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From the long hours to the pain and blame of medical errors to growing concerns over rates of workplace violence, healthcare professionals see demands unlike those faced by any other industry. It’s no wonder that healthcare workers face high rates of burnout and extreme levels of stress. How high? A 2015 Gallup survey found that a whopping four out of five healthcare workers were “struggling” or “suffering,” versus thriving.
One challenge is that healthcare workers don’t often seek the help they need to keep working safely and productively. In fact, a study published in the November 2016 issue of General Hospital Psychiatry found that doctors are less likely to seek help for depression, anxiety, and other concerns than the patients they treat. This was attributed partially to stigma and partially to state requirements, which mandate physicians to report any mental diagnosis to their state medical licensing board. Such requirements, the study found, lead physicians to worry that seeking help for mental health issues could lead to restrictions on their medical license.
The study’s lead researcher, Katherine Gold, MD, MSW, MS, of the University of Michigan Medical School, encourages medical schools, hospitals, physician groups, and medical professional societies to do more to help trainees and physicians understand that mental health symptoms can occur in anyone, especially in the medical field where expectations are so high. She encourages these groups to offer confidential, third-party, nonpunitive options for physicians and other providers to seek help when they experience symptoms.
Celeste Johnson, DNP, APRN, PMH CNS, a member of the board of directors of the American Psychiatric Nurses Association and director of nursing, psychiatric services at Parkland at Green Oaks Hospital in Dallas, agrees that it’s important to get physicians, nurses, and organizations to understand that there’s no shame in mental health problems, and that it’s crucial to put programs in place that give healthcare workers the tools they need to cope with trauma.
“Strategies that could support employees include reducing the stigma about mental health concerns, providing resilience training and care for the caregiver support programs, and providing health and wellness benefits, including policies that allow for time off for mental health concerns as well as for physical health concerns,” Johnson says.
For its part, Parkland is working to overcome the silence around mental health problems through universal screening for suicide risk. Since February 2015, it has screened approximately 1.7 million encounters, including employees seen in the employee clinic. “Suicide screening has opened the conversation about mental health with patients and with employees,” Johnson says.
While more systems are putting physician wellness programs in place, some groups are targeting the toughest problems with solutions aimed at helping medical professionals continue, or return, to work.
A framework for reducing burnout
Physician burnout is primarily a system issue—not an individual issue, wrote Drs. Tait Shanafelt and Stephen Swanson with Mayo Clinic in a February 2017 article in the American Journal of Medical Quality. It’s for this reason that more healthcare organizations are looking toward putting programs in place that give healthcare workers a place to turn when they are at their most vulnerable.
But finding the right approach can be challenging. In its 2016 Physician Wellness Survey, Stanford Medicine’s WellMD Center found that despite its focus on improving physician well-being, the organization continues to experience a decline in the health of its physician workforce that mimics the national trend. The survey revealed an increase in reported physician burnout from 26% to 39% between 2013 and 2016.
The organization has since targeted a three-pronged approach for stemming the growth of stress in the next two years. Its focus includes:
Creating a culture of wellness. Through leadership engagement, the group aims to develop a culture focused on support and appreciation for physicians, and to put their professional health first.
Boosting efficiency of practice. By recognizing the importance of wellness and advocating for process improvements, the organization aims to improve the quality of care it can provide.
Improving personal resilience. The center expects that programs and tools to promote self-compassion, improved sleep quality, and other self-care strategies can help physicians better cope with setbacks as they arise.
Resilience is critical in helping caregivers “bounce back” from trauma. When people are resilient, they’re able to cope with their mistakes rather than dwell on them. Fortunately, research indicates that resilience is a learned behavior.
The organization also has its behavioral health professionals reach out to people with high stress levels, difficulties with emotional health, or substance use concerns. By reaching out, they eliminate a common problem with caregiver support programs—that caregivers don’t always know how to find these resources.
Helping the second victim
An increasing number of organizations are recognizing that healthcare workers find themselves most in need of support following a traumatic event. These organizations are developing “second victim” programs to provide care for the caregivers—programs specifically focused on helping healthcare workers recover from trauma.
Such programs, Johnson explains, “provide timely support to employees who encounter stressful events, such as adverse medical events, workplace violence, community disasters, deaths, loss, and other events that are perceived as stressful to employees. Peer responders support colleagues to mobilize their coping skills and refer them to resources as needed.”
Since 2007, the University of Missouri Health System’s ForYOU program has encouraged healthcare workers to open up about their trauma, providing a much-needed outlet. The program helps team members identify second victim warning signs and work toward recovery. According to program co-founder Sue Scott, the program has also led to a culture of support within the system, as all team members—including those who have not undergone the eight-hour peer support training program—have gained awareness of the need to support one another.
Johns Hopkins’ RISE, or Resilience in Stressful Events, program uses an emotional peer support structure. The multidisciplinary peer responder team is made up of volunteers, including physicians, nurse managers, social workers, pharmacists, risk management, patient safety, and administration. Peer responders learn how to talk to second victims and give them a safe harbor for exploring their emotions following a traumatic event.
And Nationwide Children’s Hospital’s YOU Matter program is a three-tiered peer-based support system available to staff around the clock. The model provides on-demand intervention with immediate first aid through professional counseling, if necessary. Tier one includes local unit support, with one-on-one reassurance to the second victim. All team members receive education at staff meetings on how to identify second victim behavioral signs or symptoms, and what to say and not to say in working with a second victim. If additional help is needed, the victim turns to tier two support from trained peer supporters, the patient safety team, and risk management. Peer-trained supporters receive additional training where they hear second victim stories, learn strategies for managing documentation, explore legal concerns, and gain self-care tips geared toward supporters. Tier three is an expedited referral network to an employee assistance program, chaplain, social worker, or clinical psychologist.
Program managers at Children’s have found that a second victim program benefits from having a central portal where information can be shared, as well as clearly defined roles and responsibilities for each team member.
The value of these programs is evident in the numbers. At Children’s, more than 300 individual and 12 group encounter forms have been submitted since the program was launched in 2013.
Supporting those with substance abuse
With a lack of support for self-care, many nurses turn to substance abuse as a way to cope with stress or fight fatigue. The American Nurses Association estimates one in 10 nurses today abuse drugs or alcohol. Many nurses do not report these issues for fear of disciplinary action or career repercussions, according to information from Advanced Recovery Systems, a behavioral health care management organization.
But the Emergency Nurses Association (ENA) and the International Nurses Society on Addictions (INSA) argue that viewing these problems as a symptom of a disease, not solely as a crime, can help more nurses recover—and improve patient care.
In a joint position statement on substance use among nurses and nursing students published in the April/June 2017 issue of the Journal of Addictions Nursing, ENA and INSA call for healthcare facilities and nursing schools to adopt alternative-to-discipline (ATD) approaches to treating nurses with substance use disorders. They argue that programs that aim for retention, rehabilitation, and re-entry of these professionals into practice have been shown to be effective in treating healthcare professionals and effective in identifying more nurses with substance use disorders than disciplinary programs. The result is improved safety for the patient.
“It’s about education for prevention and fair handling when it happens,” commented Lynn Reede, DNP, MBA, CRNA, FNAP, American Association of Nurse Anesthetists senior director of professional practice, in a news release on the position statement. “Education raises awareness and understanding, and at the same time decreases the stigma related to the disease. Treatment of substance use disorder helps keep patients and healthcare professionals safe.”
In ATD programs, the nurses refrain from practice for a set time while undergoing treatment and working through a recovery program. Such programs are generally administered by a third party through contractual agreements with a state board of nursing, the ENA/INSA statement notes. Following an assessment, the parties might agree to an initial return-to-work agreement with reduced hours, limited shifts, and restrictions in assignments (for example, no access to narcotics), with continued treatment and monitoring for periods of up to five years, and a gradual lifting of restrictions with demonstrated progress.
Today, many state boards of nursing offer ATD programs for nurses with substance use or mental health disorders, but these programs vary widely, according to the statement’s authors. A consistent, supportive pathway could help more healthcare workers finally find the help they’ve been seeking.
Protecting employees from domestic abuse
In Massachusetts, nurses have found support for an entirely different issue known to lead to mental health problems, including posttraumatic stress disorder, depression, and anxiety. Two healthcare organizations are looking beyond the workplace to fully support employee well-being. In May 2017, the registered nurses of Mercy Medical Center and Providence Behavioral Health Hospital, represented by the Massachusetts Nurses Association (MNA), announced a partnership with their employer to create a program empowering staff members to respond to and prevent employee domestic violence.
“As nurses, we have an important role to play ensuring the health and safety of not only our patients, but also our colleagues, our peers, friends and loved ones,” commented Cathy Penniman, RN, BSN, of Mercy Medical Center, in a news release. “This program gives staff members at Mercy and Providence the ability to help each other by effectively guiding victims of domestic abuse to a strong support system. Our program is a model for healthcare employers that are seeking to protect and empower their workforce.”
In the fall of 2014, Andrea Fox, RN, an associate director in the MNA’s Division of Labor Action, and the MNA nurses at Mercy and Providence raised the issue of domestic violence during contract negotiations. The result was an agreement to form the joint Domestic Violence Task Force to develop domestic violence resources. The task force, made up of nurses and hospital administrators, developed safety policies and materials for all employees at Mercy and Providence who are affected by domestic violence.
Those resources include:
Outside assistance such as government agencies and nonprofits
Reserved parking spaces and escorts to vehicles
Increased security measures and signage
Spiritual care
Leave of absence provisions
Assistance on work time
Education materials for employees on how to support and respond to colleagues affected by domestic violence
The task force also created a slogan—”SHARE, because secrets don’t keep us safe”—that includes action steps:
Share right now
Hand off to someone who can help
Alert security
Respect privacy
Establish a safety plan
“The burden of this information becomes lighter when it’s shared, and this is the first step toward safety for the victim,” says Cady Spencer, RN, who serves on the detox unit at Providence Hospital and is a member of the task force.
Fox credited the office of Northwestern District Attorney David Sullivan with helping develop the idea for the program following her participation in a daylong program run by Sullivan’s Domestic Violence and Sexual Assault Unit called “Domestic Violence Affects All of Us: What Employers Can Do to Protect Your Business and Your Employees.”
The key is proactive support
The key to each of these programs is providing proactive support to employees to prevent problems before they happen, or while a positive outcome is attainable. By creating opportunities to listen to healthcare workers, organizations can begin a culture shift that ultimately leads to a safer patient, and caregiver, environment.
PSQH: Patient Safety & Quality Healthcare, September 15, 2017
The transgender population is at nine times the risk for attempted suicide as the general population. "This is really a public health crisis," says one expert.
Seven years ago, Sue Boisvert, senior risk specialist at medical professional liability insurer Coverys, found that she was starting to get more questions from her hospital and physician practice clients about transgender patients.
“I thought it was really interesting,” Boisvert says. “It was a completely new twist and not something I knew much about, so I started doing a lot of research.”
The biggest questions she received:
Should we change the patient’s name in the record?
Should we change the patient’s gender in the record?
How do we refer to the patient?
Boisvert, who lives and works in Maine, notes her state is fairly open to different lifestyles. But not all physicians are so open to learning more about helping transgender patients. A 2010 report from the National Center for Transgender Equality and the National Gay and Lesbian Task Force states:
“Denial of health care and multiple barriers to care are commonplace in the lives of transgender and gender non-conforming people. Subjects in our study seeking health care were denied equal treatment in doctor’s offices and hospitals (24%), emergency rooms (13%), mental health clinics (11%), by EMTs (5%), and in drug treatment programs (3%). … Nineteen percent (19%) had been refused treatment by a doctor or other provider because of their transgender or gender non-conforming status.”
Rampant discrimination isn’t a problem impacting only transgender patients. Members across the entire lesbian, gay, bisexual, and transgender community have reported instances of discrimination by healthcare providers, despite the fact that sex discrimination in federally funded healthcare facilities is specifically prohibited by the Affordable Care Act. But the challenges facing transgender patients are significant because those risks are not always apparent. Access to care and accuracy of health records are among the concerns that Boisvert hopes more healthcare providers will address, particularly as her insight into the challenges faced by the transgender community has grown.
Transgender suicide attempts nine times greater than the general population
The single most important thing a physician can do in caring for transgender patients, Boisvert says, is to advise them where to find counselors who can provide appropriate gender dysphoria therapy. Why? The transgender population is at nine times the risk for attempted suicide as the general population.
In 2014, the Williams Institute published a focused report on suicide attempts among transgender and gender non-conforming adults that found:
46% of trans men and 42% of trans women acknowledge suicide attempts.
Suicide risks were highest among those who are younger (18–24: 45%), are multiracial (54%) or American Indian or Alaska Native (56%), have lower levels of educational attainment (high school or less: 48%–49%), and have lower annual household income (less than $10,000: 54%).
Prevalence of suicide attempts is elevated among those who publicly disclose that they are transgender or gender non-conforming (50%).
Respondents who experience rejection have elevated prevalence of suicide attempts. This includes having a doctor or healthcare provider refuse to treat them (60%).
The 2015 U.S. Transgender Study, released in December 2016, reiterated these statistics: 40% of their nearly 28,000 survey respondents reported having attempted suicide at some point in their life, compared to 4.6% in the U.S. population.
“This is really a public health crisis,” Boisvert says. “If you think of any other group that had a number that big that was causing harm to that group, it would be huge. SARS was tiny compared to this.”
As a result, a primary care physician can be an important point of contact for getting transgender patients the mental healthcare they need.
“The absolutely most important thing you can do is know where the therapists are who know how to take care of children, adolescents, adults, and seniors who are transgender and have gender dysphoria, or who are depressed because of the challenges of having their brain tell them their gender is different from their biology.”
These issues are particularly close to Boisvert’s heart. Around the same time that she began getting questions from providers about treating transgender patients, she was dealing with the emotional process of sending her daughter off to college.
“The first part of her freshman year was the typical process of finding your way around. She made some friends, and things seemed to be going well,” Boisvert recalls. “But during the second part of the year, her Facebook posts got really dark; there were fewer calls home. Something wasn’t right.”
Over spring break, Boisvert’s daughter sat her parents down and confided that she had to tell them something important. “She was shaking all over, and I was thinking, ‘Oh my gosh, she’s going to tell us that she’s quitting school.’ Never in a million years did I think I’d hear, ‘I’m a boy. I’ve known it for a long time, and I’ve started hormone replacement therapy.’
“As a mom I was blown away,” Boisvert says. “I started crying and asked what I did wrong—which is not the right approach. Fortunately, my kid is a bit more mature than me and said, ‘Mom, this isn’t about you.’ That pushed me into nurse mode. As a nurse, I knew that transgender individuals have a very high risk of suicide behavior. … I looked at my husband and I said, ‘We have one chance to get this right. It’s the most important thing that we will ever do as parents.’ ”
The risk manager used this milestone to begin to learn as much about the challenges her son, and others like him, would face on this journey.
Providers aren’t providing basic care&
Due to the high rate of reported discrimination by primary care physicians, it’s perhaps no surprise that transgender patients may not be comfortable sharing their biological gender with their treatment provider. But without doing so, the patient will not get the appropriate care.
“For example,” Boisvert shares, “my son is biologically female. That means he still has female reproductive organs, but he looks like a man. He has facial hair, he has a deep voice, and he has a male body structure, so he doesn’t look right away female. A provider with whom he didn’t feel comfortable sharing that he was transgender wouldn’t know that he had female reproductive organs and needs some primary care for those organs. He needs to have a Pap smear, and he needs to have his ovaries checked for cancer protection, just like any other person with female reproduction organs needs to have.”
There are numerous other examples of safety risks, notes Boisvert. Consider x-rays, for example. It’s standard for radiologists to ask any woman if she could be pregnant. But what about men with female reproductive organs? At present, gender identity is not included in medical records, so a transgender patient might register with their legal gender or gender identity rather than their biological gender in order to reduce the odds of a confrontation.
“How does a radiologist handle that? Do they ask everybody whether or not they could be pregnant?” Boisvert asks. “Without gender identity on the record, important things like ‘this man has a uterus’ get missed.”
Or consider pathology. The presence of testosterone on individuals with female biology, for example, could impact lab tests. “The pathologist needs to know [gender biology] because some of the lab results will be different if a person is taking hormone replacement therapy,” Boisvert notes.
Public policies lead to growing health risks
There are also numerous risks to the health of transgender people beyond what’s being missed in the treatment room. Boisvert highlights the unexpected health risks of what she calls “the bathroom situation.”
“Bathrooms are binary,” she says. “There are men’s rooms and women’s rooms. So if you look like a man but biologically you’re a woman, where do you go to the bathroom? If you look like a man and you go in the ladies’ room, it’s going to create problems for you. If you’re in a state where you’re required to use the ladies’ room, what do you do? I’ll tell you—you avoid going to the bathroom.”
Boisvert points to some startling statistics from the U.S. Transgender Study: 59% of survey respondents reported avoiding going to the restroom in order to prevent a confrontation (Figure 1).
And as she elaborates, “How do you avoid going to the bathroom? You don’t eat and drink so you don’t have to use the restroom.” Thirty percent of survey respondents admitted that they did not eat or drink. The result, as most care providers can probably predict, is that there are health consequences to not eating or drinking, or to not using the restroom as needed. Eight percent of survey respondents reported health consequences, including urinary tract infections and kidney infections, as a result of these actions.
And given that the National Center for Transgender Equality and the National Gay and Lesbian Task Force reported that 28% of their survey respondents significantly postponed medical care when sick or injured due to discrimination, those health problems can have major impacts.
“So what do we need to do about that?” Boisvert says. “We need to have single-stall bathrooms, should not have a gender on it, and everyone who wants to use that restroom should be able to, and every public facility should have single-stall restrooms.”
While healthcare providers may not be able to impact the presence of transgender-friendly restrooms in all public spaces, they can dictate what happens in their practices, and they can speak up on the public health threat that comes with requiring people to use the bathroom of the gender they’re assigned at birth. Such requirements are popping up in a number of states (the National Center for Transgender Equality reports that 54 bills targeting transgender people have been proposed so far this year).
Are your practices doing harm?
Many healthcare providers may need to take a second look to understand how their practices are, even unintentionally, violating their oath to do no harm.
“Part of the problem is primary care providers don’t know how to take care of transgender patients, and they need to figure it out,” Boisvert says. “We don’t have an actual count of transgender patients. We can’t get that because we don’t collect gender identity in the census. But using CDC statistics, the Williams Institute extrapolated the number of people who might be transgender at 1.4 million. So there are 1.4 million people who need a primary care provider who knows how to take care of them.”
And in some cases, the keys to providing proper care might be very simple. For example, Boisvert points out, “Pronouns are very important to transgender patients. Not only do they want to be called by their preferred name, but they also want to be called by their preferred pronoun.”
Not every transgender person sees themselves as male or female, she notes, and many don’t want to be categorized as either gender. “They want a pronoun that does not reflect gender. So for the benefit of people who are not transgender—cisgender people—a lot of transgender people use the pronoun ‘they’ because it’s not gender specific,” Boisvert says.
“The challenge with ‘they’ is it’s plural, so you can run into some interesting situations. Think a medical assistant goes into the doctor and says, ‘They’re ready in the treatment room.’ Is that one ‘they’—a transgender person? Or is that ‘they’ a whole bunch of people? It’s a minor detail, but it can cause confusion.”
And it can have a big impact, Boisvert notes.
“When a transgender person is misgendered—when someone uses their wrong name or their wrong pronoun—it feels like a bee sting to them. One or two bee stings hurt. A whole bunch of bee stings can really be harmful. And that’s how it hurts them to be misgendered,” she says.
The solution may be as simple as reaching out to an expert for insight on how to encourage trust among this patient population.
PSQH: Patient Safety & Quality Healthcare, July 11, 2017
Healthcare organizations are just beginning to appreciate the number and variety of violent interactions that can occur within their institutions and to the people they serve. Ashley Withrow, MSSA, LISW-S, is a member of the Cleveland Clinic’s police department and has served the community as a victim advocate; she offers a unique opportunity to help victims simultaneous to their medical treatment and employees within their work setting.
This article first appeared in PSQH Magazine.
Ashley Withrow, MSSA, LISW-S, is a member of the Cleveland Clinic’s police department and has served the community as a victim advocate since February 2014. In that role, Withrow, supports anyone connected to the Clinic who has experienced violence, providing information and referrals in addition to emotional support.
Healthcare organizations are just beginning to appreciate the number and variety of violent interactions that can occur within their institutions and to the people they serve. From gang-related shootings in the emergency department, to fights among family members, abusive interactions among clinicians and staff members, injuries to nurses caring for patients with dementia, patients or employees who report incidents of domestic violence, and children who have suffered abuse, violent behavior is common. Withrow responds to all of these incidents and more. Her position offers a unique opportunity to help victims simultaneous to their medical treatment and employees within their work setting. Susan Carr recently talked with Withrow to learn more about her work.
Carr: What is the scope of your role as victim advocate at Cleveland Clinic?
Withrow: My role is to provide emotional support and crisis intervention to victims of crime, including patients, visitors, and employees of the Cleveland Clinic. When someone becomes a crime victim, they may need to interact with many different individuals and systems—for example, reporting to law enforcement or seeking medical attention. If the victim chooses to pursue criminal charges, he or she may have to share their story with prosecutors, judges, or members of a jury. Many people find the process overwhelming and confusing. My role is to support them emotionally and help them engage effectively with the systems. I do this by offering education, resources, and referrals.
Carr: Are you primarily providing support services for people who are engaged in the criminal justice system?
Withrow: While my primary responsibility is to educate victims about their rights and make sure those rights are upheld within the criminal justice system, victims are typically impacted by the crime in a variety of other aspects of life. I tell them what to expect as they go through the criminal justice system and provide a realistic understanding of what that system might look like. Most people haven’t been through that before and don’t know what the process looks like. It’s definitely not like what they see on television and in the movies!
In order to meet the other varying needs that arise due to the victimization or trauma, I’m familiar with our community resources and counseling and support group options. Programs such as crime victim compensation or victim information and notification are available to crime victims. Connecting people with those kinds of programs or helping them apply to a compensation program is another part of my job.
Carr: Do you ever support victims of events that are more subtle—involving less physical violence than, say, an incident involving a weapon—but are very upsetting nonetheless? How do you determine the scope of events you’re responsible for?
Withrow: I respond to a wide range of incidents and individuals and work with people who have experienced many degrees and varieties of unfortunate events and injuries. Everyone reacts differently to a traumatic event, and my job is to address their needs rather than tell them how to react. Victims can access support of a victim advocate regardless of whether or not their case will be prosecuted.
Although I’m based in Cleveland Clinic’s police department, my job is fundamentally about offering help following an incident. For example, perhaps a nurse was struck by a patient suffering from dementia or coming out of anesthesia. There’s no criminal intent, but it is still my job to say to the nurse, “Hey, how are you doing? I’m sure that was very scary for you. Is there anything I can do to support you at this point?” or, “Are you feeling safe in your workplace, and if not, what can we do to increase your safety?” My job is very focused on the emotional needs of the victim, who in this case is the employee.
Carr: It sounds like you provide services across a wide spectrum of emotional circumstances.
Withrow: That’s true; there’s lots of variety. Another example of people I support are Cleveland Clinic employees who are experiencing domestic violence at home, and it’s impacting them in the workplace. Or I’m supporting employees who are experiencing workplace violence. Sometimes my clients are patients who have come in through our emergency department saying, “I’m here because I’m a crime victim.” Or patients might be here for an unrelated reason, but during the course of their treatment they disclose that they have experienced a crime—stalking, harassment, robbery, or something else. Certainly, the need is there. Our employee and patient populations reflect what’s going on in the larger community.
Carr: Do you work alone? How do you handle what sounds like an overwhelming workload?
Withrow: Well, I’m just one person, and I definitely can’t do it all. I work collaboratively with many partners here at the Cleveland Clinic, such as committees that focus on issues related to my work. The Cleveland Clinic has committees for domestic violence, elder abuse, workplace violence, and a child protection team. I work closely with other departments, such as employee assistance, case management, human resources, and nursing to support victims. It is also critical that I maintain partnerships in our community as well. I’m active, for example, in the county sexual assault response team. I frequently refer victims to community agencies, such as the Domestic Violence and Child Advocacy Center or Cleveland Rape Crisis Center. If a survivor comes to me as the victim advocate, and they are in crisis, I have to do the best I can to help them, but I can’t do everything. For example, I do not provide shelter. So if I’m helping someone who has safety concerns at home, I will connect that victim with the local domestic violence shelter and support her through the process—hopefully—of getting into the shelter. Then the victim transitions to that provider, who can welcome them to the shelter and support them during their stay.
Individuals travel from all over the country and world to seek medical treatment at the Cleveland Clinic, so I sometimes help navigate referrals and situations at a distance, even outside of Ohio, and refer them to their local law enforcement jurisdiction.
Carr: Do you collect data about the incidents you respond to?
Withrow: I do track data on the number of victims served, as well as type of victimization and other demographics as required by my funding source, the Victims of Crime Act (VOCA). We have seen growth in numbers over the last 2.5 years since I started in this position, which indicates to me that the need continues to be present for this type of service.
Carr:How do victims find their way to you?
Withrow: The bulk of my referrals come from police officers who are out in the hospitals and on the main campus in downtown Cleveland on a daily basis. We also have officers in our regional hospitals throughout northeast Ohio. Our Cleveland Clinic police officers staff those facilities 24 hours a day. Most of my referrals come from officers responding to calls and requests for service. They might refer someone to me who is filing a police report or someone involved in an event to which the Cleveland Clinic’s crisis intervention team has responded.
However, I have seen an increase in the number of referrals coming from other sources, such as nurses, physicians, case managers, employee assistance, medical assistants, or even individuals referring themselves who have heard about the program over the last couple of years.
We hope we are creating awareness and a more victim-centered environment at the Cleveland Clinic. For example, we want to make sure our caregivers have the tools and resources they need to effectively screen patients for domestic violence. We also want caregivers to understand what workplace violence really is, and then know what to do should they feel they’ve experienced it. That’s another piece of what I do.
Carr: Given that it is unusual for a health system to provide this kind of support, are you aware of special commitment to this effort from leaders at Cleveland Clinic? How did this start, and where does the funding come from?
Withrow: In 2013, David Easthon, the chief of the Cleveland Clinic Police Department, became aware of funding through the Ohio Attorney General’s Office VOCA grant. Under his leadership, the Cleveland Clinic applied for and was granted funds for a full-time victim advocate position. VOCA funds were established in 1984 as a federal grant that takes fines and fees from convicted federal offenders and distributes the money to victim service providers across the country. We apply for continued grant funding each year.
Leadership has been important to my advocacy work as well as to our efforts to prevent workplace violence. In the case of employees who are victims of violence, the organization needs to provide support to the person who directly experienced the violence, as well as the entire department and unit where the incident occurred. The effects of violence can ripple across the team, and we must acknowledge and support each individual’s experience. Witnessing violence can cause psychological trauma, just like experiencing it directly. The message from leadership and managers following a violent incident must be clear and concise: “This was not your fault. This is not acceptable behavior. How can we help you feel safe?” I have seen many leaders come together to form a collaborative effort to address issues of workplace violence and other victim concerns in our healthcare system.
By helping patients, visitors, and employees of the Cleveland Clinic feel safe and supported through victim advocacy, we strive to improve the quality of services as a healthcare system and quality of life for those providing world-class healthcare.
PSQH: Patient Safety & Quality Healthcare, June 27, 2017
Risk management professionals should not take lightly the complexity associated with providing healthcare services. While regulations, third-party payer requirements, and licensing/accreditation standards contribute to this complexity, formalized policies and procedures can mitigate it.
This article first appeared in PSQH Magazine.
Risk management professionals should not take lightly the complexity associated with providing healthcare services. While regulations, third-party payer requirements, and licensing/accreditation standards contribute to this complexity, formalized policies and procedures can mitigate it by promoting workplace safety, regulatory compliance, and the delivery of safe, high-quality patient care. Moreover, well-written, up-to-date policies and procedures reduce practice variability that my result in substandard care and patient harm.
The operational challenges associated with drafting (and maintaining) comprehensive written policies place heavy demands on healthcare managers. Given increasing financial pressures and the top-priority status that must be given to direct patient care, managers may find it difficult to find time to review or update policies and procedures. Deferring policy and procedure development, however, may result in negative consequences. Policies and procedures may become outdated, and those who adhere to outdated policies may carry out actions that are no longer consistent with industry-recognized practices. Alternatively, they may simply elect to disregard the policy. Either choice may result in patient harm and a malpractice claim. Evidence that caregivers followed outdated policies may hinder defense of an otherwise defensible claim.
Healthcare risk managers are encouraged to collaborate with other senior leaders in their organizations in order to maximize the usefulness of policies and procedures and reduce potential associated risks. The following strategies represent best practices observed by the author:
Designate a senior leader to oversee policy development, approval, and periodic review by the appropriate policy owner(s). The Corporate Compliance Office and the Legal Department are well-suited for this responsibility since many policies pertain to regulations.
Create a tracking mechanism that will identify when each policy’s periodic review is due, issuing advance notice to the policy owner in order to assure timely response.
Issue policy development guidelines and train managers in their use.
Create a system-level policy and procedure oversight committee with multidisciplinary membership and representatives from all entities. Consider forming domain-specific subcommittees for each department: nursing, pharmacy, biomedical engineering, etc.
Incorporate training about policy and procedure compliance in new-employee orientation programs. Include discussion of each staff person’s duty to exercise judgment in specific situations and determine if any part of the policy or procedure warrants modification. In such circumstances, the staff member must understand the need to document the rationale for that decision—and the manner in which the procedure was modified—in the patient’s medical record.
Hold managers accountable for policy development, review, and revision. Incorporate review of this responsibility into the annual performance appraisal process.
Implement a feedback mechanism so staff can report situations to management that resulted in a near miss event or necessitated some form of workaround. Situations that prompt staff to use a workaround indicate possibly unreliable processes or practices. By reporting them to management, with the expectation that they will be investigated and addressed, the potential for patient harm may be reduced.
Establish a committee to review the policies of any newly-acquired business units or practices and compare them to those already within the health system. Identify policy disparities and develop a plan for standardization, unless there are legitimate reasons why the system’s current policy needs to be modified in whole or in part, because of different jurisdictional statutes or different services offered by a particular organization.
The risks associated with writing, updating, and implementing policies and procedures are often under-appreciated by healthcare managers. Healthcare risk managers, particularly those shifting to an Enterprise Risk Management approach, may wish to draw upon the ideas in this article as they: a) collaborate with system leaders in developing “system-wide” policies and procedures (modified to meet a unique characteristic of a specific entity); b) meet with department or service line managers to identify optimal policy formats and content; and c) offer input to corporate leaders regarding policy review and updating practices.
There are numerous reasons patients stop taking medication against their physician’s advice. They might feel better (or, thanks to side effects, feel worse). They might not be able to reach the pharmacy. The cost might be too steep. Then, of course, there is the potential for medications to be prescribed from a number of points of care, which is leading to more challenges regarding medication reconciliation. Whatever the cause, poor medication adherence has significant costs for both the individual and the health system.
Medication adherence issues are estimated to cost healthcare facilities approximately $177 billion each year in direct and indirect healthcare costs. According to the 2015 report from the Network for Excellence in Health Innovation, Reducing Hospital Readmissions Through Medication Management and Improved Patient Adherence, “Nearly half of all prescribed medications are not taken as indicated. An analysis of electronic prescriptions for new medications in the U.S. found a 28% non-fill rate, while a recent Canadian study uncovered nearly one-third of new prescriptions were never filled. Inadequate adherence has been linked to poor health outcomes/additional illness, avoidable hospital admissions, premature death and $290 billion in unnecessary health care expenditures annually. Conversely, improved adherence has been linked to better health outcomes.”
But does medication management reduce readmissions? Healthcare systems are exploring a number of strategies to ensure that the answer is “yes.”
Improving medication management at transitions of care
Many hospitals are seeking to improve their medication education at the transitions of care, particularly during the discharge process.
“By definition, any transition of care program that you run, if you are to have a return on investment, has got to have a huge focus on medication issues,” says James Notaro, RPh, PhD, president and founder of Clinical Support Services, Inc., a medication management, care management, and care coordination software and services provider in Buffalo, New York. But according to Notaro, the uncoordinated discharge system puts patients at an immediate disadvantage. When patients are discharged with a stack of prescriptions that the pharmacist must reconcile with previous prescriptions, the hospital is taking a leap of faith that patients will be able to provide for their own care.
“Generally people get a sub-optimized regimen day one out of the hospital—if they get their discharge medications at all; if there are not social determinants of care to prevent them from getting to a pharmacy or filling their particular medication,” Notaro says. He adds, “You’re not at your best when you get discharged from the hospital. If you don’t have good family support, then you’re really in for a sub-optimized regimen after you’re discharged. So for a lot of patients who are fragile, it doesn’t take a long time to return to the hospital.”
As a result, more healthcare providers are examining ways to start medication management programs in the hospital.
Sherri Boehringer, PharmD, BCPS, senior editor and vice president of content at TRC, the Medication Learning Company, sees a “meds to beds” program as one solution for improving medication management. “The idea is that a patient actually gets their discharge medication while they’re still in the hospital and they get education,” she explains. “It’s about ensuring patients go home on the right medications, that there aren’t therapeutic duplications, and that they get the prescriptions they need.”
At Houston Methodist, says Janice Finder, the health system’s director of health and performance improvement, “We provide patients with medication pill boxes prior to discharge and educate them so they or their family is able to fill the boxes.” It’s just one aspect of the systems’ multi-pronged patient education approach.
PSQH: Patient Safety & Quality Healthcare, June 15, 2017
A data-driven initiative raises nurse engagement in smart pump safety improvement and helps create a continuous quality loop to strengthen patient safety and gain data-driven insights.
The introduction of “smart pumps” 15 years ago began a new era in IV medication safety. Many of the medications infused directly into a patient’s bloodstream (sedatives, insulin, anticoagulants, opioids) pose a high risk of patient harm; in fact, IV medication errors are twice as likely to cause patient harm compared to medications delivered via other routes (American Society of Health-System Pharmacists, 2008). A simple mistake in programming a pump—pressing “603” instead of “6.3,” or “25,000” instead of “2,500”—can deliver a massive, even fatal, overdose. With smart pumps, if infusion programming exceeds hospital-established limits, the dose-error-reduction software (DERS) generates an alert that must be addressed before infusion can begin. By using the safety features on smart infusion pumps, nurses can help improve patient safety and avert the medication errors associated with the greatest risk of harm: IV administration errors at the point of care (Wilson & Sullivan, 2004; Williams & Maddox, 2005; Fields & Peterman, 2005; Maddox, Danello, Williams, & Fields, 2008).
In addition to providing DERS, smart pumps also automatically capture previously unavailable data on IV infusions. An advanced data-analytics applicationa allows staff to more readily view, report, and use these data to identify key areas for improvement, without the burden and expense of additional staff, software, or daily data management. Staff can take actionable items such as necessary revisions to the DERS drug library, use their expertise to make the needed changes, and then implement the revised dataset hospitalwide in a continuous quality feedback loop.
Orange Regional Medical Center (ORMC) in Middletown, New York, is a 383-bed, Joint Commission–accredited hospital and member of the Greater Hudson Valley Health System (GHVHS). ORMC implemented smart pumpsa in 2005, followed by computerized prescriber order entry (CPOE) and barcode medication administration (BCMA) in 2011; it began regular use of the smart pump data-analytics applicationb in 2015.
Except for rare instances such as clinical emergencies or investigational drugs, nurses at ORMC are expected to use DERS for every IV infusion. Studies have revealed less valid reasons for not using DERS: underappreciation of risk, a failure to adjust the drug library when alerts are not credible, and a culture that tolerates at-risk workarounds (Institute for Safe Medication Practices, 2007).
Like many hospitals, ORMC found eliminating workarounds to be challenging. Despite extensive efforts, nurses continued to use the DERS drug-dosing safeguards for only 70%–75% of infusions. Then, in 2015, ORMC launched an innovative, data-driven IV Medication Safety Improvement Initiative that increased nursing compliance with the use of the DERS drug library for selection of the medication to be infused (Figure 1). Improved communications and advanced data analytics were keys to success.
This article includes a brief description of the IV Medication Safety Improvement initiative, the remotely hosted data-analytics application, and lessons learned for increasing pharmacy-nursing collaboration, optimizing the drug library, and improving smart pump drug-selection compliance and IV medication safety.
IV medication safety improvement initiative
The overall goal of the initiative was to increase nurses’ compliance with selection of the medication to be infused from the DERS drug library. The question was, how could ORMC bring about the desired change in behavior? The Hierarchy of Controls advocated by the National Institute of Occupational Safety and Health (Figure 2) considers “administrative controls” (training and education) to be a less effective means to avoid exposing employees—or, in this case, patients—to potential harm.
With IV infusions, the best example of higher-level “engineering controls” is to integrate the smart pump system with the electronic health record (EHR). Interoperability automatically engages DERS for every infusion and pre-populates the pump with the ordered infusion parameters from the EHR. However, for many hospitals, interoperability is not a present reality. Another way to nurture compliance with smart pump technology and attention to the alerts is to optimize the smart pump drug library (Institute for Safe Medication Practices [ISMP], 2007). This increases the credibility of alerts, eliminates discrepancies between the drug libraries and actual practice, and makes it easier for nurses to select the medication from the drug library for every infusion.
Issues
To achieve this goal at ORMC, the following issues needed to be addressed:
Nurses were unaware of the lack of safeguards when the drug was not selected from the drug library and thus underappreciated the risk.
Nurses could not easily inform pharmacy about discrepancies between the smart pump drug libraries and actual practice.
Due to the lack of reporting from nursing, pharmacy was unaware of discrepancies that interfered with nurses’ use of the DERS drug library.
Without effective pharmacy-nursing collaboration to help optimize the drug library, it was not always easy for nurses to “do the right thing.” As a result, nurses did not always use the drug library to select the medications to be infused.
To address these issues and achieve the goal of increasing nurses’ selection of medications from the drug libraries, ORMC employed the methods shown in Table 1.
Education
The nursing educators invited clinical pharmacy leadership to speak to all nurses at the 2015 Nursing Annual Education sessions about the importance of using DERS. This was also emphasized in training for newly hired nurses and in face-to-face discussions with nurses at the bedside.
Easier reporting
A “drug hotline” and designated email address made it easy for nurses to submit valuable feedback. Such feedback helped identify changes that pharmacy needed to make to the smart pump drug library. Regular IV Safety Improvement bulletins encouraged nurses to inform pharmacy of any needed improvements to the DERS drug library—for example, if a drug limit was not in alignment with actual practice and thus frequently overridden, or if a commonly used drug concentration was not in the drug library. Whenever a discrepancy report was received, a response was sent by return email, informing the nurse that the change would be made and when it would happen, or that further research/consideration would be needed. Rapid feedback was critical to the success of this initiative.
Change requests were submitted to the clinical pharmacy team for review. After review, revisions were made to the drug library, which was then double-checked by two pharmacists before being “pushed out” wirelessly to the pumps. A tip sheet notified clinicians of the changes. Seeing drug library improvements resulting from their efforts further motivated nurses to report discrepancies and, most importantly, to select the medication from the DERS drug library for all IV medication infusions.
Use data to help change behavior
The remotely hosted, advanced data-analytics application played a critical role in the IV Medication Safety Improvement Initiative (Box 1). The application reported DERS usage for each infusion, which made compliance with selecting the medication from the drug library easier to see and allowed the nursing staff to more easily monitor their performance. Authorized staff could access the smart pump data anywhere, anytime from an appropriate digital device. Retrospective data aggregated from the hospital’s smart pump system could be easily viewed on the application’s “dashboard” display.
Staff could easily review, report, create graphs and slides, and share important information with nursing directors, educators, senior management, and—most importantly—bedside clinicians.
Reporting DERS usage rates by unit was challenging, because the pumps were mobile and moved regularly around the hospital. However, rates could be tracked by patient profile. Medical/surgical nurses, for example, could easily see how they compared to critical care nurses. Having the nurses see the data on a regular basis also sparked a spirit of competition between departments, which further increased motivation and nursing engagement in the initiative.
Provide frequent, fresh communication
Report distribution started out weekly, then changed first to biweekly and later to monthly as nurses’ use of the DERS drug library began to increase (Table 1). At first, IV Safety Improvement bulletins were distributed to the chief nursing officer, nursing directors, and nursing educators, but not to individual nurses (who were already receiving a great deal of email). As awareness increased and nurses became more interested and involved, individuals were added to the email distribution list.
Continuously updating the before-and-after data kept the information fresh, kept nurses interested, showed their successes, and fostered a spirit of competition. As nurses saw improvements reflected in the changing data, they became increasingly involved in pharmacy-nursing collaboration (Box 2).
Results
IV medication safety improvements
Using data to help drive improvement resulted in steady increases in the use of the DERS drug library to select the medication to be infused (Figures 1, 3, and 4).
Other results
The IV Medication Safety Improvement Initiative also:
Provided nursing and physician education regarding the importance of using DERS
Provided a mechanism for nursing to inform pharmacy of any discrepancies between the drug library and actual practice
Eliminated reported discrepancies between the drug library and actual practice
Increased pharmacy-nursing collaboration
Identified drug library entries that needed to be added or updated
Increased nursing engagement
Increased use of DERS safeguards by selecting the medication to be infused from the drug library
Helped strengthen ORMC’s culture of safety
Recognition
Every year, ORMC departments can submit one or more projects for an enterprisewide quality and patient safety award. In 2015, the IV Safety Improvement initiative was awarded top honors at the GHVHS Quality and Patient Safety Awards, an important validation of the staff’s concerted, innovative efforts and results.
Next steps
Considerable progress has been made in putting DERS and continuous quality improvement at the forefront of medication safety awareness. Nonetheless, there is more work to be done. Pharmacy presentations at nursing education sessions and monthly reports on DERS usage continue. Multiple communication channels are still available. Email has emerged as the most commonly used means of communication.
In the future, staff will also analyze data on “good catches,” alerts, and overrides as another way to identify needed improvement in nursing practice and/or smart pump drug libraries. The smart pump data and remotely hosted data-analytics application can also be used to help staff demonstrate cost avoidance, return on investment achieved through a reduction in adverse drug events, and the hospital’s compliance with certain requirements of The Joint Commission. Finally, optimizing the drug libraries helps pave the way for future implementations of smart pump-EMR interoperability.
Lessons learned
Eliminating mismatches in the smart pump drug library helps drive use of DERS
Education, easy-to-use reporting systems, face-to-face discussions, and ongoing communication with frontline nursing are effective ways to educate the nursing staff and discover inadequacies in the drug library
Responding to nursing feedback in a timely manner keeps staff engaged
Frequent communication of data showing progress is essential
Data reports help celebrate nurse accomplishments and further strengthen nursing engagement in the IV medication safety improvement efforts
Conclusion
The ISMP points out that, like seat belts, the safety features of any safety technology can be bypassed, despite various mandates requiring their use. “Thus, it is not enough to purchase smart pumps, program the library to enable the technology, distribute the pumps, educate users, and hope that the dose-checking feature will always be used. A culture of safety must exist that drives clinicians to avoid bypassing such a safety feature, or to report conditions that encourage workarounds so they can be remedied” (ISMP, 2007).
At ORMC, before-and-after data from the analytics reports provided “something new” that helped to increase staff awareness of the need to always select the medication to be infused from the DERS drug library, motivate staff to report conditions that could encourage workarounds, and increases nurses’ engagement in the medication safety improvement process. Nurses continue to work with pharmacy to keep the drug library up to date. They know that their feedback is important and have become increasingly engaged in the compliance-improvement process. They recognize more fully that smart pump safety features can save lives and have to be used. Continuously fine-tuning the drug library in the continuing quality loop helps ensure that bedside clinicians have the latest data set for the safest clinical practice—and that the right thing to do is the easy thing to do.
Note: We would like to express our appreciation to BD and Sally Graver for helping to ensure accuracy and completeness during manuscript development.
Footnotes:
a. Alaris System, with Guardrails Suite MX software, BD. Franklin Lakes, NJ.
b. Knowledge Portal for Infuse on Technologies, BD. Franklin Lakes, NJ.
Nicole Karchner, PharmD, was the clinical pharmacy manager at Orange Regional Medical Center in Middletown, New York from 2009 to 2016. She is now the director of pharmacy management for Crystal Run Health Plans. She can be contacted at ekarchner@crystalrunhp.com.
REFERENCES
The National Institute for Occupational Safety and Health (NIOSH). (2016, July 16). Hierarchy of Controls. Retrieved March 2, 2017 from https://www.cdc.gov/niosh/topics/hierarchy/default.html.
American Society of Health-System Pharmacists. (2008). Proceedings of a summit on preventing patient harm and death from IV medication errors. Am J Health-Syst Pharm, 65(24), 2367–2379.
Fields, M., & Peterman, J. (2005). Intravenous medication safety system averts high-risk medication errors and provides actionable data. Nurs Admin Quar, 29(1), 78–87.
Institute for Safe Medication Practices. (2007, April 19). Smart pumps are not smart on their own. ISMP Medication Safety Alert! Retrieved March 2, 2017 from http://www.ismp.org/newsletters/acutecare/articles/20070419.asp.
Maddox, R., Danello, S., Williams, G. K., & Fields, M. (2008). Intravenous infusion safety initiative: Collaboration, evidence-based best practices, and “smart” technology help avert high-risk adverse drug events and improve patient outcomes. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches, Vol. 4 (pp. 143–156). Rockville, MD: Agency for Healthcare Research and Quality.
Orange Regional Medical Center (ORMC). (2015). IV Medication Safety Improvement Initiative, data on file.
Williams, C. K., & Maddox, R.R. (2005). Implementation of an I.V. medication safety system. Am J Health-Syst Pharm, 62(5), 530–536.
Wilson, K., & Sullivan, M. (2004). Preventing medication errors with smart infusion technology. Am J Health-Syst Pharm, 61(2), 177–183.
Nurses serve on the front line of patient care, and so it makes sense that these talented, dedicated individuals are also at the forefront of a vigorous movement to improve patient safety.
“Across all areas of nursing, I see nurses not only working on safety but defining plans to accelerate safety both for patients and the workforce,” says Patricia McGaffigan, RN, MS, CPPS, chief operating officer and senior vice president of program strategy and management at the National Patient Safety Foundation.
This desire to effect change is being realized in a variety of forms—as varied as the circumstances facing individual nurses themselves, the largest segment of the healthcare profession. Because of their integration into every aspect of care, nurses are more than ever driving ambitious patient safety reform efforts.
Leading the way as patient advocates
Maureen Swick, CEO of the American Organization of Nursing Executives, notes that in their position as point person, nurses have the greatest opportunity to keep patients safe. It’s here, through patient engagement, that nurses are leading change. “By involving the patients and their families in the patient’s plan of care, especially as it relates to medications and understanding potential side effects, nurses help patients safely and seamlessly transition across the care continuum,” Swick says.
Given the extraordinary amount of time that nurses spend with patients, Swick says it is critical for nurses to be involved in safety initiatives. “Transforming change at the organizational level requires openness and shared responsibility by everyone in the organization,” she says. Chief in achieving this aim is creating an environment where nurses feel safe reporting errors and near-misses to leadership. “And,” Swick adds, “leadership needs to work with staff to implement new processes.”
In many instances, nurses are driving institutional improvements by moving from a reactive to a proactive stance in investigating adverse safety events.
“Many times nurses are involved in a retrospective view of patient safety events—and they may be involved in the sharp end, where the proximal error may have occurred, or they may be involved as part of the team over time where something unfortunate has occurred,” McGaffigan points out. Today, more nurses are learning to conduct effective cause analyses of events that have gone wrong. It’s a role they’re perfectly suited for.
“They’re a critical member not only of the care delivery team, but they have ample opportunity to understand why things have gone wrong—and why things go right—and be able to translate that [into action] through their ability to move the needle in terms of safety,” McGaffigan says. To do so effectively, nurses need support from leadership.
“Nurses [can] lead change by reporting all potential safety issues to leadership,” Swick says. But this only works in a culture where error reports are encouraged. Swick notes that some organizations use safety hotlines and electronic safety reporting systems, “so senior leadership can review any real or potential safety issues reported by nurses and other members of the healthcare team.”
PSQH: Patient Safety & Quality Healthcare, June 2, 2017
Care transitions have been identified as having heavy influences on readmission rates. It’s more important than ever that patients be armed—but not overwhelmed—with the information and resources necessary to manage their health post-discharge.
At the end of a hospital stay, many patients find themselves overwhelmed by their experience as well as the often lengthy care directions they’ve been given. Others might find themselves pushed into another care place, one that may not have the resources or focus to holistically address their problems. Too often patients find themselves released from the hospital, only to wind up back in that hospital bed within the 30-day readmission window—a metric closely watched by the Centers for Medicare & Medicaid Services (CMS) and hospitals everywhere.
Streamlining the discharge process has become a significant focus for hospitals since the Affordable Care Act (ACA) and CMS’ Hospital Readmissions Reduction Program (HRRP) have come into play. Yet readmission numbers remain dramatically high. Although a recent study from the U.S. Department of Health and Human Services found that the ACA has caused readmissions to fall sharply for conditions targeted by the HRRP (Zuckerman, 2016), that’s still just a drop in the bucket. In fiscal year 2016, only 799 hospitals were able to avoid HRRP penalties—a mere 23% of the more than 3,400 hospitals participating in the program (Rice, 2015).
Care transitions—from hospital to home, from acute care to long-term care, and so on—have been identified as a heavy influence on readmission rates. While numerous programs advise on clinical policies that can reduce the readmission rate for certain at-risk populations (see sidebar, “11 Programs Successfully Lowering Critical Access Hospital Readmissions”), more health systems are looking at creating spaces that let discharged patients easily access the information and resources they need while still at the hospital or near their clinical team.
Creating an informative place to wait
Among the most common problems causing patients to return to the hospital include misunderstanding, or miscommunication, about medication prescriptions and a lack of follow-up with a primary care physician. As a result, and considering the quicker discharges some patients experience today, it’s more crucial than ever that patients be armed—but not overwhelmed—with the information and resources necessary to manage their health. Many health systems are turning to dedicated discharge coaches or technology to educate patients on medications, risks, and other information. Others are finding that design can help.
PSQH: Patient Safety & Quality Healthcare, May 31, 2017
Examining 24 clinical care measures, a CMA report reveals that women receive worse care than men for three measures, similar care for 16, and better care than men for five measures.<'/h2>
Two of the most significant healthcare gender disparities are related to follow-up care and alcohol/drug treatment, according to Gender Disparities In Health Care in Medicare Advantage, a report released by the CMS Office of Minority Health in April based on 2015 data.
Examining 24 clinical care measures, the report revealed that women receive worse care than men for three measures, similar care for 16, and better care than men for five measures. For the purpose of this report, disparities in care are considered statistically significant if the difference between men and women receiving the care is three or more points after rounding.
The most significant disparity where men received better clinical care was avoiding potentially harmful drug-disease interactions in elderly patients with a history of falls. According to the report, 61% of elderly men met the standard of care, compared to approximately 50% of elderly women. Meanwhile, the top disparity where women received better clinical care occurred in follow-up after a hospital stay for mental illness (within 30 days of discharge). About 57% of women received follow-up care compared to about 50% of men.
Women received significantly better care than men in the following areas:
Follow-up after a hospital stay for mental illness (within 30 days of discharge) by 7.7%
Follow-up after a hospital stay for mental illness (within seven days of discharge) by 4.8%
Diabetes care—eye exam by 3.2%
Management of COPD exacerbation—bronchodilator by 3.6%
Rheumatoid arthritis management by 3.1%
Men received significantly better care than women in the following areas:
Avoiding potentially harmful drug-disease interactions in elderly patients with a history of falls by 11.3%
Avoiding potentially harmful drug-disease interactions in elderly patients with dementia by 8.3%
Initiation of alcohol or other drug treatment by 6.3%
PSQH: Patient Safety & Quality Healthcare, May 30, 2017
Hospitals that assess their technologies, align their databases, and strengthen their culture of safety can reduce error-prone manual infusion programming, streamline nursing workflow, and ensure accurate and timely capture of infusion data.
This article first appeared December 09, 2016 on PSQH.
By Tim Vanderveen, PharmD, MS; Nicole Wilson, RN, MSN, CPHIMS; Katie Moatsos, BS; Monica Obsheatz, RPh, MPM
The following article is based on the knowledge gained from implementation of infusion system–electronic medical record (EMR) interoperability at more than 135 hospitals to date. Many considerations go into preparing for safe and reliable smart pump–EMR interoperability. The authors realize that many infusion device companies are addressing these issues; however, as employees of BD/CareFusion, they have no direct knowledge of these efforts. The approaches suggested in this article are presented to help educate and encourage further discussion of what hospitals can do before the actual implementation begins to optimize the success of smart pump–EMR interoperability.
Smart pump–EMR interoperability is the new standard of care for intravenous (IV) infusion therapy. The IV route of administration for medications often results in the most serious outcomes of medication errors (Hicks, Cousins, & Williams, 2003). Despite the many advances made by computerized prescriber order entry (CPOE), bar code medication administration (BCMA), and intelligent infusion safety systems or “smart pumps” (Pettus & Vanderveen, 2013), problems remain. A study at a major medical center found that 67% of smart pump IV infusions have one or more errors associated with their administration (Husch et al., 2005). Multiple studies have pointed to the need for smart pumps to be interfaced with other medication use information systems, such as an EMR, CPOE, BCMA, and pharmacy information system (PIS), to generate meaningful improvements in patient safety (Husch et al., 2005; Russell, Murkowski, & Scanlon, 2009; Schnock et al., 2015).
Infusion device–EMR interoperability
With infusion system–EMR interoperability, bar code scanning is used to trigger the transmission of physician-ordered, pharmacist-reviewed infusion parameters from the EMR to pre-populate the smart pump, reducing the number of error-prone keystrokes used in manual programming. Time-coded infusion data—such as rate changes, pauses, starts, and stops—flows back into the patient’s EMR in near real time.
Interoperability also provides association between infusion pumps and specific patients, enabling accurate, time-stamped IV infusion data to improve charge capture and reimbursement. Interoperability can enable pharmacy to view the infusion status of all pumps to better plan pharmacy workflow and prepare infusions as close as possible to the time they are actually needed, reducing waste from discontinued and expired medications.
However, as ECRI has pointed out, infusion device–EMR interoperability can be “complex, difficult, and costly” (ECRI Institute, 2013). Infusion devices and the EMR were developed in separate “silos,” and many elements need to be aligned for interoperability to succeed. A change to any component of the separate systems affects all other components, and the work of one department affects all other departments. Fortunately, with more than 135 implementations completed, much has been learned to smooth the process, streamline implementation, and optimize success.
Preparing for interoperability
A growing number of hospitals have interoperability on their 24-month (or longer) road map, and they want to know how they can prepare (even before they contract with their vendors) to minimize anxiety, rush work, unplanned costs, and rescheduling.