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October 2008

Applying Lessons from Data-Driven Baseball to Health Care -- by Suzanne Delbanco, Ph.D.

Baseball Unlikely co-authors Billy Beane, Newt Gingrich and John Kerry published an opinion piece in the New York Times on Friday, October 24, 2008 stressing that our health care system would benefit from the intense data collection and analysis that has driven transformative success in professional baseball.  “Number-crunchers now routinely use statistics to put better teams on the field for less money.  Our overpriced, underperforming health care system needs a similar revolution.”


Using data on both typical and more obscure statistics, the authors suggest, allows baseball teams to determine when “an attempted steal is worth the risk,” and which players should be drafted and in what order.  They argue that doctors have more ready access to statistics to make decisions about their fantasy baseball teams than for decisions about the care they provide to their patients.


There certainly are specific examples of where using statistics in medicine has saved lives.  The opinion article cites the compiling of statistics by the Cochrane Collaborative as the spark to drive improvements in the use of corticosteroids for women at risk of preterm birth. 


But such examples are too few and far between.  A study by RAND published in the New England Journal of Medicine in 2003 revealed that patients with the thirteen most common chronic conditions receive evidence-based care only 55% of the time. 


Similarly, hand hygiene is proven to help prevent hospital-acquired infections, but adherence nationally to hand hygiene protocols hovers under the half-way mark around 40%, according to the Centers for Disease Control and Prevention.


Beane, Gingrich and Kerry conclude that “The best way to start improving quality and lowering costs is to study the stats.”  Arrowsight's Hospital Video Auditing provides a deep analysis of hand hygiene compliance day by day, hour by hour, patient room by patient room, and provides health care workers with the insights they need to improve.  Going back to the power of the authors’ baseball analogy, it’s no accident that Arrowsight Medical describes itself as “game film for health care.”


Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

More Hospitals Agree to Take Key Steps When "Never Events" Occur

Leapfrog_Logo_Tagline More hospitals than before have agreed to take key steps when a “never event” occurs during the course of care in their facilities.  Never events – serious reportable adverse events that should never happen during course of care – include surgery on the wrong body part, certain surgical site infections, and leaving a foreign object inside a patient’s body during surgery. 


These findings come from the 2008 Leapfrog Hospital Survey, which just announced that 63% of hospitals participating the Survey have agreed to:

  • Apologize to the patient or family affected by the never event;

  • Report the event to at least one of the following agencies: the Joint Commission, a state reporting program for medical errors, or a Patient Safety Organization;

  • Perform a root cause analysis consistent with the instructions from the chosen reporting agency; and,

  • Waive all costs directly related to the serious reportable adverse event.

This is an increase over last year, when 52% agreed to the policy.


For a recent interview we did with Leapfrog Group CEO Leah Binder, go here.

GAO Report on HAIs Provides New Resource and Identifies Opportunities for Hospital Video Auditing -- by Suzanne Delbanco, Ph.D.

GAO report cover On October 2, the U.S. Government Accounting Office (GAO) released a report entitled Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections. 

The report outlines which states are currently or soon planning to publicly report hospital-specific performance on specific hospital-acquired infections.  The emphasis in the 23 states with activity in this arena is largely on reporting incidence of particular infections, though a small number are also reporting adherence to protocols designed to reduce certain hospital-acquired infections.

In addition, through surveys and onsite visits, the GAO reports on the activities of fourteen hospitals known to have programs designed to reduce the spread of Methicillin-resistant staphylococcus aureus (MRSA).  These programs focus on routine testing, hand hygiene, contact precautions, and antibiotic stewardship.

All fourteen changed their hand hygiene programs in various ways with almost all increasing the number of hand hygiene compliance audits they conduct through observation and and most enhancing staff training and public education programs. A smaller number also increased the number of dispensers of alcohol-based hand sanitizer or measured the consumption of hand hygiene products.

Imagine if these hospitals had more rigorously collected data on hand hygiene compliance and ongoing feedback to staff about their hand hygiene performance, along with positive reinforcement.  To improve, staff need to know where they stand at the start.  Short term observations conducted periodically cannot produce the richness of data Arrowsight Medical gathers from hospital video audits of hand hygiene compliance 24/7/365, which can identify issues by room, by hour of day, by shift, by day of week and by type of care giver. 

While the GAO report does not touch on the rates of hand hygiene compliance calculated by the onsite observers in the hospitals that are the focus of its report, it is unlikely those hospitals were able to achieve the kind of results that Arrowsight achieved at its first pilot at an outpatient surgery center - from a baseline of 38 to 90 percent within three months, and above 90 percent for twelve months running.  Arrowsight sends automated intra-shift emails to nurse managers and attending physicians that rank current shift performance room by room.  Additionally, Arrowsight automates the delivery of aggregate team metrics to LED boards at the work site, which are updated every ten minutes for all staff to see.  Arrowsight is excited to help hospitals already committed to serious programs of infection prevention take this obvious next step.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Most Faculty and Residents Inclined to Report Errors, But Few Actually Have Done So -- by Pat F. Bass III M.D., M.S., M.P.H.

16357396 Pat F. Bass III M.D., M.S., M.P.H. is Assistant Professor of Medicine/Pediatrics at Louisiana State University Health Sciences Center - Shreveport.


While faculty physicians and residents report that they value error reporting, there may be a discrepancy between self-reported attitudes and actual reporting behaviors, according to a recent report in the Archives of Internal Medicine.  Lauris C. Kaldjian, M.D., PhD., of the Division of General Internal Medicine at the University of Iowa Roy J.and Lucille A. Carver College of Medicine in Iowa City, Iowa, and colleagues surveyed residents and faculty from three medical centers in the Midwest, Mid-Atlantic, and Northeast regions of the U.S..  The survey examined whether faculty and residents had reported actual errors, their likelihood of reporting hypothetical errors, and their attitudes toward reporting errors.
Overall, the response rate to the survey was 74 % and most respondents (84.3%) agreed that error reporting improved quality of care.  Most respondents stated they would report a hypothetical error leading to minor harm to a patient (extended treatment or pain), and major harm to a patient (disability or death) (73% and 92%, respectively).  However, only 17.8% had actually disclosed minor and errors and just 3.8% had disclosed major errors to patients.  About the same proportion of respondents admitted not reporting actual minor (16.9%) and major errors (3.8%).  Additionally, only slightly more than half of respondents knew how to report errors and nearly 4 in 10 were unsure of what kind of errors to report. A multivariate analysis of hypothetical scenarios revealed that believing that error reporting improves care, knowing the error reporting process, thinking that forgiveness is important, and being a faculty member were associated with willingness to report errors.  

"Taken together, these results suggest there may be a gap between attitude and practice among physicians regarding the reporting of medical errors," the authors comment.  While there is a knowledge deficit among physicians regarding which errors to report and how to do it, education alone may not improve error reporting.  Physicians may under-report errors that did not cause harm (often called  "near misses”).  Other barriers to reporting may include questions about who is to blame and legal liability.  The authors conclude that "institutions should consider ways to promote patient-centered ethical values that may motivate physicians to report errors in the midst of countervailing pressures, especially in teaching hospitals where role models play a vital part in the formation of trainees’ attitudes and practices. Such values are rightly seen as part of medical professionalism and reflect a commitment not merely to good systems but to the good of our future patients."


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Medicare Encouraging Patient Safety through Financial Disincentives -- by Lisa Hayden Espenschade

19392917 On October 1, 2008, Medicare placed new financial responsibilities on hospitals for certain “reasonably preventable” hospital acquired conditions.  In addition to Medicare’s new policy, covered here in more detail previously, private insurers are following suit.


Catheter insertion is associated with two conditions on the list: vascular and urinary tract infections. Medicare is also targeting surgical site infections after coronary artery bypass and some other orthopedic and bariatric procedures.


These three types of infections accounted for 42,096 cases in fiscal year 2007, according to the Centers for Medicare and Medicaid Services. Vascular catheter-associated infections are the worst offender on Medicare’s list--affecting 29,536 patients in 2007. Bladder catheterization is linked to another 12,185 infections.


Economic incentives, such as no longer elevating payments to cover the costs of preventable complications are likely to motivate improvement, but to improve, hospitals need effective systems designed to prevent the medical errors in the first place.


Many prevention principles – particularly hand hygiene – apply to both these types of catheter-related bloodstream infection (CR-BSI).  This is where Hospital Video Auditing (HVA) can help:  it gives 24/7/365 monitoring for adherence to safety practices and protocols and encourages health care workers to both improve and sustain their performance. 


Previous posts on CR-BSIs include:

Hygiene. A study at Huguley Memorial Medical Center in Fort Worth, TX, looked at simple measures for limiting infection: practicing hand hygiene, avoiding femoral lines because of proximity to the groin, using gloves and other physical barriers, and monitoring the appearance of lines.

Checklists. Atul Gawande’s December 10, 2007, article in The New Yorker detailed infection prevention research from Peter Pronovost, a critical-care specialist at Johns Hopkins Hospital. Pronovost found providers often skipped crucial steps during line insertion. Our post excerpting Gawande’s article includes information on hospital culture and successes using checklists.

Studies, Statistics & Safety. Robin Walters, RN, BSN, notes studies about costs of CR-BSIs plus strategies and guidelines for prevention. Among them: the Central Line Bundle from the Institute for Healthcare Improvement and participation in infection prevention collaboratives like the 5 Million Lives Campaign and the National Healthcare Safety Network.

Lisa Hayden Espenschade is a freelance writer based in Scarborough Maine who has written on genomics, gene therapy, stem cells, and other drug discovery topics, as well as other biotechnology issues.


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New Compendium of Strategies to Prevent Healthcare-Associated Infections

39171269 Today, the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals was released in Infection Control and Hospital Epidemiology.  The Compendium contains practical strategies for preventing the six most significant hospital-acquired infections in acute-care hospitals.  The strategies include recommendations for first- and second-tier infection control practices – ones which should be adopted by all acute-care hospitals in all cases, such as hand hygiene, and others that might need to be employed in the event of certain outbreaks.  The six hospital-acquired infections that are the focus on the Compendium are:


  • Methicillin-resistant staphylococcus aureus (MRSA)
  • Clostridium difficile infections (C-diff)
  • Central-line associated bloodstream infections
  • Ventilator-associated pneumonia
  • Catheter-associated urinary tract infections
  • Surgical-site infections

The report was sponsored by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Partners in the work were the Association for Professionals in Infection Control (APIC), the Joint Commission, and the American Hospital Association.  The Joint Commission also announced that it would be considering adoption of the strategies into its accreditation standards and patient safety goals.

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