Massachusetts Gov. Deval Patrick's administration is considering an overhaul of the college student health insurance market intended to improve coverage for thousands of Massachusetts students who now have plans with limited benefits. The administration is looking at several steps, including encouraging schools to band together to purchase higher quality plans at a significant discount, and requiring insurers to offer more generous benefits to college students, officials said. The state Division of Health Care Finance and Policy recently issued a report that revealed that insurance companies are racking up much higher profits on health coverage sold to nearly 100,000 Massachusetts college students than on plans available to the general public.
Health and Human Services Secretary Kathleen Sebelius announced Wednesday that $235 million in funds are being made available to "help us get a better handle on how health information technology will improve the quality care that Americans get."
The grants will support 15 "beacon communities," which are hospital systems, provider groups, and state and local governments "at the forefront of the new technology—already using cutting-edge technology," she said at a briefing.
"The dollars are designed to help these communities expand and strengthen their health IT systems. Their experiences will help us answer key questions [such as] what sorts of health benefits will we get when we make concentrated investments in health information technology," she said.
These communities are in a good position to lead the way in promoting meaningful use of electronic health records (EHR). Their experiences will be viewed as guidance for other healthcare communities and organizations in adopting health IT, she said.
David Blumenthal, MD, the national coordinator for health information technology, said the program is part of a series of programs that are meant to implement the HITECH provisions of the economic stimulus legislation.
The intent for the members of the beacon communities is "to be of service to their local communities, to inspire and teach other communities about how to get to meaningful use, and to be an improved, more efficient higher quality healthcare system that benefits not just local populations but every American," he said.
Blumenthal provides the examples of healthcare organizations that have "served the purpose of beacons," such as the Veterans Health Administration and its use of EHRs, along with the Geisinger Health Plan and clinics, the Marshfield Clinic, and Kaiser Permanente. "Our goal is to make that possible for communities as a whole and thereby demonstrate that entire regions of the American healthcare system can be elevated through the application of health information technology."
The government is distributing $220 million in cooperative agreements that will support the 15 chosen communities. The recipients will be asked to define, track, and report on progress toward concrete, measurable health and efficiency goals that are related to EHR adoption and meaningful use.
The goals associated with EHR adoption might include reductions in blood pressure among hypertensives, reduced blood sugar levels among diabetics, lowered smoking rates, or reductions in healthcare disparities among populations. The resulting data will be used for any mid course corrections and will help independent evaluations judge the success of the program. An additional $15 million will be used to support technical assistance to the communities and an independent evaluation of the program.
"We're going to be asking these communities to coordinate with regional extension centers and state health information exchange activities. We're also going to be asking them to leverage other federal programs that exist in their communities," Blumenthal said.
The Joint Commission's hospital accreditation program has been approved for continued deeming authority by CMS through July 15, 2014.
"We are honored that CMS has renewed our deeming authority. This validates their confidence in The Joint Commission, the predominant hospital accrediting body in the U.S," says Mark G. Pelletier, RN, MS, executive director of Hospital Programs and Accreditation and Certification Services at The Joint Commission.
Deeming authority means that hospitals accredited by an organization with deeming authority can elect to be "deemed" as meeting CMS requirements based on successful accreditation by the other organization.
CMS conducted an onsite administrative review of The Joint Commission's corporate policies; procedures for training, monitoring, and evaluating its surveyors; ability to investigate and respond to complaints against accredited facilities; and the survey review and decision-making process for accreditation.
CMS compared The Joint Commission's hospital accreditation requirements and survey process with the Medicare Conditions of Participation (CoP) and survey process outlined in the State Operations Manual. The Joint Commission made a number of revisions to its Elements of Performance (EP) during the application process to meet various CoP requirements. Areas include:
Credentialing and privileging for telemedicine
Medical staff requirements
Documentation of medical history and physical examinations
Reporting drug administration errors
Requirements regarding infection control officers
All changes made to the EPs are listed in the Federal Register.
"I'm very pleased, not only having worked for The Joint Commission, but also having watched them excel under the new leadership," said Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant based out of Trabuco Canyon, CA. "I love the changes they're making. I'm very excited they now have deeming authority, but I had no question they wouldn't—they've always excelled in advocating what's right for the patient and the organizations they accredit."
In 2008, the Medicare Improvements for Patients and Providers Act of 2008 included a provision that changed the Joint Commission's deeming authority status with CMS. The law removed a unique deeming authority given to The Joint Commission via CMS since 1965, requiring instead that the accrediting body (as well as any other accrediting bodies seeking deeming status) to apply through CMS for that authority. Fellow accrediting organizations DNV Inc., and the Healthcare Facilities Accreditation Program (HFAP) also have to undergo this application process.
In order to prevent any breaks in accreditation for Joint Commission-accredited hospitals, a two-year transition period was included in the provision for The Joint Commission to apply for deeming authority through CMS. The Joint Commission completed its application and was approved within that two-year window.
During the application process, organizations such as the American Hospital Association (AHA) urged CMS to approve The Joint Commission's application.
"The Joint Commission's set of accreditation standards go beyond the minimum requirements of the Medicare Conditions of Participation and focus on key functional areas within the hospital, such as patient rights, patient care, and infection control," Rick Pollack, executive vice president of the AHA, stated in a letter to CMS in July.
Hospitals do not need to be accredited—it is a voluntary option, as is being "deemed" through an organization like The Joint Commission. Hospitals can elect to be surveyed by state surveyors working on behalf of CMS as an alternative to an accrediting organization, such as The Joint Commission.
The Joint Commission also has deeming authority for ambulatory surgery centers, critical access hospitals, durable medical equipment suppliers, home health, hospice, and laboratories.
"The Joint Commission is proud of its tradition of collaboration with CMS to provide quality oversight of hospitals," Pelletier says. "Accreditation is a proven method for improving the care of Medicare beneficiaries."
As health providers recall the 10-year anniversary of the Institute of Medicine's celebrated wake-up call, "To Err Is Human," I flashed back to the story of Dan Jennings, a man I got to know fairly well.
Nearly 10 years ago, he was a "patient zero" of sorts in my horrifying education about avoidable harm. Bear with me while I tell this tale again.
Jennings, 47, traveled around the world teaching doctors about the diagnosis and treatment of sleep apnea. One day he got off a plane feeling severe pain in his stomach.
He went to his doctor, who admitted him to a Southern California hospital for surgery to repair a common bowel problem. He was discharged a few days later. Piece of cake.
But the pain just wouldn't go away, he repeatedly complained. Even when he moved slightly, something felt horribly wrong. Lying on his back in a station wagon, he was driven back to the hospital about two weeks later for X-rays to determine why he just kept feeling worse.
"Please get off the table, because there's some sort of object on it," the technician told him after taking the first set of images. When the artifact still showed up on the film, the technician asked Jennings to change into another gown because there must have been something wrong with the gown.
By the third series, the technician hurried to phone Jennings' surgeon.
A 14-inch long by 2-inch wide metal retractor remained lodged inside his abdominal cavity, stretched out straight. When the retractor was finally removed on Oct. 3, 17 days after Jennings' surgery, necrotizing fasciitis infection, which sometimes occurs when human tissue is exposed to metal, had begun to plow through his intestines.
How ever did this happen, with so many people in the room, was never publicly explained. Hospital staff and physicians at first pointed fingers at each other.
Jennings' learned that his was the last surgery the surgeon had scheduled during a 14-hour-long day in the operating room.
With stories like this to haunt me, I asked Paul M. Schyve, MD, senior vice president of the Joint Commission, whether patient safety has improved in the last 10 years.
What key things have we learned?
Schyve, a two-decade commission veteran with a passion for avoiding harm, says the field of patient safety is handicapped by not having a baseline to measure. Even the IOM report was really based on educated guesses.
The important thing it accomplished, he says, was to draw attention to the fact that preventable deaths occurred, and that they were much more common than previously suspected.
"It's hard to improve anything if you don't recognize you have a problem," he says. Today, he says, "Hardly anybody would say there isn't a safety problem."
Schyve lists five changes that the Joint Commission has made that he and many others believe have significantly changed both the culture and the practice around healthcare to avoid medical errors.
1. A three-step universal protocol for performing invasive procedures, such as surgery, to avoid wrong site, wrong person, wrong patient procedures, is followed in almost every acute care setting today. These include:
a) Verifying in advance that the team has all the tools and information it needs.
b)Marking the surgical site in advance—with the patient if possible.
c)Taking time out to double check immediately before the procedure to verify the patient, the procedure and the site.
"Those who consciously follow these steps find that they've eliminated wrong procedure, wrong site, wrong patient surgeries. Has anything we've done like this eliminated all risks? The answer is no."
But it has helped, Schyve says.
2. Hand hygiene gets much more attention today than it did 10 years ago. Schyve refers to studies showing that health providers wash their hands only half of the times they are supposed to, although they honestly believe they're doing it 90% of the time. Hospital officials moved sinks closer to doors and located hand-gel dispensers everywhere.
But still providers didn't always wash their hands. In some places, investigators who undertook serious efforts to find out why they didn't discovered that caregivers were carrying things when they entered and exited patients' rooms. "Their hands weren't free to use the gel," Schyve says. Now, some hospitals are installing small tables or trays where providers can place things conveniently while they use the dispensers.
Other facilities are trying the use of buzzers that automatically go off when the provider passes a dispenser without using it.
3. Providers have become more comfortable with dealing with the aftermath of a mistake and not ignoring it. "When something goes wrong, they don't just throw up their hands and feel terrible about it, they do a root cause analysis," Schyve says. "They're able to make changes to prevent it from happening again."
He adds providers are doing this today, unlike a decade ago, even when no harm to a patient occurred. It's enough that there was the potential for it to happen to prompt staff to analyze how the mistake occurred.
One example is the potentially fatal error of administering concentrated potassium chloride to a patient. The commission published a sentinel alert and now, potassium chloride is only sent to patient care units after it has been diluted by the pharmacy.
Tall man lettering, the practice of capitalizing key letters to distinguish drug one drug from another that is similarly named to avoid mistaking drugs that look alike and sound alike and not storing them in alphabetical order are other techniques that make mistakes harder to make.
4. Central venous catheter infection checklist protocols have been or are being put in place at many hospitals nationally to reduce this common cause of medical errors that can have lethal consequences.
5. Require nurses and other caregivers to always read back a physician's orders in the doctor's presence. This helps the doctor verify that what he or she said was what was intended, that the receiving caregiver heard it correctly, and both doublecheck that it was properly written down.
6. Using two identifiers to be sure the patient is the correct person. And to avoid mistakes, providers should be making it a routine practice to ask the patient to identify himself or herself. "Don't just go in and say, 'Are you Mrs. Brown?' because the patient might mishear and say yes. Ask the patient to say her name," Schyve says.
There were many other lessons Schyve mentioned. But he made the point. We don't really know if we're doing better, but we probably are. The important thing is that we're now willing to admit we're human, and we err.
And as humans we can recognize that and prevent it.
Other than making sure counts of foreign objects are performed before and after surgery, it's unclear what will work to prevent foreign objects like retractors being left inside surgical cavities.
At least in California, findings of clamps, sponges, hemostats, and towels inside surgical patients who have been closed still pepper the "immediate jeopardy" fines issued against hospitals by the state.
But increasingly, there are more ideas. Some hospitals are tagging surgical objects so an alarm will go off if they leave the suite with the patient. There's an idea to stamp numbers on sponges and towels, so they can be more easily counted when discarded, Schyve says. And some hospitals make it a policy to perform X-rays on certain patients after their procedures to make sure no objects were left inside.
The last time I spoke with Jennings, he had moved to Nashville with family, and still struggled with his recovery. I tried to call him this week, but the old number I have has been disconnected.
I wanted to know what he would say today about patient safety, 10 years after "To Err Is Human." Would he be reassured that incidents like this are much less likely to happen to someone else?
