As an academic medical center and the safety net for the St. Louis region, Barnes-Jewish Hospital sees any and all kinds of patients and conditions — making its drive for excellence especially tough.

After all, if you specialize in a few things, it’s easier to excel at them because you have a limited focus. Trying to be the best at everything, is a lot more difficult. So the hospital took on one issue at a time.

Step 1

The first step in achieving its goals was to employ “lean management.” This management system was designed to minimize waste, standardize processes and drive continuous improvement.

Standardizing patient care was key. While Barnes-Jewish Hospital standardized its processes for patient care, it allowed tailored intervention per individual patient — when appropriate. This “variation” was allowed because it benefits patients by providing care specific to their needs.

Step 2

The next step involved training the facility’s future providers. The hospital requires residents to have four hours of lean training and then they have to participate in a process improvement project.

One of these projects was for central line-associated blood stream infections (CLABSIs). Previously, the hospital’s seven intensive care units (ICUs) each had its own method for reducing CLABSI. Under the lean system, all ICUs standardized their practices in insertion, maintenance and follow-up.

For example, the clinicians who insert central lines were trained in a simulation to use evidence-based, standard practices, such as being required to wear a gown, gloves and have a sterile field.

The nurses, who maintained the catheters, had a standardized schedule for changing dressings and the hubcaps of the line.

And finally, the clinicians were trained to question the patient’s need for continued use of a central line on a daily basis using a standard checklist.

Thanks to this process improvement project, the hospital experienced a dramatic drop in CLABSIs.

Other projects tackled at the facility included: diabetes medication errors, pressure ulcers and transition of care. To read more about these click here.

Has your facility implemented any quality improvement projects? If so, tell us about them in the space provided below.

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Having positive physician/nurse relationships.

The best hospitals have their docs and nurses working hand in hand. It’s a relationship among peers: Both professions share in getting patients well, and delivering the best healthcare experience possible.

Here are two best practices Dr. Jonathan Burroughs, a certified physician executive, and president and CEO of The Burroughs Healthcare Consulting Network, has uncovered through his experience working in the hospital setting:

1. Nurse-Physician Councils — It’s a group of nurse and physician leaders, who meet with a specific purpose — to improve and optimize nurse/physician relationships and communication. They address nurse/physician issues such as:

• trust and respect
• communication, which entails consistent use of Situation, Background, Assessment, Recommendation (SBAR)  and other patient safety tools to optimize clinical effectiveness
• protocols that help to coordinate schedules so physician and nurses work together
• clinical and functional pathways to identify when they’re obligated to respond to each others needs and concerns, and
• bad behaviors.

The council addressed issue of mutual concern that affected patient safety, staff morale, turnover and frustrations.

2. Nurse-Physician Dyads — Nurses and physicians need to lead together if they are going to work effectively. In this best practice, a nurse and physician manager lead their clinical units together through all phases of operations, including:

• oversight of physician and nursing performance
• establishment of clinical and functional protocols and evidence-based practices
• oversight of the operation plan and budget
• supply chain management and inventory
• peer review and performance improvement activities, and
• modeling an effective collaborative culture.

This requires both professions to re-examine their roles and co-manage. For some it means taking on greater responsibilities, for others it entails listening and being more open to different opinions. It’s not easy, but it’s well worth it in the end.

What best practices has your facility implemented to advance nurse/physician relationships? Share your practices in the comments section below.

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To avoid such instances, Patient Safety & Quality Healthcare published four accepted, clinical best practices to keep wander risk patients safe:

1. Assess patients’ risk of wandering. Even though a patient may not be diagnosed as a wander-risk, it’s best to screen patients for memory problems, delirious behavior and disorientation. Facilities should also talk to members of the patient’s family to find out if any dementia-related diagnoses were made or if the patient has displayed any dementia related symptoms.
2. Closely supervise at-risk patients. Patients at risk for wandering should be placed in rooms in high staff traffic areas where there is only one way in or out — past the nurse’s desk or a supervisor’s station. In addition, it’s a good idea for hospitals to put wander-risk patients in different colored gowns so they are easily identifiable.
3. Minimize wandering triggers. Wandering can be brought about by environmental triggers. Foot traffic, activity and noise are known wandering triggers. Exit cues are another signal to patients to wander, such as elevators, staircases, doors, etc. Visual cues are another trigger such as suitcases, shoes, regular clothes, cars, etc. And finally, certain medications can cause wandering behaviors. To control the triggers, find out from family, friends or previous caregivers, if they know why the patient wanders: searching for a loved one, still believing they have a job to go to or a child to pick up, getting frightened in new environments, etc.
4. Treat the root cause. Make sure these patients feel safe and secure in their rooms. Only make room changes when there’s no other option. They can cause panic and confusion in dementia patients. Also, soft lighting and soothing music can help them feel safe and secure. Harsh environmental stimuli (bright lights, loud music) can cause patients to wander off in search of a more soothing environment. Pain and sleeplessness are other causes of wandering in dementia patients.

To ensure your protocols work for keeping wander-risk patients safe, administrators need to regularly test them.

In addition, it’s a good idea to register patients at risk of wandering with the National Silver Alert Program. It’s free and allows caregivers to electronically store important information about the patient, such a recent photo, medical records, power of attorney, living will, etc.

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While the facility has never had any problems with newborn safety, Colquitt Regional Medical Center, in Moultrie, GA, wanted to make sure it stayed that way — especially with all of the attempted child abductions you hear about on the news.

That’s why it implemented the Cuddles infant protection system.

Now, through the Cuddles system, every baby born at Colquitt Regional immediately is fitted with a small, comfortable bracelet around the ankle or wrist. The bracelets are uniquely identifiable to instantly match a mother and her newborn baby. That way, if a child is removed from the area, an alarm sounds and the Colquitt’s maternity ward goes on immediate lockdown until the infant is found.

The system uses radio frequency identification (RFID) to monitor infant activity on the maternity ward. And the bracelets only can be removed or deactivated by nursing personnel when the parents are ready to take their newborns home.

While the maternity ward at Colquitt is a locked unit where people have to be buzzed in and out of the department – an employee is posted at the desk to let people in and out, give them name tags and check IDs – this new system gives parents an added measure of security and comfort.

The facility is happy to report that so far, the monitors haven’t set off the alarm except for when they were going through training for the new system.

Note: The Cuddles system also has an option to enhance the system with a two-way radio that allows healthcare professionals to speak to each other, giving real-time information about the location and nature of the alarm.

Has your hospital upgraded any of its technology lately? If so, share your upgrades in the comments box below.

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From 2010 to 2011, data breaches increased 32% in hospitals and healthcare organizations, mainly because of two reasons: 

• The use of unsecured mobile devices to transmit data, and
• employee mistakes.

That’s according to the Second Annual Benchmark Study on Patient Privacy & Data Security by the Ponemon Institute. The study surveyed 72 healthcare organizations.

The rise in breaches is happening despite increased compliance with the HITECH Act and HIPAA. Unfortunately, a lot of hospitals and healthcare organizations feel a bit helpless because their security and privacy budgets aren’t sufficient to cover their expenses of training, technology, etc.

And as data breaches rise, so do the costs. This year, a compromised record cost an average of $214, while a data breach event averaged $7.2 million.

Some statistics from the study that’ll interest health executives include:

• 96% of the organization in the study had at least one data breach in the past 24 months, most of which were due to employee mistakes. On average, respondents had four data breach incidents in the past 24 month.
• 29% of respondents said in a one-year span of time, a data breach at their organizations led to identity theft.
• 81% of the facilities surveyed use mobile devices to collect, store and/or transmit some type of protected health information (PHI), and 49% of them admit these devices aren’t protected.
• The average number of lost/stolen records per breach was 2,575, and
• Only 29% of respondents said the prevention of unauthorized access and loss/theft of patient data is a priority, but 51% of respondents said they were very familiar with HIPAA/HITECH privacy, security and data breach notification laws and rules.

On the plus side, the study found healthcare organizations are making progress in their efforts to stop data breaches.

Thanks to the requirements of HIPAA and HITECH, facilities have better trained and more knowledgeable staff, as well as better policies in place. As a result, more data breaches are being discovered by employees and audits rather than patients. In fact, discovery of breaches by patients has dropped from 41% to 35%.

Do you feel your facility is on the cutting edge when it comes to policies and procedures in place to protect patients’ PHI? If so, share them in the comments box below.

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“Wrong setting” denials – where a RAC audit determines that services were provided in a medically unnecessary setting.

So why are RACs targeting hospitals?

It’s simple – it’s lucrative. The Centers for Medicare & Medicaid Services (CMS) pays a contingency fee to RACs for finding and collecting overpayments. So they go after high-dollar inpatient services.

According to Craneware InSight’s whitepaper, RAC Best Practices: Utilization Management, many facilities make themselves easy targets for RACs because they only use one set of criteria to assess inpatient admissions.

To “RAC-proof” your facility’s admission screening criteria, industry expert Karen Bowden, RHIA, who has 25 years of hospital administrative experience, suggests hospitals use the following three steps to supplement published inpatient screening criteria:

1. Adopt All procedures on “inpatient only” published lists from Medicare, payors with such lists, and ones in proprietary screening criteria.
2. Have your utilization review committee develop and approve leveling criteria for all procedures that, depending on the circumstances, can be performed and billed as an in- or outpatient. When researching these procedures, look for diagnosis combinations that can increase the risk of complications and death, and require additional monitoring and/or interventions.
3. Implement a second-level review by a case manager. The cases that should undergo a second-level review include those that:
   • don’t meet “inpatient status” admission screening criteria, but the case manager believes — based on clinical documentation — should be classified as inpatient
   • are categorized as inpatient, but the original case manager feels should be observation status. In these cases, if the second-level reviewer agrees, the cases go to a physician advisor before any status changes are made, and
   • involve observation patients in a nursing unit bed.

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Length of stay for these patients in the ICU doubled from a mean of 8.1 days to 15.8 days.

Two factors that increased patients’ risk for an HAI: coming from the emergency department and being over 75 years old.

So which infections were more likely to drive up the mortality rate?

• Bloodstream infection (24.7%)
• Hospital-acquired pneumonia (16.7%), and
• Surgical-site infection (10.9%).

The Premier Perspective hospital database, which was analyzed for the study, covered 20% of U.S. hospital discharges – 460,000 ICU patients. The study looked at patients over 18 with an ICU stay of at least 48 hours in 2007. Note: The researchers also looked at data from 2008 and 2009 and got similar results.

Cost analysis

What will really interest hospital executives is what the study found when it did a cost analysis based on direct variable costs and fixed overhead costs:

The infections cost an extra $16,000 per ICU stay, noted Florence Joly, PharmD,  from global evidence and value development at Sanofi in Paris, France, and lead researcher of the study. For a patient without an HAI, the cost was $21,500. For a patient with an HAI, the cost was $37,500.

Kenneth Christopher, MD, from Brigham and Women’s Hospital, Harvard Medical School, Boston, offered a word of caution concerning the study results. He noted that 25.8% of ICU patients who developed an HAI in the study were more likely to have a predisposition to infection-related supportive measures, such as endotracheal tube placement and intravascular lines.

He also pointed to a study the Centers for Disease Control and Prevention (CDC) published in 2011 on ICUs in the United States, which showed that from 2001 to 2009, central-line-associated bloodstream infection dropped 58%. The CDC report also found that the initiation of a bundle protocol was an effective method to reduce ventilator-acquired pneumonia.

So while many U.S. hospitals already have infection control practices implemented for critically ill patients and infection rates are down, it still poses a major threat to patients and a huge financial burden to hospitals.

Do you feel U.S. facilities’ practices to prevent HAI in the ICU are enough or can even more be done? Share your thoughts below.

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A recent study published in the New England Journal of Medicine says no.

The study spanned six years and looked at the effect the Medicare Premier Hospital Quality Incentive Demonstration had on patient outcomes. The participating facilities were assessed on 33 quality measures and received higher or lower Medicare payments based on their performances.

What the study by researchers at the Harvard School of Public Health found was following quality measures didn’t decrease 30-day mortality rates.

Why?

One reason is because many of the quality measures in the study are process-focused, not outcome related. An example of a process measure is how many heart attack patients are given a beta-blocker upon arrival at the hospital.

From 2004 through 2009, the study compared 30-day mortality rates for patients with heart attack, congestive heart failure, pneumonia and coronary-artery bypass surgery.

When researchers compared participants in the demonstration project to other facilities that publicly report their performance on quality measures, they found little evidence to support that the study group’s 30-day mortality rates were better.

It’s not that pay-for-performance doesn’t work, note the researchers. For example, Aurora Health Care System’s hospitals received $1.9 million in additional Medicare payment for achieving specific quality benchmarks during the program. And it went from a “below-average performer” at the beginning of the study to the “top-performing health system” at the end of the study.

Most hospital executives would agree it makes a lot more sense to pay more for better care than to pay more for more care that’s not effective. The challenge is figuring out how to measure better care that leads to better outcomes, because better outcomes means shorter hospital stays and less money spent.

Measuring outcomes is more difficult than measuring processes. But since the start of the study, healthcare quality measures have evolved and increasingly are focused on outcomes.

What do you think about quality measures? Are they the answer to providing better care and lower healthcare costs? Share your thoughts below.

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Pop quiz time: If an employee spots a medical error, what is he/she most likely to do?

1. Report it right away.
2. Keep it to him/herself.
3. It depends on the kind of policy your facility has on reporting safety/medical error incidents.

Of course, you’d hope the answer is A – that staff would drop everything and report it immediately. But for many facilities, the answer is C – it depends on your policy.

A recent study by the Agency for Healthcare Research and Quality (AHRQ), revealed many hospitals still are lagging behind in their open communication of medical errors. The study, which surveyed nearly 600,000 staffers at more than 1,110 hospitals nationwide, found:

• 54% said when an adverse event is reported, “it feels like the person is being written up, not the problem”
• nearly 50% of participants said they felt their mistakes were held against them, and
• almost 66% said they worried mistakes were being held in their personnel file.

The AHRQ did its first patient-safety culture report in 2007, and unfortunately, only about one-fifth of hospitals have improved their performance in the category of “non-punitive response to error,” — and 16% have gotten worse! The rest are struggling to make progress.

What hospital executives have to realize is the “carry a big stick” approach when it comes to staff making medical errors only places patients in more danger.

The American Medical Association supports non-punitive policies for reporting safety incidents. Your employees need to feel OK with admitting mistakes. They need to know that they won’t be punished – unless it’s an act intended to cause harm or noncompliance with safety protocols. But regular “oops” mistakes need to be looked into and learned from.

Yes, this is much easier to write than to do, but studies are showing that higher safety culture scores are correlated with better clinical outcomes and lower rates of hospital-acquired conditions.

Here are some articles from the AHRQ that can help you improve your safety practices:

• Safe practices for better health care
• Impact of working conditions on patient safety
• Patient safety tools: Improving safety at the point of care

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That bodes well for healthcare executives looking to keep their facilities staffed with top-notch people. However, while the CHWS study expects healthcare employment to grow faster than general employment, it sees a hiring shift moving away from hospitals, and toward home care and ambulatory settings.

Reason: More emphasis is being placed on preventive care and reduced admissions.

“For a long time, acute-care services tended to trump everything else, and that seems to be changing,” said Jean Moore, director of CHWS at the State University of New York at Albany. “There’s a growing awareness that it’s penny-wise and pound-foolish not to pay attention to preventive and primary care.”

But as baby boomers age and need additional inpatient care, hospitals will still need to grow their workforce by nearly a million between 2010 and 2020 – a 17% jump.

Here are other projected healthcare workforce projections from the study:

• offices of doctors and other health-care professionals are projected to hire 1.4 million people by 2020, a 36% increase
• home healthcare jobs will increase by 872,000, an 81% growth, and
• jobs related to ambulatory care will grow by 2.7 million, a 44% increase.

Another finding of the study that should interest healthcare executives: While there was a reduction in administrative healthcare jobs during the recession, hospitals are now hiring more administrative staff to deal with all of the regulation required by the 2010 Affordable Care Act.

Is your facility experiencing any kind of hiring resurgence? Share what you’re finding to be the hottest jobs in the comment area below.

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