On December 3, 2009, The Leapfrog Group issued its annual list of "Top Hospitals." For the first time, The Leapfrog Group added efficiency measures into the equation. Across three categories including urban, rural and children's, Leapfrog recognized 34 hospitals, among the 1206 who participated in the voluntary Leapfrog Hospital Survey, as hitting high marks on quality, patient safety and efficiency.
In this week's New England Journal of Medicine, nationally-recognized patient safety experts Peter Pronovost, MD, Ph.D. and Robert Wachter, MD argue that the "no blame" approach to improving patient safety needs to be balanced with accountability. While refraining from blaming individual health care workers for making preventable medical mistakes makes them feel more comfortable to report mistakes, it may not be enough to propel forward efforts to improve care that are stalled.
Citing poor hand hygiene practices as an example, the authors review the structural changes and information campaigns that hospitals have implemented and conclude that they have not done enough to bring hand hygiene compliance to an acceptable level. What's left to do? Hold health care workers accountable when they fail to adhere to patient safety practices known to protect patients from adverse outcomes.
There are certainly different ways to assess how well workers comply with critical protocols as well as myriad ways to hold them accountable. But the authors highlight, in the case of hand hygiene, that one prerequisite is to have in place a fair and transparent auditing system of which clinicians are made well aware. By way of footnote, Arrowsight is referenced as providing one methodology - video - that can be used both to measure and to provide feedback to clinicians. Pronovost and Wachter cite the fact that meatpacking plants use remote video to hold workers accountable for performance (also Arrowsight's work) -- isn't it time we offer the same protection to patients?
Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.
The U.S. Department of Health and Human Services has announced that it is allocating $25 million to address patient safety and medical liability. Through the Agency for Healthcare Research and Quality(AHRQ), HHS will provide grants of up to $3 million each to states and health care systems wanting to implement or evaluate demonstration projects aimed at improving patient safety while fixing the problems with the liability system. There will also be smaller planning grants available for up to $300,000. AHRQ will also conduct a "review of what works," to be done by December 2009, of initiatives to improve quality and reduce medical liability to help guide HHS' work and investments in this area.
The Funding Opportunity Announcement will be available on www.grants.gov by October 17, 2009.
The results of the 2008 Leapfrog Hospital Survey, released this week, suggest that hospitals still have tremendous work to do to be safe for patients.
For example, sixty-five percent yet to put in place all of the recommended policies to prevent hospital-acquired infections (though this is an improvement from 87% in 2007). Similarly, seventy-five percent do not fully meet the standards for thirteen critical safety practices from hand washing to the competency of the nursing staff. Just 30% of hospitals are fully meeting the standards for preventing hospital-acquired pressure ulcers and only 25% are meeting standards for preventing certain injuries in the hospitals.
The Leapfrog Group's Survey included 1,276 hospitals in 37 major metropolitan areas.
The National Quality Forum has released the 2009 Safe Practices for Better Healthcare. These 34 evidence-based practices build on six years of development, and represent practices that should be implemented in every hospital.
The 2009 report adds new practices in areas such as pediatric imaging, glycemic control, organ donation, catheter-associated urinary tract infection, and multi-drug resistant organisms. The report updates other previously endorsed practices based on new evidence, including the pharmacist’s role in medication management and pressure ulcers, and an entire chapter on healthcare-associated infections. Some of the Safe Practices remain the same, such as hand hygiene and management of patients in ICUs by doctors with special training in critical care.
The Texas Medical Institute of Technology funded the project. The National Quality Forum will be holding webinars throughout the year to review implementation strategies for the Practices.
Childbirth is the number one reason for hospitalizations in the U.S. and is also the runaway leader in hospital charges. Studies show that we over-use costly and risky interventions in maternity care, and underuse beneficial methods like continuous labor support that are generally safer and cheaper. There are 4.3 million births in the U.S. each year, and evidence is mounting that the quality of maternity care is deteriorating in some areas, as indicated by recent increases in maternal death among some populations. There are also incentives built into the delivery system to provide technology-intensive care to a primarily young and healthy childbearing population who may not need it. The quality and safety of maternity care warrants the nation's attention.
The Millbank Memorial Fund recently published a report called Evidence-Based Maternity Care: What it Is and What It Can Achieve, authored by the leaders of Childbirth Connection, a national, non-profit organization. The report contains a systematic review of maternity care practice and highlights that much of the care pregnant women receive has no basis in the evidence. In fact, some of it can be harmful. The Los Angeles Times op-ed about the report claimed, “The Obama administration could save the country billions by overhauling the American way of birth.”
I have been volunteering to support two efforts to focus attention on this topic that are likely of interest to others working to improve the safety and quality of health care.
First, Childbirth Connection will be hosting what could be one of the most important discussions of 2009. Transforming Maternity Care: A High Value Proposition, will be held on April 3 in Washington, DC. Over 200 multi-stakeholder participants will be recommending ways to improve maternity care and to align payment with quality as part of producing a “Blueprint for Action.”
Second, the California Maternal Quality Care Collaborative (CMQCC) aims to eliminate preventable maternal death and injury and promote equitable maternity care in California. The group works to bring resources, tools, measures, and quality improvement techniques to providers, administrators, and public health leaders. CMQCC has produced many of the measures of maternity care now included in standards and goals produced by the National Quality Forum, the Joint Commission, and other groups.
Improving maternity care will require more informed health care professionals and patients alike. Since expectant parents have months to conduct careful research on providers and facilities, maternity care presents the ultimate opportunity for increasing consumer engagement in health care. Careful measurement and tracking of maternity care outcomes, along with public reporting, could provide a solid start to reversing some of the negative trends toward excessive clinical intervention of recent years. That would be a high value proposition for all involved.
Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.
There is always a lot of debate about whether clinical information technologies really improve patient outcomes, or if they just systematize errors.
In the first study of its kind, researchers from the University of Texas Southwestern Medical Center and Johns Hopkins University conducted a cross-sectional study of urban hospitals in Texas, measuring the hospitals' level of automation and its association with inpatient mortality, complications, costs and length of stay.
Based on 41 of 72 hospitals responding (58%) to requests to complete a clinical information technology assessment tool, the study found that a 10-point increase in the automation of notes and records was associated with a 15% decrease in the adjusted odds of fatal hospitalizations. Higher scores in order entry were associated with 9% decrease in the adjusted odds of death for myocardial infarction and a 55% decrease in the adjusted odds of death for coronary artery bypass graft surgery. Higher scores for decision support were associated with a 16% decrease in the adjusted odds of complications for all causes of hospitalization. In addition, higher scores on test results, order entry and decision support were associated with reduced costs for all hospital admissions.
While the study does not take into account the return on investment to hospitals of putting the clinical information technologies in place, such as the costs of installation, it does suggests that once they are in place, the benefits can accrue to both the patients and the institution.
Eight hospitals in eight different countries participated in the World Health Organization's Safe Surgery Saves Lives Program and found they cut the risk of dying from surgery almost in half.
Using a checklist that contained nineteen items, including whether the patient has any known allergies, whether the surgical site is marked (if applicable) and whether relevant, post-surgical needle, sponge and instrument counts are complete, mortality from non-cardiac surgery dropped from 1.5% to 0.8% and other complications dropped from 11% to 7%.
More details are available in the complete study, published in the New England Journal of Medicine on January 14, 2009.
Patient falls top the list of the most frequently reported adverse events for hospitalized adults. Even with possible under-reporting, rates of inpatient falls range from 1.7 to 25 per 1,000 patient days, depending upon the area of the hospital in which patients receive care . This translates to falls occurring among 1.9% to 3% of all acute care hospitalizations, totaling as many as one million falls per year.
Serious injuries occur in 2% to 8% of acute care falls, resulting in about 90,000 serious injuries and 11,000 deaths each year in the U.S. And according to the CDC Web site, up to 75% of nursing home residents fall each year. Among these, serious injuries occur 10% to 20% of the time, leading to approximately 1,800 deaths annually.
Hospitals that participate in national reporting databases such as the American Nurses Association, National Database of Nursing Quality Indicators(ANA-NDNQI) can compare their rates of falls and injuries to similarly-sized hospitals with comparable types of patients.
Patients in rehabilitation, behavioral health, and oncology settings are at higher risk for falls. Pediatric patients are at much lower risk, possibly because parents tend to stay with children, providing increased supervision. The five main risk factors for falls among all types of patients are: side effects from medication, gait problems, increased toileting needs, a history of falls, and—perhaps most significantly—confusion. Extrinsic risk factors include: inadequate lighting, objects in patient rooms that are colored so similarly to the room itself that they are hard to distinguish, and poorly-placed handrails
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When hospitalized patients fall and are injured, hospital charges rise by about 60%. The impact on a hospital’s bottom line is likely to grow now that Medicare, as well as many private insurers, will no longer reimburse for diagnoses resulting from injuries caused by falls during the hospital stay.
Of all the hospital acquired conditions on the “no-pay” list, falls can be the most difficult to prevent. Instruments to assess patient risk for falls and injuries have been unreliable, and a review of the literature raises questions about the effectiveness of today’s fall prevention programs.
The evidence does support focusing on each patient’s most important risk factors for falls and using a combination approach to prevention, including the following practices:
Review and monitor medication side effects Treat contributing conditions such as anemia, syncope and impaired vision Check confused patients for toileting needs every two hours Educate staff about risk factors for and prevention of falls Use bed/movement alarms Make environmental changes (e.g., better room design) Conduct post-fall assessments
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. Be sure to also read Robin's other contributions on bloodstream infections, hand washing compliance, and culture of safety.
A new report issued by the Agency for Healthcare Research and Quality (AHRQ) suggests that pressure ulcers among hospitalized patients have become significantly more prevalent over the last fifteen years. Based on data from the Healthcare Cost and Utilization Project (HCUP), the analysis found that in 2006 there were more than 500,000 hospital stays with pressure ulcers noted as a diagnosis as compared to during about 280,000 in 1993 - an increase of almost 80%.
These numbers include both patients who were admitted to the hospital for treatment of pressure ulcers as well as those who developed them during a hospital stay for treatment of some other condition.
Pressure ulcers - commonly referred to as bed sores - can be very painful for patients and can lead to life threatening infections and added costs. Any patient with impaired mobility can be at risk as pressure ulcers are typically caused by very long "periods of uninterrupted pressure on the skin, soft tissue, muscle and bone," according to AHRQ.
Severe pressure ulcers are considered serious reportable adverse events, or "never events," by the National Quality Forum, and are on the list of Hospital-Acquired Conditions for which the Medicare program will no longer elevate hospital reimbursement.
There is no national agreement on which is the best protocol for the prevention of pressure ulcers - or which protocol helps keep existing pressure ulcers from becoming more severe. However, Arrowsight Medical's Hospital Video Auditing methodology can help hospitals track how often clinical staff are changing the position of at-risk patients, which could significantly aid in the refinement of protocols and lead to dramatic improvements. Arrowsight is eager to partner with hospitals to turnaround the disturbing trends identified in AHRQ's report.
Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.
