Clinical Quality & Infection Control

Transcription

1 Special Section on Reducing Readmissions p. 10 INSIDE How Health Systems Can Create a Robust, Enterprise-Wide Patient Safety Program p. 12 Strategies to Prevent Multidrug-Resistant Organism Outbreaks p. 16 Report: Top Academic Medical Centers Have High Variation in Care Practices p. 13 Study: Higher Patient Satisfaction is Linked to Lower Hospital Readmissions p Hospitals With the Lowest 30-Day Mortality Rates For Pneumonia p. 23 INDEX Infection Control p. 16 Clinical Quality & Infection Control 10 Top Patient Safety Issues for 2013 By Rachel Fields 5 Tips on Engaging Physicians in Major Process Changes February 2013 Vol No should be a busy year for patient safety experts at hospitals and surgery centers; as quality reporting requirements continue to go into effect, facilities will be expected to ramp up compliance programs and prove their progress. Here, three patient safety experts discuss the most pressing safety topics for the next year and what facilities can do to make sure they re up to speed. 1. Utilization of surgical checklists. Atul Gawande, MD, is an American surgeon and journalist whose books include Better, Complications, and most relevant to this subject The Checklist Manifesto. He has advocated heavily for surgical checklists, arguing that the fallibility of human memory opens the door for serious, fatal errors continued on page 7 The healthcare industry is facing tremendous change, including a movement to value-based care, new reimbursement models and a focus on collaboration. To be successful in the new healthcare environment, hospitals will need to change some of their long-held beliefs and processes. Hospital leaders can facilitate the transition to a new process or culture by engaging physicians and staff members in the change initiative. Managing change at CTCA: Case study An example of engaging clinicians in a major change is the development of a Certified Quality Breast Center of Excellence at the Cancer Treat- 10 Guiding Principles for Patient- Centered Care In August, Mountain States Healthcare Alliance, a 13-hospital integrated healthcare delivery system based in Johnson City, Tenn., received the 2012 National Quality Healthcare Award from the National Quality Forum, recognizing the system s achievement of multiple qualityfocused goals. Rather than just representing a culmination of efforts, the award is spurring the system to continue providing quality care, according to Dennis Vonderfecht, president and CEO of MSHA. No matter how many quality awards we receive, we can never sit back and say we are satisfied with the level of quality we have achieved, he says. So while we are extremely gratified to be recognized at this level, we will continue to work just as diligently to ensure that we are providing the best care possible to the people of our region. One of the areas NQF praised MSHA for was its commitment to patient-centered care. MSHA follows 10 patientcentered care guiding principles to ensure the health system puts the patient first in every decision. Tamera Parsons, vice president of quality and patient safety at MSHA, describes the 10 patient-centered care guiding principles. continued on page 8 continued on page 9 SIGN UP TODAY! Clinical Quality & Infection Control Becker s Clinical Quality & Infection Control E-Weekly at or call

2 P R O F I T A B I L I T Y T H R O U G H P E R I O P E R A T I V E P R O C E S S I M P R O V E M E N T IMPROVEYOUR BOTTOM LINE. Surgical Directions' consultants deliver sustainable operational improvement through measurable results and culture change. Surgical Directions consistently helps hospitals improve their perioperative performance. Over the past seven years, our consultants have changed the culture, and most importantly, improved the bottom line for more than 400 clients: from community-based hospitals to large quaternary academic medical centers. Our multi-disciplinary teams of anesthesia, nursing and business consultants typically help hospitals increase profitability by $250,000 $750,000 per OR by improving: Surgeon satisfaction Turn over time Close to cut time On-time starts Block time Materials/supply spend Labor spend Anesthesia service levels RN and anesthesia staffing models Profitable incremental OR volume Improving OR leadership We are eager to discuss your specific issues within Perioperative Services as well as tell you about successful strategies used by other organizations to address similar situations. Contact us to schedule a free, no obligation conference call to review your situation and design a path to operational excellence! Let our clinically active consultants help you enhance your bottom line through improved quality outcomes, improved perioperative process and overall operational improvement. perioperative & anesthesia consulting assessment interim management

3 Save the Date for 2013 Conferences Becker's Hospital Review Annual Meeting May 9-11, 2013 Westin Michigan Avenue, Chicago Keynotes: Lou Holtz, legendary football coach and ESPN analyst; Bret Baier, anchor of FOX News Channel's "Special Report with Bret Baier"; Patrick Lencioni, author of The Five Dysfunctions of a Team, among other books To learn more and register, visit and click the Conferences tab. 11th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference June 13-15, 2013 Westin Michigan Avenue, Chicago Keynotes: Mike Krzyzewski (Coach K), former basketball player and head coach at Duke University; Brad Gilbert, former professional tennis player, TV tennis commentator, author and tennis coach; Geoff Colvin, senior editor-at-large for Fortune Magazine and author of Talent is Overrated; Forrest Sawyer, TV journalist and entrepreneur in innovative healthcare To learn more and register, visit: and click the Conferences Tab. 20th Annual Ambulatory Surgery Centers Conference October 24-26, 2013 Swissotel, Chicago Surgery center CEOs, administrators, surgeons and industry experts will lead several sessions on the biggest trends and opportunities in the ASC industry. Look for more information coming soon at For information on sponsorship and exhibits, call Jessica Cole at (800)

4

5 THERE ARE AN ESTIMATED 23 MILLION NOROVIRUS CASES PER YEAR. IS YOUR FACILITY READY? Clorox Healthcare Hydrogen Peroxide disinfecting wipes and sprays are EPA-registered to kill Norovirus in 3 minutes (wipes) and 1 minute (sprays). No harsh chemical odors or fumes Kill 41 pathogens, including Norovirus, TB and 13 antibiotic-resistant organisms Get your free prevention kit. While supplies last. Limit one per customer. Business or institutional customers only. Use as directed on hard, nonporous surfaces Clorox Professional Products Company. NI-20065

6 6 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Clinical Quality & Infection Control February 2013 Vol No. 1 Editorial Lindsey Dunn Editor in Chief / ldunn@beckershealthcare.com Rachel Fields Editor in Chief, Becker s ASC Review / rfields@beckershealthcare.com Laura Miller Editor in Chief, Becker s Spine Review / lmiller@beckershealthcare.com Molly Gamble Associate Editor / mgamble@beckershealthcare.com Bob Herman Associate Editor / bherman@beckershealthcare.com Heather Linder Writer/Reporter / hlinder@beckershealthcare.com Jim McLaughlin Writer/Reporter / jmclaughlin@beckershealthcare.com Heather Punke Writer/Reporter / hpunke@beckershealthcare.com Sabrina Rodak Writer/Reporter / srodak@beckershealthcare.com Kathleen Roney Writer/Reporter / kroney@beckershealthcare.com Anuja Vaidya Writer/Reporter / avaidya@beckershealthcare.com sales & publishing Jessica Cole President & CEO / Cell: / jcole@beckershealthcare.com Ally Jung Director of Sales / Cell: / ajung@beckershealthcare.com Lauren Groeper Assistant Account Manager / Cell: / lgroeper@beckershealthcare.com Heidi Harmon Assistant Account Manager / hharmon@beckershealthcare.com Maggie Wrona Assistant Account Manager / Cell: / mwrona@beckershealthcare.com Cathy Brett Conference Manager / Cell: / cbrett@beckershealthcare.com Katie Atwood Director of Operations/Client Relations / Cell: / katwood@beckershealthcare.com Scott Becker Publisher / sbecker@beckershealthcare.com Becker s Clinical Quality & Infection Control is published by ASC Communications. All rights reserved. Reproduction in whole or in part of the contents without the express written permission is prohibited. For reprint or subscription requests, please contact (800) or scott@beckershealthcare.com. For information regarding Becker s Clinical Quality & Infection Control, Becker s ASC Review, Becker s Hospital Review or Becker s Orthopedic & Spine Practice Review, please call (800) features 1 10 Top Patient Safety Issues for Tips on Engaging Physicians in Major Process Changes 1 10 Guiding Principles for Patient-Centered Care Focus on Reducing Readmissions 10 Turning Heart Failure Into Heart Success: Transitioning CHF Patients to Home 11 Study: Wide Variation in Implementation of Strategies to Reduce Readmissions 11 Study Finds Social Factors Linked to Hospital Readmissions, Mortality 12 How Health Systems Can Create a Robust, Enterprise-Wide Patient Safety Program 13 Report: Top Academic Medical Centers Have High Variation in Care Practices 14 Study: Higher Patient Satisfaction is Linked to Lower Hospital Readmissions 14 The Joint Commission to Add 2 Medical/Surgical Hospital Requirements 14 CMS to Develop Survey on Patient Experience in the ED 15 Study: 37% of Physicians Give in to Patients Demands for Brand-Name Drugs 15 Study: Surgery Generally More Cost-Effective Than Radiation for Prostate Cancer 15 Surgeons Make Preventable Mistakes 4,000 Times a Year, Study Says Infection Control 16 Hospital Cleaning Protocol Has Limited Effect on Multidrug-Resistant Bacteria 16 6 Risk Factors for Central Venous Catheter-Related Blood Stream Infections 16 Strategies to Prevent Multidrug-Resistant Organism Outbreaks 16 Study: 26% of C. Diff Patients Received Only Unnecessary Antimicrobials 17 7 Hospital and Health System CEOs: What Disruptive Innovation Means to Me 19 Which Hospital Markets Had the Best 2013 Value-Based Purchasing Results? 19 3 Simple Ways Hospitals Can Engage Patients in Their Care 21 Population Health Management is a Two-Way Street: Encouraging Patient Engagement 21 Database of Downloadable Safety and Quality Tools & Resources Now Available Hospitals With the Lowest 30-Day Mortality Rates For Pneumonia 23 Advertising Index

7 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Top Patient Safety Issues for 2013 (continued from page 1) when surgeons rely on their training alone. According to Dr. Gawande, the use of checklists dates back to the 1930s, when airplanes were gaining more sophisticated technology in the cockpit. Though the technology was intended to improve safety, it was widely considered too complicated for a lone pilot to manage, and the rate of airplane crashes soared. In response to the climbing error rate, pilots developed checklists to ensure that every necessary task was completed prior to take-off. The instance of crashes dropped significantly. Dr. Gawande says in The Checklist Manifesto that the same results have been proven with surgical checklists: When an OR team goes through each item one-by-one, they are less likely to miss something serious. But healthcare has been slow to adopt the tool, in part because of ingrained theories about good medicine. Surgeons, who have gone through years of training, often believe that good medicine is up to the talents of an individual physician not the collective, systematic effort of a checklist. Hospitals and surgery centers will be implementing surgical checklists throughout their facilities in 2013 to avoid reductions in reimbursement. According to Kim Haines, RN, certified OR nurse and vice president of clinical resources for Medline, implementation comes down to communication and education of staff. You have to get staff to understand the goals and have that true buy-in, where they understand the list is used to improve quality of care, she says. She adds that surgical facilities must customize checklists available through WHO, AORN and various other organizations to make sure they fit the flow of the facility. A lot of facilities role-play during training to make sure everyone understands what they re supposed to do and supposed to say, she says. 2. Implementing time outs in the OR. Similar to the idea of the surgical checklist is the concept of the time out, which requires OR team members to stop prior to surgery to confirm the correct side, site, patient and procedure. Ms. Haines says implementing this process, which is required by the Joint Commission and other accrediting bodies, is a matter of breaking down barriers in the operating room. From a speaking-up standpoint, there may be intimidating between nursing staff and a physician, she says. Make sure the leadership at your institution clearly communicates the need for a time-out and implements rules to allow anyone to speak up. Certain institutions have red rules, which mean that any provider or team member can stop the process and point out a problem. You need to set a very clear methodology that takes the pressure off the nurse, Ms. Haines says. 3. Increasing hand hygiene compliance. Hand hygiene compliance has been promoted in surgical facilities for years; Lisa Spruce, RN, DNP, ACNS, ACNP, ANP, CNOR, director of evidence-based perioperative practice for AORN, calls it the one proven concept that absolutely works for preventing infections. Despite progress in this area, however, compliance in hospitals hovers around 50 percent, according to the University of Geneva Hospitals in Switzerland. Promotion of hand hygiene is a major challenge for infection control experts, wrote Didier Pittiet, of the University of Geneva Hospitals, in an article for the CDC. No single intervention has consistently improved compliance with hand hygiene practices. Non-compliance can be attributed to a number of factors, but experts agree that staff apathy towards the practice is a big one. Dr. Spruce says for many hospitals, monitoring staff hand-washing practices can improve compliance. There s been some success with just watching people and seeing how well they re doing, she says. In some cases, the sinks are monitored through a video camera, and the tapes are reviewed every week or at random to determine how well people are doing. In other cases, a staff member is assigned to walk through the hand-washing area and note staff members who fail to wash their hands. A wonderful way to improve the process is just to have someone monitor it and then talk to the team afterwards and explain what could be done better, she says. 4. Promoting collaboration between providers. The surgical team should be trained together to make sure everyone is on the same page about OR processes, Dr. Spruce says. Historically, the OR has functioned as a hierarchy, with the surgeon on top and the other providers at his or her service. This is a problem for patient safety, because nurses and other OR providers may be hesitant to speak up if a surgeon fails to wash his hands. Staff members should be educated together, and leadership should encourage the idea that OR providers are a team. 5. Implementing a debriefing after surgery. Dr. Spruce recommends that OR teams conduct a debriefing after surgery, which means they come together and talk about the surgery that just happened. If they have that brief conversation, they re more aware and can talk about any issues and how to prevent them, she says. If they don t have that conversation, they can t pass that information on. She says even though debriefings are incredibly useful in predicting future problems and reviewing old mistakes, they are one of the least used patient safety tools. She says for instance, the team might discuss the surgery and discover through the conversation that the patient might have a bleeding problem during recovery. That information is essential to being prepared in case complications arise, so that staff can deal with them immediately. 6. Using evidence to educate. Evidence-based practice should be the foundation from which all surgeons practice, so that patients know they are receiving care proven to work, Dr. Spruce says. Some physicians, who have had years of training and experience in the operating room, may be hesitant to adopt a surgical checklist because they feel they already know what they re doing. But the evidence doesn t lie: In a 2008 study from the University of Toronto, published in the Archives of Surgery, researchers found that communication failures per procedure declined from 3.95 prior to list use to 1.31 after list use. Thirty-four percent of surgical briefings demonstrated the utility of the list, including identification of problems, resolution of critical knowledge gaps, decision-making and follow-up actions. Of course, the most effective education involves holding a mirror up to the providers themselves. This is why debriefings after surgery are so important because they point out errors that would have occurred if not for the checks and balances in place. 7. Promoting sharps safety. In March 2012, AORN released a new Sharps Safety Tool Kit, which includes new resources to help perioperative professionals reduce the risk of sharps injuries in the OR. Patient safety issues involving sharps fall into several main categories: Knife blades. According to Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, executive director of AORN, patient safety experts recommend nurses and surgeons implement a safe zone, where the nurse can place the knife blade for the surgeon to pick up. This eliminates the danger of cutting the surgeon or the nurse by directly handing the knife blade from provider to provider. Double-gloving. Double-gloving can prevent needle sticks, as wearing two pairs of gloves is likely to prevent a needle from going straight through the glove material. Unfortunately, providers are still hesitant to double-glove because of decreased sensitivity. Blunt suture needles. Blunt suture needles are proven to be safe and effective for surgery, but surgeons have hesitated to embrace their use because they feel sharp needles are more appropriate. The use of blunt needles decreases the likelihood of puncturing a patient or staff member. 8. Eliminating wrong site/side/procedure surgery. In late 2012, Johns Hopkins University published a study in Surgery that totaled the incidence of wrong site/side/procedure/patient surgery over the last two decades. The numbers were staggering: Between 1990 and 2010, over 9,700 cases of retained surgical items, wrong-site surgery, wrong-patient surgery or wrong-procedure surgery occurred. Those numbers only include those

8 8 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at cases that resulted in indemnity payments, meaning the real number (including unreported cases) is probably much higher. Study authors estimated that 4,082 of these surgical errors probably occur in the U.S. every year. Wrong site/side surgery is entirely preventable, said Martin Makary, lead author of the Johns Hopkins study and associate professor of surgery at the hospital. Dr. Spruce says the key to preventing these errors is to educate from the top down. Providers don t make these mistakes intentionally, she says. It s a combination of things system design, human factors and faulty equipment. She says it s important for hospital leaders to insist that OR teams implement a time-out, during which the providers can confirm the correct site of surgery, ask the patient to identify him or herself, and confirm the procedure with the patient s chart. 9. Retained surgical items. Dr. Spruce says Joint Commission reports are still showing the incidence of retained surgical items and indeed, the recent Johns Hopkins found that surgeons left around 4,857 items in patients over the past two decades. In order to prevent retained surgical items, AORN recommends that the OR providers work together to count all items on the sterile field, including sponges, needles and instruments according to a list prepared for the case. At the end of the case, those items are counted again to make sure everyone is accounted for. Dr. Spruce says this is important to think about, since a retained surgical item or any other surgical error can be disastrous for a patient s health. We need to remember that the ultimate cost is to patients and family members, because we can cause them to die or be disabled for the rest of their life, she says. 10. Standardizing surgical language. If people are using different language to communicate in the OR, they may misunderstand each other, Dr. Spruce says. She recommends that all hospitals and surgical facilities work to develop a common language. This means that if a nurse wants to stop the procedure, she knows whether to say, Stop, or, I want to invoke the red rule, or some other variation. n 5 Tips on Engaging Physicians in Major Process Changes (continued from page 1) ment Centers of America at Midwestern Regional Medical Center in Zion, Ill. To receive designation as a center of excellence from the National Quality Measures for Breast Centers Program, the breast cancer team had to meet 36 quality standards on a variety of breast care measures. The hospital needed to redesign its data collection system to effectively track and report the hospital s performance on these 36 measures. The process of developing a new data collection system was one of the biggest challenges of this initiative, according to Stephen Ray, MD, medical director of the breast center and medical director of oncoplastic and reconstructive surgery. Besides people s natural aversion to change, gaining buy-in for changing the data collection process was made more difficult by the nature of clinicians schedules. Clinicians had to learn a new workflow in addition to maintaining their normal responsibilities. It was taking people who were already working extremely hard and asking them to work harder, and convincing them the effort we were engaging them in was worthwhile, Dr. Ray says. However, by keeping the emphasis on the patient, focusing on small steps and providing feedback, the hospital successfully engaged clinicians and received certification as a Quality Breast Center of Excellence in October. 5 tips Here are five tips on engaging clinicians in a major process change such as changing data collection processes. 1. Support bottom-up change. Successfully implementing widespread changes that affect physicians and staff members day-to-day work often relies on leadership from these physicians and staff members. Driving change from the bottom-up, as opposed to the top-down, with administration mandating certain changes, is crucial for engaging people in the project. One of the things we learned is you need to find a small group of people who have a passion for the vision that you re trying to manifest, Dr. Ray says. This isn t something that can be readily dictated from above. It has to be something that s driven by the passion of the people who work with patients daily. CTCA at Midwestern formed a multidisciplinary leadership group including medical oncologists, surgical oncologists, radiation oncologists, radiologists, registered dietitians, pathologists, mindbody therapists, naturopathic oncology providers and pastoral counselors. This group led the creation of the breast cancer center, including the redesign of the data collection process. While these projects were also supported by hospital leaders, the implementation of the changes was led by clinicians who work with breast cancer patients. 2. Focus on the patient. To gain clinicians buy-in for any initiative, hospital leaders need to keep the focus on how the initiative will help patients. One thing that drives everybody here at CTCA is that we re all about the patient, says Lana Poirier, director of quality at CTCA at Midwestern. If we can derive a better treatment, better outcomes for patients, we re all going to do it. The breast cancer care leadership group at CTCA at Midwestern emphasized how accurate and effective data collection can help patients. Being able to track the hospital s performance on key metrics helps providers identify opportunities for improvement of patient care. Hospital leaders can identify not only performance trends within the hospital, but also performance compared to other breast cancer centers. Collecting and analyzing data can thus help drive quality improvement. Importantly, hospital leaders should emphasize the impact on patients not only when pitching the process change and gaining initial buy-in, but throughout each step of the project to maintain people s motivation and engagement. When challenges may cause some clinicians to question the project and resist the change, refocusing on patient care and quality can get people back on track, according to Ms. Poirier. Furthermore, keeping the patient at the center of the change helps clinicians focus beyond their personal challenges and frustrations to the end result for patients. As [the project] gathered momentum, people felt they were something much bigger than themselves, Dr. Ray says. 3. Break the project into smaller pieces. Hospitals can gain clinicians buy-in for a large project by breaking the project into smaller pieces, which makes the initiative seem more manageable. Dr. Ray compares this strategy to a strategy he used when mountaineering, which is one of his passions. Sometimes the only way was to literally focus on one step at a time, and not look ahead because [you would get] scared, he says. When CTCA began the data collection project, the breast cancer program leaders wanted to get a consensus from team members on the new strategy for collecting data. However, as the team was a large group with people from multiple disciplines, reaching a consensus was difficult. To address this challenge, the breast care leadership team broke down the data collection change into small elements and discussed with individual physicians the elements that would affect them. Then, leaders would try to get physicians to agree to these elements of change. By going through this process with all physicians, leaders would gain buy-in for the entire project. Dr. Ray likens this effort to putting pieces of a puzzle together to form a whole each clinician focuses on the parts of the change that affect him or her so that together, clinicians support the entire change. 4. Conduct a trial. Once clinicians buy in to the change, hospital leaders should conduct a trial to test the new processes. Chunk it down into small pieces, be persistent and get people to agree to a trial, Dr. Ray says. While the trial can initially result in slowed processes and frustration, persisting with the change will eventually result in a smooth workflow.

9 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Provide positive feedback. Hospital leaders can encourage clinicians to persevere when facing challenges in process changes by providing positive feedback for incremental improvement. Dr. Ray suggests providing specific positive feedback on relatively small successes to demonstrate to the physician that his or her contribution is important for the overall project. Similar to framing the project in small steps, feedback on small parts of the larger change can keep physicians motivated when challenges arise. We kept them focused on one step we were asking them to change, not the whole journey, Dr. Ray says. We tried to keep the journey in context, but we would reward the step. n 10 Guiding Principles for Patient-Centered Care (continued from page 1) 1. All team members are considered caregivers. Under this principle, everyone in the workforce, from housekeeping staff to the CEO, is part of patients care experiences. Regardless of one s role, each person is expected to put the patient first. To create a patient-centered culture, MSHA has patient-centered care training for new employees. They learn from day one that all team members are caregivers, Ms. Parsons says. In addition, MSHA recognizes employees through thank-you-notes and awards for demonstrating patient-centered care principles. 2. Care is based on continuous healing relationships. This principle reinforces a focus on the continuum of care for patients rather than episodes of care. We re here to not only provide care, but also to provide healing a more personal level of healthcare, Ms. Parsons says. 3. Care is customized and reflects patient needs, values and choices. The principle of customizing care recognizes that each patient is different and may have different needs and preferences. In addition to customizing the care plan for each patient, MSHA works to make the environment comfortable to individual patients. For example, one patient may want music in the room, where another patient may not. It allows the patient s individuality to be a component of care, Ms. Parsons says. 4. Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers. In a patient-centered environment, all members of the care team including the patient need to be aware of the patient s status and care plan. If the patient is going to be the center of care, [he or she] absolutely needs to be informed and part of the decision-making, Ms. Parsons says. 5. Care is provided in a healing environment of comfort, peace and support. Part of a patient-centered culture is the environment. MSHA has several features that create a healing environment for patients, including music, healing gardens, soothing color schemes and pet therapy programs. The hospitals also ensure rooms have pleasing scents, such as lavender or the smell of baked cookies, according to Ms. Parsons. 6. Families and friends of the patient are considered an essential part of the care team. MSHA recognizes that family and friends are essential supports for the patient s healing process. Family and friends support patients not only emotionally, but also physically, as they can help patients understand physicians instructions. In the health system s Very Important Partner program, patients identify an individual to listen to care information with them. Patients [may be] in a state of discomfort and pain or fear, and don t always hear information, so it [allows] a trusted family member or friend identified by the patient to participate in the sharing of information and guidance we give before sending patients home or to the next level of care, Ms. Parsons says. 7. Patient safety is a visible priority. Making patient safety a visible priority demonstrates the organization s commitment to patient care. MSHA implements policies and procedures to enforce patient safety best practices. For example, the system had a campaign around employee immunization and hand hygiene. MSHA also has a balanced scorecard called the blue print. The scorecard tracks the system s performance in key areas, such as heart failure, pneumonia and surgical care. 8. Transparency is the rule in the care of the patient. This principle recognizes that true patient-centered care requires transparency between providers and patients and among providers. Providers should be upfront and honest with information so [patients] can make informed decisions with us, Ms. Parsons says. One way MSHA supports transparency is by posting its quality and safety performance on its website. 9. All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient. All processes at MSHA, even those that don t involve patients, should be performed from a patient-value perspective, Ms. Parsons says. For example, she says the coding and billing process is done from the perspective of the patient; staff has worked to make bills clear and easy to understand for patients. 10. The patient is the source of control for their care. A core tenet of patient-centered care is that the patient controls his or her care. Making patients the source of control of their care is the result of effective deployment of all other guiding principles, Ms. Parsons says. To be the source of control, you have to have transparency and share information, create an environment that allows the patient to heal and focus work on the patient. After discharge, patients can still have a degree of control by participating in a patient advisory group that meets regularly at each MSHA facility to provide input on how the system can improve care and become more patient-centered. The groups are comprised of six to 12 patients who provide input on specific care models, such as diabetes programs. Dennis Vonderfecht Tamera Parsons Soliciting suggestions from those on the receiving end of healthcare gives patients some control over future healthcare services and helps MSHA continue to put patients first in their decisions. Embedding principles in everyday work To emphasize the importance of these principles to all MSHA operations, system leaders explicitly connect policies to one or more of these patientcentered care principles. For example, MSHA s social media policy states, MSHA seeks to optimize communication and social presence through the official use of social media and also recognizes the importance of supporting team members in shaping industry conversation through their responsible use of social media. The policy then lists All team members are considered caregivers and Patient safety is a visible priority as applicable patient-centered care principles. By clearly linking policies to these principles, MSHA brings patient-centered care from an abstract philosophy to a concrete practice. n

10 10 Focus on Reducing Readmissions Turning Heart Failure Into Heart Success: Transitioning CHF Patients to Home Under CMS Readmission Reduction Program, which took effect Oct. 1, hospitals will lose Medicare funds for excessive preventable readmissions of patients with acute myocardial infarction, heart failure or pneumonia. To avoid financial penalties and improve care for patients, many hospitals are targeting these diseases with new processes and interventions. In January, Charlotte, N.C.-based Carolinas Healthcare System began a pilot program to improve care for congestive heart failure patients. Preliminary results have shown that the program, called Heart Success, has reduced readmission rates and improved the quality of care. Brainstorming healthcare solutions One of the ways CHS aimed to improve heart failure care was by standardizing processes across the system. We felt being able to improve and reduce variability of care would lead to downstream improvement such as a reduction of readmission rate and an increase in satisfaction and quality of life, says Sanjeev Gulati, MD, medical director of advanced heart failure at CHS Sanger Heart & Vascular Institute, which includes Heart Success. It led us to relook at how heart failure was managed. To develop a standardized protocol for heart failure patients, a multidisciplinary group of senior administrators, cardiologists, family practitioners, IT employees, nurses and other stakeholders held several meetings to discuss where the gaps in care were and how to eliminate them. Then, a smaller heart failure team worked to design a transition clinic that would support, educate and provide resources for heart failure patients. The purpose was to close a potential gap in care where patients were discharged from the hospital with no specific resources to manage their complex disease. Beginning with a pilot To test their design, the heart failure care stakeholders began with a pilot project that could later be scaled up to the entire CHS organization. In the pilot program, a nurse navigator who Dr. Gulati calls the quarterback of the team would visit all inpatients who had a primary diagnosis of congestive heart failure. This evaluation went beyond clinical factors to include an assessment of the patient s, as well as his or her family s, needs. The nurse navigator also gave patients initial education on the complexities of their disease. Within three days after hospital discharge, patients who voluntarily entered the Heart Success program met with advanced care practitioners and nurses trained in heart failure to receive more in-depth education on how to better manage their disease. These practitioners, along with a pharmacist, dietician and social worker, educated patients about medication, diet and other behavior, and helped patients identify resources, such as cardiac rehab and home nursing, and other needs based on the evaluation sent from the nurse navigator. In addition to helping patients access the care they need, this process helps the practitioners identify which patients are at higher risk for readmission and who may need more monitoring. In the first week of the pilot, this first educational meeting took an average of two-and-a-half hours. We felt that period of time was a little overwhelming, Dr. Gulati says. [Patients] are just out of the hospital with a chronic disease, and they have a two-and-a-half-hour lecture. That can be difficult. The team quickly changed the structure of the first educational meetings, which shortened the time to one hour. Expanding the pilot to the system To make the educational component more manageable, the Heart Success team schedules each patient for up to four, 30-minute in-clinic meetings over the next four weeks after the initial meeting. The care team will also call patients throughout that time period to follow up on what was discussed in the previous meeting and to answer questions about diet or medicine the patients may have. While Heart Success is part of Sanger Heart & Vascular Institute, it focuses on the short transition period between hospital and home, rehabilitation or a skilled nursing facility, whereas the Institute focuses on long-term care. Separating transition services from chronic care services allows CHS to devote the appropriate resources to each patient depending on the acuity of their condition. Multiple points of entry One of the biggest challenges of expanding Heart Success system-wide was coordinating care for patients entering through multiple entry points, such as the emergency department, a primary care physician or a specialist. Each hospital within the system had to evaluate its own patient population and needs to tailor the program to the institution, Dr. Gulati says. In order for programs to succeed in other hospitals, each program has to be tailored to the primary, tertiary and quaternary environment of each facility. Dr. Sanjeev Gulati, MD To reach chronic heart failure patients who are not inpatients at CHS and receive the majority of their care from their primary care physician or cardiologist, the Heart Success team communicates with these physicians to make them aware of the transition program. The Heart Success team developed and distributed algorithms and protocols to primary care physicians and cardiologists to notify them of the resources for their chronic heart failure patients. Provider engagement The value of Heart Success lies not only in helping patients connect to needed resources, but also in encouraging provider and patient engagement in the patient s care. What really developed here, and what you need to be successful in the management of heart failure, is a model where providers are engaged, Dr. Gulati says. The Heart Success program fosters provider engagement because it enables physicians to care for patients beyond discharge. By focusing on not only medical needs, but also logistical needs such as transportation, health insurance and personal support, the transition clinic forces providers to take a holistic, rather than a siloed, narrow view of the patient. Educating heart failure patients and helping them access post-discharge services also encourages patient engagement, because patients have a better understanding of what resources they need to stay healthy and how they can access those resources. It s transforming patients from having things done to them to becoming active managers of the disease. It s empowering

11 Focus on Reducing Readmissions 11 them to be successful in managing their disease, Dr. Gulati says. Patient engagement can increase patient satisfaction because patients feel more in control, and can improve long-term outcomes. What s in a name? Empowerment The name of the transition program itself also promotes patient engagement and empowerment, according to Dr. Gulati. He says that while it may seem corny, it was chosen very deliberately. Failure is not a good term for patients having a good outlook. There s a negative connotation even though everybody uses [the term heart failure ]. We wanted to empower patients from a psychological standpoint. Focusing on heart success instead of heart failure may help patients think more positively about their condition and their ability to manage the disease. n Study: Wide Variation in Implementation of Strategies to Reduce Readmissions By Jaimie Oh Research published in the Journal of the American College of Cardiology suggests there is wide variation in hospitals implementing effective strategies to reduce hospital readmissions. For the study, researchers administered an online survey to 537 hospitals participating in the Hospital to Home quality improvement project to determine how hospitals implement quality improvement resources and performance monitoring, medication management efforts and discharge and follow-up processes. The results of the feedback show almost all (90 percent) of hospitals indicated they had a written objective to reduce preventable hospital readmissions for patients with heart failure or acute myocardial infarction. However, hospitals have much-less frequently implemented strategies to meet that objective. For example, while hospitals have created teams to target readmissions for patients with heart failure 87 percent of the time, hospitals have done the same for patients with AMI only 54 percent of the time. In addition, less than half of hospitals have partnered with local physicians and less than one-quarter of hospitals have partnered with other local hospitals to coordinate care for high-risk patients. Less than one-third of hospitals linked inpatient and outpatient prescription records or always directly sent discharge summaries to the patient s primary physicians. n Study Finds Social Factors Linked to Hospital Readmissions, Mortality By Jaimie Oh Researchers have determined a range of social factors are associated with increased risk of hospital readmissions or mortality, according to a study published in the Journal of General Internal Medicine. For the study, researchers mined the OVID, PubMed and PSYCHINFO databases for studies published from 1980 to 2012 on the subject of readmissions. Seventy-two articles were ultimately chosen for conclusion in this study. They found the following key points: Studies often, but inconsistently, cited lower education, low income, and unemployment as linked to higher readmissions for communityacquired pneumonia patients. In addition, low income was associated with higher mortality for community-acquired pneumonia patients. Medicaid coverage, low income and rural living situation, lack of social support, being unmarried and portraying risky behaviors were also associated with higher readmissions for heart failure patients. Similar factors contributed to higher risk of mortality for heart failure patients, in addition to psychiatric comorbidities, lack of home resources and further living distance to hospitals. n REGISTER TODAY! Becker s Hospital Review Annual Meeting CEO Strategy, ACOs, Physician- Hospital Integration, Improving Profits and Key Specialties 83 Health System Executives as Speakers Co-Chaired by Chuck Lauer and Scott Becker May 9-11, 2013; Chicago Westin Michigan Avenue, Chicago For more information and to register, visit:

12 12 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at How Health Systems Can Create a Robust, Enterprise-Wide Patient Safety Program Detroit-based Henry Ford Health System launched its No Harm Campaign in 2008, a system-wide approach to patient safety that has a goal of reducing adverse events by 50 percent by HFHS is already more than halfway there it has reduced harm events by 34 percent so far. The system also reduced system-wide mortality by 12 percent by 2011, achievements which garnered the system the 2011 Malcolm Baldrige National Quality Award and the John M. Eisenberg Patient Safety and Quality Award in William Conway, MD, senior vice president and chief quality officer of HFHS and CMO of Henry Ford Hospital in Detroit, and Sue Hawkins, senior vice president of performance excellence at HFHS, describe how HFHS created a patient safety program that spans five hospitals and numerous other sites of care. The program s structure To be sustainable in different environments, whether by type of provider or geographic location, an enterprise-wide patient safety program needs to have a clear, robust structure that enables frequent communication across facilities. The No Harm Campaign s structure has three areas of focus: 1. Process: Understanding what the highrisk areas are and what processes can improve the harm rate. 2. Culture: Creating a safety culture through education and training. 3. Safe practices: Following evidence-based safety protocols, such as hand hygiene. All three areas support the campaign s goal of reducing harm. The campaign s goals are executed through several subteams that report to a larger, multidisciplinary committee that meets monthly for two hours. The subteams work toward reducing specific types of harm. The campaign looks at all harm, whether currently preventable or not, and separates them into six categories: infection-related harm, medication-related harm, procedural harm, care delivery harm, employee harm and other, which includes hospital-acquired renal failure, pulmonary embolisms and deep vein thrombosis. Embedding patient safety practices in the culture Implementing a multi-year patient safety program across different hospitals and care sites depends on a strong safety culture. Making patient safety part of the organization s culture was one of the biggest challenges but also one of the biggest keys to success of the No Harm Campaign. Ms. Hawkins says HFHS tried to make patient safety practices part of people s daily work and culture so it doesn t feel like an extra activity. Embedding these practices in one s workflow is important not only for physicians and staff members, but also for the system s leaders. We re concentrated on aligning the existing leadership to adopt [eliminating] harm as part of their daily work, Dr. Conway says. For example, the CMO of HFHS is responsible for insulin protocols, and nursing officers are responsible for falls and pressure ulcer protocols. The leaders report their progress on a regular basis, and their performance review takes this progress into account. Leadership and accountability Managing a system-wide patient safety program also requires accountability to and by leaders leaders need to hold others accountable for their efforts, and the leaders need to be held accountable for their role in the initiative. In addition to performance reviews, HFHS leaders progress on meeting patient safety goals also affects their compensation. HFHS drives accountability from the top of the organization down to ensure improvement in meeting the No Harm Campaign s goals. The board evaluates patient safety data and the system s performance. Patient safety leaders at HFHS encourage the board to hold them accountable to their improvement goals to continue to challenge them on patient safety efforts. We actually insist to our board that they ask us hard questions and keep asking us how it s going on these initiatives, Ms. Hawkins says. We do the same thing at the next level, which is our quality and safety team, and at the next level, the senior leaders of the organization they are required to report on what s going on and what s not working. We re very transparent about what s not working. William Conway Sue Hawkins Transparency of results Transparency is a critical component of a system-wide patient safety program, as it promotes communication among different stakeholders. At HFHS, transparency keeps everyone informed on progress toward the common goal of reducing harm by 50 percent by For example, the system posts each unit s progress on the harm they re responsible for. Transparency of data can motivate physicians and staff to improve their performance. We don t blind any of the results because it drives healthy internal competition, Dr. Conway says. Constant vigilance One of the challenges of a system-wide patient safety initiative is maintaining energy and performance. For HFHS, taking on the formidable

13 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at 13 task of reducing harm events by half over six years presented the challenge of maintaining enthusiasm for patient safety efforts and maintaining improvements. It takes constant vigilance to make sure improvements are sticking, Dr. Conway says. Many times there s a period of relapse after introducing change. It s very hard to achieve consistent [improvement]. To ensure patient safety advances are long-lasting, it is essential health systems constantly measure patient safety metrics. Never stop measuring data, Ms. Hawkins says. By not measuring data, organizations are susceptible to not recognizing patient safety issues right away, which makes improvement more difficult. There s a constant dynamic between [infections] and people, Dr. Conway says. When we see a spike in infections, we figure out why it happened and get on top of it right away. While a health system may have multiple hospitals across several regions or states, it is possible to implement a single approach to patient safety. Some key components of engaging all providers in the patient safety effort include a robust structure, a culture of safety, accountable leadership, transparency and continued monitoring of data. n Report: Top Academic Medical Centers Have High Variation in Care Practices Top academic medical centers vary widely in their intensity of care, procedure rates, patient experience and patient safety, according to a report from the Dartmouth Atlas Project. The report, What Kind of Physician Will You Be? Variation in Health Care and Its Importance for Residency Training, explores variation in care among 23 academic medical centers to guide medical residents as they choose teaching hospitals. The medical centers consist of hospitals that were rated by U.S. News & World Report as the best hospitals for clinical excellence in as well as other notable hospitals. Cleveland Clinic, The Johns Hopkins Hospital in Baltimore, Northwestern Memorial Hospital in Chicago and University of Washington Medical Center in Seattle are among the hospitals featured in the report. Together, the hospitals represent approximately 17 percent of all primary residency slots in The authors used 2010 Medicare data and data for surgical procedures from 2008 to 2010 for their report. Examples of variation in care include the following: In 2010, nearly half of chronically ill patients treated at The Johns Hopkins Hospital were enrolled in hospice in their last six months of life compared with only 23.1 percent of patients treated at Mount Sinai Medical Center in New York City. The authors suggested a Mount Sinai resident may learn a higher threshold for referral to hospice care, while a Johns Hopkins resident may be better trained in discussing patients preferences. Patients were twice as likely to undergo knee replacement surgery in Salt Lake City as in Manhattan. Patients at NYU Langone Medical Center in New York City were 47 times less likely to contract an infection from a urinary catheter than patients at the University of Michigan Health System in Ann Arbor. The authors wrote that while all 23 academic medical centers have aboveaverage scores on patient experience, patient safety and processes of care and provide high-quality care, there is still room for improvement. David C. Goodman, MD, MS, co-principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy & Clinical Practice, said These findings challenge the assumption that clinical science alone drives medical practice at these prestigious institutions and thus raise a serious issue for academic medicine, according to a news release. With such drastic variations from one institution to the next, they clearly cannot all be right. Academic medicine needs to address this gap in clinical science. n REGISTER TODAY! Becker s Hospital Review Annual Meeting CEO Strategy, ACOs, Physician-Hospital Integration, Improving Profits and Key Specialties 83 Health System Executives as Speakers Co-Chaired by Chuck Lauer and Scott Becker May 9-11, 2013; Chicago Westin Michigan Avenue, Chicago For more information and to register, visit:

14 14 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Study: Higher Patient Satisfaction is Linked to Lower Hospital Readmissions Hospitals with low readmission rates tend to have high patient satisfaction scores, according to a report by Press Ganey Associates. The report, The Relationship Between HCAHPS Performance and Readmission Penalties, is the first in a series of studies that will examine aspects of patient experience. Press Ganey used data on hospitals readmission penalties and hospitals scores on CMS Value-Based Purchasing program to determine the connection between patient satisfaction, clinical performance and readmission rates. The report showed that while higher scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey were closely tied to lower readmission rates, performance on clinical measures did not correlate with readmission rates. Overall HCAHPS scores of 0 to 19 were associated with a 0.4 percent readmission penalty much higher than the average. In contrast, HCAHPS scores of 80 to 100 were associated with a 0.1 percent readmission penalty much lower than average. n Sign Up for the Free Becker s Clinical Quality & Infection Control E-Weekly at clinicalquality. The Joint Commission to Add 2 Medical/Surgical Hospital Requirements The Joint Commission announced it will expand performance measurement requirements for accredited general medical/surgical hospitals from four to six core measure sets, effective Jan. 1, The additional requirements are part of The Joint Commission s ORYX performance measurement initiative to stimulate and guide quality improvement efforts. The four current measure sets required for general medical/surgical hospitals include acute myocardial infarction, heart failure, pneumonia and the Surgical Care Improvement Project. The new fifth measure set, the perinatal care measure set, will be required for hospitals with at least 1,100 births per year. The new sixth measure set (or fifth and sixth measure sets for hospitals with fewer than 1,100 births per year) will be chosen by general medical/surgical hospitals from the approved list of core measure sets, which include children s asthma care, emergency department care, hospital-based inpatient psychiatric services, hospital outpatients, immunization, tobacco treatment, stroke, substance use and venous thromboembolism. Hospitals must modify and update measure set selections two months before data collection begins Jan. 1, However, data for the new measure sets will not be used in calculating Performance Improvement Standard PI or the Top Performers on Key Quality Measures program until sufficient data are received, according to the release. This provision will enable hospitals between 12 and 23 months to gain experience with the new measure sets before the data are incorporated in performance calculations. Critical access hospitals and specialty hospitals, such as children s hospitals and psychiatric hospitals, will continue to follow current performance measurement requirements. n CMS to Develop Survey on Patient Experience in the ED The Centers for Medicare and Medicaid Services is seeking input on the development of a survey of patient experience in the emergency department. CMS is designing a survey to measure patients experiences in the ED as part of HHS National Quality Strategy developed under the Patient Protection and Affordable Care Act. CMS plans to submit the survey to the Agency for Healthcare Research and Quality for recognition as a Consumer Assessment of Healthcare Providers and Systems survey. The primary focus is a survey for consumers and patients aged 18 and older, but CMS is also interested in a survey for pediatric patients, according to the request. CMS seeks suggestions for topic areas, such as communication with providers and waiting time as well as publicly available instruments for measuring patient experiences with emergency care. CMS is looking for instruments that have the following two elements: 1. The source of information is from consumers and patients who directly received care at an ED or caregivers who were directly involved in the care (e.g., parents of young children). 2. Patients or caregivers identified the information as important to them in evaluating ED care (e.g., wait time and medical staff and physician communication). Instruments that have been tested, have a high degree of reliability and validity and have been used widely are preferred, according to the request. n

15 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at 15 Study: 37% of Physicians Give in to Patients Demands for Brand-Name Drugs Thirty-seven percent of physicians sometimes or often give in to patients demands for brandname drugs when equivalent generic drugs are available, according to a study in JAMA Internal Medicine, formerly Archives of Internal Medicine. Researchers studied physicians prescribing decisions using data from 1,891 physicians in seven specialties who responded to a national survey. Overall, 37 percent of physicians sometimes or often gave in to patients requests for brand-name drugs. Among physicians in practice for more than 10 years, this percent rose to 43 percent, compared with 31 percent of physicians in practice for 10 years or less. The study identified several factors associated with capitulation to patients request for brandname drugs: Pediatricians, anesthesiologists, cardiologists and general surgeons were significantly less likely to give in than were internal medicine physicians. Physicians in solo or two-person practices were more likely to give in than were those working in a hospital or medical school setting, with rates of 46 percent and 35 percent, respectively. Thirty-three percent of physicians who received free food and/or beverages in the workplace from drug companies (industry) yielded to patients demands for brand-name drugs compared with 39 percent who did not receive these items. Forty percent of physicians who received drug samples from companies gave in compared with 31 percent of those who did not receive samples. Forty-percent of physicians who often met with industry representatives to stay up-to-date gave in compared with 34 percent of physicians who did not meet with representatives. n Study: Surgery Generally More Cost-Effective Than Radiation for Prostate Cancer Surgical treatment for localized prostate cancer is generally more cost-effective than radiation therapy, according to a study in the British Journal of Urology International. The researchers aimed to determine the differences in outcomes and costs for various prostate cancer treatments, including radical prostatectomy (open, laparoscopic or robot-assisted) and radiation therapy (dose-escalated three-dimensional conformal RT, intensity-modulated RT, brachytherapy or combination). The researchers used a model to determine the probable outcomes of primary treatment for hypothetical men with low-, intermediate- and high-risk localized prostate cancer. The authors based probabilities on a literature search of 232 publications and they determined costs from the USA payor perspective. Results showed only slight differences in quality-adjusted life years across all treatment types. Surgical methods were generally more effective than RT methods, except for combined external beam and brachytherapy for high-risk disease. However, there was a wide range of costs, spanning from $19,901 for robot-assisted prostatectomy for low-risk disease to $50,276 for combined RT for high-risk disease. n Surgeons Make Preventable Mistakes 4,000 Times a Year, Study Says By Rachel Fields Despite a significant push to reduce never events surgical errors such as wrong-site surgery, mistaken patient identity and retained surgical items surgeons make such mistakes more than 4,000 times a year in the United States, according to a Johns Hopkins study published in Surgery. According to the study, which used data from the National Practitioner Data Bank, over 9,744 cases of retained surgical items, wrongsite surgery, wrong-patient surgery and wrong-procedure surgery occurred between 1990 and 2010 in the U.S. In these cases, just over 6 percent of patients lost their lives. Another 32.9 percent suffered permanent injury, and 59.2 percent suffered temporary injury, according to the report. A prior study indicated that only 12 percent of surgical adverse events result in indemnity payments meaning only those cases would be listed in the National Practitioner Data Bank. This means that up to 4,082 mistakes could occur in the U.S. every year, with 78 percent of those cases going unreported. Hospitals are required to report events that result in a settlement or mention in the National Practitioner Data Bank. According to Martin Makary, lead author of the study and associate professor of surgery at Johns Hopkins, these types of surgical errors are entirely preventable. Hospitals and other healthcare facilities have been working for years to implement safety programs to prevent adverse events. Such programs include surgical checklists, as touted by the World Health Organization and surgeon-author Atul Gawande, MD, and timeouts before surgery to ensure nothing is amiss. n

16 16 Infection Control Hospital Cleaning Protocol Has Limited Effect on Multidrug- Resistant Bacteria Current cleaning protocol may be insufficient to eliminate multidrug-resistant Acinetobacter baumannii in patient rooms, according to a study in the American Journal of Infection Control. Researchers studied cultures from 32 hospital rooms from which patients with a known history of MDR A. baumannii were recently discharged. Fifteen rooms (46.9 percent) tested positive for MDR A. baumannii before terminal cleaning of the room. After cleaning, eight rooms 25 percent remained positive for the bacteria. Of the 12 sites in the rooms that tested positive after cleaning, 12.5 percent were the floor, 10 percent were the call button, 9.4 percent were the door handle, 7.4 percent were the bedside table and 3.8 percent were the supply cart. n 6 Risk Factors for Central Venous Catheter-Related Blood Stream Infections Congestive heart failure is a risk factor for hospital-acquired peripherally inserted central venous catheter-related blood stream infections, according to a study in Infection Control and Hospital Epidemiology. Researchers studied adult patients with PICCs placed from Jan. 1, 2006 through July 31, 2008 at Barnes-Jewish Hospital in St. Louis. The researchers identified the following independent risk factors for PICC BSIs: Congestive heart failure Intra-abdominal perforation Clostridium difficile infection Recent chemotherapy Presence of tracheostomy Double or triple lumen n Strategies to Prevent Multidrug- Resistant Organism Outbreaks Multidrug-resistant organisms are a significant threat to hospitals and other healthcare organizations, according to a report in the New England Journal of Medicine. Reliable adherence to basic infection control practices is the key to interrupting transmission in our hospitals, the authors wrote. They suggest six strategies healthcare facilities can use to prevent MDRO outbreaks. 1. Follow hand hygiene guidelines. 2. Thoroughly clean and disinfect the environment. 3. Adhere to best practices for invasive devices, such as central venous catheters. 4. Embed major tenets of antimicrobial stewardship into routine frontline work to reduce antibiotic use. 5. Use screening media to quickly identify patients colonized with MDROs. 6. Create a cordon sanitaire, or quarantine line, to identify and isolate patients transferred from other hospitals or chronic care facilities, especially when they are transferred from facilities known to have problems with specific MDROs. n Study: 26% of C. Diff Patients Received Only Unnecessary Antimicrobials Twenty-six percent of patients with a recent Clostridium difficile infection received only unnecessary antimicrobials, according to a study in Infection Control and Hospital Epidemiology. Researchers studied 246 patients with new-onset CDI diagnosed at Minneapolis Veterans Affairs Medical Center from January 2004 through December Two infectious disease physicians evaluated the use of non-cdi antimicrobials (those that are inactive against C. diff), which they defined as unnecessary if not fully indicated. Data showed 57 percent of patients received non-cdi antimicrobials during and/or after their CDI treatment, and 77 percent received at least one unnecessary antimicrobial dose. Twenty-six percent of patients received only unnecessary antimicrobials. n

17 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Hospital and Health System CEOs: What Disruptive Innovation Means to Me By Molly Gamble Disruptive innovation is broadly defined as the creation of new market values and breaking away from existing market trends. Like many other buzzwords, its generous definition is open to interpretation among hospital and health system leaders. Becker s Hospital Review asked seven current presidents and CEOs to explain what the term means to them, their organizational strategy and the healthcare industry as a whole. Kenneth L. Davis, MD, President and CEO of The Mount Sinai Medical Center in New York City. Technologies that change the direction of medicine are disruptive. They can be as diverse as how we deliver healthcare services, drugs that markedly change a patient s prognosis, or new surgical procedures that offer outcomes previously unachievable. From that perspective, moving from fee-for-service medicine to risk management, some of the new drugs to treat various cancers, and mitral valve repair instead of mitral valve replacement, are all examples of disruptive technologies. Robert C. Garrett, President and CEO of Hackensack (N.J.) University Health Network. Hospitals and health systems across the country are facing a state of controlled schizophrenia, as I refer to it. This represents the dilemma of moving forward with accountable care organizations in order to keep our patients well and out of the hospital, while keeping in mind that the majority of a hospital s reimbursement comes from hospital inpatient admissions. As an industry, we need to focus on other areas of business growth to compensate for reduced admissions. By way of example, Hackensack University Health Network [recently formed a] joint venture partnership with community physicians and United Surgical Partners International in the acquisition and operation of two ambulatory surgery centers, and [established a] clinical affiliation with MinuteClinic, the retail healthcare division of CVS Caremark. Implemented appropriately, these changes could also help lead the way toward opening areas of opportunity for other aspects of care. The outcome is a healthcare delivery system that results in higher quality and is less costly. This is an exciting time for the healthcare community. HackensackUMC is optimistic that changes made to accommodate upcoming reform will eventually help to better serve our community and patients while maintaining a stable financial position. Carlos Migoya, President and CEO of Jackson Health System in Miami. Too often, the corporate world thinks of disruption as a negative we talk about a disruptive employee or a disruptive incident. At Jackson Health System, we think about the ways the Beatles and Rolling Stones disrupted music and Julia Child disrupted home cooking and Jonas Salk disrupted medicine. Disruption is a natural part of innovation. It s coming to our industry whether we like it or not via healthcare reform, increased competition and shifting market forces. We can be overtaken by it or we can leverage it and shake off our complacency. Susan Nordstrom Lopez, President of Advocate Illinois Masonic Medical Center in Chicago. In healthcare, every major advance in science and technology is accompanied by a low-tech response. Each miraculous high-tech development creates an echoed demand to re-infuse medicine with a high-touch, integrated and compassionate approach. For example, at Advocate Illinois Masonic Medical Center, an urban, community-based teaching hospital, the demand for a comprehensive hospice program accompanied major advances and life-sustaining treatments. Our Alternate Birthing Center was a success in bringing much sought-after home-birthing into a setting offering nurse-midwife-assisted deliveries in a safe hospital setting. Now, as ACOs [are] supported by sophisticated computer-based and data-intensive outcomes tracking systems, we re simultaneously reminded that each patient is best served by coordinated, patient-centered care. In my experience, disruptive innovation is a reminder of what we can t afford to leave behind as our skills develop. Listening to patients is critical not just to what they say, but to what their actions tell us. Home medical testing, surging Google self-diagnosis and the use of complementary treatment modalities constantly remind us we can t simply offer a menu of stand-alone islands of excellence. The care we offer to the patients and communities we re privileged to serve must be accompanied by a system of integration, assuring they won t be sacrificing the long-term partnership, coordination or care they need now more than ever before. Randy Oostra, President and CEO of ProMedica in Toledo, Ohio. The current model in healthcare is unsustainable. Disruptive innovation challenges the status quo and our current business models. The past challenges to the delivery of high-quality, cost-effective care have now been replaced with a whole new set Kenneth L. Davis, MD Carlos Migoya Robert C. Garrett

18 18 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Susan Nordstrom Lopez Randy Oostra of disruptive changes that include broadened access, significant payment reductions, new care settings, advances in information technology and an evolving revolutionary model of population health. Disruptive innovation brings about reduced costs, higher quality and greater access or convenience, often while meeting a significant underserved need. By offering more than what the country and its consumers currently need or want in a way that is simpler and less costly, we are seeing disruptive innovation can be a game-changer and is challenging everything we are doing. Larry Anderson, CEO of Tri-City Medical Center in Oceanside, Calif. Disruptive innovation is the process of creating a new market by creating new expectations and values and, thereby, replacing an existing market. At Tri City Medical Center, we have used this concept to create value and new processes. More than a year ago, we introduced robotic spinal surgery to southern California through the use of the Mazor Renaissance technology, which allows for a simple pre-surgery scan to serve as the roadmap for the precision placement of rehabilitative hardware. The process, available in only a handful of U.S. hospitals, produces accuracy that cannot be equaled by the most experienced surgeons, and avoids the need for multiple doses of radiation in the surgical suite. Accuracy of placement reaches 99 percent with experienced surgeons. Second, we have used a variety of techniques to reduce the incidence of readmissions in the diagnosis of heart attack, heart failure and pneumonia with amazing success. Essentially, we have put processes in place that ensure every patient [is] followed with hospital resources post-discharge to ensure they have and are using the appropriate medications. We also ensure they have access to a physician, when necessary, irrespective of ability to pay. While this process goes above and beyond our legal obligations, the results are impressive. Tri-City Medical Center now ranks 14th in the nation in lowest readmission rate for heart attack and 84th in the nation for lowest readmission rate for heart failure. It has achieved a rate of 136th in the nation for lowest readmission rate for pneumonia. While this has added some expense, it is the right thing for our community and our patients and will eventually become the norm for all hospitals. Chris Van Gorder, President and CEO of Scripps Health in San Diego. I prefer to use the term sustaining innovation rather than disruptive innovation because I think it more accurately reflects healthcare as a mature but rapidly changing business. Sustaining innovation refers to evolving an existing market into one that creates better value and, in my opinion, that is the most important thing we can do in healthcare right now. There are many examples of work being performed right now to increase the value equation for our patients, providers, employees and society. Certainly, finding ways to improve quality while lowering costs will require new and innovative processes. Tightly linking ambulatory with inpatient [care] or focusing on wellness versus just illness or injury will require significant change and innovation. And the development of new care management systems both within and outside hospitals will create more value. I suspect many of the changes ahead will be disruptive certainly when compared to our past but I prefer to focus on the future ahead as a time to focus our research and innovation so we can both sustain and grow in our importance to patients and society. n Larry Anderson Chris Van Gorder Sign Up for the Free Becker s Clinical Quality & Infection Control E-Weekly at clinicalquality.

19 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at 19 Which Hospital Markets Had the Best 2013 Value-Based Purchasing Results? By Jim McLaughlin Hospitals in the Fort Wayne, Ind., region, on average, performed the best on CMS Value-Based Purchasing Program, which went into effect this year, and Washington, D.C., hospitals collectively scored the worst, according to a regional analysis by Kaiser Health News. The Value-Based Purchasing Program rolled out this fiscal year to reward or penalize hospitals for patient satisfaction results and care standards adherence by raising or lowering Medicare payments up to 1 percent. Individual hospitals results can be searched by region on an interactive chart by KHN. All seven D.C.-market hospitals were penalized an average of 0.33 percent of Medicare payments through September One Fort Wayne-area hospital took a hit, but the other 14 will average a 0.27 percent increase. KHN analyzed 212 hospital referral regions with five or more hospitals and 92 smaller hospital regions for the report. Maryland has a separate payment agreement with CMS and didn t participate in the program; therefore it wasn t included in the analysis. In 16 markets, every hospital received a bonus, and in 20 markets, every hospital received a penalty. Large markets: The rest of the top 10 hospital regions with at least five hospitals after Fort Wayne are: Greenville, S.C; Newport News, Va.; Boise, Idaho; Florence, S.C.; Bangor, Maine; Grand Rapids, Mich.; Jackson, Tenn.; Portland, Maine; and Charleston, S.C. The other low-performing regions with at least five hospitals besides D.C. are: Buffalo and the Bronx, N.Y.; Bakersfield, Calif.; Syracuse, N.Y.; Altoona, Penn.; Hartford, Conn.; Corpus Christi, Texas; Saginaw, Mich.; and Springfield, Mo. Small markets: Three of the 92 markets with fewer than five hospitals beat out the large markets on average bonuses: Bloomington, Ill., Victoria, Texas, and Wilmington, N.C. On the other side of the coin, five small hospital markets will see greater penalties on average than any large market: Grand Forks and Minot, N.D.; Grand Bend and Salem, Ore.; and Oxford, Miss. By state: Maine, Nebraska, South Dakota, Utah and South Carolina reaped the most rewards on average. The District of Columbia, Connecticut, New York, Wyoming and Delaware were slapped the hardest. n 3 Simple Ways Hospitals Can Engage Patients in Their Care Successfully reducing readmissions and improving patient satisfaction requires hospitals to engage patients in their care. Patients who are involved in decision-making about their health are more likely to understand how to take care of themselves and thus prevent a hospitalization or readmission. Engaged patients also have a greater sense of control and tend to be more satisfied. Here are three simple ways hospitals can engage patients in their care. 1. Educate patients through verbal and written communication. Education is one of the top strategies to engage patients in their care, because patients who are educated about their condition and their choices feel more empowered to partner with healthcare providers in their care. Hospitals should educate patients through multiple modalities, including verbal communication and written instructions. For example, Placentia (Calif.)-Linda Hospital provides a patient guide that includes clinical information, such as the importance of tracking medications, and practical information related to the hospital, such as instructions on adjusting the hospital bed, according to Pam Walrod, director of marketing and community relations at the hospital. 2. Encourage patients to ask questions. Hospitals should also encourage patients to ask questions and discuss their care with their providers. Patients may not ask questions because they are afraid or they don t know what to ask. To overcome these challenges, Placentia-Linda Hospital includes examples of important questions to ask healthcare providers and space for note-taking in its patient guide. 3. Encourage feedback. In addition to providing information to patients, hospitals should also provide channels for patients to make comments about their care. Hospitals can promote patient feedback by directly asking patients about their stay; administering surveys by mail or phone; and establishing patient advisory committees to suggest or comment on changes, among other strategies. Placentia-Linda Hospital has a phone line dedicated to patient satisfaction that patients can use to provide feedback on their care. n REGISTER TODAY! Becker s Hospital Review Annual Meeting CEO Strategy, ACOs, Physician-Hospital Integration, Improving Profits and Key Specialties Co-Chaired by Chuck Lauer and Scott Becker May 9-11, 2013; Chicago Westin Michigan Avenue, Chicago For more information and to register, visit:

20 Becker s Hospital Review 4th Annual Meeting May 9-11, 2013 Westin Michigan Avenue - Chicago, Illinois 83 Leading Health System Executives Speaking Great topics and speakers Focused on Strategy, Physician Hospital Integration, Improving Profitability, ACOs, and Key Specialties - 93 Sessions Speakers Thank You to Our Corporate Sponsors Coach Lou Holtz Patrick Lencioni Bret Baier Chuck Lauer Coach Lou Holtz - Former College Football Coach, Active Sportscaster, Author and Motivational Speaker Bret Baier - Fox News Anchor on Special Report with Bret Baier, Former Chief White House Correspondent Patrick Lencioni - Founder and President of The Table Group, Author of Ten Best Selling Books Charles S. Lauer - Author, Consultant, Speaker, Former Publisher of Modern Healthcare Magazine For more information, call Becker s Hospital Review If you would like to sponsor or exhibit at this event, please call To Register, call Fax registration@beckershospital.com

21 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at 21 Population Health Management is a Two-Way Street: Encouraging Patient Engagement Under CMS Readmissions Reduction Program, hospitals will be financially penalized for having high readmission rates for heart attack, heart failure and pneumonia. Making hospitals financially accountable for patients up to 30 days after they leave the hospital gives hospitals the responsibility of ensuring patients have the care they need beyond inpatient care. However, the patient also plays a role in preventing readmissions. The patient needs to comply with discharge instructions, such as making appointments with physicians, filling prescriptions and taking medication as prescribed. Hospitals strategies to improve patient care and reduce readmissions can go only so far then it is up to patients to meet them halfway and follow instructions. As hospitals try to manage population health and reach out to patients with chronic conditions, it will be even more important for hospitals to engage patients in their own care to improve outcomes. Establishing the hospital s role in the community A hospital s first step in engaging patients in their care is demonstrating its value to the community. It has to have that reputation for being a really vital member of the community as a community resource for health and wellness, says Tom Lundquist, MD, CEO of AnewCare Collaborative, an accountable care organization formed by 13-hospital Mountain States Health Alliance based in Johnson City, Tenn. Proving the hospital is part of the community and cares for the community helps gain patients trust and makes them more willing to get involved in their healthcare decisions. One way hospitals can demonstrate their value to the Database of Downloadable Safety and Quality Tools & Resources Now Available Visit Becker s Healthcare s database of free downloadable safety and quality tools to access more than 400 resources to help healthcare organizations improve patient safety and quality. The database is available at The tools are organized by category and include resources on hand hygiene, medication management and surgical safety. Note: Tools provided for download are for educational purposes only. Please review your facility s policies, accreditation standards, and state community is by guiding patients through the continuum of care from primary care and preventive health to inpatient care and postacute care. Patients need to know the health system cares for their total journey through the healthcare system, Dr. Lundquist says. He suggests hospitals work toward creating an integrated, streamlined system of care by partnering with other providers. An integrated delivery system, such as an ACO that includes hospitals, physicians and other providers, makes it easier for patients to engage in their care because they do not have to travel to multiple places with different providers; instead, they can receive care from one coordinated system in a convenient way. It should not be the patient s responsibility to coordinate their care. Our service should be that we create that transition and coordination, Dr. Lundquist says. The patient s job is to get engaged. Commit to transparency of cost and quality Hospitals can also engage patients by providing greater transparency of the costs and quality of their services. If patients don t know the differences in cost and quality among healthcare providers, they cannot choose the most efficient and high-quality provider and reward providers for their performance with their business. Without that knowledge, there is no way to change market behavior, Dr. Lundquist says. By offering easy access to quality and cost information, hospitals encourage patients to be more proactive in choosing their providers. and federal agency requirements before adapting and using these resources in your organization. Some of the most popular tools available on the database include: This is Your Hand Unwashed Poster PowerPoint Presentation for Hand Hygiene Education 10 Hand Hygiene Posters for Clinical Staff From the Department of Veteran Affairs 6 Steps to C. Difficile Prevention Poster To help patients understand cost differences among providers, Dr. Lundquist suggests hospitals bill patients in a simpler manner. Currently, different areas of the hospital, such as the emergency department, radiology and the lab, bill separately for their services. If a patient undergoes a complicated procedure that involves many departments, he or she may receive several bills. If healthcare is serious about creating a better value for patients, they should start to bundle those pieces together and create a fixed price this still may allow for some variable costs that can be outlined in the bill, but it should be easy for patients to look at their bill and understand what services they received and at what price for their purchase. And as much as possible, these costs for services should be available in advance of elective and non-urgent services, he says. Having a better understanding of the costs of healthcare can encourage patients to get involved in their healthcare decisions because they can understand the costs associated with each decision they make. The same principle applies to quality data. Hospitals should actively share their performance on processes of care and outcomes so patients can make a well-informed decision about where they seek their care. Practicing engagement with employees Hospitals with their own health plans can refine strategies to engage patients by incentivizing their employees to make healthy decisions. Hospitals can set an example as an employer by designing healthcare benefits to really encourage health, wellness, exercise [and] engagement with providers and primary care, especially for members that have chronic diseases that need to be managed, Dr. Lundquist says. Hospitals can then translate these employee engagement strategies into patient engagement strategies. n Perioperative Nurse Competency Checklist Environmental Cleaning Checklist Audit Tool Patient Discharge Planning Checklist From CMS NC Center for Hospital Quality Infection Control Toolkits Two Johns Hopkins Hand Hygiene Observation Tools Environmental Checklist for Monitoring Terminal Cleaning From CDC n

22 Hospital Review BUSINESS & LEGAL ISSUES FOR HEALTH SYSTEM LEADERSHIP 2013 Healthcare Leadership Awards Now Accepting Nominations! 3 Becker s Hospital Review is accepting nominations for its Healthcare Leadership Awards, which recognize men and women who have made remarkable achievements in healthcare. The nomination period ends March 1. Awards will be announced and distributed at the Becker s Hospital Review Annual Meeting, May To submit a nomination, please Molly Gamble at mgamble@beckershealthcare.com or Scott Becker at sbecker@beckershealthcare.com

23 Sign up for the Free Becker s Clinical Quality & Infection Control E-Weekly at Hospitals With the Lowest 30-Day Mortality Rates For Pneumonia Here is a list of 51 hospitals with the lowest 30-day mortality rates for pneumonia from July 2008 through June 2011, according to data from CMS Hospital Compare database. 1. Cedars-Sinai Medical Center (Los Angeles) 6.8 percent 2. Tri-City Regional Medical Center (Hawaiian Gardens, Calif.) 7.1 percent 3. Saint Vincent Medical Center (Los Angeles) 7.2 percent 4. Huntington Memorial Hospital (Pasadena, Calif.) 7.3 percent 4. University of Texas Health Science Center at Tyler 7.3 percent 6. Greater Baltimore Medical Center 7.4 percent 6. Maimonides Medical Center (Brooklyn, N.Y.) 7.4 percent 8. Mayo Clinic Hospital (Phoenix) 7.5 percent 8. United Regional Medical Center (Manchester, Tenn.) 7.5 percent 10. NYU Hospitals Center (New York City) 7.7 percent 10. Grandview Hospital & Medical Center (Dayton, Ohio) 7.7 percent 12. Spring Valley Hospital Medical Center (Las Vegas) 7.8 percent 12. Kane (Pa.) Community Hospital 7.8 percent 14. West Anaheim (Calif.) Medical Center 7.9 percent 14. Lake Forest (Ill.) Hospital 7.9 percent 16. Lehigh Valley Hospital-Muhlenberg (Bethlehem, Pa.) 8 percent 17. NewYork-Presbyterian Hospital (New York City) 8.1 percent 17. Rex Hospital (Raleigh, N.C.) 8.1 percent 17. Portland (Ore.) VA Medical Center 8.1 percent 20. Providence Tarzana (Calif.) Medical Center 8.2 percent 20. Mount Sinai Medical Center (Miami Beach, Fla.) 8.2 percent 20. Mary Greeley Medical Center (Ames, Iowa) 8.2 percent 20. Norwood (Mass.) Hospital 8.2 percent 20. Falmouth (Mass.) Hospital 8.2 percent 20. Liberty (Mo.) Hospital 8.2 percent 20. Exeter (N.H.) Hospital 8.2 percent 20. Hillcrest Hospital Cushing (Okla.) 8.2 percent 28. Oroville (Calif.) Hospital 8.3 percent 28. St. Luke s Hospital (Cedar Rapids, Iowa) 8.3 percent 28. Skaggs Regional Medical Center (Branson, Mo.) 8.3 percent 32. Willis Knighton Medical Center (Shreveport, La.) 8.4 percent 32. Miles Memorial Hospital (Damariscotta, Maine) 8.4 percent 32. MedStar Good Samaritan Hospital (Baltimore) 8.4 percent 32. Beth Israel Deaconess Medical Center (Boston) 8.4 percent 32. Genesis Healthcare System (Zanesville, Ohio) 8.4 percent 32. Geisinger-Bloomsburg (Pa.) Hospital 8.4 percent 39. Parkview Medical Center (Pueblo, Colo.) 8.5 percent 39. Jupiter (Fla.) Medical Center 8.5 percent 39. Medical Center of Southeastern Oklahoma (Durant) 8.5 percent 39. Sharon (Pa.) Regional Health System 8.5 percent 43. Desert Valley Hospital (Victorville, Calif.) 8.6 percent 43. Porter Adventist Hospital (Denver) 8.6 percent 43. Adventist La Grange (Ill.) Memorial Hospital 8.6 percent 43. Elmhurst (Ill.) Memorial Hospital 8.6 percent 43. Casey County Hospital (Liberty, Ky.) 8.6 percent 43. Benefis Hospitals (Great Falls, Mont.) 8.6 percent 43. Betsy Johnson Regional Hospital (Dunn, N.C.) 8.6 percent 43. Grand Lake Health System (Saint Marys, Ohio) 8.6 percent 43. Norton (Va.) Community Hospital 8.6 percent n Advertising Index Note: Ad page number(s) given in parentheses Beutlich Pharmaceuticals, LLC. beutlich@beutlich.com / / (800) (backcover) Clorox. (p. 5) Palmero Healthcare. customerservice@palmerohealth.com / / (800) (p. 4) Surgical Directions. info@surgicaldirections.com / / (312) (p. 2) 28. The Methodist Hospital (Houston) 8.3 percent 32. Exempla Lutheran Medical Center (Wheat Ridge, Colo.) 8.4 percent

24 ONE ONE AND ONLY ONE UNIT ONE DOSE ONE AND ONLY An Innovative Non-Aerosol Unit Dose Topical Anesthetic Spray Meets Joint Commission Standard for the most ready-to-administer form available.* Fast onset. Short duration. Virtually no systemic absorption. Utilizes bar code medication administration (BCMA) to accommodate point-of-care scanning. Virtually eliminates adverse events resulting from preventable medication errors, ensuring the 5 Rights are met: Right Drug Right Patient Right Dose Right Route Right Time Single unit-of-use packaging eliminates the potential for cross-contamination. Increases billing accuracy and improves supply chain costs. ORDERING INFORMATION NDC# AMERISOURCE BERGEN LLC CARDINAL HEALTH MCKESSON MORRIS & DICKSON CIN CIN ml each PRODUCT HurriCaine ONE Unit Dose Non-Aerosol Spray Box of 2, fl. oz. (0.5 ml) each HurriCaine ONE Unit Dose Non-Aerosol Spray Box of 25, fl. oz. (0.5 ml) each If HurriCaine ONE is not yet available through your wholesaler, request it by name and NDC Number. *Joint Commission Standard: MM , EP 10 MAKE THE SWITCH TODAY. Call to place your order or request more information. HurriCaine ONE is a registered trademark of Beutlich Pharmaceuticals, LLC. HCOA