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June 2008

Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance

As we continue our interview series with today’s thought leaders in patient safety, we spoke with Dr. Meghan Dierks, Assistant Professor, Harvard Medical School.

HVA (Hospital Video Auditing) is an innovative, non-intrusive, 24/7 auditing technology that significantly improves compliance with patient safety and hand washing practices and protocols

In structuring the HVA program at a surgery center in the southeastern United States, Dr. Dierks has witnessed compliance scores soar from 35% to 90%+... and even more striking, she's seen compliance rates remain there.

In what ways, and to meet which specific goals, is the healthcare facility using HVA?

"We applied the technology to tackle a refractory problem in the healthcare compliance arena--the very basic safety protocol revolving around hand-hygiene and getting physicians to modify their safety behavior. The technology was two-fold: first, it would provide us the ability to collect highly reliable data and we hadn't been able to in the past. And, second, by nature of collecting high-quality data and instilling a feedback loop to relay that data to physicians practicing in that environment we could achieve a behavioral change.

We had two goals, both of which were achieved through the use of HVA. First, we needed to be able to collect highly reliable data over a sustained period of time on hand hygiene behaviors--something that has been difficult to achieve using other strategies. Second, in order to achieve a behavioral change, we needed to be able to use this data to provide continuous performance feedback to the healthcare workers practicing in that environment."

What significant points of success and improvements have you witnessed from the surgery center using the technology?

"Prior published studies have demonstrated that other efforts and interventions--such as employing human observers or posting educational signage--achieve short term, but not sustainable improvements in compliance. HVA is a highly reliable data-collection technique that enabled us to continuously measure performance over a long period of time in the surgery center, and document positive movement toward an established goal.

We are now reaching our sixth month of continuous measurement and feedback. Using HVA, we identified a relatively low baseline compliance rate of 38%. We provided weekly feedback, and over the next several weeks, saw dramatic improvements in compliance. This relatively high compliance rate has now been sustained in the 88%-98% range for six months. While the fact that we achieved 98% compliance within four weeks is remarkable, equally striking is the sustainability of the behavior change."

Continue reading "Interview Series: Dr. Meghan Dierks discusses how HVA increases hand-hygiene compliance" »

Interview Series: Dr. Kumar discusses PMEs and Fatal Care

As part of our interview series with today’s thought leaders in patient safety, we spoke with Dr. Sanjaya Kumar, author of the just-released book Fatal Care.

Each year as many as 98,000 patient deaths occur in the United States as a result of preventable medical errors (PMEs) in hospitals--with PMEs impacting or harming at least 5 million Americans annually and costing more than $17-21 billion.

These sobering statistics from the Institute of Medicine (IOM) and the Institute for Healthcare Improvement (IHI) provide a glimpse into a national crisis that harms or kills hundreds of innocent people each day. But they are only nameless, faceless numbers and can't illustrate the human cost behind the data. Moreover, they only reveal the problem and not the underlying causes or potential solutions.

Unique and unlike other healthcare-related books, Fatal Care blends true, real-life dramas that illustrate gaps in the healthcare system with factual information and analysis for healthcare consumers and professionals.

What inspired you to write Fatal Care?

"There is an epidemic in this country called preventable medical errors. They, for the most part, go unnoticed while claiming the lives of hundreds of people in the United States each day.These deaths are sacrifices that are unreported, unrecognized and not acknowledged.

I wrote Fatal Care in an effort to provide a voice and a face to those nameless and faceless victims. I want the world to know that this epidemic exists and that they can easily become the next victim. My hope is that this book helps both those accessing care and those who provide that care."

In your opinion, what are the "top actions/priorities" that will move the industry much closer to eradicating PMEs and HAIs?

"First and foremost the actions and priorities outlined are long-term solutions. There are no easy fixes to complex system issues such as preventable medical errors. That said, there are several high priority actions healthcare providers and consumers need to address in order to drive positive change. First, healthcare providers need better cataloging of errors in a standardized fashion. This will allow for accurate trend and intervention identification leading to preventable medical error reduction.

Secondly, the industry needs increased shared knowledge access for cross industry learning. Also, healthcare organizations have to embrace adherence and compliance to evidence-based best practices as this ensures known mistakes are not repeated.

Finally, consumers really need to become educated advocates for their own care. Gone are the days where people can go blindly to their healthcare provider and expect that everything will be taken care of for them."

Continue reading "Interview Series: Dr. Kumar discusses PMEs and Fatal Care" »

Interview Series: Dr. Halamka discusses how technology can improve patient safety

As part of our interview series with today’s thought leaders in patient safety, we spoke with John D. Halamka, MD, MS.

Dr. Halamka is Chief Information Officer of the CareGroup Health System, Chief Information Officer and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE (the Regional Health Information Organization), Chair of the US Healthcare Information Technology Standards Panel (HITSP), and a practicing Emergency Physician.

If that sounds like a tremendous amount of responsibility, it is--in all, his work supports 3,000 doctors, 18,000 faculty and 3 million patients... not to mention his finding time to publish an informative and enlightening blog.

Q: How are the hospitals that you’re working with using technology to reduce errors and lower risk?

A: “Populate electronic medical records: Achieve 85% electronic clinical documentation by 2011 via consistent use of automated history and physicals, electronic progress notes, eForms and scanning technologies.

Medication Management: Achieve end to end electronic medication administration by 2009 through the consistent use of provider order entry in all inpatient areas, electronic prescribing in all ambulatory areas, medication reconciliation at each transition in the care process, and electronic medication administration records based on bar coded medications.

Training, education and competency: complete a new hospital policy requiring the consistent use of our EMR to manage problem lists, medication management, notes and ordering by July 2008.”

Q: Do you think technology (or tech innovations/solutions) has the potential to help hospitals improve patient safety, and why?

A: “Coordination of care among providers via e-Prescribing and use of electronic health records will ensure smooth handoffs, reducing medical error. Empowering the patient to be the stewards of their own data via personal health records will encourage doctor/patient shared decision making, transparency into the medical record including the correction of errors, and respect for patient privacy preferences when sharing data.”

Q: In your opinion, what are the “top actions/priorities” that will move the industry much closer to eradicating PMEs and HAIs?

A: "End to end electronic medication workflows including e-Prescribing, provider order entry, and electronic medication administration records.

100% electronic documentation including all outpatient and inpatient notes, diagnostic test results and images.

Decision support systems which enforce best practices including guidelines, protocols and care plans."

  • For Dr. Halamka's blog, please go here.
  • Is there a thought leader that you would like to see interviewed? Please email us here.
  • For all interviews with today's patient safety thought leaders, please go here.

Nurses and women come up cleaner in hand washing studies -- by Robin Walters, R.N., B.S.N.

As part of our guest contributor program, we thank Robin Walters R.N., B.S.N, for her article below that illuminates some interesting differences in the hand hygiene behavior of men and women--both in healthcare settings and outside of them. The results may surprise you...

In order to improve hand washing behavior, it helps to know who needs to improve. Recent studies indicate that men and physicians (73% of whom in the U.S. are male) need to wash up more often.

For a study published in the June 2008 Infection Control & Hospital Epidemiology, observers documented the hand hygiene behavior of workers at the University of Toledo Medical Center for roughly five months. The results? Nurses complied with hand washing at a rate of 91.3%, while medical attending physicians (the lowest performers) registered at 72.4%.

 A 2007 study sponsored by the American Society for Microbiology and The Soap and Detergent Association (SDA) also suggests that campaigns to improve hand washing need to focus more on men. Observers recorded the hand washing behavior of adults who used public restrooms at six large sites in four major U.S. cities, and overall, 88% of the women and 66% of the men washed up.

The confessions of moms and dads further support a gender divide in hand hygiene. As part of the 2007 Clean Hands Report Card, the SDA surveyed by telephone parents of school-age children and found that 97% of the mothers vs. 89% of the fathers reported always washing their hands after using the bathroom. Although results of observational studies strongly suggest a gap between reported and actual hand washing behavior, the difference between what moms and dads own up to remains significant.

And, this lean toward women as better washers may be global. At the University of Geneva Hospital, a hand hygiene study appearing in the November 2007 Infection Control & Hospital Epidemiology revealed that “female sex . . . increased the likelihood of compliance with hand hygiene.” With the U.S. R.N. force 92% female, this is good news for patients.

About the author: Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural.

Interested in submitting content to PatientSafetyFocus.com? Please go here to learn more.

Interview Series: Leapfrog leverages collective purchasing power for big leaps in patient safety

To kickoff our interview series with today’s thought leaders in patient safety, we spoke with Leah Binder, CEO of The Leapfrog Group.

Launched in 2000, Leapfrog is a unique initiative because it is driven by organizations that buy healthcare with the aim of mobilizing their employer purchasing power to alert America’s health industry that big leaps in healthcare safety, quality and customer value will be recognized and rewarded.

Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information, as well as rewards for hospitals that have a proven record of high quality care.

How is The Leapfrog Group working to improve patient safety?

Leapfrog represents the interests of the nation’s large employers, formed by a group of CEOs who were very disturbed by the 1999 IOM report that estimated that up to 98,000 Americans die unnecessarily every year from preventable medical errors (PMEs), with millions more harmed as a result of hospital-acquired infections (HAIs). So our founders wanted to see if we could make major change to address that problem--and they named it “Leapfrog” to make giants leaps forward, not just incremental change.

What Leapfrog does is survey hospitals and we ask them questions based upon NQF’s well-established, evidence-based measures that tell us about the quality and safety of hospitals. We then score them and place the information online so that employers may use that information to work with health plans and structure pay-for-performance (PFP) programs.

Employers have not traditionally used their purchasing power to influence healthcare services they purchase--they haven’t been able to simply insist that they deserve a certain level of quality for what they’re spending. Leapfrog is employers’ answer to that. In addition to asserting employers’ standards as purchasers of healthcare, Leapfrog advocates transparency so that people can choose hospitals based on safety practices and quality of care.

In your opinion, what are the “top priorities” that will move the industry much closer to eradicating PMEs and HAIs?

There are three top priorities. The first priority is to transform financing, because we currently have a financing system that too often rewards the wrong things. We tend to reward what we don’t want to happen and we tend to under-finance what we do. For example, right now--though not for long--the hospitals that have the highest levels of HAIs are probably getting the highest reimbursements from Medicare. Another example: our healthcare system tends to pay inadequately for prevention but readily spends huge sums for emergency or acute care that might have been avoided through better prevention. So we as a country are often financing at odds with our values.

The second top priority is that we have to support hospitals and recognize how difficult it is to change. It’s a comprehensive systems change to decrease HAIs and involves a change across the board and everyone--from doctors to administrators to those that register the patients--needs to play a role in that change. Employers, like our organization’s members, are the first to recognize how hard change is because they understand it from the standpoint of their own companies--but they also understand that we are in the business of enforcing accountability.”

The third top priority is transparency. Purchasers and consumers need to have information on the safety of providers in order to choose the best. Having more consumers using information about quality helps drive change in the system.

Continue reading "Interview Series: Leapfrog leverages collective purchasing power for big leaps in patient safety " »

Night-shift staffing another issue in patient safety

"People get sick 24 hours a day, but there is a stark discrepancy in the quality of care on nights and weekends" when 50% to 70% of patients may be admitted, says David Shulkin, chief executive of New York's Beth Israel Medical Center."

An interesting (and alarming) article by The Wall Street Journal columnist Laura Landro raises another issue in the plight to increase patient safety (and decrease preventable medical errors)...namely the high risk of low-staffed hospital night shifts. According to Landro:

"Hospitals are waking up to the fact that substandard care on nights and weekends is endangering patients -- giving new meaning to the term 'graveyard shift.'

Patients suffer higher rates of death, complications and medical errors when they are treated during thinly staffed off hours. Now, some hospitals are taking steps to improve safety and reduce their own legal liability from mishaps.

Institutions that long relied on having doctors on call at home are hiring physicians known as nocturnists, who work only night shifts. Some hospitals have begun staffing intensive-care units round-the-clock with critical-care specialists who do double-duty coping with a crisis anywhere in the hospital. And new policies are being put in place to improve communications at the hand-off between the day and night shifts."

The Society of Hospital Medicine reports that last year about 1,200 hospitals had either a nocturnist or hospitalist sharing the coverage--compared with just 700 four years earlier, a dramatic 70%+ increase. Moreover, a study published in the journal Circulation cited that more than half of 62,814 heart-attack patients arrived at night...exactly when the coverage is compromised. Moreover, this group is 66% less likely than daytime patients to receive an angioplasty, a procedure to open clogged arteries that the American Heart Association recommends occur within a 90-minute window.

Currently, right at 6% of the nation's 22,000 hospitalists are nocturnists and those without night doctors result in patients waiting until the next day to see the "day" doctor as Emergency Room Doctor roles are centered more on triage. Conversely, as Landro's article points out, "Teaching hospitals have long relied on medical residents and interns for overnight duty. But changes in work rules in recent years have forced them to reduce the number of hours medical trainees can work. This has resulted in shorter shifts and more frequent "hand-offs" of patients between shifts."

As for after-hour care risks? According to several studies, it's well documented. There are higher death rates for stroke patients who arrive at the hospital at night, as well as for patients already in the hospital who suffer cardiac arrests. Ergo, it's not only caregivers' practices and hygiene protocols that need to be improved to ensure better care and few victims of medical errors. And while patient safety technologies work 24/7, administrators will need to identify how to responsibly staff around the clock as well.

Full article with more information worth reading is located here.

HAIs on the rise in NY State

According to KaiserNework.org, the rate of hospital-acquired infections (HAIs) has increased in New York State. What isn't clear is whether the rise is due to an actual increase in HAIs or the ability of the state to better track a larger number of them. According to Kaiser's report:

"The report found that about 3,200 of 1.45 million hospitalizations resulted in a hospital-acquired infection in the state, an increase from about 2,900 out of 1.48 million hospitalizations a year earlier. Coalition President Bruce Boissonnault said that the number represents "a small fraction of the infections. For example, many people do not show symptoms of an infection until they're discharged, and those patients would not be in that sample (used in the study)." This is the first year a health trend has worsened since the coalition began conducting the study six years ago, the AP/Times Union reports."

The report also cites that the overall likelihood of dying from a hospital procedure decreased from 8.5% for eight inpatient procedures in 2002 to 7.4% in 2006. State Health Department spokesperson Jeffrey Hammond said, "While it may be possible that infection rates are getting worse, it may also be true that hospitals are more vigilant at reporting infections, and that's good news for patients".

Transparency in reporting is a good and necessary first step in acknowledging the problem but we need to understand the full range of infections we need to be reporting against--and the practices and technologies that all hospitals should be implementing in order to eradicate them. Then the numbers will serve us in not only tracking the breadth of HAIs and their main causes, but the successes of hospitals that have initiated better protocols, tests and auditing systems.

Summary of report located here. 2008 New York State Hospital Report Card is available online.

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