gather, interpret and report clinical, financial, and cost data to help drive physician engagement and impact clinical supply cost and utilization. Executives should ensure that their organizations have ongoing access to metrics, such as: gross profit margin by case; net profitability by case, procedure and service line; physician payer mix, reimbursement and profitability by case, procedure and service line and detailed costs and supply utilization profiles by physicians, by case. Finally, having a road map in place to create actionable initiatives is an essential component.
Physician engagement is a must in reducing supply costs
Physician preference items (PPI) account for 40% of non-pharmacy supply spend, with prices and consumption continuing to rise. To successfully engage physicians and get them on board to reduce supply costs, hospitals must have the right data and information to ensure physicians that cost reductions will not compromise patient outcomes such as length of stay, time in the OR, and other clinical factors. Physicians are significantly more likely to accept implant cost reduction when a complete context of what drives cost for their cases is presented, along with recognition of the complexity of their daily jobs. Executives should ensure that their organizations have a way to marry supply costs and demand information with patient billing and utilization data to develop the complete picture of current clinical practice and utilization at the hospital and successfully engage physicians.
Supply chains as agents of change
When managed correctly, hospital supply chains can become a change agent for accomplishing organization-wide goals and objectives. With the right metrics and methodologies in place, supply chains can optimize both their transactional and strategic roles to drive bottom-line improvements for hospitals.
Rand Ballard is senior executive vice president and chief operating officer with MedAssets, Inc. He may be reached at solutions@medassets.com.
Hospitals are where medical miracles are performed each day. But given the tenor of the healthcare debate, it seems that many also think of hospitals as a big part of the problem of increasing healthcare costs, as havens of just plain old waste, and as a good place to go if you want to get sicker through debilitating infections or medical mistakes. As CEO, you're in charge of that perception, right or wrong.
In the big picture, that perception is largely deserved, I'm sorry to say. Several studies have suggested waste in healthcare of near 30%, the Institute of Medicine shook the establishment years ago when it published its "100,000 Lives" study, and stories about surgical instruments left in patients or the infections they get while in the hospital are regularly among the most-read, according to our statistics.
And whether this perception is reality for the majority of hospitals or not, just like it took a lot of mistakes, miscalculations, and misplaced priorities for hospitals to get to this place of dubious distinction in the American psyche, it's going to take a lot of hard work to recover from it, even if you are one of the good guys.
Speaking of good guys (and gals) this new breed of CEO doesn't backslap at the chamber of commerce. He doesn't recruit important specialist physicians over rounds of golf or rounds of martinis. She doesn't spend her time playing the political games that many seem to feel are so necessary for modern hospitals' survival. OK, maybe sometimes he or she does those things, and still needs to, but more often, the people who will be leading hospitals 10 years from now roll up their sleeves, talk to their lieutenants, and motivate caregivers to help reduce waste and achieve better outcomes. That is, after all, the stated reason for the hospital's existence in the first place.
Doing the hard work of improving outcomes and taking better care of patients is a process that's been going on for nine of the 13 years that Jim Anderson has been at the helm of Cincinnati Children's Hospital.
"I was unburdened by knowledge of how healthcare really worked and it was clear there was a dramatic difference in attitude and approach to quality," he says (as opposed to his previous work as president of an industrial company where improvement and quality were near theology). "That was perplexing and intriguing to me, but I didn't know what to do with it until IOM's 100,000 lives program."
In early 2000, Anderson says, he and the hospital's top leaders were exposed to the idea of family-centered care as the featured characteristic of better healthcare outcomes.
"Healthcare is dysfunctional and the opportunity to focus on processes to provide better value was a critical underdeveloped area, filled with enormous opportunity," says Anderson, who will retire at the end of the year.
OK, yes, it's a children's hospital. And adult hospitals face vastly different—some claim more difficult—challenges than their children's hospital counterparts. But that doesn't mean you can't learn plenty of lessons from their examples. Stay tuned. Next week I'll tell you more about the specifics of how Cincinnati Children's solved the problem of improving outcomes while still growing revenues at a 15%-a-year clip.
"We didn't intend to be ahead of our time," he says, "but the evidence just made such compelling argument."
Commenting about the status of the House healthcare reform bill (HR 3200) Thursday, House Speaker Nancy Pelosi (D-CA) said, "We're coming around the curve, but we're not in the stretch yet. What she meant is that the bill is now being prepared for the Congressional Budget Office (CBO) for scoring—or determining how much it will cost.
Meanwhile, the Senate Finance Committee will vote on its bill, which received a preliminary CBO score this week, on Tuesday.
Included with the House bill will be a "robust public option," she said. "I think it's very clear from our conversation with the [House] members that the votes are there for a public option." The anticipated cost of the public option is expected to be $110 billion over a 10-year period.
At the same time, she admitted that the House still is examining ways to generate income that will offset reform costs. In particular, they were "looking at what the Senate has done and to see if there is any common ground" that could be found there, she said.
"But at the same time, I thought that there was more the insurance companies could contribute to this healthcare reform. After all, they are going to get 50 million new consumers and many of them subsidized are by the taxpayer," she said. She said both insurers and the pharmaceutical manufacturing industry both have "much more that they can put on the table."
This action is occurring at the same time House Ways and Means Chairman Charles Rangel (D-NY) has found himself increasingly under scrutiny. On Thursday, he House ethics committee said it was expanding its investigation of the congressman—looking at allegations in his ongoing case related to the restatement of his personal finances this summer.
A Republican sponsored resolution that tried to remove Rangel from his chairmanship position was voted down on Wednesday. However, House Minority Leader John Boehner (R OH) on Thursday repeated his call for Rangel to step down until the committee completes its investigation. "We're going to continue to press this case," he said.
An estimated 206 patients at an unnamed healthcare facility have received CT scan radiation doses that were eight times normal levels, the federal Food and Drug Administration warned.
The agency said yesterday the overdose exposures came about during multi-slice CT imaging to diagnose and treat stroke over an 18-month period. The agency, which said it is investigating the incidents, did not release the hospital's name, location or period of time the excessive radiation doses occurred, saying only that it "has become aware" of the overexposures.
"Instead of receiving the expected dose of .5 Gy (maximum) to the head, these patients received 3-4 Gy (a unit of absorbed radiation dose due to ionizing radiation). In some cases, this excessive dose resulted in hair loss and erythema (redness of skin). The facility has notified all patients who received the overexposure and provided resources for additional information," the agency said.
The FDA called the magnitude of the overdose "significant" and said it may reflect more widespread problems with CT quality assurance programs, "and may not be isolated to this particular facility or this imaging procedure (CT brain perfusion)."
Lower doses of radiation than 3-4 Gy, but which are higher than .5, may not cause obvious radiation injury, but underlying problems "may go undetected and unreported, putting patients at increased risk for long-term radiation effects," the FDA said.
FDA officials added they are "working with the parties involved to gather more data about this situation and to understand its potential public health impact. As FDA obtains more information that better defines the problem, we will be better able to determine if there are more widespread risks."
The notification was distributed to CT facilities, emergency physicians, radiologists, neurologists, neurosurgeons, radiologic technologists, medical physicists, and radiation safety officers.
The agency urged hospitals and other users of CT devices "to report deaths and serious injuries associated with the use of medical devices," including adverse events related to CT devices that do not meet requirements for mandatory reporting."
Earlier this year, California health officials fined Mad River Community Hospital in Arcata, CA, $25,000 because of an incident in January 2008 that put one youngster in immediate jeopardy.
A 23-month-old boy was given a massive radiation overdose during a series of 151 CT scans of his cervical spine over a 65-minute period.
The patient, Jacoby Roth, received an estimated 2.8-11 Gy, much higher than the dose he should have received. The child had been admitted to the emergency department for a possible neck injury resulting from a fall out of bed at home. An X-ray showed a possible injury.
The child's injuries included redness on the patient's left and right checks. The boy's parents have filed a lawsuit alleging medical malpractice and battery. An expert epidemiologist has suggested the child is at increased risk of cancer.
Nearly 2% of health providers, including 1.6% of physicians and osteopaths, are practicing without a license and 18.7% have some cloud on their credentials, according to a new report from a company that checks licensing, credentialing, and malpractice litigation history.
The survey, published by Medversant of Los Angeles, used a patented tracking system to provide background checks on nearly 30,000 health practitioners for clients, such as state governments, hospitals, health plans, and nursing registries.
Matthew Haddad, president and CEO of Medversant, says the finding of so many practitioners who shouldn't be practicing is alarming, and points to a potential for widespread fraud.
"What's often the case is that when you have a provider billing who is not licensed, very often that patient is fictitious," he says. He adds that many state and federal agencies are interested in the finding in an effort to prevent paying bogus claims as well as safeguard quality of care.
The Medversant system checks for daily updates on licensees, which Haddad says is a vast improvement over the routine practice of checking once every two to three years, a requirement from The Joint Commission, healthcare accrediting organizations, government regulatory agencies, and the Center for Medicare and Medicaid Services.
The survey also revealed:
Adverse findings were found in 20.4% of 20,243 physicians, 13.5% of 208 dentists, 25.8% of 585 podiatrists, 6.4% of chiropractors, 11.3% of 646 physician assistants, 9% of 1,621 nurse practitioners, and 8.7% of 5,475 allied health professionals.
Expired, cancelled, delinquent, inactive, lapsed, not renewed, not registered, null and void, revoked, suspended, surrendered, terminated or voluntarily surrendered licenses were discovered among 5.1% of physicians assistants, 2.8% of nurse practitioners, 2.7% of allied health professionals, 2% of podiatrists, 1.6% of physicians and osteopaths, 1.4% of dentists, and .7 % of chiropractors.
Among the 29,845 practitioners reviewed, 80 were either deceased or retired. "These practitioners, at the time of license verification, were listed in one or more health plan provider directories as a participating provider."
The company is marketing its services in an effort to help payers guarantee quality of care.
It checks the Educational Commission for Foreign Medical Graduates, specialty board certifications, licensing agencies, the Drug Enforcement Administration, state controlled drug and substance agencies, professional liability coverage listings and claims history, the National Practitioner Data Bank, healthcare facility affiliations, employment, peer references, and history of failure to disclose adverse actions.
For example, a state government might wish to know whether a Medicaid provider who files a reimbursement claim is licensed to provide the service. A hospital may wish to validate the disciplinary peer review history of a physician seeking staff privileges. And a health plan may wish to expand its network to providers within a certain network.
"The consequences to an organization that employs or uses services from an unlicensed physician can be extreme," Haddad says, even if the license is merely overdue for renewal.
He recalls a case in Georgia involving a home health therapist employed by an agency owned by a chain of hospitals. The therapist had failed to renew his license, and subsequently was involved in a negligence suit involving a patient death in the home.
"Even though the negligence wasn't caused by the license issue, or linked to negligence, the court ruled it was a liability for the hospital because the therapist did not have a license at the time," Haddad says.
According to the company's report, the number of practitioners with problematic credentials or licenses, or an unusual number of malpractice payouts has gone up since the previous report was done in February 2008. In that earlier report of 9,600 practitioners, 11.3% "were practicing with one or more of 52 questionable findings."
In the latest survey of 29,845 practitioners, 18.7% were found to be practicing with one or more of 110 questionable findings, and 8.9% had one or more reports in the National Practitioner Data Base. Of those with problems, 4.6% had one or more license actions requiring review according to accreditation and regulatory standards.
The Medversant survey noted that a 2006 report from the National Practitioner Data Bank suggested that practitioners with more than one malpractice payment report "are responsible for more than half of malpractice payments made, and are one third more likely to have other adverse findings than practitioners with a single malpractice payment report."
"Continuous monitoring of credentials can be shown to identify higher risk practitioners who might otherwise be missed in a traditional biennial or triennial credentialing process," the survey said.
Rapid City, SD-based Regional Hospitals and Regional Senior Care facilities are asking anyone displaying symptoms of the H1N1 virus to stay away. The facilities are also discouraging visitation by children under the age of 12 to limit a potential H1N1 outbreak.
