Announced plans to move military detainees from Guantanamo Bay to the United States to face trial could have lingering effects on hospital security departments.
And in the broader picture, the concern is not just about Guantanamo detainees—it's about all high-value prisoners who might show up in your emergency room.
"I think it would serve [hospital executives] well to take a real look at what they've committed to" in terms of treating prisoner patients, says James Blair, FACHE, president and CEO of the Center for HealthCare Emergency Readiness based in Nashville.
First detainee arrives on U.S. soil
On June 9, Ahmed Khalfan Ghailani, a detainee from the U.S. military prison in Guantanamo, appeared in a federal courtroom in New York City to face conspiracy charges related to the 1998 bombings of U.S. embassies in Kenya and Tanzania.
When not in court, Ghailani—an alleged member of Al Qaeda—is being held at the Metropolitan Correctional Center, according to The New York Times.
The correctional center, which is overseen by the Federal Bureau of Prisons, is in Lower Manhattan, across the street from the courthouse. Hauling Ghailiani between the prison and the courtroom, even under tight security, "opens windows of opportunity for anyone who would try to spring him," Blair says.
In the case of terrorism suspects, the threat rises because sympathizers within a parent organization have the patience and expertise to plot intricate escape plans, adds Blair, who is a former chief of education and training for the U.S. Office of the Army Surgeon General.
A common arrangement for hospitals
Many U.S. hospitals have contracts in place to help prisons and jails handle medical treatment for prisoners. Prisoner patients typically arrive at a medical center under the control of one or two prison officers.
Over the years, there have been dozens of incidents where prisoners attempt to escape custody while at a medical facility. Some turn deadly, such as a prisoner patient escape from Montgomery Regional Hospital in Blacksburg, VA, in August 2006, during which the suspect shot and killed a security officer in the facility as he fled.
"I don't care if you are a 30-bed hospital or a 1,000-bed hospital—you are getting [prisoner] patients one way, shape, or form," says James Kendig, MS, CSE, CHSP, vice president of safety, security, and clinical transport services at Health First, Inc., in Melbourne, FL. Kendig spoke recently to HealthLeaders' sister publication, Healthcare Security Alert.
It is important for hospitals with federal prisons in their community to think ahead of time about security issues surrounding prisoner patients, Blair said.
CEOs and hospital security directors should take the following two actions, as outlined by Blair:
Verify whether the hospital has a contract for prisoner care in regular times or will provide mutual aid for prisons during a community disaster
Determine what steps the Federal Bureau of Prisons will take to guard prisoner patients coming to your hospital
Kendig helped create a PowerPoint presentation that trains law enforcement officers about the nuances of taking prisoners to healthcare facilities for treatment. The Florida Hospital Association has posted the video on its Web site (scroll down to the Law Enforcement and Corrections Training for Hospitals" link).
Blair says he worries about high-value prisoners, such as terrorism suspects, if they are transported to a hospital for a feigned illness. He imagines a plot in which sympathizers bomb the hospital's emergency department as a diversion for local law enforcement and then forcibly free the prisoner en route while police presence is elsewhere.
This scenario might be a good test of the hospital's emergency operations plan as required by The Joint Commission, he adds.
Editor's Note: This is the second of three contributed features submitted by members of the International Medical Travel Association's Board of Directors. The IMTA is a not-for-profit global organization of stakeholders in the international medical travel industry.
Tracking medical travel since 2006, there has been a rapid growth and change from dental and cosmetic services to more advanced surgeries. Price sensitivity is one reason, as there are nearly 50 million uninsured patients in the United States. Furthermore, employers cannot afford the rising costs of healthcare for their employees. Finally, self-insured firms are offering voluntary medical travel options for employees. The epidemiology of U.S. patients is changing, as baby boomers are aging and requiring "parts replacements" such as knee and hip replacements. Many patients simply cannot afford healthcare in the U.S.
Finding "parts replacements" outside of the U.S. has become necessary for many American patients, especially those who are unable to work and are disabled from continuous pain and lack of mobility from orthopedic problems. Data on costs for procedures outside the U.S. are readily available, including complete travel packages for the medical traveler.
However, while price and affordability for patients is a primary issue for medical travel, few would support the growth of medical travel if the cost savings came at the expense of quality and patient safety. Adapting the more traditional and evidence based measures of quality to a newly global practice environment has become an emerging challenge for providers and patients. While the healthcare system in the U.S. is heavily regulated by several sets of quality and safety measures, the global environment presents local/cultural differences that may be unfamiliar, unmeasured, and most certainly unregulated.
Assessing Quality
Assessing healthcare quality can include:
The credentials and performance of healthcare providers
The performance of hospitals
Care provided to particular groups of patients
Care received by caseloads of patients stratified by procedure or diagnosis.
To provide an assessment from a more global perspective, quality can be measured internally by a hospital, or externally by an accrediting agency. For example, a hospital that is focused on maintaining and improving quality and safety will have systems and measures (or metrics) in place to support peer review, credentialing, complications from procedures and treatments, nosocomial infection rates, and patient feedback on their experience by a healthcare team, to name a few.
From an external view, accreditation and certification from a truly international organization appraises and rates a healthcare organization against a set of vetted international standards that are healthcare specific, patient focused, and reflective of an organization’s focus on continuous improvement towards the best possible outcomes.
For example, accreditation by the Joint Commission International (JCI) has provided this external validation/accreditation for more than 200 hospitals worldwide. Specific Patient Safety Goals are required as part of a JCI review: proper patient identification throughout the treatment process; surgical ‘time outs’ by the Operating Room team before starting surgery for a patient to ensure the correct patient, for the correct procedure on the correct body part; specific communication requirements for treatment orders; specific "high alert" medications removed from patient care units; appropriate hand hygiene to prevent infections; and effective strategies to reduce patient falls. These JCI goals are based upon evidence from both U.S. and international hospitals and are minimum goals for maintaining acceptable quality and safety for patients and staff.
Maintaining high quality and safety for patients globally, beyond accreditation, requires identifying suitable measures of quality and safety for patients, and promulgating these measures across borders. This will help in identifying gaps in quality and assist health care organizations to "raise the bar." We know in the U.S. that there are more than 98,000 preventable deaths in hospitals due to medical errors; 50% of these errors are medication errors and most errors are unreported. We also know that infection rates in Massachusetts alone costs $473 million annually and that deaths in the U.S. are typically from infections related to surgical sites, central venous catheters, poor hand hygiene and ventilator associated pneumonias.
Raising the quality bar and closing the gaps globally requires efforts to achieve the following:
Sharing best practices across borders
Identifying and sharing common quality measures and outcomes
Collaborating in the development of evidence based metrics
Promoting international competition among healthcare organizations on quality and safety
Establishing guidelines for developing global centers of excellence in specialty care across borders.
There are hundreds of quality measures available, however—it remains challenging to select and agree on a universally-appropriate set that is meaningful to patients and will encourage organizations to identify these measures and compare data across hospitals and across international borders. Quality is neither a matter of opinion, nor is it the latest in fancy technology. Quality and safety are a property of systems and processes that are intentionally designed and measured. From the point of view of the delivery of care, I refer to the Institute of Medicine's framework: safe, timely, effective, patient centered, efficient, and equitable.
Quality and Safety: Looking Ahead
Medical travel (or ‘medical tourism’) is projected to be a $60 billion global business, with an estimated 750,000 Americans who have traveled outside the US for medical care in 2007. A 2008 Deloitte study projects the number of medical travel to increase to 6 million by 2010. More than 30 countries worldwide offer a range of medical services to medical travelers: executive check-ups, joint replacement surgery, cardiac surgery, spinal surgery, dentistry, and plastic surgery makeovers. Medical Travel remains an unregulated but attractive source of revenue for foreign hospitals, clinics and travel companies.
Competition for the medical traveler continues to focus on affordability; however. As this industry begins to sort itself out, there will emerge a select few that will become Centers of Excellence for specific types of care/procedures. These Centers of Excellence will provide transparency in the processes and outcomes of care that are measurable, reliable, and important to patients who choose to travel.
Sharon S. Kleefield, MA, PhD,is currently on the faculty of Harvard Medical School. She is developing International Health Care Education and Training programs with physicians at HMS and Harvard Medical Faculty Physicians at the Beth Israel Deaconess Medical Center. She may be reached at skleefield@hms.harvard.edu.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
The Knowledge-Based Nursing Initiative (KBNI)—a joint venture by Aurora Health Care, Cerner Corporation, and the University of Wisconsin-Milwaukee—will spread its vision to accelerate the use of evidence-based knowledge in nursing practice via technology during a visit to the United Kingdom this week.
The goal of the KBNI is to infuse research and other evidence-based nursing knowledge into nurses' workflow by facilitating clinical decision-making, populating data repositories as care is documented, and conducting analyses of the data in the repositories. Through these efforts, the KBNI hopes to improve the quality of patient care.
To date, the KBNI has completed "knowledge development" for 25 clinical health problems, such as risk for falls, infection control, and medication management. This knowledge development includes developing a series of interconnected, actionable, evidence-based clinical practice recommendations for assessments, diagnoses, interventions, and outcomes based on "analyzing and synthesizing the evidence through a search for relevant literature," according to the KBNI Web site.
"As the nurses use this, their data automatically gets transferred to a clinical data repository that we can then use while the patient is in the hospital or healthcare system, but also can be queried for reports," says Norma Lang, PhD, a co-principal investigator with the project. "The more you can pull standardized data to screen elements out electronically, the less demanding it is on people to do this manually."
In collaboration with the other partners, the recommendations are made executable within the information system to provide support for clinical decision-making. Last year, the recommendations for six clinical health problems were implemented at Aurora Health Care as a pilot test.
This week, Lang is in the United Kingdom meeting to present to the Royal College of Nursing and other UK health leaders about her work with KBNI. The quality issues that the KBNI tries to improve, such as decreasing falls and patient readmissions, are universal and best practices should be shared between countries, Lang says.
"We think we are really different, but people are people," says Lang, who is also an honorary Fellow of the Royal College of Nursing in London. "It's very good to share things across the water—I don't know if either country has the answer, but we can sure share a lot, we can learn from each other."
This type of information sharing was one of the premises on which the KBNI was founded: Partnerships between businesses, service organizations, and academia can accelerate quality and outcome improvement that would be difficult for one organization alone to achieve.
Lang says KBNI also was formed to help define nurses' contributions to patient care outcomes because they are able to determine what care contributes to the best results and how to implement these practices. With the rapid development of clinical health IT, nurses and their patients can benefit greatly from the best practices and evidence-based care that is developed through KBNI, Lang says.
"There was very little emphasis on nurses, and yet nurses are the ones who are actually using these systems 24 hours a day, seven days a week, and also nurses have the most complex information needs," Lang says.
And with nurses all over the world facing similar quality-related issues, Lang says she can definitely see knowledge-sharing practices used by KBNI spreading. While there are no immediate plans to spread the word apart from this week's trip to the UK, Lang says the KBNI's best practices has the potential to be implemented in hospitals all over the world.
"The needs are there all over, and actually in every language too," Lang says. "There is an incredible amount of interest, and I can see it building."
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A new poll finds that most Americans continue to support the idea of healthcare reform, even though they don't want to pay more for it, and they are easily swayed by arguments on all sides of the issue.
A Kaiser telephone tracking poll of 1,205 adults, conducted in the first week of June and released today, finds that 61% of Americans believe health reform is more important than ever, given the country's economic problems. The results are in line with similar bimonthly Kaiser polls dating back to October 2008.
The latest poll also found that:
69% support employer coverage mandates, while 71% back individual mandates.
65%-67% support the public plan option, depending upon the wording.
Only 41% of the public say they're willing to pay more for healthcare reform.
40% support taxing employer-based health insurance.
Those public sentiments run afoul with some of the stated positions of key special interest groups in the healthcare reform debate. The American Medical Association, America's Health Insurance Plans, and the U.S. Chamber of Commerce, for example, have all voiced opposition to the public plan.
All might not be lost for those special interests, however, because the poll found that the public is easily swayed, and can shift by as much as 40 percentage points when arguments are tested.
Kaiser President and CEO Drew Altman says the malleable state of public opinion means that Congress must quickly get a health reform bill on President Barack Obama's desk "so that a protracted debate and a Harry-and-Louise-style ad war do not undermine the high level of public support we see today."
The poll suggests that a majority of Americans' support for health reform comes from personal experiences, with 55% of respondents saying they or a member of their household have delayed or foregone medical care or prescription drugs within the past year because of cost concerns.
A narrow majority of the public (53%) supported limiting future increases in how much doctors and hospitals are paid under Medicare to help pay for health reform (37% opposed). A majority (56%) of those under 65 supported this while only four in 10 of those age 65 or older did.
A large majority (70%) liked the idea of insurance exchanges to help people purchase insurance on their own.
While the public clearly favors some sort of healthcare reform, they are very much divided on how to pay for it, the poll found. A slight majority (54%) say they are not personally willing to pay more to expand coverage to the uninsured, while 60% say the healthcare system can be reformed without spending more money if policymakers do it correctly.
Roughly two-thirds (67%) oppose across-the-board increases on income taxes, but a narrow majority supports taxing soda (53%) and unhealthy snack foods (55%). Clear majorities support increased taxes on the wealthy (68%), cigarettes (68%), and alcohol (67%) as a way to pay for health reform.
"With all the talk of inefficiencies in the system and achieving future savings, the public may confuse the potential for long-term savings with the need for short-term outlays and think that healthcare can be reformed for free," Altman says. "This could make policymakers' jobs tougher when the price tag for the legislation comes out."
While a clear majority of Americans favor health reform, the poll found large areas of disagreement reflected by partisan politics. Nearly three-quarters (74%) of Democrats and 59% of independents say the nation's economic straits make health reform more important than ever, while 56% of Republicans say we can't afford it right now. A slim majority of Democrats (53%) are willing to pay more for providing coverage, while 38% of independents and 29% of Republicans say the same.
Boston is becoming a hub for information technology and games that help people achieve fitness goals. AWare Technologies Inc., FitnessKeeper Inc. and Molecular Inc. all track fitness data via cellular phones and web applications, for example.
U.S. Oncology, Inc. has announced the launch of iKnowMed to the open market. iKnowMed is an oncology-specific electronic health record system designed by oncologists for oncologists, according to a U.S. Oncology, Inc. release.
The American Medical Association has announced it is working with Microsoft to better connect patients with their physicians through Microsoft's HealthVault, a platform developed by Microsoft to store and maintain health and fitness information. Through this collaboration, physicians will be able to access self reported patient health information at the point of care, while enabling patients to access vital information that has been entered through the physician's office, according to an AMA release.
Terry Hill, executive director of the Rural Health Resource Center in Duluth, MN, discusses the impact of the HITECH Act on critical access hospitals. [Sponsored by Emdeon]
Memorial Health System of East Texas has started using the "RP-7," a wireless "remote presence robot." Through a partnership with MHSET, doctors from the Methodist Hosptial in Houston will have the capability of "beaming" into the Lufkin hospital through the robot, providing quicker more complete care, according to its creator, InTouch Health. MHSET's RP-7 is one of only 250 worldwide.
Microsoft is teaming with the University of Miami for a pilot study to see if software and primary care can improve the healthcare of 25 diabetics. The 25 patients, most of them on Medicaid, will be given computers and, if necessary, trained in how to use them. They will then use several Microsoft programs through a Web portal to communicate with an advanced nurse practitioner and doctors about what's happening with their conditions.
