In a letter to Senate Democratic leaders, President Obama on Wednesday outlined what his vision for healthcare reform should look like—including addressing the idea of "moving towards a principle of shared responsibility—making every American responsible for having health insurance coverage and asking that employers share in the cost."
"I share the goal of ending lapses and gaps in coverage that make us less healthy and drive up everyone's costs, and I am open to your ideas on shared responsibility," he said in a letter to Senators Edward Kennedy (D-Mass.) and Max Baucus (D-Mass.) who chair the two Senate panels overseeing healthcare reform. However, he requested that they provide a hardship waiver "to exempt Americans who cannot afford it"—especially small businesses.
Obama, writing the letter one day after meeting with two dozen Democratic senators in the White House, told the leaders that the "plans you are discussing embody my core belief that Americans should have better choices for health insurance—building on the principle that if they like the coverage they have now, they can keep it, while seeing their costs lowered as our reforms take hold."
For those who don't have such options, "I agree that we should create a health insurance exchange—a market where Americans can one stop shop for a health care plan, compare benefits and prices, and choose the plan that's best for them, in the same way that Members of Congress and their families can."
While covering the uninsured could cost upwards of $1.5 trillion over the next decade, Obama did not propose how that entire cost would be covered. However, he did suggest that "fulfill this promise," he would set aside $635 billion in a health reserve fund as a down payment on reform.
This reserve fund, he said, would include several proposals to cut spending by $309 billion over 10 years, which would include: reducing overpayments to Medicare Advantage private insurers; cutting Medicare and Medicaid waste, fraud and abuse; improving care for Medicare patients after hospitalizations; and encouraging physicians to form "accountable care organizations" to improve the quality of care for Medicare patients.
He also said he was "committed to working with the Congress to fully offset the cost of health care reform by reducing Medicare and Medicaid spending by another $200 to $300 billion over the next 10 years, and by enacting appropriate proposals to generate additional revenues."
Obama said these savings will come not only by adopting new technologies but going after the key drivers of skyrocketing health care costs, including unmanaged chronic diseases, duplicated tests, and unnecessary hospital readmissions. These steps, he said, could close loopholes, would raise $326 billion over 10 years.
Effective July 1, The Joint Commission will roll out a series of scoring changes to 45 elements of performance (EP) within its accreditation standards.
The majority of the amendments adjust the environment of care (EC) and life safety (LS) standards, which generally fall under the responsibilities of your safety officers and facility directors.
Other affected standards include:
Leadership
Medication management
Provision of care
Performance improvement
Rights and responsibilities
The Joint Commission reviewed standards scoring earlier this spring, said George Mills, FASHE, CHFM, CEM, senior engineer for the accreditor. Mills spoke during a Joint Commission Resources audio conference June 3.
Some criticality levels altered
The changes—which were published in the June issue of Joint Commission Perspectives—center on The Joint Commission's criticality scoring levels and scoring categories. Here's a quick rundown of criticality levels by number:
1—Immediate threat to life, which is self-explanatory and can lead to preliminary denial of accreditation. No single EP in a standard has an immediate threat designation; instead, the status results from a combination of serious problems.
2—Situational decisions rules, which are based on specific situations during a survey and can result in preliminary denial of accreditation or conditional accreditation.
3—Direct impact requirements, which are likely to create immediate risks to patient safety. The risks stem from a lack of processes to offset the threats.
4—Indirect impact requirements, which center on planning and evaluation of processes. Failure to resolve concerns with these processes may increase risks to patient safety over time.
Eight EPs within the EC and LS standards have been upgraded from indirect to direct impact requirements. "Occasionally we felt things were a greater risk, so we changed [them] to direct impact," Mills said.
For example, standard EC.02.03.05, EP 11 requires hospitals to test their fire pumps every 12 months and will be a new direct impact requirement as of July 1. Joint Commission officials felt this was an "extremely important test" that warranted a higher criticality ranking, Mills said. In fact, fire pump failures are often noted by Joint Commission officials as situations that would trigger criticality 1, so the connection to pump testing is clear.
From point C to point A
Other upcoming changes affect the scoring categories. These categories include either an A or C designation:
"A" EPs are for requirements in which a hospital either has a policy or plan, or doesn't have a policy or plan
"C" EPs are for requirements whose compliance is judged by the number of times a hospital does or doesn't meet a provision
For example, standard LS.02.01.34, EP 3, requires hospitals to put a fire alarm annunciator panel in a location approved by the local fire department. This EP went from a C score to an A because typically there is only one such panel in a building, thus it better meets the criteria for an A score, Mills said.
The Joint Commission discontinued B-scored items in January 2009.
Virginia officials this week began mailing direct individual notifications to more than a half-million people whose Social Security numbers may have been contained in the Prescription Monitoring Program database that was hacked into in April by a criminal demanding a $10 million ransom.
"Although the investigation has yet to determine what, if any, personal information is at risk, DHP nonetheless recommends that persons remain vigilant over the next 12 to 14 months," says Sandra Whitley Ryals, director of the Virginia Department of Health Professions, which oversees the PMP data base.
State and federal authorities continue to investigate the April 30 breach. Ryals says all PMP data was backed up and all back-ups have been secured. There is no evidence that systems beyond the PMP were involved.
Ryals says the mailing is to directly inform individuals of the potential exposure of Social Security numbers and to advise persons of precautionary steps that may be taken. "While there are over 35 million prescription records in the PMP database, only the 530,000 individuals whose prescription records may have contained Social Security numbers will receive the direct mailing," said Ryals. "Additionally 1,400 registered users of the program who may have provided Social Security numbers when they registered for the program also are being sent an individual notification."
The PMP system has been closed since the breach. It will reopen for registered users when new security measures are cleared by the Virginia Information Technology Agency and other law enforcement agencies.
The as-yet unidentified hacker left a ransom note in April at the Web site that read: "I have your [stuff]! In *my* possession, right now, are 8,257,378 patient records and a total of 35,548,087 prescriptions. Also, I made an encrypted backup and deleted the original. Unfortunately for Virginia, their backups seem to have gone missing, too. Uhoh :(For $10 million, I will gladly send along the password."
Two new fictional nurses, "Jackie Peyton" (portrayed in Showtime's Nurse Jackie) and "Christina Hawthorne" (TNT's HawthoRNe), will light up TV screens in the next two weeks. In the fall, NBC will introduce "Veronica Callahan" when it premieres the nursing drama Mercy. But how the shows will affect real world nurses has come into question.
"Television shows largely depict physician characters doing the work that nurses do in real life," says Sandy Summers, RN, MSN, MPH, founder and executive director of The Truth About Nursing, and co-author of Saving Lives: Why the Media's Portrayal of Nurses Puts Us All at Risk. "Hollywood media shows physicians performing triage, defibrillation, patient education, IV medication administration, providing 24/7 surveillance, and handling complex ICU machinery—this is all exciting, dramatic work of nursing that nurses deserve credit for."
The debut of Nurse Jackie on June 8 and HawthoRNe on June 16 will bring nurses back in the limelight as the shows' main characters. It's been more than 15 years since a nurse-centered TV series (NBC's Nurses) aired in the U.S., despite the myriad of emerging medical shows, such as Grey's Anatomy, House, Scrubs, and ER.
While Summers is happy nurses are getting more TV exposure, she stresses the damages current dramas have on the profession.
"Career seekers who want to pursue careers with autonomy look elsewhere," she says. "Who would want the job of nursing as it is portrayed on House or Grey's Anatomy? Nurses barely exist on those shows, but to the extent they do appear, they are fawning or bitter lackeys—the lowly clean-up crew of healthcare." Such depictions, Summers says, will not lead to funding for nursing practice, education, or research.
So will the upcoming shows accurately illustrate the lives of real nurses or support some of Hollywood's longstanding stereotypes?
Much controversy already surrounds the dark comedy, Nurse Jackie, which will capture Peyton's life as an ED nurse working at a New York City hospital. Peyton's depicted drug addiction to Oxycontin pills, for one, has ignited some heated debates among nurses.
"I think many nurses are having a reflexive negative reaction to Nurse Jackie," says Summers. "But it provides us with so many opportunities to change how the public thinks about nursing and to change how nurses think about the media. [The Truth About Nursing's] main goal is to get nurses and the public—like it or not—to watch the show and talk about what nursing is, what it is not, and what it should and could be."
Adrianne E. Avillion, DEd, RN, owner of Avillion's Curriculum Design in York, PA, who has more than 30 years of nursing experience, also has a strong distaste for today's onscreen nurses and believes a nurse consultant is needed on the set of the shows to infuse some much-needed realism. "The portrayal is horrific," she says, adding that ER, Grey's Anatomy, and House are some of the worst abusers. "The view of nursing is that the only thing we are capable of doing is nodding when the doctors say 'Do this and do that.'"
Avillion's opinion on Mercy doesn't seem more promising. The show will follow the happenings of a hospital through Callahan, who just returned from a tour in Iraq, and two other nurses. According to the NBC Web site, the show will also include interactive digital features, such as a "Test Your Nursing Skills" quiz with first aid questions and answers. The concept came across demeaning to Avillion.
"Just get right on there," she says "Anybody can do it. Anybody can be a nurse …There's nothing about 'Test Your Doctor Skills.'"
HawthoRNe, which stars Jada Pinkett Smith, appears to deliver more optimism. As a chief nursing officer, Hawthorne is depicted as a hero who "prides herself on standing up for her patients and preventing them from falling through the cracks of hospital bureaucracy," states TNT's Web site.
Regardless of how the shows unfold, Summers will view them as mediums to reshape nursing's image.
"Each show looks promising in its own way, but we won't know more until we see the full episodes," says Summers. "And even after they air, I'm sure there will be things we think work well to educate the world about nursing and things that reinforce longstanding stereotypes. But there seems to be basic understanding on each of the shows that stereotypes need to be broken."
Clinical documentation improvement (CDI) are three buzz words in today's healthcare lingo that have come to signify a means of achieving better data quality that leads to more accurate reimbursement and perhaps even better patient care.
Most of the sources with whom I've spoken—including coders, nurses, and even physicians—advocate for the CDI efforts. However, one danger of such a program is that hospitals must ensure safeguards to prevent leading physicians down the long and winding path to a diagnosis.
Having a CDI program doesn't negate the fact that physicians must continue to maintain their authority in providing a diagnosis. And therein lays the conundrum for many hospitals: How to obtain this much-needed information without leading docs in the process.
Verbal queries, in particular, have remained a source of contention for hospitals simply because they are difficult to audit and monitor. Coders and CDI specialists know that they aren't supposed to lead physicians to a diagnosis, yet when questions are posed verbally, there is a significant risk that this will take place during course of conversation meant clarify documentation.
Hospitals need to specify—in their policies and procedures—why a coder or CDI specialist will initiate a verbal query as well as what the content of that verbal query will include. Consider adding the following language:
The clinical documentation specialist may have a discussion about a patient with a physician. This discussion will be an opportunity to educate the physician and to obtain specificity in the documentation. The clinical documentation specialist may discuss the clinical findings and documentation with the physicians involved in the care of the patient. The role of the clinical documentation specialist is to educate the physician on the specificity of verbiage which can result in improved capture of severity of illness. In addition, the clinical documentation specialist will pose verbal queries (questions) to the physicians so that clarification may be documented.
"I think having a policy in place that outlines the role of the CDI specialist and the parameters of the verbal queries will protect your organization if ever there is an outside review of your charts," says Melissa Ferron, RHIA, CCS, president, Melissa Ferron Healthcare Consulting, LLC.
In terms of creating a policy, hospitals should outline that the verbal query be designed to communicate the request or need for clarification based on existing clinical documentation. Consider adding the sentence "Under no circumstances will the CDI specialist tell the physician what to document," Ferron says.
Regardless of whether the verbal query is concurrent or post-discharge, hospitals should ensure that the individual posing the verbal query document the following information:
Date of discussion with the physician
Physician name
Summary of the discussion
In terms of monitoring, verbal queries can pose a challenge. "By nature of a verbal query, there isn't a document that we can go to when comparing the composition of a verbal query from one coder or CDI specialist with another," Ferron says.
However, by encouraging documentation of verbal queries, health information management (HIM) directors or coding supervisors will have some data with which to work, Ferron adds. "If there is a high percentage of physicians adding diagnoses in the chart after the initiation of a verbal query, that might be a prompt that a verbal query is leading," she says. This could definitely raise a red flag for an outside reviewer.
Hospitals may also want to consider a direct observation technique in which an HIM director or coding supervisor observes those who are posing verbal queries. "It might be a little more labor intensive, but I think that nonetheless, you need to have that in your policy," she adds.
Those who think Medicaid and the Children's Health Insurance Program should increase families' out-of-pocket contributions for their children's care might see the idea backfiring because paying for that care could become unaffordable, according to a paper published this week in the journal Health Affairs.
"If families didn't have to pay any cost sharing, no premiums, no co-payments and no deductibles, there would still be quite a few kids living in families where the burden of paying for healthcare bills exceeds 10% of the family's income," says Thomas Selden, an economist with the U.S. Health and Human Services Agency. The family financial situation gets much worse with even low levels of required out-of-pocket cost sharing.
"If increasing cost-sharing for these families leads to a much greater financial pressure, it could result in a reduction in how much care they may get for their kids," Selden says. "Or it might mean the mom won't get care that she might need."
Additionally, although federal law restricts a family's out-of-pocket spending for publicly insured children to no more than 5% of family income, total family spending and income is seldom tracked by providers and is not well enforced, the authors said. Many states have policies that reduce that 5% cap as well, but families often aren't aware of it.
"The hospital or the doctor who sees a patient who is paying for their care may provide something, a notice of some sort perhaps, saying 'your bills are capped according to state policies, at such and such a rate, and once you get over that in a three, or a six month period, you can qualify for free care," Selden says.
"We need to educate health providers, and we need to tell patients about the importance of maintaining a shoebox to store all those receipts," he says.
Selden prepared the paper with colleagues from the Agency for Healthcare Research and Quality with support from the David and Lucille Packard Foundation. The research was conceived in light of concern about the Children's Health Insurance Program and Medicaid's bulging health care bill, and the debate about whether imposing more cost sharing on Medicaid families would make them less likely to seek unnecessary care.
"On the one hand, higher cost sharing has been promoted as a way of ensuring the sustainability of Medicaid and CHIP by sharing the financial burden with families and by reducing 'unnecessary' service use and the crowding out of employer-sponsored coverage," Selden and the authors wrote. "On the other hand, there is concern that higher cost sharing will increase uninsurance rates and reduce 'necessary' service use and adherence to recommended treatments among children."
The report was based on telephone interviews and information collected under the Medical Expenditure Panel Survey of households and included information on 7,885 children. Families were asked to recall what they paid in health costs as well as their family income. That information was compared with actual Medicaid bills and payments.
The authors concluded that even with zero Medicaid and CHIP cost-sharing requirements for children, 12.7% of publicly insured children would be in families for whom out-of-pocket medical spending consumed 10% of their family income.
The percentage rises to 16.3% among families with incomes below the federal poverty level, versus 5.6% of families with income above 200% of the federal poverty level.
Enforcing caps is one way to reduce the burden on families, Selden says. "The logistical challenge, however, is for states to implement caps so that cost-sharing is eliminated once the cap is reached, which may prove difficult given the limitations for tracking families' incomes and their spending on medical care."
A day after signaling a willingness to consider taxing employer-sponsored health insurance, President Obama indicated a new openness toward a nationwide requirement that every American have health coverage. Obama previewed what could be the outlines of a compromise on two of the thorniest issues confronting Congress: He said he could support mandates on both individuals and employers to contribute to the cost of health insurance if the bill provides protections to certain small businesses and poor people.
Many hospitals and medical schools offer some variation of simulation-based training in which medical and nursing students learn clinical techniques of suturing and administering medication by using lifelike mannequins. This strategy of helping clinicians develop skills on mannequins before treating actual patients is nothing new, but some hospitals are taking things to the next level by tying simulation to a newer concept: a culture of safety.
With the involvement of multiple levels of clinicians and nonclinicians in simulation centers designed with patient rooms, physician rooms, and nurses' stations, hospitals now use simulation training to improve patient safety through communication and teamwork.
Patient safety starts with teamwork
When the 450-bed Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, NH, renovated its second floor, hospital leaders made part of it into an 8,000-square-foot simulation center. The center is equipped with six patient rooms, an ICU, mannequins, and a nurses' station.
"It's a mini hospital," said George Blike, MD, quality and patient safety officer at DHMC and medical director at its Patient Safety Training Center. Having hospital leadership support the idea of investing in a simulation center is important to Blike. He said it can be tough to convince people that the answer is not always more production space, but rather more space to make production better.
"It's a place where people can learn how to learn," he said, emphasizing how quickly medicine changes. "The day you finish your training is the day you start becoming incompetent." He added that the center helps fight such complacency and keeps staff members entrenched in new methods and technologies.
"People learn technical skills here, but they are also learning peer communication," said Blike. "It's not just medical students and residents, but 7,000 staff who need and want to maintain their skills."
Patient safety begins with learning simple behaviors, such as how to brief and debrief, said Blike. He noted that a surgical safety checklist—something most hospitals use—is simply a way to ensure teams are briefing and debriefing. Simulation, he said, is all about enforcing these behaviors.
"That's a good habit to instill in people," Blike said. "That's what shifts culture ... they're learning how to have a [type of] behavior that is useful in every single patient encounter. Hopefully, it is unleashing and moving people over time toward being more reflective practitioners."
At the Tulane Center for Advanced Medical Simulation and Team Training in New Orleans, medical director James Korndorffer Jr., MD, FACS, is hoping Tulane's months-old center will benefit the medical students at Tulane University's School of Medicine, as well as staff members at the Tulane Medical Center. As with DHMC's simulation center, students and professionals use simulation training with a focus on teamwork. Using an incomplete team for simulation doesn't make good sense, said Korndorffer.
"When you're doing a coronary angiogram, for example, it's not just the cardiologist in there. It's the cardiologist, the radiation technicians, the nurses . . . everybody's involved," said Korndorffer. He notes that different simulation events also contribute to a culture of safety by providing a less stressful environment in which clinicians might be more likely to speak up when things aren't going right.
A good exercise for every hospital
The Agency for Healthcare Research and Quality (AHRQ) is currently funding research studies to determine how simulation training affects patient safety. Among them is a study run by David Gaba, MD, associate dean for immersive and simulation-based learning at Stanford (CA) University and director of the Patient Simulation Center of Innovation at VA Palo Alto Health Care System.
Gaba's team conducted a baseline safety culture assessment in three diverse hospitals: a large tertiary care academic hospital, a medium-sized suburban hospital, and a 25-bed rural critical access hospital. His team developed three 2.5-day simulation training programs, one for each hospital. The study is ongoing, but Gaba said the training is working.
"No matter how small a hospital is, it's possible for them to do very useful and beneficial simulation training," he said. "A lot of people think it's only for the big academic hospital, and really, that isn't true."
Like the other simulation centers, Gaba's focus is on behavior and teamwork as well as skills.
"In many courses we run, we shoot for about 40% on particular medical and technical issues . . . and 60% on generic behavioral principles of decision-making and teamwork, such as using all available information, cross-checking information, calling for help early, team management, leadership, communication, and distribution of workload," said Gaba.
To read more about simulation training, please see Briefings on Patient Safety, a publication of HCPro, Inc.
Tami Swartz is an associate editor at HCPro, Inc., where she serves as editor for books, videos, and other resources in the accreditation, quality/patient safety, and hospital safety markets. Tami also writes forBriefings on Patient Safety, an HCPro monthly publication. Contact Tami by e-mailingtswartz@hcpro.com.
Hawaii-based Queen's Medical Center has paid $2.5 million to settle lawsuits that the hospital overbilled government healthcare programs for prescription medications, federal prosecutors said. The settlement was the result of two whistleblower lawsuits brought by former pharmacy technicians, who alleged that Queen's overbilled the state's Medicare and Medicaid programs, as well as TRICARE, the federal health insurance program for military dependents. The lawsuits were filed under the federal and state False Claims Acts, which allow the government to claim up to triple the damages, plus penalties, for submitting false claims to government programs.
U.S. Rep. Bobby Rush is calling for a congressional investigation into the University of Chicago Medical Center's Urban Health Initiative, questioning whether it has engaged in "patient-dumping" practices by steering the poor to other health facilities in the city. The initiative has been controversial and has generated protests from the community and patients, as well as physicians and students inside and outside of the medical center.
