Federal health officials are casting doubt on a funding scheme by California to keep nearly 700,000 children from being yanked from a government health insurance program for the working poor. U.S. health officials said the plan adopted by the state in the final days of the legislative session and signed into law by Gov. Arnold Schwarzenegger may not meet regulatory muster, the Los Angeles Times repors. As a result, children's health advocates are warning that by the end of 2010, hundreds of thousands of children could lose their health insurance.

This article from the Wall Street Journal states that the fate of U.S. healthcare legislation likely depends on the question of whether Democrats conclude they are better off passing a highly controversial bill than passing nothing at all. To get to this point, Senate Democrats already have had to nearly ditch the "public option," and appear to have decided to compromise further on one of the ideas that has become part of the alternative to the public option, the Journal article states.

When a new patient enters a hospital, staff members generally follow the same routine. The admitting nurse asks the patient's name, date of birth, symptoms, and any allergies to medications. From this information, a medical record is created and the patient may be admitted and is taken to a room.

However, at JPS Health Network in Fort Worth, TX, there is one extra step for admitting nurses in the Department of Psychiatry: photographing new patients.

This extra step was implemented in early 2006 when Allison Mason, RN, BS, MHA, program manager in the Department of Psychiatry at JPS, attended a monthly performance improvement review regarding medication errors.

After a medication error occurred on the adult inpatient unit resulting from the misidentification of a patient, Mason and the committee reviewed other patient identification practices on various units within the hospital's psychiatry department.

They found that the adolescent inpatient unit used patient photographs as a second identifier during medication administration and had only two recorded medication errors because of misidentification in the five years after implementing this process.

The committee rolled out this process on the adult inpatient units after hearing of its success on the adolescent unit. In the four years since photos have been used, there have been only a handful of medication errors in the JPS adult inpatient unit. When later addressed, these errors were found to have occurred because nurses had failed to use the patient photograph as a second identifier. These nurses were educated further about the process using a root-cause analysis and examining the occurrence step-by-step, says Mason.

Medication errors because of patient misidentification are especially challenging in psychiatry because patients are frequently noncompliant with wearing identification bands, are unable to answer identifying questions, or intentionally answer incorrectly, says Mason.

"In psychiatry, patients sometimes are not able to answer identification questions," says Mason. "The patient may be psychotic or unwilling to answer questions correctly, which presents the department with unique challenges."

Although patient photographs may raise a red flag for many working in healthcare and hospital settings as a possible violation of HIPAA laws, Mason says it is different for psychiatric units. HIPAA laws protect the privacy of patient health information.

"Our state laws and other regulatory standards we have to abide by are actually more strict," says Mason. "We explain to the patient what the picture is used for and how it improves their safety and quality of care."

When a patient is admitted, the admitting nurse takes a picture of the patient, which goes on his or her chart as well as a 3x5-inch index card.

Along with the picture, the patient's name, date of birth, and medical record number—unique to each patient—are all included on the card.

"Each patient card is handed down, shift to shift, by nurses and is used for identification during medication administration," says Mason.

In addition, patients wear an identification bracelet, which has a bar code that matches the one on the index card and is unique to each patient, says Mason.

Easy implementation
JPS purchased a digital camera so nurses could print patient pictures immediately.

"We wanted to make the process as easy as possible because we did not want to slow down the admission process or make it a burden," says Mason. "[Our] information technology [department] installed the camera program on one of the computers in the nurses' station, and now, taking a patient's picture during admission has just become part of the process."

The key to the process is to have a camera on each unit so all nurses have access to one, she says.

Another important factor in the success of this process was the support provided by upper management, says Mason.

"Everyone here is always ready to do something that will improve patient safety and quality of care," says Mason.

To read more about this program, please see the January 2010 issue of Briefings on Patient Safety, a product of Patient Safety Monitor.

By just about any measure, Joint Commission accreditation is an affirmation that your physician practice has reached the pinnacle of professionalism, particularly in quality and patient safety issues.

"It's the new gold standard," says Billy Taylor, practice administrator at Midtown Urology, a five-physician practice in Atlanta that achieved Joint Accreditation status in the late 1990s. "It helps you run a better establishment because state and federal regulations are similar to what the Joint Commission says. They kind of shadow each other. You know that if you're in good with one, you are in good with the other."

Michelle Koury, MD, with Crystal Run Healthcare LLP, says Joint Commission accreditation meshes with the Middletown, NY–based multispecialty group practice's "mission and core values."

"We feel the Joint Commission is truly the national standard in benchmarking quality in healthcare," says Koury, COO at the 190-physician practice that first became Joint Commission accredited in 2006. "We felt the external validation would further distinguish us from our peers. It would distinguish us with payers and patients and with politicians, regulators, all of our constituents and stake holders."

If your practice is thinking about going for Joint Commission accreditation, Taylor and Koury say you have to be willing to commit the staff, the energy, and the time to do it correctly.

"Especially during the initial phase, you put in a ton of man hours," Taylor says. "As we geared up, for a good six months, there were three of us focusing on it for about 30 hours a week."

At Midtown, Taylor and the practice's medical and nursing directors each assumed responsibility for parts of the accreditation process. "We created three big binders that make up our total policies and procedures. We call them The Trinity," Taylor says. "One is the administrative volume that covers administration policies and procedures. The next one is our patient care, and one is our environment of care."

"It is arduous getting policies and procedures and guidelines in place. That is the most tedious part," Taylor says. "But it's not something you have to go back and completely recreate. You may modify, but you never have to recreate again. It doesn't take a lot of effort once you get over the initial hump."

At Crystal Run, executives identified a five-person leadership team and hired a consultant to teach standards and survey methods. "There is a lot of work that gets done ahead of your first survey. There is data that has to be collected, metrics and policies that have to be in place," Koury says. "You may already be doing it, but this formalizes and creates a reporting structure that enhances communication. Also, your physicians must be engaged and they must respect the process and understand why you are pursuing this. You have to engage them because some changes may impact their workflow, and their buy-in is critical."

Taylor stresses that staff must be given the time to prepare for Joint Commission accreditation. This is not an endeavor that someone in the office can do in his or her spare time or between answering telephone calls. "You have to have that dedicated time. You can't expect somebody to do their regular job and Joint Commission at the same time," he says. "You need to have a couple of days a week where that is all they're doing, or there has to be some way to divide it. Everything else has to stop so you can focus specifically on this."

Work doubles as business tool
Now that Crystal Run is accredited, Koury says that Joint Commission policies have proven to be a good business tool as well by creating consistency in measurements across an array of service lines. "Given the growth and the size and complexity of our organization, Joint Commission provides a way to operationalize quality and patient safety and engage the staff," she says.

Having Joint Commission procedures in place has also proven useful for Crystal Run as it prepares to open an ambulatory services center next year. "We are going to pursue Joint Commission accreditation for that facility as well," she says. "Our policies and how we are outfitting our OR will all be in compliance with Joint Commission standards. It makes process easier. It provides an operational framework that helps you with credentialing and patient safety policies, and it makes your staff literate in these very important areas of quality and patient safety."

Koury says not having Joint Commission accreditation doesn't necessarily mean that a physician group is providing inferior service. "Obviously, one can be knowledgeable about the standards and provide safe care without getting accreditation, and it probably wouldn't make sense for smaller practices," she says. "But for practices that offer a wide variety of complex services, that see the variety of cases that we do, I absolutely feel it can be essential tool to maintain quality and patient safety."

Is it worth it? Taylor and Koury say "yes," although they acknowledge it's hard to demonstrate a return on investment. "I guess you could measure those things, but to us it's not a meaningful measure," Koury says. "If we decrease our risk or error, if we have better patient outcomes, if we avoid malpractice and provide safe and effective care, if these standards help us to reduce the opportunity for error and improve patient outcomes, that is hard to quantify a dollar value. It's hard to quantify quality as a cost."