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CORPORATE COMPLIANCECARE TRANSITIONS AND

PATIENT SAFETYREVISITING THE

ADVERSE OUTCOME INDEXINFECTION CONTROL

& Q U A L I T Y H E A LT H C A R E& Q U A L I T Y H E A LT H C A R E

Patient SafetyPatient SafetyM A Y / J U N E 2 0 1 1

N E W S • S C I E N C E • R E S E A R C H • O P I N I O NN E W S • S C I E N C E • R E S E A R C H • O P I N I O N

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MEASUREMENT & EDUCATIONHAND HYGIENEHAND HYGIENE

2 Patient Safety & Qual i ty Healthcare ■ May/June 2011 w w w . p s q h . c o m

Features

18

Departments

Columns

34

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ContentsMAY/JUNE 2011 • VOLUME 8 ISSUE 3

14 HAND HYGIENE MEASUREMENT AND EDUCATION John Govednik, MS; Maryanne McGuckin, ScEd, MT(ASCP)

18 CENTRAL LINE INFECTIONS: TARGETING ZERO ON AN ONCOLOGY UNIT Dawn Garcia, BSN/MS, CMQ-O/E

22 REVISITING THE PERINATAL ADVERSE OUTCOME INDEX Emily Hamilton, MD; Samuel Smith, MD;

Dorothy Berry, RN, DFASHRM; Omer Ben-Yoseph, MD;

Dan O’Keeffe, MD; Eric Knox, MD

28 UNDERSTANDING CARE TRANSITIONS AS A PATIENT SAFETY ISSUESara Butterfield RN, BSN, CPHQ, CCM;

Christine Stegel, RN, MS, CPHQ; Shelly Glock, LNHA, MBA;

Dennis Tartaglia, MA

4 EDITOR’S NOTEBOOKOn Being Wrong (and Human)Susan Carr

6 CORPORATE COMPLIANCEFederal Initiatives to Drive Quality of Care: What PatientSafety Officers Need to KnowRenee H. Martin, JD, RN, MSN; Katherine Autieri, JD

8 ISMPMeasuring Up to Medication SafetyInstitute for Safe Medication Practices

10 HEALTH IT & QUALITYWatson, come here. I need you!Barry P. Chaiken, MD, FHIMSS

12 VIEWPOINTA Supplier’s PledgeBrad Cates

42 MEDICATION SAFETYThe “Other” Healthcare Reform MovementSusan Stinson, RN, FACHE

44 INFECTION CONTROL SHOWCASEBattling the BugsTom Inglesby

46 ABQAURP NEWS

48 AUTHOR GUIDELINES

48 ADVERTISING INDEX

48 CONFERENCE CALENDAR

34 QUEST 2011: A RALLYING POINT FOR PATIENT SAFETY ADVOCATES, A COMMITMENT TO RESHAPE CULTURE Christine Winters

38 THE STATE OF COMPASSIONATE HEALTHCAREJulie Rosen

I’ve developed a soft spot for error—not for the stubbornness and denial that too oftenaccompany error, nor of course for the harm that can result from it. I’ve been charmedrecently by people who are comfortable admitting error and who accept that beingwrong is part of being human. Learning to accept and even embrace the fact that mis-takes are inevitable establishes humility as the foundation for improving performanceand living contentedly with others and ourselves.

At the unSummiton Bedside Barcoding(www.unsummit.com),Jerry Fahrni, PharmD,gave a talk called “TheReal Work Starts AfterImplementation.” Jerryis an effective speak-

er—informative, confident, and relaxed. In that style, he talked about manythings that went wrong with the barcoding implementation at a large hospitalfor which he, as the IT Pharmacist, was responsible. He had prepared thor-oughly to go live with barcoding for medication administration—assembled aninterdisciplinary team, tested software and hardware, saw to myriad details thatare well known elements for success—and, yet, all kinds of problems presentedthemselves as the hospital adjusted to working with the new system. Labels weremisapplied over other labels, obscuring important information; drop-downmenu items were chosen because they appeared at the top of a list, not becausethey were the correct choice; barcodes got scratched in handling, etc. Someglitches remained mysterious and eluded correction through weeks of investi-gation. Jerry conveyed the bafflement, surprise, satisfaction, duh! moments, andlessons to which we all can relate. The audience was engaged and sympatheticas Jerry’s stories rang true.

Kathryn Schulz is another charming error expert, whose name on Twitter is@wrongologist. Her TED talk,“On Being Wrong” is an excellent introduction to herwork: http://www.ted.com/talks/kathryn_schulz_on_being_wrong.html Schulz is theauthor of Being Wrong: Adventures in the Margin of Error and “The Wrong Stuff,”a seriesof interviews for Slate (www.slate.com/blogs/blogs/thewrongstuff/default.aspx). In herTED talk, Schulz explores the experience of being wrong, pointing out that disap-pointment, embarrassment, and shame are associated with the realization of beingwrong, not with wrongness in itself. In fact, the real-time experience of being wrongfeels exactly like being right, which of course is the problem. Schulz embraces beingwrong as a vital part of the human condition, crucial to learning, and sometimes anopportunity to go in directions we might not otherwise have discovered.

Accepting the fact that we all make mistakes is an important step toward develop-ing and accepting systems, such as bedside barcoding, that can protect patients fromerror and harm. When we go beyond acceptance and join with colleagues in appreci-ation of our occasional slips and lapses, error becomes an opportunity to connectaround our shared fate. ❙PSQH

Patient Safety & Qual i ty Healthcare ■ May/June 20114 w w w . p s q h . c o m

S L U G G O E S H E R E By Susan Carr

E D I T O R ’ S N O T E B O O K

On Being Wrong (and Human)

American Board of Quality Assurance and Utilization Review Physicians

National Patient Safety Foundation®

SPONSORING ORGANIZATIONS

May/June 2011Volume 8 Issue 3

The real-time experience of being

wrong feels exactly like being right,

which of course is the problem.

James C. Benneyan, PhDDir., Quality & Productivity LabIndustrial Engineering and OperationsResearchNortheastern UniversityBoston, Massachusetts

Joel V. Brill, MDChief Medical OfficerPredictive Health, LLCPhoenix,Arizona

Barry P. Chaiken, MD, FHIMSSChief Medical OfficerDocsNetwork, Ltd.Boston, Massachusetts

Douglas Dotan, MA, CQIAPresident & COOCRG Medical, Inc.Houston,Texas

Tim GeeConnectologistMedical Connectivity ConsultingBeaverton, Oregon

Martin J. Hatlie, JDPresidentPartnership for Patient SafetyCEOProject Patient CareChicago, Illinois

Linda K. KenneyPresident, Executive DirectorMITSSChestnut Hill, Massachsuetts

Sanjaya Kumar, MD, MPHChairman & Chief Medical OfficerQuantrosFremont, California

Frederick Levy, MD, JDAssistant ProfessorDept. of Emergency MedicineThe Johns Hopkins School of MedicineBaltimore, Maryland

Barbara B. Loeb, MD,MBA, CPE

Physician CoachStuder GroupImmediate Past President, Medical StaffAdvocate Good Samaritan HospitalDowners Grover, Illinois

Maggie Lohnes, RN,CPHIMS, FHIMSS

Administrator,Clinical Information ManagementMultiCare Health SystemTacoma,Washington

Renee H. Martin, JD, RN, MSNTsoules, Sweeney & Martin, LLCExton, Pennsylvania

Lawrence M. Pawola,PharmD, MBA

Clinical Associate Professor Associate Dean Biomed. & Health Info. SciencesCollege of Applied Health SciencesUniversity of Illinois at ChicagoChicago, Illinois

Diane C. Pinakiewicz, MBAPresidentNational Patient Safety FoundationBoston, Massachusetts

Stephen M. Powell, MS, BSPrincipal, Managing PartnerHealthcare Team Training, LLCFayetteville, Georgia

Grena G. Porto, RN,ARM, CPHRM

PrincipalQRS Healthcare Consulting, LLCHockessin, DE

Dennis Robbins, PhD, MPHPresidentIntegrated Decisions, Ethics,Alternatives and SolutionsPhoenix,Arizona

David W. Roberts, MPA, FHIMSSVice President, Government RelationsHIMSSSolana Beach, California

Brian F. Shea, PharmD,FCCP, BCPS

Senior Manager, Health & Life SciencesPracticeAccentureWellesley, Massachusetts

Susan E. Sheridan, MIM, MBACo-founder, Consumers AdvancingPatient SafetyPresident, Parents of Infants andChildren with KernicterusEagle, Idaho

Allen J.Vaida, PharmDExecutive Vice PresidentInstitute for Safe Medication PracticesHorsham, Pennsylvania

Mitch Work, MPA, FHIMSSPresidentThe Work Group, Inc.Lincolnshire, Illinois

Barbara Youngberg, BSN, MSW,JD, FASHRM

Visiting Professor of LawLoyola University ChicagoBeazley Institute for HealthLaw and PolicyChicago, IllinoisChief Learning OfficerEmergency Medicine Patient SafetyFoundationAuburn, California

5May/June 2011 ■ Patient Safety & Qual i ty Healthcare

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E D I T O R I A L A D V I S O R Y B O A R D

& QUALITY HEALTHCARE

Patient Safety

Under the recently enacted Patient Pro-tection and Affordable Care Act(PPACA), every healthcare providerparticipating in Medicare or Medicaidmust now have a corporate complianceprogram in place. Medicare is seekingtransparency, quality, and accountabilityfrom healthcare providers. To that end,Medicare is financially incentivizingproviders who can demonstrate qualityoutcomes, and will also require thatproviders can accurately collect andtransmit data regarding their qualityoutcomes as an integral part of theircorporate compliance program. Failureto achieve quality outcomes, or theimproper or false reporting and collec-tion of quality data, will lead to federalprosecution at worst; at the very least, itmay be grounds for recoupment ofmoney paid to the provider. Safety andquality officers should be aware of thisaspect of enforcement and how itimpacts their role.

Background of ReportableEventsSerious reportable events, “wrong” sur-gical events, present-on-admission indi-cators, and hospital-acquired conditionsall involve reporting requirements forquality issues. This began in 2002, whenthe National Quality Forum (NQF)published “Serious Reportable Events inHealthcare: A Consensus Report,”whichlisted 27 adverse events deemed “seri-ous, largely preventable, and of concernto both the public and healthcareproviders.” Over the years this list hasbeen revised and currently contains 28of the most serious adverse events thatcan happen in a hospital (e.g., death of apatient after a fall, death of a motherwith a low risk pregnancy). Various ini-tiatives standardize the reporting of


By Renee H.Martin, JD,RN,MSN;Katherine Autieri, JD

C O R P O R A T E C O M P L I A N C E

Federal Initiatives to Drive Quality of Care:What Patient Safety Officers Need to Know

these “never events,”which involve clini-cal quality failure and can result in thewithholding or recoupment of paymentby health insurers. Reportable eventscan vary by state and may use the NQFlist, a subset, or a hybrid version.

The Centers for Medicare andMedicaid Services (CMS) initiated aprogram to reduce payments to hos-pitals for inpatients that experiencea hospital-acquired condition(HAC). CMS’s list of HACs includesa number of the serious reportableevents from the NQF list (e.g.,retention of foreign body in apatient post-op).

In addition to HACs, since October1, 2007, hospitals must report Presenton Admission (POA) indicators for alldiagnoses reported on Medicare inpa-tient acute care claims for discharges. APOA is a condition that is present at thetime the order for inpatient admissionoccurs, and the indicator is a way to dif-ferentiate conditions present at admis-sion from those developed during thepatient’s stay. Reported POA indicatorshelp to identify HACs, which are specif-ic, reasonably preventable conditionsidentified by Medicare that may beacquired during a hospital stay (e.g.,catheter-associated urinary tract infec-tion, air embolism). As of October 1,2008, Medicare reduces payment forthese conditions when they are notPOA and the condition increases reim-bursement.

CMS has also determined that itwill make no payment whatsoever ifcertain never events occur. OnJanuary 15, 2009, CMS issued aNational Coverage Determination(“NCD”) concerning three surgicalevents that should never occur and,accordingly, for which CMS will not

pay. Specifically, CMS will not payfor a surgery/procedure when thepractitioner erroneously performsthe wrong procedure on the patient,the correct procedure but on thewrong body part, or the correct pro-cedure on the wrong patient.

If one of these wrong proceduresis performed, Medicare will also notcover the hospitalization stay andother services related to these non-covered procedures. CMS requiresthat the hospital report the erro-neous surgery related to the NCD1.Medicaid and many private insurersquickly followed Medicare’s lead an-d will no longer reimburse for thesethree never events.

1If covered services/procedures arealso provided during the same stayas the erroneous surgery, hospitalsmust submit two claims, one claimwith covered services/proceduresunrelated to the erroneous surgery,the other claim with the non-coveredservices/procedures as a no-payclaim.

Although there are no

federal laws with explicit

punitive provisions to

punish poor quality care,

federal prosecutors have

successfully used the

federal False Claims Act

to do so.

May/June 2011 ■ Patient Safety & Qual i ty Healthcare 7

Patient Protection andAffordable Care ActPPACA increased the funding for theHealth Care Fraud and Abuse Controlprogram (HCFAC), which providesprimary funding for the Office ofInspector General (OIG). HCFACfunds various OIG activities, includingestablishment of Medicare Fraud StrikeForce teams; support of Civil FalseClaims Act investigations and enforce-ment; support of administrativeenforcement activities; and audits ofpayments to hospitals. From 1997 to2008, HCFAC program activities havereturned more than $13.1 billion to thefederal government through audit andinvestigative recoveries.

The PPACA will therefore armthe OIG with the additional andrequisite tools to better monitor andenforce quality of care issues. TheOIG continues to remind providers,especially hospitals and skilled nurs-ing facilities, of the OIG’s ability toexclude them from participation infederal healthcare programs if afacility provides substandard careand asserts that providers shouldadopt quality of care protocols andimplement procedures for assessingcompliance with them. Thus, com-pliance plans mandated under thePPACA must include these ele-ments.

Although there are no federal lawswith explicit punitive provisions to pun-ish poor quality care, federal prosecutorshave successfully used the federal FalseClaims Act (“Act”) to do so. The FalseClaims Act (31 U.S.C. §§ 3729-3733) is aCivil War era statute aimed at prevent-ing and prosecuting fraud by govern-ment contractors. It is a civil statute,which permits the government to seektriple the amount of the alleged falseclaims and up to $10,000 per allegedfraudulent claim. The Act was revised in1986 by Congress to encourage privatecitizens with first-hand knowledge offraudulent activity to act as whistleblow-ers and bring suit against a provider. Ifthe federal government intervenes in theaction and assumes the prosecutionagainst the provider, the whistleblower

can be rewarded up to 25% of themonies either reached in settlement orawarded by the court.

In addition to penalties imposedunder the Act, if convicted, the provideris also subject to the exclusionary pow-ers of the OIG and could be precludedfrom participation in Medicare andMedicaid. To avoid this dire result, mostproviders choose to enter into settle-ment agreements whereby fines arepaid, but no wrongdoing is admitted—liability under the Act, therefore, isavoided and so is the possibility ofexclusion.

The fraud theory used by prosecu-tors in connection with the Act andquality-of-care failures is as follows. Inreturn for payment from Medicare orMedicaid, providers agree to adhere toall the requirements imposed by thoseprograms; when the quality of carebecomes sufficiently substandard that itamounts to no care at all, the claim sub-mitted to Medicare or Medicaidbecomes a claim forservices not renderedand therefore a falseclaim under the Act.Examples of substan-dard nursing homecare centered on inad-equate nutrition andhydration, wound anddecubitus care, staffingpatterns, and inade-quate facilities.

Notably, prosecu-tors have repeatedlystated that a single iso-lated instance of poorquality care will notgive rise to prosecutionunder the Act; instead,prosecutors look forpatterns or practiceswhich substantiate fail-ure of care.

Further, the FalseClaims Act will cer-tainly be implicated ifMedicare determinesthat the data submit-ted related to neverevents, HACS, POAs,

or quality of care measures are inaccu-rate for falsified.

These increasing links between pay-ment and quality further increase safe-ty and quality officers’ (as well as otherclinical and administrative leaders’)responsibilities for ensuring qualityoutcomes and avoidance of neverevents. To improve outcomes andreduce healthcare costs, Medicare andMedicaid are clearly linking paymentsto clinical outcomes. Medicare andother insurers will continue to developpayment methods that serve to rewardquality performance, refuse paymentfor preventable errors, and prosecuteproviders for falsifying or inaccuratelyreporting quality data. ❙PSQH

Renee Martin and Katherine Autieri arewith the healthcare law firm of Tsoules,Sweeney, Martin & Orr, LLC located in Exton,Pennsylvania. Martin is a member of theEditorial Advisory Board for Patient Safety &Quality Healthcare and may be contactedat [email protected]

Medications are among the most com-mon interventions used to improvehealth. So it should come as no surprisethat adverse drug events—injuriescaused by the use of medications—are asubstantial source of preventable harmto hospitalized patients. Measuring thelevel of safety is fundamental toimprovement. Yet, measuring medica-tion safety has long been a conundrum.Historically, measurement efforts havefocused on practitioner reporting ofmedication errors, which, at best,uncovers just a fraction of the errors,most of them harmless. Still, measure-ment is the only way to answer theseessential questions:• Do we have a problem?• What is the extent of the

problem?• Have improvement efforts been

successful?• How do we compare to others?

There are four types of measures thatshould be tracked if you want toimprove medication safety.

Process measures. These measureshelp assess how well you are performingcore processes associated with medica-tion use. Measuring core processes helpsdetermine if there is variation in carry-ing them out, which could lead to unde-sirable outcomes, and if there arepreventable risks associated with pro-cesses, which could result in harm. Pro-cess measures can be identified for allfacets of medication use. However, high-volume and high-risk processes, or pro-cesses associated with high-alertmedications, should be targeted to max-imize the benefit to patient safety. A fewexamples include:• Number of pharmacy profiles

without allergy information pernew admission orders

• Percent of medication orderswith prohibited error-proneabbreviations

• Percent of encounters in whichtwo identifiers are not used for


By the Institute for Safe Medication Practices

I S M P

Measuring Up to Medication Safetypatient verification before drugadministration

• Time interval between pre-scribing and administering “stat”medications

• Number of pharmacy interven-tions per 100 admissions

• Percent of chemotherapy ordersthat do not comply with stan-dardized prescribing guidelines(e.g., mg/m2 dose included withcalculated dose; single daily dose,not course dose).

One newly evolving measure toevaluate improvement within a pro-cess is to track the total risk prioritynumber (RPN) of a process that hasundergone a failure mode and effectsanalysis. As an organization works toimprove the process, the RPN shoulddecrease over time as effective changesare implemented. For more informa-tion on this process measure, visitwww.ihi.org (click on Topics, PatientSafety, Medication Systems, Mea-sures).

Structure measures. These mea-sures assess the organizational culture,values, and leadership. They differ fromprocess measures in that they are nottask oriented, but foundational innature. Examples include:• Percent of days on which pre-

established nurse/patient staffingratios are maintained

• Percent of staffing met withagency staff

• Number of error reports received(reporting rate helps measure theculture)

• Percent of staff reporting a posi-tive safety culture.

The Agency for Healthcare Researchand Quality (AHRQ) released testedsurveys for assessing the safety culture inhospitals. The tools also offer guidanceon sampling, data collection, and analy-sis of findings (see http://www.ahrq.gov/qual/patientsafetyculture/ for details).

Outcome measures.These measuresassess whether your efforts to improvemedication safety have been successful.As such, many believe that medicationerrors are the most useful outcomemeasure for medication safety. Howev-er, harm is a much more reliable andpowerful measure, especially if it keepsyou intellectually engaged with the pos-sibility that all harm is preventable.

If errors are used to measure medica-tion safety, self-reporting is the typicaldata-gathering tool,which is highly inac-curate. Errors are the obvious focus, soany adverse drug events uncovered arequickly sorted into preventable and“non-preventable” categories. This, inturn, promotes the tacit acceptance of“non-preventable”harm as a property ofthe medication system, something forwhich you have no responsibility. On theother hand, if harm is used as a measureof medication safety, the measure is reli-able, clear, and direct, and the focus is onall unintended results. This keeps youintellectually engaged with the possibili-ty of reducing all patient harm, to admitthat you can do better, to raise the barwhen it comes to patient safety. Forexample, most hospitals collect data onreadmissions to the hospital. If bleedingepisodes from warfarin caused some ofthe readmissions, these events may notbe fully assessed if the focus is on errorsalone. In these cases, errors may not beapparent, so the events would likely betagged as “non-preventable” adversedrug reactions. But if focused only onpreventing harm in patients who takewarfarin, not error, you’re more likely toexplore ways to reduce all occurrences ofbleeding. Thus, the best outcome mea-sure for medication safety is all adversedrug events, regardless of causation.

Evaluating patient records using a listof triggers is the most effective means ofcollecting data on adverse drug events.Triggers are clues that an adverse drugevent may have occurred. Follow up isneeded for confirmation. An extensivelist of triggers can be found at


http://www.ismp.org/newsletters/acute-care/articles/20050310_2.asp.

Examples include:• Drugs: diphenhydramine,

vitamin K, flumazenil, glucagon • Labs: elevated drug levels, aPTT,

INR, serum creatinine• Others: rash, lethargy, falls,

abrupt medication stop, transferto a higher level of care.

Computerized methods for detect-ing adverse drug events via a trigger toolhave proved very effective (Classen &Metzger, 2003). However, this method-ology requires a high level of automa-tion with customized software linkageto clinical databases, so the initial outlaymay be costly. However, recently, a rela-tively low cost, “low tech” method forusing a trigger tool to uncover adversedrug events has been devised and testedin more than 80 hospitals (Rozich et al.,2003). The technique, which requiresminimal training, appears to increasethe rate of adverse drug event detection50-fold over traditional reportingmethodologies.

Classen et al., (2011) recently pub-lished an article on errors and adverseevents. This analysis compared the use ofthree methods to detect adverse events,voluntary reporting, the use of the Agen-cy for Healthcare Research and Quality’sPatient Safety Indicators and the Insti-tute for Healthcare Improvement’sGlobal Trigger Tool. The study revealedthat overall, adverse events occurred inone-third of hospital admissions. Theauthors concluded that relying on vol-untary error reports missed 90% of theadverse events that were discoveredthrough the use of Global Trigger Tool.

Balancing measures. These mea-sures are used to ensure that a change inone part of the system is not causingproblems in another part of the system.For example, by using balancing mea-sures, one hospital quickly learned thata change in anti-emetics to reduce thetime a patient must spend in the oncol-ogy clinic actually resulted in reducedpatient satisfaction. Patients felt rushedand unable to talk to staff about theirdiagnosis and therapy.

Measuring medication safety is noteasy, but it must be a core component ofyour improvement efforts. If you do nothave an effective measurement plan inplace, an interdisciplinary team shouldconsider the examples above and iden-tify a place to start. Be sure to clearlydescribe each measure, its goal, and thedata collection plan. Remember: tradi-tional efforts to measure medicationsafety have not been successful in guid-ing improvement. Thus, even if you cur-rently have a measurement plan inplace, it may be time to look at it againwith fresh eyes and updated tools. ❙PSQH

This column was prepared by the Institutefor Safe Medication Practices (ISMP),an independent, nonprofit charitableorganization dedicated entirely tomedication error prevention and safemedication use. Any reports described inthis column were received through the ISMPMedication Errors Reporting Program.Errors, close calls, or hazardous conditions

may be reported online at www.ismp.org orby calling 800-FAIL-SAFE (800-324-5723).ISMP is a federally certified patient safetyorganization (PSO), providing legalprotection and confidentiality for patientsafety data and error reports it receives.Visit www.ismp.org for more information onISMP’s medication safety newsletters andother risk reduction tools.

Classen, D. C., Metzger, J. (2003). Improvingmedication safety: The measurementconundrum and where to start.International Joural for Quality in HealthCare, 15, i41-i47).

Classen, D. C., Resar, R., Griffin, F., Federico,F., Frankel, T., Kimmel, N., & Whittington, J.C. et al. (2011 April) ‘Global Trigger Tool’shows that adverse events in hospitalsmay be ten times greater than previouslymeasured, Health Affairs, 30(4), 581-589.

Rozich, J. D., Haraden, C. R., & Resar, R. K.(2003). Adverse drug event trigger tool: Apractical methodology for measuringmedication related harm. Quality andSafety in Health Care, 12, 194-200.

REFERENCES

Although a call for Watson brings tomind Alexander Graham Bell’s firstwords on the telephone or SherlockHolmes’s greeting to his physiciancompanion, The New York Times her-alded another Watson on its February17, 2011, front page. The artificialintelligence computer system won onthe game show Jeopardy! In the televi-sion program’s only computer versusmachine match-up, Watson defeatedBrad Rutter, the biggest all-timemoney winner, and Ken Jennings, therecord holder for the longest champi-onship streak. Watson had access to200 million pages of structured andunstructured content, which con-sumed more than four terabytes ofdisk space. Fortunately for Mr. Rutterand Mr. Jennings, Watson did not haveaccess to the Internet.

While Watson surely bested itshuman competitors in its ability to“push the buzzer”—the computerwas directly connected to the signal-ing device—it struggled withcategories rich in nuance, particu-larly those containing only a fewwords. While most humans can dis-cern meaning from shortexpressions by combining personalexperience with generalization of


By Barry P. Chaiken, MD, FHIMSS

H E A L T H & I T Q U A L I T Y

Watson, come here. I need you!

word meanings, Watson processeddata much too literally.

This experience with Watson illu-minates how artificial intelligencecomputer systems offer healthcareproviders robust, evidence-basedclinical decision support. In addi-tion, it identifies the special rolehumans play in diagnosing andtreating patients. If combinedtogether, these capabilities can syn-ergistically offer higher levels ofvaluable and effective care.

Need for More CliniciansWith passage of the Affordable CareAct of 2010, as many as 32 millionadditional individuals will be added tothe insurance rolls as the provisions ofthe Act take effect over the next fouryears. The baby-boom generation isjust reaching retirement age and thepoint in their lives when their demandfor healthcare services increases signif-icantly. Massachusetts, the leader inhealthcare reform and universal cover-age, is experiencing a severe shortageof primary care physicians, leading tolong waits for appointments despitethe fact that it has one of the country’shighest physician-to-patient ratios.The American Association of MedicalColleges projects a shortage of 45,400and 65,800 primary care physicians inthe United States in 2020 and 2025respectively.

Although expansion of educationand training provides a means toaddress these shortages in the future,clinical decision support, properlydeployed among a variety of differ-ent types of clinicians, offers asignificant tool to leverage existingclinical resources now. Intelligentlydesigned clinical decision support,properly implemented among

trained staff, expands the capabilitiesof clinicians at all levels, allowingthem to expand the number andtypes of patients they treat.

Innovative Use of HIT NeededTo meet the healthcare needs of our fel-low citizens, our healthcare systemrequires a health information technolo-gy revolution, a drastic change in theway we deliver care by utilizing informa-tion technology (IT) in new and inno-vative ways. Deploying healthcare IT toreplicate the processes and workflowsthat currently deliver our poor resultson so many measures only guaranteescontinued suboptimal and unacceptableclinical and financial outcomes.

We must focus on three keyareas: 1) information technologytools, 2) processes and workflows,and 3) healthcare provider tasks,duties, and responsibilities.

Solutions come from an in-depthunderstanding of tools and creativethinking around what each health-care professional can do and howbest to deploy an individual’s skill.Valued healthcare IT solutions offerthese professionals healthcare ITtools that leverage their unique skill,while organizing the processes andworkflows to deliver a consistentlyhigh quality, safe, and efficienthealthcare outcome.

Clinical Decision SupportExpands AccessClinical decision support at the pointof care plays a significant role inexpanding the number of cliniciansavailable to provide primary care.Through such healthcare IT tools,best practices—those that we knowfrom scientific evidence offer thehighest probability to produce the

Clinical decision support offers a significant tool toleverage existingclinical resourcesnow.


best healthcare outcome—can bedelivered to each patient by health-care professionals educated, guided,and “double-checked” by the health-care IT tool.

Currently, patient care deliveryrelies upon an unreliable systemformed from poorly integrated andhighly variable human parts. Solu-tions integrating clinical decisionsupport provide needed supporttools that increase the reliability ofthe human components, while inte-grating these components througheffective processes and efficientworkflows. In addition, as best prac-tices change, they can be deliveredefficiently through the existing work-flow by simply changing the knowl-edge contained in the clinicaldecision support tool. Currently,changing practice patterns requiresthe inefficient, and mostly ineffective,method of targeted medical educa-tion.

Changing What Clinicians DoDeployment of clinical decision supportwithin healthcare IT systems funda-mentally changes what physicians, nurs-es, and other healthcare professionalsdo. Physician activities become morechallenging on a cognitive level as otherroutine tasks such as drug dose recall,use of best practice order sets, and drug-allergy checking become automated.Physician expertise is assigned to moreimportant tasks including solving diffi-cult diagnostic problems, devising cus-tomized patient treatment plans, andinfluencing patient adherence to chron-ic disease care regimens.

Work for nurses and otherhealthcare professionals changesdramatically too. More tasks, for-merly done by physicians orhealthcare specialists, are completedby these professionals guided byintelligent processes and workflowsthat include meaningful healthcareIT. Therefore, the number of quali-fied clinicians available to deliverquality care increases to meet thedemands of the increasing insuredpopulation.

Clinical knowledge and experi-ence, normally obtained onlythrough years of study and work,can now be codified in clinical deci-sion support tools that less trainedclinicians can apply to their patients.The delivery of care is now stan-dardized around a high level ofquality, with outlier patients—thoseidentified as having unusual medicalproblems and in need of more com-plex care plans—referred to primarycare physicians or physician special-ists.

As chronic care patients make upthe majority of an ambulatory adultmedicine practice, many visitsengender monitoring of a patient’smedical condition rather than diag-nostic activities or significantchanges made to therapeutic plans.Reducing the number of these typesof patients seen by physicians freesthem up to care for patients requir-ing higher levels of service.

Expanding the capabilities of allclinicians through the deployment ofclinical decision support increases theavailability of primary care providerswhile ensuring high levels of qualitycare.

The revolution for healthcareproviders is inherent in the dramat-ic change needed in whatprofessionals do and how they do it.Therefore, effective change manage-ment techniques must be utilized tofacilitate the acceptance of newresponsibilities and duties in addi-tion to the new processes andworkflows required of these newroles.

For information technology toplay a valuable role in reducinghealthcare costs while enhancingquality of care, it must be deployedin a way that completely reinventshow care is delivered, professionalsprovide the care, and technology isleveraged. Watson’s success onJeopardy! demonstrates the capabili-ties of computers to store andretrieve medical knowledge at thepoint of care, thereby freeing clini-cian minds from the unnecessary

burden of recalling facts. Cliniciansare freed to focus on their patientswhile more effectively utilizing theirability to identify unusual patternspreviously obscured by the “noise”inherent in a busy practice.

In 2011, progressive organiza-tions will further the deployment ofcomputer-based clinical decisionsupport, rework the roles of all care-givers, and transform their processesto achieve ever-increasing levels ofquality, safety, and efficiency of caredelivery. ❙PSQH

Barry Chaiken is the chief medical officer ofDocsNetwork, Ltd. and a member of theEditorial Advisory Board for Patient Safety &Quality Healthcare. With more than 20years of experience in medical research,epidemiology, clinical informationtechnology, and patient safety, Chaiken isboard certified in general preventivemedicine and public health and is a Fellow,and former Board member and Chair ofHIMSS. As founder of DocsNetwork, Ltd., hehas worked on quality improvement studies,health IT clinical transformation projects,and clinical investigations for the NationalInstitutes of Health, U.K. National HealthService, and Boston University MedicalSchool. He may be contacted [email protected].

Markoff, J. (2011, February 16). Computerwins on ‘Jeopardy!’: Trivial, it’s not. TheNew York Times. Available athttp://www.nytimes.com/2011/02/17/science/17jeopardy-watson.html

Watson (computer). (2011, April 26). InWikipedia, The Free Encyclopedia.Available at http://en.wikipedia.org/w/index.php?title=Watson_(computer)&oldid=425982822

REFERENCES

Currently, patient care

delivery relies upon an

unreliable system formed

from poorly integrated

and highly variable human

parts.

As I kicked off the 2011 Quest PatientSafety Summit, I wasn’t quite sure whatto expect. We had assembled a group of50 patient safety advocates and thoughtleaders from around the country for aday of dialog and collaboration. Ourmission was to create an environmentwhere passionate, talented people couldcome together, share experiences andbest practices, and ultimately makepatients safer. The success and impact ofthe day, however, would ultimately bedefined by the conversation in theroom.

Hospital-acquired infections andmedical errors are a systemic challengefor the U.S. healthcare system. Every day,patients are harmed, and the fact is thatmany of these situations are pre-ventable. While the challenges are con-siderable, I was humbled and inspiredby the passion coming from the Questparticipants. This group of doctors,nurses, administrators and changeagents are clearly committed to openly


By Brad Cates

V I E W P O I N T

A Supplier’s Pledge

addressing patient safety issues, chal-lenging paradigms, driving change, andsaving lives.

As I listened throughout the day, itbecame clear that so many of the chal-lenges providers face are adaptive andcultural. Real and perceived lines existacross the continuum of care that oftenprevent collaboration and complicateprocesses. As solutions providers for theindustry, we have an opportunity to stepup to many of these challenges. A morecomprehensive systems view is missingin healthcare. Often, human factors areoverlooked or ignored in engineeringtechnology solutions.Though well inten-tioned, solutions often don’t fully alignwith workflows, which ultimately opensthe door to further workarounds andmake patient care all the more complex.

As the leader of Standard RegisterHealthcare, I am committed to playing alarger role in supporting patient safetyadvocates and intend to leverage theconsiderable resources and talent of our

business to support their mission.Whilewe’re clearly concerned with profits, thishigher purpose aligns naturally with ourvalues and allows us to spend our timebuilding a business that matters. Weabsolutely can be a socially conscious,profitable enterprise that makes a differ-ence in the name of safer patient care.

I’ve personally taken up the challengeof our keynote speaker, Dr. PeterPronovost, who sought to keep themomentum going with a specific call toaction. My commitment is to continueto support healthcare in advancing safe,patient care through mindful innovationand solutions, and by facilitating eventslike the Quest 2011 summit wherehealthcare’s leadership can come togeth-er to share ideas, promote best practices,and ultimately make patients safer. ❙PSQH

Brad Cates is president of StandardRegister’s Healthcare Business, whichcurrently serves more than 3,100 hospitalsand 100 of the top 150 integrated deliverynetworks in the United States. Under hisleadership, the business has focused ondelivering solutions to help healthcareproviders accelerate performance, attractand educate patients, enhance their safety,and improve the quality of care. He believesa company’s path to market leadership mustbegin by intently listening to all the market’sstakeholders, mindful of the internal andexternal pressures they face. Cates may becontacted [email protected].

For more about the 2011 Quest Patient Safety Summit, see page 34.

PROGRAM RESOURCE

While we’re clearly

concerned with profits,

this higher purpose aligns

naturally with our values

and allows us to spend

our time building a

business that matters.


By John Govednik, MS, and Maryanne McGuckin, ScEd, MT(ASCP)

Hand HygieneMeasurement and

EducationCompliance improvement can be successful,

sustained, and cost effective.

around their care area. These remind the HCW to performHH. Just as important, they also assure the patient that askingis the norm at your facility.

The World Health Organization’s First Global Patient Safe-ty Task Force produced the WHO Guidelines for Hand Hygienein Health Care (2009) and included patient empowerment asone of the tactics for your patient safety and quality strategy. Inthe January 2011 issue of the Journal of Infection Control andHospital Epidemiology, the task force also published a strategyfor incorporating patient empowerment .

The total cost of reminding a healthcare worker for per-forming hand hygiene = $0.00. How you implement the pro-gram with visual reminders is up to your creative team. WhenHCWs are empowered to invite and patients are empowered toask, everyone benefits.

Product Usage MonitoringGuidelines and peer-reviewed research offer direction whendeveloping the measurement component of your plan. Expertssuggest there is no single method to measure hand hygienecompliance without human bias (direct observation) or with-out behavior detail (product usage measurement) (Haas & Lar-son, 2008; Boyce, 2008). However, nobody has concluded youneed major capital investments or binding long-term serviceprogram contracts to achieve higher results.

Allocate Your Resources

Observation is an investment in personnel hours for data collec-tion and reporting. Researchers at Virginia CommonwealthUniversity Medical Center calculated that it cost $21,252 forhired data recorders to conduct observations in a 24% timesample (Stevens et al., 2009).We calculated annual costs for hos-pitals can be between $12,000 (depending on number of units)using nonprofessional observers and $36,000 for professionalsto monitor one hour per unit per week (McGuckin, Waterman& Govednik, 2009). As you see, your program design impactscost. Observation is the standard, and both WHO and JC sug-gest at least minimum criteria for observation monitoring.

Given that observation is the standard, you can investthose dollars and hours in observing the units where HHperformance needs the most improvement. Product usagemeasurement has been recognized as a surrogate for


and hygiene (HH) is one of the most effectivepractices that all individuals in a healthcare facilitywho deliver healthcare services and have directcontact with the patient (healthcare worker, orHCW) can perform to help prevent the spread ofinfection among patients. Measurement and feed-

back of HH performance encourages improvement. In theUnited States, HCWs are performing at or below 50% compli-ance (BioMedReports.com, 2011) even after monitoring hasbeen implemented over a period of time (McGuckin,Waterman& Govednik, 2009).

Better results are attainable but challenging. How canthe infection prevention community improve compliancewhen many budgets are hovering in cost control mode?Rely on the resources you already have: patients and prod-ucts.

The Centers for Disease Control and Prevention (CDC), theJoint Commission (JC), and the World Health Organization(WHO) each promote the use of multimodal HH complianceprograms within a healthcare facility. Recommended compo-nents typically are: HCW training, patient education, practicemeasurement, and feedback for the healthcare team. Whendesigning your approaches to education and measurement,consider opportunities that cost you less but give you more.That’s less time and money, and more clinically proven relia-bility.

Patient EmpowermentWhen developing your educational component, consider howmany different HCWs see a patient over the course of their stay.Your program will impact every HCW type on every shift. Asvarious HCWs enter the patient care area day and night, theonly consistent factor in that room is the patient. Patients can beeffective participants in your HH education efforts if they aregiven permission to participate. In a 2006 study of 1,000 con-sumers in the United States, we found 4 out of 5 consumers saidthey would be willing to ask their HCW about HH if they wereinvited to do so (McGuckin, Waterman & Shubin, 2006).

Patient empowerment is growing in acceptance as aneducational foundation. When patients are given back-ground information on the risk of hospital acquiredinfections, they are made aware. Couple that knowledgewith basic questions and reminder tasks presented tothem by HCWs (sometimes referred to as explicit permis-sion), and patients will have a fresh set of skills to act ontheir knowledge.

ImplementationIn our HH compliance program (see sidebar), when patients areadmitted to the hospital, a HCW (usually the nurse at initialassessment) discusses infection risks. The nurse can explicitly tellthe new patient that he or she is invited to remind anyone com-ing into their care area to wash or sanitize their hands. It can beas simple as saying,“thank you for washing,”when approached.

Some hospitals will give patients what we call visualreminders—buttons, stickers, etc.,—that patients can place

H When designing yourapproaches to education

and measurement, consider opportunitiesthat cost you less but

give you more.

observation, because data gathered on where product isused (or not used) provides insight on HH activity with-out requiring someone to monitor. Supporting productusage measurement methodology, the JC monographMeasuring Hand Hygiene Adherence: Overcoming theChallenges (The Joint Commission, 2009) includes 10 dif-ferent product usage programs in their review (out of atotal of 37 programs in the publication).

Measuring product usage includes the following fac-tors: 1) product used, 2) patient bed days, and 3) dosageof individual HH event. Results will indicate the numberof HH events performed on the unit per patient per day.A facility-wide report will show which units are perform-ing HH more, or less, per patient. Focus observation onunits where HH frequency is low. Observation will tellyou why the lower HH frequency and provide insight forimprovement strategy. The resulting program is a moretargeted use of your personnel and dollars, while still get-ting a facility-wide picture of compliance with littleinvestment needed.

In our program, the four most common methods thatinfection preventionists use for measuring product usageare 1) housekeeping collects empty product containers ina central location; housekeeping or an infection preven-tion representative counts the product containers as theyare accumulated; 2) housekeeping tallies the products asthey are replaced in each room or common area; 3) mate-rials management provides the orderings per unit toinfection prevention for calculating; or 4) any combina-tion of the above. Each hospital has a method that worksbest for their team. You don’t need additional equipment,software, or personnel to monitor your entire facility, unitby unit. Your staff is already replacing and ordering prod-uct; simply introduce the program to them and ask fortallies.

Success at the Local, State, and NationalLevelsGood Samaritan Hospital in Baltimore, Maryland, highlightedhow compliance improvement increased with a multimodalplan in a scientific conference abstract (Karanfil et al., 2009).Observation alone produced scores that matched management’sgoals. But, once McGuckin’s product usage monitoring wasintroduced, compliance differences between observation and

product measurement revealedlower rates on some units. Infectionpreventionists knew from other HHresearch that the high observationrates might be biased. The planhelped target specific areas forimprovement not made apparentwith observation. Their programwas selected as part of the kickoff forthe Maryland Hand Hygiene Col-laborative (2009).

Hospitals are not in this alonewhen devising compliance plans.

The Washington State Hospital Association added the productvolume measurement program in a group of 55 facilities.Compliance increased after 5 months (McGuckin et al., 2007).Working together they devised a “safe table”discussion formatto share improvement tactics and to support individual hospi-tals trying to meet desired goals from management. We con-gratulate Washington State Hospital Association on recentlybeing awarded the 2010 John Eisenberg Award for Patient Safe-ty and Quality, in which the safe table program was acknowl-edged.

By 2009 the resulting database from the first 300 hospitalsin our program gave, to the best of our knowledge, the firstnationwide study of compliance improvement in the UnitedStates (McGuckin, Waterman & Govednik, 2009). At baseline,HCWs in ICUs were performing HH 26% of the total oppor-tunities presented for HH. After 12 months, ICUs increased to36%. Baseline for non-ICUs was 36% and after 12 months,increased to 51%.

Have we improved since 2009? At a hand hygiene forum inMarch 2011, Mark R. Chassin, MD, FACP, MPP, MPH, presi-dent of The Joint Commission, shared that hospitals partici-pating in the JC’s Center for Transforming Healthcare wereperforming at 48% compliance (BioMedReports.com, 2011).We still have a long way to go!

National Benchmarking and LocalPerformanceOur database of product usage measurement from healthcarefacilities in the United States provides insight in nationaltrends—information that individual hospitals can apply to theirown data analysis. We compared soap vs. sanitizer usage andfound that when HCWs were faced with an HH opportunity,they were choosing soap more frequently in 2008–2009 than inpast measurement periods (Govednik,Waterman & McGuckin,2009). Recalling the guidelines from WHO and CDC, sanitizer


HAND HYGIENE

The authors offer a program called “All for One: One Patient, OneHealthcare Worker, One Question: Did You Wash Your Hands?” plusother resources, research, and compliance measurement tools atwww.hhreports.com.

PROGRAM RESOURCE

You don’t need additional equipment, software, or

personnel to monitor your entire facility, unit by unit.


is the recommended method for hand hygiene if your hands arenot visibly soiled. Nationally, we are trending backward fromthese recommendations.

On a local level, a hospital that tracks product usage candetermine which units are using less sanitizer than soap andthen focus observation on discovering why. This could impactlocal training, or could impact future placement of sanitizerproducts on that unit.

In another example of national and local applicability, wewere able to compare product usage results for the period ofheightened Novel A H1N1 activity (spring 2009 to spring 2010)to the period prior to the onset of H1N1 (spring 2008 to spring2009).We found ICUs, non-ICUs, and ERs had greater HH fre-quency during H1N1 period than in the same time for theprior year. However, as the CDC reported a drop in the num-ber cases of patients admitted with influenza-like illnesses, HHdropped back to pre-pandemic compliance levels before thewinter flu season was over (Govednik, Waterman, &McGuckin, 2010).

As one infection preventionist explained to us, complacen-cy set in with HH practices once HCWs felt we all dodged abullet (recalling the unknown with H1N1 and some specula-tion in various media that many people would get infected andrequire hospitalization). Individual hospitals can track theirHH usage trends against local or global health concerns as well,noting which units have increased or relaxed their HH prac-tices as HCW’s perception of danger has passed.

With product usage measurement, your team gets morethan just instant compliance feedback. The returns on yourminimal investment of tallying product provide great insightinto your hospital’s usage trends as applied to greater HH andinfection prevention matters

Plan for Now and the FutureWhich brings us to fiscal planning for 2012 and beyond. In thelong term, we are monitoring the growing number of compli-ance-monitoring electronic devices to see how, or if, technologyis proven in peer-reviewed research or healthcare scientific con-ferences.We emphasize the focus on scientific research to distin-guish from what we’ve noticed to be pre-clinical-trial pressreleases flooding our news feeds. Will applications of electronicsurveillance simply introduce another method with strengthsand weakness to consider just as we’ve seen in comparisons ofobservation and product usage measurement? Will new tech-nology appeal to a cost-conscious budget? Many questions needto be answered via peer-reviewed studies and future guidelinereview from CDC, JC, and WHO.

For those in cost-control mode, we have outlined cost-effective education and measurement that has beenproven in research, reviewed in the guidelines, andapplied at hundreds of hospitals in the United States. Thefocus is not on glossy solutions, but rather on the simpletask of getting HCWs to wash or sanitize their hands. Let’sget back to basics! ❙PSQH

John Govednik is the program manager for McGuckin MethodsInternational’s (MMI) hand hygiene measurement and consumer

programs. He is the primary contact for infection preventionists whoimplement MMI’s measurement program. He is a former member ofthe National Directorate Board of the American College PersonnelAssociation’s Health and Wellness Commission and has held positionsin counseling, multicultural affairs, and educational assessment atseveral colleges and universities. He has written for several peer-reviewed journals and has presented at APIC, IDSA, SHEA, andspoken to several healthcare groups. He may be contacted [email protected].

Maryanne McGuckin is founder and president of McGuckinMethods International (a Patient Safety Organization), and is asenior scholar in the health policy department at Thomas JeffersonUniversity in Philadelphia. She has been on the faculty and staff ofthe University of Pennsylvania for more than 30 years, focusing oninfection control and hospital epidemiology. She served on theCenters for Disease Control and Prevention task force that developedthe Guideline for Hand Hygiene in Healthcare Settings and was leadauthor for the chapter on patient empowerment for the World HealthOrganization’s WHO Guidelines on Hand Hygiene in Health Care. Shemay be contacted at [email protected].

BioMedReports.com (2011, March 16). Experts agree U.S. needs to step upinfection control efforts starting with hand hygiene practices.http://biomedreports.com/2011031665101/experts-agree-u.s.-needs-to-step-up-infection-control-efforts-starting-with-hand-hygiene-practices.html (Accessed March 30, 2010). Program Information athttp://www.centerfortransforminghealthcare.org/

Boyce, J. (2008). Hand hygiene compliance monitoring: Currentperspectives from the USA. Journal of Hospital Infection, 70(S1), 2-7.

Govednik, J., Waterman, R., & McGuckin, M. (2009). Hand sanitizercompliance in the USA: A six-year multicenter trend analysis. Abstractpresented at the Infectious Diseases Society of America annualconference, Philadelphia.

Govednik, J., Waterman, R., & McGuckin, M. (2010) What effect did Novel AH1N1 have on HH events at the bedside in US hospitals? A multicenteranalysis of compliance in ERs, ICUs, and Non-ICUs. Abstract presentedat the 5th Decennial International Conference on Healthcare-Associated Infections, Atlanta.

Guideline for Hand Hygiene in Healthcare Settings. (2002). Centers forDisease Control and Prevention. Available at:http://www.cdc.gov/handhygiene/Guidelines.html

Haas, J., & Larson, E. (2008) Compliance with hand hygiene guidelines:Where are we in 2008? American Journal of Nursing, 108(8), 40-44.

Karanfil, L., Finch, K., Knox, B., Govednik, J., & McGuckin, M. (2009). A four-step hand hygiene compliance and accountability model. Abstractpresented at Society for Healthcare Epidemiology of America annualscientific meeting, San Diego.

Maryland Hospital Hand Hygiene Collaborative. (2009, November 3).Kickoff materials page.http://www.marylandpatientsafety.org/html/collaboratives/hand_hygiene/kickoff.html (Accessed March 30, 2011).

McGuckin, M., Wagner, C., Shubin, A., & Waterman, R. (2007). Statewidepartnership and CEO challenge to increase and sustain hand hygienecompliance. Abstract presented at Society for Healthcare Epidemiologyof America annual scientific meeting, Baltimore.

McGuckin, M., Waterman, R., & Shubin, A. (2006). Consumer attitudesabout health care-acquired infections and hand hygiene. AmericanJournal of Medical Quality, 21(5), 342-346.

McGuckin, M., Waterman, R., & Govednik, J. (2009). Hand hygienecompliance rates in U.S. – A one-year multicenter collaborative usingproduct/volume usage measurement and feedback. American Journalof Medical Quality, 24(3), 205-213.

Stevens, M. P., Hunter, J. D., Ober, J., Bearman, G., & Edmond, M. B. (2009).Watching them wash: A hand hygiene observation program. Abstractpresented at Society for Healthcare Epidemiology of America annualscientific meeting, San Diego.

The Joint Commission. (2009). Measuring hand hygiene adherence:Overcoming the challenges. Available at:http://www.jointcommission.org/Measuring_Hand_Hygiene_Adherence_Overcoming_the_Challenges_/

The World Health Organization. (2009). WHO guidelines on hand hygiene inhealth care. Available at: http://www.who.int/gpsc/en/

REFERENCES


physician commented that he was concerned aboutcentral line care for his patients. While this is a com-mon concern in many organizations, it was notacceptable in one that aspired to achieve perfor-mance at best practice levels. Our hospital—SacredHeart Hospital in Eau Claire, Wisconsin—has an

excellent reputation for quality and caring, competent clinicians.As a new quality leader in the organization, I had the opportuni-ty to evaluate this physician’s concern objectively and to work onmeeting our patients’ needs and expectations.

It didn’t take long to identify that the physician’s perceptionhighlighted a true opportunity. I reviewed data throughout thehospital related to the incidence of central line infections andcompared it to national trends. A particular area of interestemerged on the oncology unit. Despite a stable and experi-enced nursing team and dedicated physicians, the unit hadexperienced several central line infections within a 6-monthperiod. While these patients were high risk, and our rates werenot uncommon compared to national rates, at Sacred Heart webelieved that we could and should reduce the factors that may

By Dawn Garcia, BSN/MS, CMQ-O/E

CENTRAL LINE INFECTIONS:

Targeting Zero on anOncology Unit

AShari Vanpuyvelde, RN, OCN, educates a chemotherapy patient about infection prevention in Sacred Heart Hospital’s oncology unit.

Courtesy of Sacred Heart Hospital

have contributed to these patients experiencing central lineinfections. If all of the current best-practice evidence wereapplied to routine aspects of care for these patients, infectionswould decline. The foundation of the project was based uponkey organizational safety practices noted by the Institute forHealthcare Improvement coupled with the central line bundleinterventions emerging as best clinical practice for the care ofpatients in critical care units. The immuno-compromisednature of patients in critical care is similar to that of patientsundergoing chemotherapy and radiation. If best-practice inter-ventions geared to the critical care population were appliedeffectively to the high-risk oncology population, we believedthat we could achieve similar results.We began to target zero onour oncology unit.

When facing a challenge to patient safety and quality, there isno time to waste.We reviewed historical data, which indicated astable pattern over prior months. The team, however, didn’t rec-ognize the impact of the issue to their patients’ course of careand the potential of sepsis morbidity and mortality. The careteam was called to action, including the physician who made theoriginal observation. Team meetings with all colleagues on theoncology unit identified several immediate opportunities foraction. In department meetings, nursing colleagues were givenbackground information on the impact of healthcare infections,especially central line infections, to risks among their specificpatients. Best-practice strategies were shared using appliedlearning techniques to real patient situations. The team immedi-ately took responsibility, believed that they could do better, andset out to plan their actions.

Behind the ScenesInfection control is always top of mind with healthcare execu-tives to ensure patient safety and the best possible patient expe-rience. In addition, the Center for Medicare and Medicaid Ser-vices (CMS) added an incentive as of October 2008 by notproviding payment for additional expenses associated with cer-tain hospital-acquired conditions (HACs), including central lineinfections. Our quality leadership team realized that standardsand processes needed to be heightened to meet a higher perfor-mance bar, especially within departments where there was ahigh risk of infection.

An effective strategy for achieving these outcomes wouldrequire standardized work processes designed to deliver con-sistent results. Use of a performance improvement methodol-ogy would provide a framework to ensure that the keyprocesses interconnect to avoid gaps that could create error orwaste. Human error in this case would create the potential fora central line infection. One tactic to prevent error is to create“standard work” processes for critical parts of a work process,such that every step is a must do, every time. Creating standardwork processes is a necessity when variability in processes can-not be tolerated and is the key to process consistency, whichultimately creates consistent results.

Sacred Heart Hospital has an established model for perfor-mance improvement and a performance improvement coordi-nator, who is a black belt in Six Sigma. The performance

improvement model is based upon the DMAIC model (SixSigma) with an additional last step intended to support spreadand deployment. The phases of the model include: Define(Plan), Measure, Analyze, Improve (Do), Control (Check, Act)and Learn (Communicate). The model is introduced to all newcolleagues and leaders during orientation. As improvement pro-jects and opportunities are identified, first-hand experience withthe model is applied to the situations with coaching support.Specific tools for leaders and teams to use in performanceimprovement are maintained on an internal site, and are updat-ed as processes and tools are improved. Outcome data from per-formance improvement projects are reported on a shared inter-nal data repository, viewable by all leaders within theorganization. This tool provides transparency of results and pro-ject efficiency to avoid duplication.All leaders within our organi-zation are accountable for metrics showing performance of theirareas of responsibility, as they affect overall organizational per-formance. Such results are a factor in annual performance com-pensation.Other tools have been developed as needed to supportwork teams and shared reporting of results, including an A-3report that serves as a mini-posterboard of the project focus,change elements, and current status to project goal.

As projects move through the performance improvementprocess and the future state is controlled to target, best practicesin the project are spread to other areas of potential benefit. Thespread process always begins with the rationale for the area orproject selection, and the potential benefit to the populationserved. In this way, the team is engaged and the cultural accep-tance can begin. Once established, data is shared with the teamson a monthly basis to ensure engagement and to informdepartments of progress to targets. Team recognition of pro-ject milestones is built into the PI process, and achievement ofoverall project goals occurs at organizational celebration events.

Identification of central line infections as an important areaof focus came from a review of the priority criteria and areview of the current performance. We use a matrix to reviewoverall organizational performance annually, to explore by keymetrics, areas that are statistically in control or areas that needprocess improvement.

Within Sacred Heart Hospital’s organization, we establishedthree key priorities:1) Critical to service, as the “best possible patient experi-

ence.”2) Critical to sustainability, as our business imperative to

be the provider of choice in value and services.3) Critical to quality, as meeting our safety and regulatory

requirements.

After evaluating our processes and performance in view ofthese priorities, we determined that the oncology unit was anopportunity that would support multiple “critical to” items byfocusing on the patient experience and infection prevention.

The InterventionsUsing the performance improvement model, the oncology teamevaluated recent performance and fallouts from the target. From


there, the team evaluated all possible contributing factors andranked them in importance for interventions. After reviewingthe Institute for Healthcare Improvement (IHI)’s central linebundle, we ensured that these best practices were incorporatedinto our own process. As we approached the opportunity, wealso evaluated the observations from our colleagues, patients,and providers. Our colleagues were focused on delivering thevery best care to the patients, and we knew that any possible bar-rier or impact to that goal should be evaluated and overcome ifpossible. We began with the process of line insertions andapplied the IHI central line bundle components to this process,involving specific site location away from infection sources,chlorhexidine preparation, and full-barrier draping. Line siteselection is the physician’s decision, however, the patient’s homesituation and therapy needs are significant considerations forsite placement. Regardless of where the line is placed, a consis-tent insertion process includes a full barrier drape and otheraseptic precautions with initial line securement.

We then critiqued the process of the current orientation andskill development of colleagues to assume a key role in effectivecentral line care. The nursing educator reviewed with eachnurse the appropriate steps of the standard work process forcentral line care and conducted return demonstrations untilshe was confident that the process was consistent to those stan-dards. In addition, we reviewed how we communicated amongthe team to ensure that the same best-practice expectationswere known and supported by all. Central line care is includedas part of the bedside report discussion that occurs at each in-coming and off-going nursing hand-off process.

Physicians were engaged in the process to know what theteam was focused on and to identify additional variables fromtheir perspective. Physicians were also engaged in terms of typeof catheter or device, the setting for placement and ongoingcare, and assessment of the line as part of the overall course ofcare. All members who came in contact with our oncologypatients were taught the goals and tactics to achieve infectionprevention with special focus to at-risk elements, especiallyhand hygiene and isolation precautions. Strategic placement ofhand sanitizers and signage informed all who entered the unitof the need to protect patients who were at risk and the specif-ic actions needed from them. Patients were taught and coachedto ask and remind family members and healthcare team mem-bers to consistently use hand hygiene before and after contactwith touch surfaces or the patient.

The ResultsA systematic process to designing effective care processes and aunit culture focused on eliminating central line infections waseffective. Our oncology unit experienced a 16-month intervalwithout any central line infections and continues to experienceonly a rare event. Still, the process discipline requires ongoingmonitoring and weekly review of any cases that may evidencecentral line infections hospital-wide. The upstream and down-stream impacts are considered for patients that experience carepre-admission and post-admission, and care aspects are coordi-nated in conjunction with primary care and other practice set-

tings. As a high-risk area, infections in the oncology populationare common. However, even in these situations, a concentratedfocus and application of systematic performance improvementcan achieve stellar results.

Lessons LearnedWhile the overall process of minimizing central line infectionswithin the department was a success, there were two key oppor-tunities that needed to be addressed within the department. Thefirst issue was a knowledge deficit among the colleagues andinterdisciplinary team. While healthcare professionals under-stand and know all factors contributing to healthcare infections,until the situation relates to someone that they’ve touched, whohas experienced an infection, they may not feel like they reallyhave a part in the process. When the message relates to the partthat each person plays in a specific case outcome and the criticalfactor of one break in the system, healthcare professionals get onboard. The benefit of sharing stories is huge; clinicians generallydo not put together the pieces from multiple patient experiencesto see the nature of the original problem.

The second issue that needed to be addressed was engagingpatients and their family members. Often, patients and familymembers do not know all of the aspects that they can controlto support low infection rates. When patients were educated,and the prompts to protecting the patients became part of whatour visitors do, compliance with hand hygiene and other sim-ple measures became routine and effective. The power ofengaging the patient cannot be underestimated, and the fami-ly’s role will only magnify this effectiveness in the overall pro-cess of care. This is one of the key components to ensuringpatient safety.

We also realized through the use of the performance-improvement model that there are a few processes we would dodifferently. First, we ask stakeholders to make suggestions, butwe did not have a formal process for incorporating this feed-back into our prioritization matrix. This would have enabledour clinical experts to prioritize this patient outcome initiativeabove other important projects that may not have had such aclear clinical outcome correlation. Second, we needed to devel-op a flow chart and process map to validate key processes thatmay impact the outcome. That work was done once we hadalready scoped our project. When the results of this analysiswere shared with the colleagues, they were amazed at all of thesteps in the process! From this work, we were able to identifythe standard work processes to ensure consistent results.

Sacred Heart Hospital continues to look into the future toensure consistency and a positive patient experience not onlywithin the oncology unit, but across the organization and with-in our sister hospital, St. Joseph’s Hospital in Chippewa Falls,Wisconsin (20 minutes north). Both facilities are part of theHospital Sisters Health System, based in Springfield, Illinois.The last step of our performance-improvement model is Learnand Communicate, so the learnings from the experience atSacred Heart Hospital are being incorporated into the experi-ence on the critical care unit there and throughout the organi-zation at St. Joseph’s Hospital.


CENTRAL LINE INFECTIONS

Keys to SuccessEnsuring patient safety and following processes have been fairlyeasy tasks within our oncology unit. After being involved in theperformance-improvement process, nurses have become metic-ulous about cleansing access sites for patient lines and centrallyplaced ports. They have become partners with patients and theirfamilies to ensure that everyone on the team knows the plan andis supporting the same. The nurses provide a bedside report,which allows the offgoing nurses to look at the access site, dis-cuss any issues with the patient, and then address any of theissues with the oncoming nurses. This process ensures that allgaps are taken care of and nothing falls through the cracks. Inshort, the key to the performance success on this unit has beenthe development of a cultural expectation that no patientshould acquire a central line infection and that we are commit-ted to doing everything possible to engage the entire team insupport of that goal. The patients are active members in thiseffort, and there is a level of confidence and joy in the outcomesachieved. Our mission is to provide the very best patient experi-ence. Keeping our patients safe and free from potential infectionis one way that we can support our mission of service to themand to our community.

Next StepsSacred Heart Hospital is actively involved in a catheter-associat-ed urinary tract infection initiative to further improve our cur-

rent performance and is actively engaged in other infection-pre-vention initiatives developed in view of national practice trendsand best practices.

At the project level, standardization of some of the process-es learned in this project has certainly strengthened our confi-dence in the potential results achieved when caring clinicianscome together to create a better patient experience.We now usecase examples and stories of patients to teach colleagues of theimpacts, and the best practices that are evolving, for rapidadoption and improvement.

We turned what used to just be the “right thing to do” into acommitment to our patients. The process takes time, but whenyou engage the entire team and keep them accountable for theiractions within the department, success can be achieved. ❙PSQH

Dawn Garcia is the divisional director of medical staff/quality for theWestern Wisconsin Division of Hospital Sisters Health System. Sheprovides administrative oversight to medical staff operations, qualityresources and organizational learning. Garcia has spent more than30 years in the healthcare field, including leadership positions innursing/patient services, administration, and medical staffoperations. She holds a master’s degree in nursing administrationfrom State University of New York Institute of Technology in Utica,New York, and a bachelor’s degree in nursing from the University ofNorth Carolina, Chapel Hill. Garcia also has been recognized by theAmerican Society for Quality (ASQ) as a Certified Manager ofQuality/Organizational Excellence. She can be reached [email protected].



he challenge of sorting through copious amounts ofdata to find the essential information is not new. Overthe years, various professions have developed keymarkers to highlight the essential. For example, clini-cians use vital signs, accountants have bottom lines,

and journalists pen pithy headlines. Perinatal safety profession-als grapple with complex systems and also desire a succinctsummary to measure the impact of their programs. The AdverseOutcome Index (AOI) and its cousins the Weighted AdverseOutcome Score (WAOS) and Severity index (SI), are compositescores that were designed to measure quality of perinatal care(Mann et al., 2006; Nielsen et al., 2007; Pettker et al., 2009).While a simple numerical score is enticing, the AOI only partial-ly answers the three key questions that safety professionals mustask: Did clinicians do what they were supposed to do? Did itmake a difference? Was there a plausible link between the inter-vention and outcome?

Epidemiologists are quick to point out that the clusteredprospective randomized clinical trial is the best method todetermine a solid relationship between intervention and out-come. Sometimes such trials are not possible because rare peri-natal events require an extraordinarily large sample size so thatresearchers may draw conclusions with confidence or such tri-als may even be unethical if an accepted standard of care wereto be withheld. While a cause-and-effect relationship can neverbe proven in an observational study, such studies can be help-ful with the caveat that sufficient additional information is pro-vided in order to judge the plausibility of the link.

The purpose of this report is to describe the history of theAOI concept, demonstrate limitations in the AOI construct,and suggest alternative approaches to better understand theimpact of safety interventions.

History of the AOIThe AOI was first created by a research team studying theimpact of team training in the labor and delivery environment.Team training was expected to reduce the occurrence of medical

errors and adverse outcomes associated with medico-legal liabil-ity and was not targeted to any specific obstetric outcome. Thestudy was funded by the Department of Defense, the Risk Man-agement Foundation of the Harvard Medical Institutions, andthe Beth Israel Deaconess Medical Center Foundation andinvolved 15 hospitals. Consensus conferences involving medicaland nursing leaders from participating hospitals identified 10adverse obstetrical events that were considered modifiable withimplementation of team training. Because the frequency of eachindividual event was low, a composite measure reflecting the 10adverse outcomes was considered to be appropriate (Mann etal., 2006). Grouping these outcomes together resulted in a com-posite outcome that was more common and lessened the needfor excessively large study populations. The AOI, however,included items with vastly different clinical importance, forexample maternal death and perineal laceration. To attempt toequalize the contribution of such disparate items, a consensusprocess created individual weighting factors for each adverseevent. Maternal death was considered the most severe event andcarried a weight of 750. The sum of the weights of the othernine adverse events also equalled 750, with perineal lacerationhaving the lowest weighted value as shown in Table 1. Obtainingconsensus on a set of obstetrical measures (outcome andweights) that were acceptable to a wide range of key stakehold-ers was a considerable accomplishment but does not necessarilymean that they are either valid or reliable.

The Adverse Outcome Index (AOI), defined as the percent-age of deliveries with one or more of the adverse events, becamethe primary outcome measure. Secondary measures were theWeighted Adverse Outcome Score (WAOS), calculated as thesum of weighted adverse outcome scores divided by the numberof deliveries, and the Severity Index (SI), calculated by summingthe weighted outcome scores and dividing by the number ofdeliveries with a complication (Mann et al., 2006). Creators ofthe AOI recognized that while the AOI was a significant step for-ward in obstetrical quality metrics, additional study of the toolwas needed. A combination of professional society support and

Emily Hamilton, MD; Samuel Smith, MD; Dorothy Berry, RN, DFASHRM;Omer Ben-Yoseph, MD; Dan O’Keeffe, MD; Eric Knox, MD

Revisiting the Perinatal AdverseOutcome Index

T

notable publications promoting this tool were likely responsiblefor its relatively rapid adoption by many organizations today.

With the passage of time, we have much more sophisticat-ed data sources available to us today through clinical informa-tion systems in obstetrics. The availability of large data sets withdetailed information about the nature of care received as wellas perinatal outcomes prompts us to revisit this index. Ourreview has identified four limitations with the AOI and itsderivatives. Understanding these limitations will lead to betterusage and perhaps assist in its refinement.

LimitationsTo illustrate these points, we have constructed a simple AOI scorewith 3 of the more common components from the AOI defini-tions, namely a third- or fourth-degree perineal laceration, a 5-minute Apgar score of 6 or less, and use of maternal transfusion.AOI scores were defined as the percentage of patients with anyone or more of these factors. Scores were constructed using de-identified data extracted from the electronic medical record usedin a four- hospital system with more than 7000 births annually inthe Baltimore-Washington corridor. The analysis period wasbetween January 2005 and April 2010. The results are shown inFigure 1.

Limitation 1. Dominance by Common Components

It is a basic mathematical fact that a composite score will bemost heavily influenced by its most prevalent components. Sim-ply said, common factors will swamp uncommon ones. This isevident in Figure 1 where the trend of the AOI (black) is paralleland similar to its most common component—perineal lacera-tion (green). The stable trend in the AOI masks an increasingtrend in one of the less common components, transfusion rates.In our example, no matter what interventions might have beenintroduced a composite score would largely reflect the domi-nant effect of perineal laceration rates.

Limitation 2.Ambiguous Link between Intervention andOutcome

A composite outcome measure does not allow the reader tomake a plausible link between a specific intervention and a spe-

cific and related outcome.As described above, the perineal lacer-ation effect dominates, and it is hard to imagine how an inter-vention such as team training in communication would affectthis specific parameter. Consequently, the relationship between aspecific safety intervention and this AOI is ambiguous. In addi-tion, unmeasured factors, apart from the safety initiative, alsomay be influencing the AOI. In our example, the rate of perineallaceration could have been reduced simply by increasing cesare-an rates and thus diminishing the numbers of vaginal births andthe potential for perineal laceration. Cesarean birth, use ofinstrumental vaginal techniques (forceps and vacuum) and epi-siotomy use are key procedures under the control of the clini-cians and do have a plausible link to perineal laceration. Assess-ing the rates of these interventions is essential for understandingwhy and at what cost perineal laceration rates are decreasing.Fig-ure 2 highlights these rates in our data and reveals clearly thatfalling perineal laceration rates were associated with falling use ofinstrumental vaginal delivery methods and episiotomy and notrelated to primary cesarean rates that were stable.

Rates of episiotomy and instrumental vaginal birth havebeen decreasing nationwide for many years based on resultsfrom clinical trials and changing practice guidelines from pro-fessional societies (Oliphant et al., 2010; Frankman et al., 2009).It is impossible to distinguish the influence of these general ten-dencies from the influence of concomitant quality programsbased on the AOI trend displayed in Figure 1.

Limitation 3. Changing Complexity of Patient Population

A composite outcome score does not provide information onthe underlying health status of the patient population, whichalso affects outcome. Clinical outcomes are a function of both


Table 1. Adverse Outcomes and Weights Associated with Each Adverse Outcome

Adverse Outcome

Maternal death

Intrapartum or neonatal death (greater than 2500 g)

Uterine rupture

Maternal admission to ICU

Birth trauma

Return to OR/ Labor and delivery

Admission to NICU (greater than 2500 g for over 24 hours)

APGAR score <7 at 5 minutes

Blood transfusion

Third or fourth degree perineal tear

750

400

100

65

60

40

35

25

20

5Figure 1. Trends in the AOI and Each of Its Components

Figure 2. Trends in Intervention Rates

Weight

healthcare received and the basic health status of the patients.Fig-ure 3 shows trends in three common perinatal risk factors in ourstudy population.All risk factors showed increasing trends,whichwould be expected to affect outcomes negatively. Thus in ourexample the stable AOI underestimated performance because itdid not account for the rising complexity levels in the mothers.

Figure 3. Trends in Maternal Conditions

Limitation 4. Paradoxical “Adverse” Outcomes

Maternal transfusion rates exemplify this problem. Walker et al.(2010) reviewed 342 medical records with an adverse outcomein order to assess the accuracy and clinical relevance of all 10standard AOI components. Transfusion rates were particularlyproblematic as a measure of poor quality because in 39% of thecases reviewed, the transfusion was necessitated by a pre-existingcondition such as placenta previa, abruption or preeclampsia-associated hemolysis. In these situations, failure to transfusewould have been a significant quality of care issue yet the act oftransfusion was counted as an adverse outcome. The paradoxarises because transfusion contributes to the AOI, which isintended to reflect poor care, but indicated transfusion is amarker of good care.

This paradoxical effect is propagated and amplified in the SIwhere the impact of transfusion is weighted 20 fold.

In summary, a composite AOI is tempting in obstetricsbecause adverse outcomes are rare and combining severaluncommon events creates a number with an incidence that isamenable to statistical analysis without requiring huge datasets. However, the limitations are considerable: trends in a sin-gle factors can mask important and contrary trends in lesscommon factors. Additionally, one cannot see the targeted

effect of specific interventions or gauge the influence of otherchanges in the population under study. Finally, including out-comes such as transfusion rates confuses the issue as they donot consistently indicate a quality of care problem. Adding anumber of internal multipliers (weights) further obfuscates theinterpretation of its derivative the SI.

Alternative ApproachesComplex problems usually require complex solutions than

can seem unattainable. Often the first step in solving complexproblems is to break them into simpler parts. Perinatal out-comes and quality of care are separate, albeit related, issues.Furthermore perinatal outcomes depend, in part upon thequality of care and the complexity level of the case mix. Thusthere are at least three distinct elements that are interrelated—complexity of patient population, the quality of care received,and ultimately the perinatal outcomes. We suggest that a moreinformative picture is provided when measurements of each ofthese elements are provided to the reader.

Table 2 demonstrates this approach in a well designed studythat is easy to interpret. Clark et al. (2010) examined a singleproblem—elective delivery prior to 39 weeks—and the effec-tiveness of three different policies. Each of the three policygroups began with equal complexity as measured by their base-line rates of elective delivery before 39 weeks. Measures of qual-ity of care were presented along with outcome measures. Thechosen outcome was plausibly linked to the care intervention.The study sample was large enough to examine differences withstatistical confidence. Together this data presents a clear andcompelling case for Policy A, because one can see improvingrates in the quality-of-care marker (elective delivery under 39weeks) as well as improving rates of the related adverse out-come marker (intensive care admissions) with no other illeffects (increase in stillbirth rates).

The checklist in Table 3 summarizes concepts to considerwhen planning a study using composite scores to measure theeffects associated with a quality of care intervention, whichimplies answering the three basic questions: Did clinicians dowhat they were supposed to do? Did it make a difference? Isthere a plausible link between the two?

A second alternative approach is the application of risk adjust-ment methodologies to obstetrical process and outcome mea-surement. As yet, no uniform methodology for risk adjustment


REVISITING PERINATAL AOI

Table 2. Different Approaches to Lower Elective Delivery Before 39 Weeks

Intervention

Study design

Education and 3 policies regarding elective delivery between 37 and 39 weeks. (“elective” defined as any planneddelivery without a recognized medical or obstetric indication)

Comparisons among the three clusters of hospitals, each one following a different policy.

Complexity Marker Quality Marker Outcome Marker

Baseline rate of elective delivery at < 39weeks before study commencement.

Policy A Policy B Policy C8.2% 8.4% 10.9%

Percentage of births with elective delivery at < 39 weeks after adoption of a new policy.

Policy A Policy B Policy C1.7% 3.3% 6.0%

Percentage of term babies admitted to newborn intensive care

Policy A Policy B Policy CFell over the course of the study

Policy A. No exceptions to policy allowed. Hospital staff empowered to refuse request for elective induction or cesarean. Policy B. Exceptions to policy allowed and all exceptionsreferred to peer review committee. Policy C. Education regarding problems with elective delivery under 39 weeks, and management left to clinician discretion.

Emily Hamilton is an experienced obstetriciangynecologist and the senior vice president, clinicalresearch, at PeriGen. Her research focuses oncomplications found during the labor and delivery period.

Samuel Smith is chairman of the department ofobstetrics and gynaecology at Franklin Square Hospital inBaltimore, Maryland, where he been recognized as aleader in many successful initiatives to improve thequality of obstetrical and gynecological care.

Dorothy Berry is a distinguished fellow of theAmerican Society of Healthcare Risk Management, and acertified professional in healthcare risk management andin Six Sigma. She applies both her nursing andprofessional risk management expertise in her role assenior vice president, patient safety, risk managementand clinical services at PeriGen.

Omer Ben-Yoseph has extensive experience inbiomedical informatics and has been a key member ofthe design and development of PeriGen’s PeriBirthsoftware as well as transforming the collected clinicaldata to measure and track quality performance.

Dan O’Keeffe is PeriGen’s chief medical officer.Drawing upon his broad clinical and administrative

experience, Dr. O’Keeffe also serves as the executive vice president ofthe Society for Maternal Fetal Medicine.

Eric Knox is the chief patient safety officer at PeriGen. He was afounding board member of the National Patient Safety Foundation,and currently consults and advises leaders in healthcare organizationsthroughout the United States on perinatal issues.

PeriGen is a technology-enabled professional services companyspecializing in risk reduction and clinical quality improvement inObstetrics. PeriGen is a US corporation headquartered in Princeton,New Jersey, with offices in Canada and Israel. For more information,please visit www.perigen.com

exists for obstetrics, although efforts to tackle this for maternalmorbidity and cesarean rates are emerging (Srinivas, Fager &Lorch, 2010; Srinivas, Epstein, et al., 2010).We agree with the cre-ators of the AOI that application of risk adjustment methodolo-gies and standardized definitions are necessary in order to fairlycompare results across organizations (Mann et al., 2006).

Measuring quality of care is inherently complicated, as itimplies answering many questions such as “Was the right inter-vention performed, at the right time, and for the right reason?Did it make a difference? Was it cost effective? To date, mostdirect quality program assessments involve chart reviews in asample of medical records. We applaud the human effort toaccomplish this—particularly if required repeatedly in order toexamine long-term trends.

Systematic examination of electronic medical records isanother approach to obtaining this information in a compre-hensive and unbiased way. Even with computerization, thisprocess is demanding and requires careful definition of thequality indicators and validation that the computerized extrac-tion is an accurate representation of the care given. Once thismethodology is validated, automated periodic analyses are easyand greatly reduce the human effort.

Medical history is replete with examples of technologicaladvances that have caused quantum leaps in our understandingof disease. Examples include radiological techniques to viewinside the body, biochemistry to detect aberrant internal pro-cesses, and genetic markers to predict who will become ill. Thewidespread adoption of electronic medical records provides thatkind of advance as well as a data platform from which to exam-ine the healthcare delivery processes.We are early in the journeyof discovery regarding what makes for safer patient care; we are,however, beginning to have tools that can help us dissect andanalyze these problems directly and provide insights that help uscontinue to build models to evaluate “next generation”tools formeasuring the quality of perinatal care. ❙PSQH


Clark, S. L., Frye, D. R., Meyers, J. A., Belfort, M. A., Dildy, G. A., Kofford, S.,Englebright, J., et al. (2010) Reduction in elective delivery at <39 weeksof gestation: Comparative effectiveness of 3 approaches to change andthe impact on neonatal intensive care admission and stillbirth. AmericanJournal of Obstetrics & Gynecology, Jul 7. [Epub ahead of print]

Frankman, E. A., Wang, L., Bunker, C. H., & Lowder, J. L. (2009) Episiotomyin the United States: Has anything changed? American Journal ofObstetrics & Gynecology, 200(5), 573.e1-7. Epub, 2009 Feb 24.

Mann, S., Pratt, S., Gluck, P., Nielsen, P., Risser, D., Greenberg, P., Marcus,et al. (2006) Assessing quality obstetrical care: Development ofstandardized measures. Joint Commission Journal on Quality andPatient Safety, 32(9), 497-505.

Nielsen, P. E., Goldman, M. B., Mann, S., Shapiro, D. E., Marcus, R. G., Pratt,S. D., Greenberg, P., et al. (2007) Effects of teamwork training onadverse outcomes and process of care in labor and delivery: Arandomized controlled trial. Obstetrics & Gynecology, 109(1), 48-55.

Oliphant, S. S., Jones, K. A., Wang, L., Bunker, C. H., & Lowder, J. L. (2010)Trends over time with commonly performed obstetric and gynecologicinpatient procedures. Obstetrics & Gynecology, 116(4), 926-931.

Pettker, C. M., Thung, S. F., Norwitz, E. R., Buhimschi, C. S., Raab, C. A.,Copel, J. A., Kuczynski, E., et al. (2009) Impact of a comprehensivepatient safety strategy on obstetric adverse events. American Journal ofObstetrics & Gynecology, 200(5), 492.e1-8. Epub, 2009 Feb 27.

Srinivas, S. K., Epstein, A. J., Nicholson, S., Herrin, J., & Asch, D. A. (2010)Improvements in US maternal obstetrical outcomes from 1992 to2006. Medical Care, 48(5), 487-493.

Srinivas, S. K., Fager, C., & Lorch, S. A. (2010) Evaluating risk-adjustedcesarean delivery rate as a measure of obstetric quality. Obstetrics &Gynecololgy, 115(5), 1007-1013.

Walker. S., Strandjord, T. P., & Benedetti, T. J. (2010) In search of perinatalquality outcome measures: 1 hospital's in-depth analysis of the AdverseOutcomes Index. American Journal of Obstetrics & Gynecology, 203(4),336.e1-7.

REFERENCES

Table 3. Designing Composite Scores to Assess the Impact of Quality of Care Interventions

Considerations

• What are the “clinical behaviours” the intervention seeks to

address?

• Can we measure the clinical behaviours?

• Are the clinical behaviours plausibly linked to specific

outcomes?

• Can we measure these specific outcomes reliably?

• Are there potential negative outcomes from the quality

intervention? If yes, these outcomes should be measured.

• Are other factors likely to affect my selected outcomes?

If yes, these factors should be measured.

• How many patients will be required in this study to be

statistically confident about the expected changes?

• Is my population becoming more or less risky over time?

• Have you considered interpretation challenges arising from

mixing outcomes with greatly different severity?

• Have you considered interpretation challenges arising from

mixing outcomes with greatly different incidences?

• Are you included any “paradoxical” outcome markers?

Aspect

Quality of CareMarkers

OutcomeMarkers

ComplexityConsiderations

Special Considerations


he global re-hospitalization rate of acommunity reflects the cumulativequality of care provided acrossdiverse healthcare settings andproviders. Nationally, almost 20% of

Medicare beneficiaries are readmitted to thehospital within 30 days of discharge (Jencks,et. al., 2009). The Medicare Payment AdvisoryCommission (MedPAC) estimates that up to76% of these re-hospitalizations may be pre-ventable (MedPAC, 2007).

Despite the best intentions of healthcareprofessionals, each setting tends to operateindependently, leaving professionals unawareof issues that impact care as patients moveacross the care continuum. Incidents associat-ed with poor transitions of care can lead topatient safety issues, medication errors, andmiscommunication among patients, care-givers, and providers, which endanger patients’lives, waste resources, and frustrate healthcare consumers.

The term “care transitions” refers to the movement ofpatients between healthcare practitioners and settings as theirconditions and care needs change during the course of a chron-ic or acute illness (The Care Transitions Program, 2007). Inter-ventions that identify and rectify system-level drivers of frag-mented cross-setting care coordination are associated withreductions in re-hospitalizations. The success of improvementefforts depends on the development and strengthening of com-munity partnerships that collectively acknowledge the patient asthe center of focus when planning for the patient’s healthcareneeds.

Cross-Setting CollaborationIPRO, the Medicare Quality Improvement Organization(QIO) for New York State, is one of fourteen QIOs funded bythe Centers for Medicare & Medicaid Services (CMS) nation-ally to improve care transitions for Medicare patients, theirfamilies, and caregivers. IPRO’s 3-year project (August 2008 toJuly 2011) is being conducted in five contiguous counties inupstate New York, involving 50 providers and impacting morethan 68,000 Medicare beneficiaries (Figure 1). These providersrepresent the hospital, home health, skilled nursing, short-term rehabilitation, hospice, dialysis, and physician practicesettings.

By Sara Butterfield RN, BSN, CPHQ, CCM; Christine Stegel, RN, MS, CPHQ;Shelly Glock, LNHA, MBA; and Dennis Tartaglia, MA

Understanding Care Transitions as

a Patient Safety Issue

T

Figure1. IPRO’s Care Transition Initiative five-county target community is located in the Upper Capital Region of New

York State

Courtesy of IPRO

The goals of this project include:• development of cross-setting provider partnerships,

with the patient at the center of attention;• improvement in communication between provider set-

tings to strengthen care coordination;• facilitation of streamlined access to patient-specific

information across provider settings;• improvement in patient satisfaction regarding the care

transition process, and enhancement of patient chronicdisease self-management skills; and

• implementation of systems to decrease adverse drugevents during the transition process.

Initial Focus: Facilitating PartnershipsThe focus of this initiative has been to facilitate cross-settingpartnerships among providers that share care management ofMedicare beneficiaries within each community and to develop ashared learning collaborative model for all participatingproviders to learn from one another’s successes and challenges.The initial strategy was to improve the patient and caregiverexperience and outcomes by bringing providers together to shiftthe paradigm of care management away from “siloed” caredelivery with little direct communication between providers, topatient-centered care that spans the healthcare continuum.

The six participating hospitals have taken an active role incollaborating with their community partners to address carecoordination, information exchange, patient education, andmedication reconciliation on a cross-setting level. They havealso investigated their own internal systems and processes inthese areas to target opportunities for improvement and toimplement strategies and interventions to improve care coor-dination. Following are some of the New York Care TransitionsInitiative hospital providers’ experiences so far.

Bringing Together a Care Community

Ellis HospitalSchenectady, New York

For Ellis Hospital, a 455-bed acute care facility serving bothurban and surburban municipalities, all healthcare providers inthe community are key partners in reducing potentially avoid-able readmissions. “The community has worked together todevelop systems of care management,”says Stephen Wright, RN,BS, cardiology program director, who has spearheaded the hos-pital’s efforts to reduce heart failure (HF) readmissions.

The effort has brought together providers including com-munity-based cardiologists and primary care physicians, as wellas the leadership of skilled nursing facilities (SNFs) and homehealth agencies (HHAs), in an effort to address this issue.

The project began in 2008, shortly after Wright and col-leagues were contacted by IPRO about participating in thecommunity-wide care transitions program. Medicare claimsdata analyzed by IPRO showed that HF patients had the high-est 30-day readmission rate at Ellis.

Wright worked with Director of Medical Staff QualityJames Desemone, MD, to begin outreach to the healthcare

community, and pulled together an internal care transitionsteam, which includes case managers, hospitalists, dischargeplanners, nurses, and representatives from hospital pharmacy,nursing education, medical records, and information services.

Monthly meetings, which include IPRO, are held to discussissues, share information, and measure progress against bench-marks. The team has two subgroups—one works on issuesrelated to medication reconciliation, while the other focuses onother care transitions issues, including information sharingwith HHAs and SNFs. One of the team’s first projects was thecreation of a patient-centered HF pathway.“Patients need to beinvolved in this pathway from the day of admission, so they arewell prepared for when they return home,” says Wright.

Starting on Day 1 of hospitalization, patients learn aboutheart failure, their medications, tests, and other key informa-tion. On Day 2, Wright and his colleagues begin using “teachback”methods—asking the patient to explain back to the clin-ician what he or she has learned.All elements of how to care foroneself on returning home are taught through videos, one-on-one reinforcement, and teach back, beginning on the patient’ssecond day in-hospital.

One educational tool developed as part of this initiative is abrief self-care guide for heart failure patients. The guide isarranged into green, yellow, and red “zones,”each using bullet-ed lists to describe symptoms, activities, and action steps corre-sponding with how well controlled the patient’s HF is. This andother tools are explained while the patient is in the hospital andare reinforced during the discharge process to enhance thepatient’s understanding of his or her chronic illness, increaseadherence, and improve self-management skills.

A large percentage of Ellis’ HF readmissions are from skillednursing facilities, so early on in the project, the hospital’s caretransitions team began meeting with the leadership and medi-cal directors of the region’s SNFs to strengthen communicationand reduce avoidable hospitalizations. HF patients dischargedto home are referred to the Care Transitions InterventionCoaching program.

The Coleman Care Transitions Intervention (CTI)Coaching Model (The Care Transitions Program, 2007)was developed by Dr. Eric Coleman from the University ofColorado. In this model, a Care Transitions InterventionCoach works closely with high-risk patients and theircaregivers to help them better understand management oftheir chronic illness and to facilitate self-empowerment byconducting a follow-up visit and phone calls to help pro-vide continuity and reinforce learning.

The Coleman CTI Model is built on four pillars:1. Physician follow-up appointments within 1 to 2 weeks

of hospital discharge.2. Completion of accurate medication reconciliation.3. Red Flags (patient education regarding high-risk

symptoms).4. Use of a personal health record (PHR).

In the Ellis program, a care transitions coach visits thepatient at the hospital prior to discharge to go over self-care


instructions, the importance of follow-up doctor visits, and toreview medications. The coach then visits the patient at homeas well, with subsequent follow-up phone calls for a 30-dayperiod to ensure appropriate follow-up care post-discharge.

Interdisciplinary Teams Work to ImproveCommunication

Northeast Health / Albany Memorial HospitalAlbany, New York

Northeast Health / Samaritan HospitalTroy, New York

Northeast Health is a large healthcare system in New York’s cap-ital region, comprised of two hospitals, an acute rehabilitationhospital, a large home health agency, and a number of skillednursing facilities. Readmission reduction efforts have centeredon improving processes of care, according to Karen Julian, RN,and Valerie McMahon, RN, case management coordinators for

Albany Memorial and Samaritan Hospitals, both of whom haveplayed key roles in these efforts. An interdisciplinary team thatmeets daily at each hospital has been the key to NortheastHealth’s attempts to reduce readmissions at the system’s hospi-tals by 30%.

Northeast Health began working on care transitions withthe Institute for Healthcare Improvement (IHI) in 2009, andthen started working with IPRO in early 2010.A major empha-sis has been placed on improving communication with patientsand their families.“What we learned from both IHI and IPRO,is that in order to improve patient communication we need toproblem solve every day about what is and is not working,”saysJulian.

Interdisciplinary teams at both hospitals hold daily meet-ings to ensure that a comprehensive plan is in place for allpatients. Included on the team are representatives of dietary,nursing, pharmacy, nursing education, respiratory therapy, andphysical therapy departments; case managers; nurse directors;and representatives of Northeast’s visiting nurse associationand rehabilitation facilities.

Northeast Health makes use of information technology toidentify patients who are at high risk for readmission. Amongthe ways high-risk patients are identified are: key diagnoses(CHF, diabetes etc.); known readmissions within 30 days; andmore than one readmission per calendar year. The team hadsome data when it started the readmission reduction initiative,but key elements were missing.

“Because we didn’t have readmission data on patients dis-charged from one of our hospitals and readmitted to hospitalsoutside our health system, readmission rates were underesti-mated,” says Daniel Silverman, MD, vice president of medicalaffairs. IPRO was able to share Medicare paid claims data thatprovided a more comprehensive rehospitalization picture.While the retrospective review required a major time commit-ment, it did help the team identify patients at high risk, allow-ing for pro-active interdisciplinary case management.

It became critical to engage primary care physicians in thecommunity to ensure that there was continuity when patientswere discharged, as hospitalists provide most inpatient care inNortheast’s hospitals. One care transitions goal is to havepatient discharge summaries dictated by the hospitalist forimmediate transcription, with a copy provided to eachpatient/family member and a copy automatically faxed to thepatient’s PCP. Hospital staff members also work with physicianpractices to establish a follow-up appointment within 7 daysfollowing acute discharge. The appointment is incorporated

into discharge instructions toensure that patients receivetimely follow-up care.

A unique strategy at North-east for all transfers (includingrehab and SNF) is a verbal“nurse to nurse report,” saysJulian. The verbal report,which is given by the hospitalnurse to the nurse receiving the

patient, includes detailed information on diet, activities of dailyliving, medications, social issues, and many other areas. Forshort-term rehabilitation transfers, the patient and family areeducated on and engaged in the discharge plan by beingincluded in this discussion when possible.

A number of additional strategies are used to improve caretransitions, including transition coaches, teach back, and ongo-ing meetings with community providers.

Medication Reconciliation, Seven-DayAppointments Reduce Readmissions

Seton Health / St. Mary’s HospitalTroy, New York

In 2008, at the start of the care transitions initiative at SetonHealth/St. Mary’s Hospital, hospital leadership looked at whatdiagnoses were most likely to lead to readmission. Seton Healthis a health system that includes a hospital and a home care agen-cy, as well as a significant number of affiliated practices and clin-ics. Respiratory conditions—COPD, pneumonia, adult asth-ma—were found to have the highest rates.

The team started the initiative on a nursing unit populatedmainly by high-risk patients with these and other conditions.The first priority was to establish a comprehensive, individual-ized discharge plan for the high-risk patients, which includes a7-day follow-up physician appointment post-discharge, coor-dinated by case managers. Even when family members had to


CARE TRANSITIONS

It became critical to engage primary care physicians in the community to ensure that therewas continuity when patients were discharged, as hospitalists provide most inpatient care in

Northeast’s hospitals.

shift their schedules to accommodate physician appointments,they were grateful for the help, says Case Manager MargoWalsh-Perras, RN. The program is now house-wide.

Another key care transitions intervention at Seton has beenthe design and development of a cross-setting medication rec-onciliation process, involving close collaboration between hos-pitalists, hospital nursing, unit-based pharmacists, and homehealth agency nurses.

Prior to discharge, the discharge summary, discharge orders,prescription list provided by home health, lab results, and a listof active medications from the patient’shospital stay are given to the physician toreview, compare, and write prescriptionsfor discharge. The pharmacist performsthe discharge medication reconciliationprocess and confirms that prescriptionsare correct.

Before the first post-discharge homevisit, the home health nurse reviews thepatient’s final discharge medication listfrom the hospital electronic health recordsystem and is able to address any medica-tion-related questions directly with thepharmacist.

Medication discrepancies significantlydecreased from 81% in the first 6 monthsof 2009 to 65% for the first 6 months of2010, as a result of this intervention. Sys-tem-level discrepancies decreased from84% to 56% for the same time period.

Walsh-Perras emphasizes that the inter-disciplinary nature of the care transitionsteam is one of the most important factors inreducing readmissions. Home care, casemanagement, pharmacy, hospitalists, com-munity-based primary care physicians, andothers working together have helped Setonaddress a number of issues.

The team, facilitated by Jean Endryck,FNP-BC, NE-BC, director of palliativecare and transitional care interventioncoach, meets monthly to trouble shootand discuss specific cases. Endryck’s exper-tise in palliative care management is anasset to the team and the program inaddressing the care needs of patients withchronic, co-morbid health conditions.

Partnerships, PatientEducation, and Follow-Up Pay Off

Saratoga HospitalSaratoga, New York

Saratoga Hospital, which began work withIPRO on the Care Transitions initiative in

2008, has focused on heart failure patients, a high readmissionpopulation for this hospital.

One of the first things the hospital did was send letters to allphysicians in the community, to engage them in the initiativeright away. The care transitions team sought partnerships withothers in the community: home health agencies, dialysis centers,nursing homes, and senior centers.“We wanted to create a safe-ty net of partnerships to keep patients safe in the home setting,”says Cindi Lisuzzo, BS, RN, CCM, director of care management.

The care transitions program was piloted on a medical-sur-


gical cardiac telemetry unit, incorporating daily rounding onpatients, with special focus on HF patients. The interdisci-plinary readmissions team, which includes the director of caremanagement, direct care staff from the nursing unit, chargenurses, cardiologists, hospitalists, care managers, registereddieticians, the core measure specialist nurse, and pharmacists,meets monthly. In addition, Lisuzzo regularly discusses dis-charge issues with home care, and strategizes on how to helpkeep patients safe at home. Patient education and follow up areongoing, and involve caregivers as well.

“In order to help high-risk patients, we have found that it isnecessary to do care management outside the walls of the hos-pital. A family of healthcare professionals is needed to take careof our patients,” says Lisuzzo.

Communication between hospitalists and primary carephysicians in the community is also critical, and informationtechnology helps make this possible. On patient arrival in theemergency department, staff are able to determine from thehospital’s electronic medical record whether the patient hasbeen readmitted within 30 days. The patient’s primary carephysician receives an electronic notification from the hospitalistservice when the patient is admitted. To improve communica-tion, the hospitalists are starting a new process that includes acall back to the patient’s primary care physician that makes him

or her aware of the admis-sion and provides criticalpatient-related informa-tion to both parties.

Post-discharge patientfollow-up is critical. Nurs-es and social workers alsofollow up with home careonce the patient is dis-charged to discuss variousaspects of care such asmedication reconciliation,dietary guidelines, supportsystems, and a physicianappointment within 7days of discharge. Nursesare responsible for placinga follow-up phone callwithin 48 hours for allpatients they discharge,and if there are issuesrequiring the involvementof a physician, nurse, orcare manager, they areresolved within hours.This strategy has helpedthe team anticipate indi-vidual patient/familyneeds and has promotedincreased patient satisfac-tion.

Using the “Four Pillars” of Coleman Model

Glens Falls HospitalGlens Falls, New York

Glens Falls Hospital is located in a rural region of New York thathas a very large geriatric population.At the start of the readmis-sion reduction project, the hospital had a 19.35% all-cause 30-day readmission rate. That number has been reduced by 2%.

To address readmissions, the hospital and the HudsonHeadwaters Health Network group practice first sought andreceived a grant to reduce the hospital’s 30-day readmissionrate. The team began working with IPRO on the Care Transi-tions Initiative at around the same time and dovetailed the twoprojects. The grant incorporated many of the practices includ-ed within Dr. Eric Coleman’s CTI Model. The group developeda work team from Hudson Headwaters and Glens Falls hospi-talists, as well as representatives from two referring home healthagencies. The team drew on IPRO for resources, educationalprograms, tools, data collection methods, and high-risk dis-charge screening criteria (Figure 2).

The project initially focused on patients with HF, acutemyocardial infarction, and pneumonia. These criteria weresoon expanded, however.“We found we needed to expand thetarget population because patients with other co-morbidities


CARE TRANSITIONS

Figure 2. IPRO’s Discharge Planning Guide for referral to home healthcare services

Courtesy of IPRO

presented with similar, unmet needs,”says Chris Freire, LMSW,director, care management. “The average patient had 7 to 12co-morbid conditions.”

The CTI coaches included a physician assistant from theHudson Headwaters practice who educated hospitalizedpatients regarding the program and two care transition coachesto conduct home visits within 48 hours of discharge. Hospital-based care managers and physicians encouraged patient partici-pation in this program.

Care Transitions Intervention staff visited physician prac-tices and developed relationships with office personnel. Thiswould prove key as they later worked to get expedited post-dis-charge appointments for patients. The team worked closelywith the home health agencies to eliminate duplication anddevelop a patient-friendly “hand off”process that caused min-imal disruption for patients and their families.

“What others can learn from our experience is that the con-sumer is always the constant,” says Freire. “The more we canengage the consumer, the more likely we are to succeed indeveloping an effective care transitions plan.”

In addition to work with the group practice and homehealth agencies, the hospital expanded its collaborativeefforts to include nine regional skilled nursing facilities, asdata analysis identified the SNF population as anothersource of patient readmission. This team adopted MOLST(Medical Orders for Life Sustaining Treatment) as aregional advanced directive standard. MOLST is a docu-ment that functions as an actionable medical order, whichtransitions with a patient through all healthcare settingsand defines his or her wishes for life-sustaining treatment.The collaboration between the hospital and SNFs onMOLST facilitated resident/family education regardingtreatment options.

IPRO instructed the SNFs on a variety of INTERACT(Interventions to Reduce Acute Care Transfers) strategies,which are designed to improve the quality of care by pro-viding tools and resources that will help staff reduceavoidable acute care transfers. These practical tools aid inthe early identification of residents’ change of status,guide staff through a comprehensive resident assessmentand improve documentation when a change has beenidentified, and enhance communication with otherhealthcare providers on status changes. This traininghelped engage SNF staff in recognizing and communicat-ing these changes, and fostered earlier communicationand evaluation on whether hospitalization was needed.

The team supports a number of additional processesand interventions, including on-site care transitionsliaisons from the two county home health agencies;scheduling follow-up physician appointments; and dailyfollow up and monitoring of all-cause 30-day readmis-sions by care managers.

Glens Falls Hospital and other regional providers continueto collaborate on a variety of initiatives, creating shared goalsfor its patient population, and implementing processes to sup-port an improved community healthcare model.

Improvement Throughout Targeted RegionAt the beginning of the Care Transitions Initiative, IPROworked with each participating provider to identify patientpopulations at high risk for rehospitalization, and to conductan organizational assessment of each provider setting. Theseanalyses help determine which interventions and strategieswould best address causes of readmission and opportunitiesto improve both internal and cross-setting systems and pro-cesses.

Throughout this initiative, a shared learning model has beenin place across the individual communities and within all of theparticipating providers to support efforts to improve thepatient/caregiver experience during transitions of care. Each ofthe Care Transitions hospital partners has taken an individual-ized approach to reducing hospital readmissions, yet each orga-nization has demonstrated that collaboration and a focusedeffort can make a major difference for patients across the con-tinuum of care.

Equally important, each provider community hasestablished collaborative relationships that have enabledthe respective providers to communicate more effectively,understand the challenges within one another’s setting,and continue to work on readmissions drivers on a cross-setting level. These collaborations are the foundation forsustaining and building on the improvements and suc-cesses within the program achieved to date. ❙PSQH

This material was prepared by IPRO, the Medicare QualityImprovement Organization for New York State, under contractwith the Centers for Medicare & Medicaid Services (CMS), anagency of the U.S. Department of Health and Human Services.The contents do not necessarily reflect CMS policy. 9SOW-NY-THM7.2 11-17

Sara Butterfield serves as the theme lead for the IPRO CMS 9thScope of Work Care Transitions Initiative. She may be reached [email protected].

Christine Stegel serves as a senior quality improvement specialiston the IPRO CMS 9th Scope of Work Care Transitions Initiative ProjectTeam. She may be reached at [email protected].

Shelly Glock serves as a quality improvement specialist on theIPRO CMS 9th Scope of Work Care Transitions Initiative Project Team.She may be reached at [email protected].

Dennis Tartaglia, a writer and communications consultant, ispresident and founder of Tartaglia Communications. He may bereached at [email protected].


Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009, April 2).Rehospitalizations among patients in the Medicare fee-for-serviceprogram. The New England Journal of Medicine, 360(14), 1418-1428.Available from:http://content.nejm.org/cgi/content/abstract/360/14/1418.

Medicare Payment Advisory Commission. (2007, June). Report to congress:Promoting greater efficiency in Medicare [Internet]. Washington (DC):Medicare Payment Advisory Commission. 297. Available from:http://www.medpac.gov/documents/Jun07_EntireReport.pdf.

The Care Transitions Program, Improving Quality and Safety During CareHand-Offs [Internet]. (2007). Aurora, CO: The Division of Health CarePolicy and Research. Available from:http://www.caretransitions.org/definitions.asp

Transitional Care Model. (2008–2009). Philadelphia, PA: New CourtlandCenter for Transitions and Health. Available from:http://www.transitionalcare.info/.

REFERENCES

March 24, there was an aura of optimism anda sense of empowerment building among apassionate group of doctors, nurses, and hos-pital administrators who had convened at theHyatt Regency Baltimore for Quest 2011,

sponsored by Standard Register. They had come to this eventbecause they were committed to patient safety.They had come toexplore ideas for improving the quality of patient care and creat-ing a culture that fosters patient safety.

Erasing the LinesQuest was a different kind of forum, where interactivity wasencouraged and hierarchical lines that so often exist in a hospi-tal setting were erased as participants sought to untangle thecomplex issues of delivering safer care. It was an entirely appro-priate format for keynote speaker Dr. Peter J. Pronovost and thesubject at hand.

“I don’t believe we’ll move the agenda forward until weerase these lines and start aligning forces, guided by a goodscorecard and informed science,” Pronovost said.

Pronovost, who is a practicing anesthesiologist and criticalcare specialist physician, is medical director of the Johns Hop-kins Center for Innovation in Quality Patient Care. He is bestknown for developing a simple, research-based checklist thatdramatically reduced the rate of central line-associated bloodstream infections (CLABSIs), first in the ICU at Johns Hopkinsand then in Michigan, and it is now being rolled out to hospi-tals across the country, state by state.

Culture is LocalPronovost stressed that improvements in patient safety mustrely on both science and culture change to gain traction and sus-


tain results. He shared the model that was the foundation for thesuccessful CLASBI initiative at Michigan’s Keystone Center forPatient Safety & Quality. It combines robust measurement, amethod to put the science into practice (the checklist), and acomprehensive unit-based safety program (CUSP) that relies onthe wisdom and commitment of unit clinicians. “Culture islocal, and the individual units need to own the problems,” heemphasized.

Borrowing from behavioral scientists, Pronovost follows afour-step approach to facilitate culture change—engage, edu-cate, execute, and evaluate.“To drive change, all the stakehold-ers must be engaged—senior leadership, team leaders, andfrontline staff. They must understand what you’re asking themto do and how it will make the world better. They must knowwhat’s expected of them. It can’t be ambiguous,” he explained.

Tap into the Tribal KnowledgeIn planning a CUSP program, Pronovost urged that organiza-tions tap into their tribal knowledge and experience to assureit can be implemented, establishing specific goals, and makingpeople on the unit accountable for results. “You want to makeit easy to comply and use metrics your clinicians believe in,” hesaid.

He reiterated the need for measurement and sharing results,and told the audience to anticipate having to fine-tune the pro-cess.“Modifications need to be locally owned,”he emphasized.“External controls are highly resisted and largely ineffective,”hesaid.

People Want to Do the Right ThingPronovost underlined the importance of addressing the adap-tive issues, steering clear of judging, blaming, or shaming.“Most

A Rallying Point for Patient Safety Advocates,

a Commitment to Reshape Culture

OnBy Christine Winters

people really want to do theright thing. If they can’t, there’soften a barrier that’s preventingthem. Our job is to surface[those barriers] and under-stand them,”he said.

Inspired by Pronovost’smessage and methodology,Quest participants joined intable discussions to sharetheir top cultural challenges,exploring underlying prob-lems and ways to addressthem. In reporting back toPronovost and the largergroup, it was evident manyshared the same issues. Theydetermined what is needed isa team approach thatrespects the contributions ofeach member without regardfor title, a global view with buy-in throughout the organi-zation, greater accountability, transparency, and morefocus on protection instead of production.

Aligned in purpose, the table teams then regrouped tobrainstorm potential solutions to the challenges, sharing theirideas with the room of energized participants.

The Biggest Barrier:Whether You BelievePronovost affirmed their thinking and their determination,saying, “The biggest barrier [to improving patient safety] iswhether you believe you can actually you do this. The voice inyour head so often says, ‘I can’t do it. I’m afraid.’ This is hardstuff, but whichever one of the voices wins will determinewhether we’re going to make healthcare safe. The reality iseach of you have in you amazing leadership abilities that cando this.”

The energy and optimism of the morning’s programcarried over into the afternoon as Quest participantsjoined in discussions with two panels of distinguishedclinicians and patient safety advocates who are in thethick of reshaping healthcare delivery.

The Power of CommittedPeopleThe first discussion, which focusedon state collaboratives, offered evi-dence of the power that groups ofcommitted people can have whenthey work together to take science tothe bedside. Dr. Robert Hyzy, criticalcare director at University of Michi-gan Medical School was one of thepanelists. He leads the ICU programat Michigan’s Keystone Center forPatient Safety & Quality that first

applied CUSP to reduce CLABSI rates. “The state is a goodentity around which to rally. It’s something that works when itis animated with purpose,” Hyzy said.

He noted that competition between hospitals never stoodin the way of their progress. “We are critical care people. Thiswas a quality improvement initiative. It was important. Weended up having a bandwagon effect in our state. Peter(Pronovost) wanted 20 hospitals. We got 100, and today I canlook across the room and see 350.“

“This is not just a strike of lightning,” Hyzy continued.“People are the same everywhere. Well-intentioned people canbond together to make something happen. Today, our collab-orative is moving onto sedation delirium, assessment holidays,and early mobility statewide. That was home grown in Michi-gan. It’s too good to fail,” he said.

The Future Patient SafetyWhat of the future for others? Though an article published inthe April 1, 2011, issue of Health Affairs, “Global Trigger TollShows That Adverse Events In Hospitals May Be Ten TimesGreater Than Previously Measured,”(Claussen et al.) presents a


Stephanie Dougherty, director of patient safety and patient safety officer for Hunterdon Healthcare of Flemington, NJ, (back row, third

from left) understands the importance of alignment and brought her team of clinical unit leaders to Quest for a day of learning and

interaction with Dr. Peter Pronovost (front row, center) and other thought leaders.

Courtesy of Standard Register.

Quest sought to stimulate conversation and ideas among panelists and attendees. Shown here (left to right) are Bon Secours

St. Mary’s Julia Campbell, director of patient safety and quality; Brian Fillipo, vice president of medical affairs, and his wife,

Sherri; and Barb Olson, director of patient safety for HCA’s Clinical Services Group, at the welcome reception.

Courtesy of Standard Register.

disturbing picture of the current state of patient care, the Questpanel on “The Future of Patient Safety” offered insights to thechallenges and hope for change.

Dr. Brian Fillipo, vice president of Medical Affairs for BonSecours St. Mary’s, Richmond, Virginia, observed that health-care has had 100 years of uninterrupted advances that haveimproved technology and outcomes, but also made healthcarecomplex.“Unfortunately, how we deal with reliability in health-care hasn’t kept pace,” he said.

Over the next 10 years, however, Fillipo expects reliability toimprove. “We’re going to become more transparent, morepatient-centered, and partner with our families and patientsbetter than we’ve done before. We are going to move from a

blame-and-train mentality, and we will measure not just thenumbers of errors, but we’ll learn from them so we can antici-pate errors going forward.”

The Paradigm is ShiftingDr. Steve Pratt, chief of the Division of Quality and Patient Safe-ty for the Department of Anesthesia, Critical Care, and PainMedicine at Beth Israel Deaconess Medical Center (BIDMC) inBoston, sees the paradigm shifting as well.“We will be able to dobetter at working together in multidisciplinary ways to care forwhat is best for our individual patients, and for the groups ofpatients for whom we’re caring, whether they are on our unit, inour hospital, or in our community.”

He added,“Healthcare reform will require it, and account-able care organizations will help us to do it. Second, we will bebetter able to do it because of our IT capabilities. Third, I real-ly believe this truly possible.”

Pratt’s conviction comes from the transformation he’s seenat BIDMC where, in 2000, a series of errors during deliveryresulted in a prospective mother’s loss of her baby, a hysterec-tomy, and prolonged hospitalization (Sachs, 2005).

After that, the medical center took a 10-year journey dur-ing which it implemented interdisciplinary teams, protocols,drills, and guidelines. Pratt explained,

We’ve completely changed the culture of the way we deliver medicine.

It’s a different paradigm for the delivery of healthcare on our labor and

delivery unit. We now have multi-disciplinary teams truly working

together to care for each patient and to prioritize the care of all the

patients. Obstetricians alert anesthesiologists about concerns related to

patients that are not even theirs, anesthesiologists help make sure that

obstetricians have adequate back-up when they are busy, and nurses

help everyone. In addition, we’ve reduced adverse events by 25 percent,

and this has been sustained for seven years. So I really believe this is

doable.

Podcasts from Quest 2011 were made available to partici-pants via a private web-based hub that Standard RegisterHealthcare created to facilitate further collaboration. The com-pany will be making portions of the content available to thebroader patient safety and quality improvement communitythrough Patient Safety & Quality Healthcare (PSQH), which wasexclusive media sponsor for the event. Watch for PSQH e-alertsfor notice of their availability. ❙PSQH

Christine Winters is communications and media relations managerfor Standard Register Healthcare and editor of the company’squarterly e-newsletter, Insights for Healthcare. She was part of theteam that planned and managed Quest 2011. Winters may becontacted at [email protected].


QUEST 2011

Robert Curtis Hyzy, MD

Director, Critical Care Medicine UnitUniversity of Michigan Health SystemAnn Arbor, Michigan

Brian H. Fillipo, MD, MMM, FACP

Vice President Medical AffairsBon Secours St. Mary's HospitalRichmond, Virginia

Lorri R. Gibbons, RN, BSN, CPHQ

Vice President, Quality Improvement and Patient SafetySouth Carolina Hospital AssociationColumbia, South Carolina

Inga Addams-Pizarro

Director, Operations & DevelopmentMaryland Patient Safety CenterSilver Spring, Maryland

THE INFLUENCE OF STATE COLLABORATIVES ONPATIENT SAFETY

Stephanie Dougherty, RN, BSN

Director Patient Safety & Patient Safety OfficerHunterdon Medical CenterFlemington, New Jersey

Brian H. Fillipo, MD, MMM, FACP

Vice President Medical AffairsBon Secours St. Mary's HospitalRichmond, Virginia

Barbara L. Olson, MS, RNC, FISMP

Director, Patient SafetyHospital Corporation of AmericaClinical Services GroupNashville, Tennessee

SStephen D. Pratt, MD

Chief, Division of Quality and SafetyDepartment of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterBoston, Massachusetts

THE FUTURE OF PATIENT SAFETY

Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., &Whittington, J. C. et al. (2011 April). ‘Global Trigger Tool’ shows thatadverse events in hospitals may be ten times greater than previouslymeasured. Health Affairs, 30(4), 581-589.

Sachs, B. P. (2005). A 38-year-old woman with fetal loss and hysterectomy.JAMA, 294(7), 833-840.

REFERENCES


ow do patients and physicians view the issue ofcompassionate healthcare? Is there a gap betweenthe compassionate care that patients say should beprovided and what they experience in their ownlives? Can good communication and emotional

support—the key elements of compassionate healthcare—havean impact on whether a patient lives or dies?

These were some of the questions included in a nationalpublic opinion poll commissioned by the Schwartz Center forCompassionate Healthcare, a Boston-based nonprofit with asimple, yet compelling mission: to promote compassionatehealthcare so that patients and their professional caregiversrelate to one another in a way that provides hope to the patient,support to caregivers, and sustenance to the healing process.

The survey was conducted in the fall of 2010 among 800patients who had been hospitalized for at least 3 days within thepast 18 months and 500 physicians who spend at least some oftheir time taking care of hospitalized patients. The findings pro-vided the basis for a November 2010 symposium sponsored bythe Schwartz Center about the state of compassionate healthcarein the United States. Among the poll’s major findings were:• Both patients and physicians believe strongly that com-

passionate healthcare makes a difference in how wellpatients recover from illness and whether a patientlives or dies.

• The current healthcare system receives mixed gradeson compassion, and a majority of both patients andphysicians are concerned that the changes taking placein the U.S. healthcare system will make it even moredifficult for caregivers to provide compassionate care inthe future.

A panel of experts fromdifferent sectors of thehealthcare system dis-cussed the results fromtheir diverse perspectives.Panelists included Mau-reen Bisognano, BSN,MSN, president and CEOof the Institute for Health-care Improvement; AliceCoombs, MD, a criticalcare specialist and presi-dent of the MassachusettsMedical Society; ThomasLynch, MD, director of theYale Cancer Center, physi-cian-in-chief of theSmilow Cancer Hospital atYale-New Haven and Schwartz Center board chair; and RobertRestuccia, executive director of Community Catalyst, a non-profit advocacy organization working to build consumer partic-ipation in the U.S. healthcare system. Health Affairs Editor-in-Chief Susan Dentzer moderated the forum.

Compassion Gaps and DisconnectsDentzer began the forum on a very personal note. She told theaudience of almost 300 people that her sister was sufferingfrom late-stage lung cancer and was just days away from death,so the topic of compassionate care and the mission of theSchwartz Center for Compassionate Healthcare resonateddeeply with her.

By Julie Rosen

The State ofCompassionate

Healthcare

H

Experts discuss survey at symposium hosted by The Schwartz Center for Compassionate Healthcare.

Health Affairs Editor-in-Chief Susan

Dentzer moderated the Schwartz Center

Compassionate Care Symposium

“This is a ‘no brainer’ for much of the American public,”Dentzer said.“Almost all patients believe that compassionatecare is critical to their medical outcomes, and almost all doctorsalso believe that is the case. We know this issue resonates very,very deeply in a profound way that even transcends theresearch.” She went on to point out that “solid research doesexist. This is not just an emotional, feel-good, squishy impulse.We can prove it.”

Bisognano, whose organization, the Institute for HealthcareImprovement, works to make healthcare safer and more effec-tive, said that caregivers must be able to remove their profession-al mantle and simply talk to patients on a purely human level.“Don’t just do something, stand there,”Bisognano said, quotinga favorite aphorism of Linda Lewis, MD, the former dean of stu-dents at Columbia University College of Physicians and Sur-geons. “Ask a nonmedical question, help patients live in themoment.Ask them what the best trip was they ever took in theirlife or what was the most fun they ever had with their children.”

Coombs said that as a critical care specialist, she often talksto patients and families about end-of-life care, but manypatients never have these kinds of conversations with theircaregivers.“Once physicians start an aggressive form of thera-py, they often become locked in, believing that they must con-tinue care,” said Coombs. “But physicians need to talk to thepatient and family to find out what they really want.” Coombssaid, “Doctors believe they deliver compassionate care, butwhen it comes to end-of-life care, we get a C–.”

Lynch agreed with Coombs that a significant “compassiongap”exists, particularly at the end of life.“That’s where the workof the Schwartz Center comes in,”he said.“This gap is where theSchwartz Center works, where it tries to make a difference.”

Restuccia said that he was surprised at how positive patientsare about their hospital experiences overall, considering thecare fragmentation that exists in the U.S. healthcare system.”“Looking to the future, there is opportunity,” said Restuccia.“We have people like Don Berwick, who are looking to create ahealthcare system that is more rational and less fragmented.Weneed a healthcare system that is responsive to patients andallows caregivers to be more compassionate.”

Lynch said that despite what some people say, time is not theenemy of compassion, but rather our short attention spans.“Some of the most compassionate healthcare is seen in the ERand ICU, where physicians connect with patients they don’tknow in a matter of minutes,” said Lynch. Lynch said it’s “lazy”to blame lack of compassion on a changing healthcare system.

Teaching CompassionPanelists had a number of ideas about how to engender morecompassionate care among clinicians.“I believe compassion canbe taught and role-modeled,” said Lynch. “You can be taughthow to talk to people, and we can train physicians how to inter-act, just like we train physicians on medical concepts.” Lynchadded that current practitioners must also be included.“If all wedo is focus on medical students, it will take 30 years to makechanges to our system,” he said. “If we don’t reach mid-careercaregivers, we won’t have a chance.”

Coombs spoke of the need for physicians in training,whether they be medical students, residents, or fellows, to do a“fellowship of suffering”—a metaphorical commitment towalk with a patient through thick and thin until the end oftheir journey. As did Lynch, Coombs stressed that as the Unit-ed States becomes increasingly diverse, physicians will need tolearn to understand and appreciate cultural differences, animportant component of compassionate healthcare.


Rooted in the experience of one patient,the Schwartz Center for CompassionateHealthcare—based at MassachusettsGeneral Hospital in Boston and online atwww.theschwartzcenter.org—has growninto a national organization that addresses a common concern of bothpatients and caregivers.

In 1994, healthcare attorney Kenneth Schwartz, 40, was diagnosed withlung cancer. During his 10-month ordeal, he came to realize that what mat-tered most during his illness was the human connection he had with hisprofessional caregivers. He wrote movingly about his experience in an arti-cle for the Boston Globe Magazine, “A Patient’s Story,” in which he remind-ed caregivers to stay in the moment with patients and emphasized how“the smallest acts of kindness made the unbearable bearable.” The piecehas become a touchstone for the Schwartz Center and for patients andcaregivers throughout the United States.

At the end of his life, Schwartz outlined the organization he wanted cre-ated in his name, with a bequest from his estate. It would be a center thatwould nurture compassion in medicine—encouraging the sorts of caregiv-er-patient relationships that made all the difference to him.

The Schwartz Center for Compassionate Healthcare’s signature programis Schwartz Center Rounds, now conducted at more than 200 hospitals, out-patient centers, and nursing homes across the country. The sessions pro-vide a unique forum where caregivers from diverse disciplines can discussand reflect upon the most difficult emotional and psychosocial challengesof caring for patients. In contrast to traditional clinical or ethics rounds,Schwartz Center Rounds focus on the human dimension of medicine. Care-givers discuss actual patient cases and share their experiences, thoughts,and feelings. Rounds make caregivers examine their prejudices, their feel-ings of loss when patients die, their frustration with “difficult” patients, andtheir beliefs about spirituality and religion, among other topics.

The Schwartz Center’s other programs include:

Clinical Pastoral Education for Healthcare Professionals. An intensive

course for physicians, nurses, social workers and other clinicians

that teaches them how to integrate spiritual caregiving skills into

their practice.

Grants. Financial support for projects that improve communications

skills, especially in the areas of cultural competency, end-of-life

care, and spirituality.

Speaker Series. Educational programs for healthcare professionals

that explore the most topical issues related to compassionate

healthcare.

The Schwartz Center Compassionate Caregiver Award®. An annual

awards program that honors a caregiver who displays extraordinary

compassion in caring for patients as well as award finalists.

Honor Your Caregiver. A program through which patients can honor

and recognize their caregivers for providing compassionate care.

THE SCHWARTZ CENTER FORCOMPASSIONATE HEALTHCARE

Bisognano pointed to several programs that are instill-ing students with a greater sense of compassion forpatients. One at Hofstra North Shore-LIJ School ofMedicine puts new medical students into ambulanceswith emergency medical technicians during their firstthree months of training, according to Bisognano. “Thefirst patients these students see are in their homes or onthe street,” said Bisognano. “Their first experience is as thelowest caregiver. They’re learning from the bottom up. It’sbeen transformational for the medical students.”

Bisognano also mentioned University of Pittsburgh Medi-cal Center orthopedic surgeon Anthony M. DiGioia, MD, whoassigns each medical student a patient who is having either ahip or knee replacement.“Students take the entire journey withtheir patients,” Bisognano said.“They learn about the patient’spain, their dietary problems, their home environment, observ-ing details as small yet vital as whether they have a ‘grab bar’ intheir shower.”

Public Policy SolutionsModerator Dentzer asked panelists whatchanges in public policy could strengthenthe patient-caregiver relationship.Coombs pointed to the patient-centeredmedical home model, which ensures that“you’re never left out in the cold,” as sheput it.“You have a care community, focus-ing on primary care, creating close con-nections between patients and caregivers.You don’t have to feel like you’re in astrange land.”

Lynch said he believes healthcareinformation technology plays animportant role in improving care fortwo reasons: it gives clinicians easyaccess to current and accurate infor-mation about patients and facilitates“seamless” communication. Inresponse to criticism that computers inthe exam room get in the way ofpatient-physician communication,Lynch said, “We need to redesign examrooms so the computer and the patientare in the same line of vision.”

Dentzer concluded the symposium byemphasizing the importance of compas-sionate care, noting that all Americanshave a stake in it. “What we know is thatcompassion matters, there’s no substitutefor it, there’s no time but the present tomake our healthcare system more com-passionate, and it’s never been moreimportant,” she said. ❙PSQH

Julie Rosen has served as executive director ofthe Schwartz Center for CompassionateHealthcare in Boston for the past 7 years andhas worked in the healthcare field for morethan 25 years. Prior to joining the SchwartzCenter in 2004, she was an assistant vicepresident at Tufts Health Plan in Boston andexecutive director of the Conference of BostonTeaching Hospitals. She is a graduate of TuftsUniversity and holds a master’s degree inhuman services management from the HellerSchool for Social Policy and Management atBrandeis University. She can be reached [email protected].


COMPASSIONATE HEALTHCARE

M E D I C A T I O N S A F E T Y

By Susan Stinson, RN, FACHE

While most mainstream media coveragein recent months has framed discus-sions of healthcare reform around issuesof access and cost management, there isan equally critical type of healthcarereform evolving within hospitals thatimpacts nearly every patient—improv-ing medication safety. While it is unde-niably a question of enhancing patientsafety, there are strong economic moti-vators behind these initiatives as well.

Ten years ago, the median compen-sation award for medication errors wasa staggering $668,000, a figure that mostassuredly skyrocketed during the lastdecade. Additionally, each adverse drugevent (ADE)—the profession’s languagefor drug-driven harm to the patient—costs the hospital an average $8,750 totreat, a significant amount that cannotbe billed to the patient’s insuranceprovider. With 4 out of 10 medicalerrors in U.S. hospitals related to medi-cation mismanagement, such hits to thealready strained bottom lines of U.S.hospitals are causing more and morehospitals to question their own medica-tion safety practices.

More often than not, increasedreliance on technology is seen as theprimary action for improving medica-tion safety. Yet the sizable investmentrequired by many technology solutionscan also be the core reason why cash-strapped hospitals and care facilitiespostpone implementation.

Truth be told, however, better tech-nology is only half the solution; the“people” component is equally impor-tant.

Improving Medicine SafetyStep by StepStudies indicate that more than half themedication errors that reach the patientoccur in the last 100 feet to the bedside.Not surprising, institutions currentlyleading the safer medicines movementliterally walk that distance in the shoesof their doctors and staff to better

understand the daily challenges theyconfront, directly and indirectly, to getthe right medication in the right dose tothe right patient at the right time.

Limited resources, increased work-loads, sicker patients, new technologiesthat require training and process design,evolving regulatory requirements andpractice variation are among the mostcommon underlying causes for ADEs.To devise meaningful safe medicationpractices, it is imperative that hospitaladministrators and their risk manage-ment teams first understand the medi-cation process as it unfolds on theirunits rather than simply in the idealworld of a procedures manual. Only bydoing so can they truly understand howand where human error transpires.

Having walked numerous hospitalhallways step-by-step with their multi-disciplinary teams to identify opportu-nities to streamline their drugdispensing and administration process-es, there are certain things that forward-thinking hospitals consistently do rightfrom the “people” perspective. Chiefamong them:

Adopt a holistic approach. Safemedication practices require more thansound policy. They require a safety cul-ture. As such, mitigating an institution’smedication-related risks should not bedelegated to one administrative func-tion or medical team for oversight. Norshould one group be held solelyaccountable.

Appoint an executive sponsor.While cultivating a medication safetyculture requires multidisciplinary par-ticipation and dedication, it alsorequires an executive-level sponsor toinitiate that first step. The executivesponsor plays a critical role in champi-oning the cause and acting as the inter-nal voice of change.

Identify and engage committedfront-line ambassadors to “walk thetalk” on medication safety. Forward-thinking companies facing

organizational change recognize thatintroducing new practices andphilosophies requires more thansolid, committed leaders to spread themessages in meaningful ways. It alsorequires fully engaged staffers outsidethe C-suite to cascade those messagesthroughout the organization and helpimplement them.

Foster a more collaborative rela-tionship between the pharmacy andnursing functions that reflects theirshared responsibility in delivering safemedications to patients. Once a medica-tion enters the hospital system, there aretwo primary functions that are respon-sible for its physical handling – pharma-cy and nursing. Consequently, it isimperative that both teams work as aunified force in driving safety improve-ments.

Appropriate and safeguard adedicated budget that reflects thecritical importance of maintaining aculture of safer medications.Organizational change does notcome easily, quickly, or without cost.It requires a long-term commitmentof people and financial resources todiligently, continuously push safemedicine standards. A one-time spe-cial project allocation cannot deliversustainable, meaningful change.

By streamlining and optimizing theprocesses by which medication-relatedtools and technologies are used, patientsafety-oriented hospitals are reportingnot only fewer mistakes, but also staffproductivity and performance gains,more consistency in medication out-comes, reductions in medicine shrink-age, and realized cost savings from thedecreases in ADEs.

Decreased costs and better patientoutcomes? Now that’s an easy pill toswallow. ❙PSQH

Susan Stinson is vice president and clinicalpractice lead at AmerisourceBergen. She maybe contacted [email protected]


The “Other” Healthcare Reform Movement

The headline would scream if printcould speak: Superbug found in Califor-nia hospitals!

Over seven months in 2010 therewere more than 350 cases of carbapen-em-resistant Klebsiella pneumoniae(CRKP), according to a study by theLos Angeles County Department ofHealth. The cases were in healthcarefacilities such as hospitals and nursinghomes. CRKP has been officiallyreported in 36 states, but health offi-cials expect it’s also in the 14 otherstates where reporting is not required.

Only one antibiotic, colistin, iseffective against CRKP and, accord-ing to Dr. Arjun Srinivasan,associate director for healthcareassociated infection prevention atthe Centers for Disease Control andPrevention, it doesn’t always workand can cause kidney damage.

Once news like this hits thepapers, people get nervous abouthospitals; procedures that shouldbe done are postponed; doctors areinundated with queries about thesafety of family members who arecurrently in the hospital; infectioncontrol becomes highly visible. Insome respects, that last point isactually a benefit from the head-line.

People need to be reassured thatinfection control procedures are inplace throughout the facilities theydepend on for their healthcare. Thisis especially true in the ICU accord-ing to Cindy Plante-Jenkins,infection control specialist at RLSolutions, a Toronto-based softwareand services company offering solu-tions for infection surveillance.“This is obviously due to the inva-sive nature of the treatments and thefact that patients are often immunecompromised while there. Other


By Tom Inglesby

I N F E C T I O N C O N T R O L S H O W C A S E

Battling the Bugs

areas of concern are wards andshared rooms and, of course, theemergency department wherealready-infected admissions can takeplace. The problem is that health-care workers do not follow routinepractices. Rapid detection and iden-tification, initiating the properprecautions, and following up con-tacts are important in preventingfurther transmission.”

Trish Roberts, infection preventionand control consultant at RL Solutionsadds, “The operating suite must be asterile environment with an effectiveinstrument reprocessing program,adherence to surgical technique, atten-tion to skin asepsis, the administrationof appropriate prophylactic antibiotics,and maintenance of normothermia.Once the patient is transferred toICU/CCU the concern moves to com-pliance with ‘5 moments for handhygiene,’ adherence to CVC & VAP*bundles, cleaning shared patient equip-ment, strict adherence to cleaning pro-tocols, and healthcare worker educationaround infection control principles.”

Hospitals need strong infectioncontrol departments with adminis-trative support; proper staffing toensure education of patients, staffand visitors; and modern tools to beable to quickly track, follow up,monitor, and analyze infectionswithin the facility. There must beproperly staffed and trained envi-ronmental services departments toensure environmental cleaning isdone properly and thoroughly.

For example, Bemis Health Care,Sheboygan Falls, Wisc. offers itsQuick–Drain system as a means forsafe liquid-waste management,reducing cost and exposure by emp-tying canister contents directly intoa sanitary sewer system. By confin-

ing liquid infectious waste andthereby reducing splash and air-borne risks, Quick–Drain easesenvironmental impact, reduces redbag waste cost, removes the need forsolidifiers or disposables, requiresno electricity and satisfies OSHA'sBloodborne Pathogen Standardwhile complying with EPA, CDCand NIOSH guidelines.

High turnover areas such as emer-gency, endoscopy, diagnostic imaging,etc. require special consideration asthere is pressure to get another patientinto the bed as soon as possible. And, ofcourse, senior management needs tosupport, model and value infectioncontrol and environmental services ini-tiatives and activities.

Still, as Plante-Jenkins says,“Patientsneed to be their own advocates, oftenwhen they are not in a state to do so —asking the surgeon about his or herinfection rates, asking caregivers if theyhave washed or sanitized their handsprior to delivering care, asking hospitalsabout any current or recent outbreaks,looking at the publicly reported data ofthe healthcare organization they aregoing to be in and comparing to otherhospitals of similar size and mix ofpatients.” ❙PSQH

*CVC – central venous catheter, VAP- ventilator-associated pneumonia

Tom Inglesby is an author based inSouthern California who has coveredautomatic identification since the early1980s.

Senior managementneeds to support,model and value infection control

Most agree that the solution to our

nation’s health care challenges remain elu-

sive and difficult… perhaps the ultimate in

Quality Conundrums. So I awaited with

great excitement the April announcement

by HHS Secretary Kathleen Sebelius and

Administrator of the Centers for Medicare

& Medicaid Services Donald Berwick

regarding the launch of the Partnership for

Patients: Better Care, Lower Costs. This

program comes with a price tag of one bil-

lion dollars, with federal funding available

through the Affordable Care Act. Half of

that money will drive through the Com-

munity-based Care Transitions Program,

and the remainder will flow through the

CMS Innovation Center.

The laudable goals of the partnership

are:

1) to keep patients from getting

injured or sicker in the hospital,

with an associated metric of

decreasing preventable hospital-

acquired conditions by 40% (from

baseline 2010 till end 2013), saving

an estimated 60,000 lives; and

2) to help patients heal without

complications, decreasing pre-

ventable complications occurring

during care transition by 20% in the

same time frame.

The potential savings from this project,

over the next 3 years, have been estimated at

10 billion dollars to the Medicare program.

While I fully support this initiative, I

am disappointed by the emphasis on

improving the flaws in our existing system,

rather than revisiting the core issues that

cause illness. Would we be better served by

developing a more effective universal

approach to the diffusion and use of best

practices, certainly with regard to managing

and preventing complications, but even

more importantly, by maintaining health

and avoiding illness to begin with? What

new partnership would you design?

For more information about the Part-

nership for Patients, see the department’s

press release at http://www.hhs.gov/

news/press/2011pres/04/20110412a.html.

Please send inquiries and comments to [email protected], please use Quality Column in the subject line.

We look forward to your participation in this new column.

Lynn Helmer, MD, MBA, CHCQM • ABQAURP Diplomate since 1998 • http://www.drdnj.com

PARTNERSHIP FOR PATIENTS: A NEW QUALITY CONUNDRUM?

Want to be featured in

Patient Safety & Quality Healthcare?

ABQAURP wants to recognize members for their

achievements in advancing the field of healthcare quality

management and patient safety. Please send your news to

ABQAURP by email to

[email protected]

for consideration.


A B Q A U R PA B Q A U R P

As a Diplomate or AIHQ Member, you are ABQAURP’s strongest and most valuable

resource.Your involvement in this year’s membership development campaign plays an essen-

tial role in ensuring the vitality of our organization. A strong membership foundation

ensures a strong association!

ABQAURP will be rewarding the member who recruits the largest number of new

members with a $200 VISA gift card plus a Member Spotlight on the home page of

ABQAURP’s website. In addition, Diplomates and AIHQ Members continue to earn a $25

credit for each referred individual who converts to an AIHQ or Corporate Member or sits

for the HCQM Certification Exam by December 31, 2011. This credit may then be used

toward membership fees, publication purchases, or conference registrations. The top

recruiter will be awarded the prize in January 2012.Visit www.abqaurp.org and go to the

“Member’s Only” page for eligibility rules and full details.

ADVANCE A COLLEAGUE'S CAREER ANDHELP STRENGTHEN YOUR ORGANIZATION

QUALITY CONUNDRUMS

MEMBER UPDATE“Like” us on Facebook and join in a Discussion for a

chance to win exciting prizes. Discussion questions are

posted weekly with prize drawings every month.

For more information, please call Deborah Naser at (800) 998-6030, ext. 118.

deeply committed to patient safety,health care quality, and effectivecare. Those certified in HCQM havedemonstrated superior skills in theirability to critically evaluate the liter-ature, identify evidence-based bestpractices, and make a recommenda-tion that balances appropriatenessof services with cost and quality.HCQM certification addresses theneed for effectiveness, efficiency,equity, safety, and timeliness.

We are now accepting applications forthe 2011 International Health CareQuality and Management (HCQM)Board Examination.

ABQAURP is dedicated to establish-ing Health Care Quality and Manage-ment as a specialty with definablestandards upheld by knowledgeableexperts.

Professionals who have achievedcertification in Health Care Qualityand Management (HCQM) are

UPCOMING ABQAURP ACCREDITED EVENTS


N E W S N E W SABQAURP

American Board of Quality Assurance and Utilization Review Physicians, Inc.

6640 Congress StreetNew Port Richey, Fl 34653

Toll-free 800/998-6030 • Tel. 727/569-0190Fax. 727/569-0195 • www.abqaurp.org

HCQM CERTIFICATION EXAMINATION

ABQAURP welcomes applications for joint sponsorship of educational activities for continuing

education credit. ABQAURP accredits a variety of activities, including:

• Live Activity • Internet Activity Live

• Enduring Material • Internet Activity Enduring Material

• Journal-Based CME • Performance Improvement

ABQAURP is accredited by the Accreditation Council for Continuing Medical Education

(ACCME) to sponsor continuing medical education for physicians and is also accredited by

the Florida Board of Nursing to sponsor nursing contact hours. As an accredited provider,

ABQAURP is here to work with each joint sponsor organization to ensure the accreditation

process runs as smoothly as possible. Benefits of working with ABQAURP include: one-on-

one assistance, on-site assistance, contact for speakers and commercial supporters, evaluation

compilation, one-time mailing list to drive attendance, website placement, and advertising in

Patient Safety & Quality Healthcare magazine.

ABQAURP believes that ongoing continuing education in new research, identified prob-

lem areas in clinical practice, and areas of interest in the quality assurance, utilization review,

risk management, and managed care fields is a worthy endeavor to pursue. Participants

improve the efficiency, effectiveness, and quality of health care delivered to the patients to

improve the overall clinical outcome. Plus, each activity encourages participants to put into

practice knowledge learned and assess the impact. Innovative courses provide important

updates and practical tools for all health care professionals. These activities ensure that par-

ticipating health care professionals receive up-to-date information on the ever-changing

health care environment.

IS YOUR MEDICAL EDUCATION ACCREDITED?

Visit the website at www.abqaurp.org and choose Certification for more information.

To accredit your educational events for continuing education credit, contact Deborah Naser at 800-998-6030, ext. 118.

JOINT SPONSORSHIPS

Philips-VISICU

The Source:What's New Monthly Articles October 1, 2010 – September 30, 2012

(online Education)

http://www.abqaurp.org/module2.asp?CourseID=66

Capitol Spine & Pain Centers (CSPC)

Conservative Approach to Low Back PainMay 25, 2011

Fairfax,VA

www.treatingpain.com

Illinois Hospital Association (IHA)

Better to Best: IHA 2011 Annual Quality

Leadership ConferenceJune 1–2, 2011

Lisle, IL

www.ihatoday.org

URAC

Medication Adherence Summit:A Crucial

Link to Healthcare ValueJune 3–4, 2011

Washington, DC

www.urac.org

Capitol Spine & Pain Centers (CSPC)

Cervical RadiculopathyJune 22, 2011

Fairfax,VA

www.treatingpain.com

ABQAURP EVENT

Save the Date!34th Annual Conference and

2nd Annual Nursing ConferenceNovember 4-5, 2011

The Westin Riverwalk

San Antonio,TX


Patient Safety and Quality Healthcare (PSQH)welcomes original submissions from all healthcare professions on topics related to safety and quality.PSQH publishes a variety of articles, to reflect the breadth of workbeing done in this field: case studies, surveys, research,book or technology reviews,guest editorials, essays, and letters to the editor.

Please send manuscripts,proposals and inquiries directly to the editor,preferably by e-aail:

S U S A N C A R [email protected] 978/287-0195 • F 978/287-9565349 Lexington Road, Concord, MA 01742

With submissions, authors should include contact information including mailingaddress and telephone number and a biographic sketch of no more than 100 words.

C O P Y R I G H TArticles are accepted for publication with the understanding that they are original andwill be published exclusively in Patient Safety and Quality Healthcare.All authors are asked to sign a release form (available at www.psqh.com) that assignscopyright ownership to Lionheart Publishing, Inc.

Conference Calendar

Visit www.psqh.com for more conference listings.

2 0 1 1

IBC ABQAURP800.998.6030www.abqaurp.org

3 AHI OF INDIANA, INC.866.653.6660www.ahiofindiana.com

47 BEMIS HEALTH CARE

800.588.7651www.bemishealthcare.com

40 ENDUR [email protected]

21 HEALTHLINE SYSTEMS, INC.800.733.8737www.healthlinesystems.com

37 NATIONAL PATIENT SAFETY FOUNDATION

617.391.9900www.npsf.org

31 NEXT LEVEL PARTNERS

[email protected]

IFC OHIO MEDICAL CORPORATION

866.549.6446www.ohiomedical.com

47 THE PATIENT SAFETY GROUP

617.418.1805survey@patientsafetygroup.comwww.patientsafetygroup.org

1, 47 RL SOLUTIONS

www.rlsolutions.com

43 SAFER HEALTHCARE

866.398.8083www.saferhealthcare.com

BC SAGE PRODUCTS, INC.800.323.2220www.sageproducts.com/preserveheels

13 STANDARD REGISTER

[email protected]/wristband

24-25 THE QUALITY COLLOQUIUM

800.684.4549www.QualityColloquium.com

41 UNIVERSITY OF MICHIGAN,

COLLEGE OF ENGINEERING

InterPro.engin.umich.edu/LeanHealthcare

Aut

hor

Gui

delin

esA

utho

r G

uide

lines

June 8-10

Annual Conference on Quality andPatient SafetyThe Joint Commission and Joint Commission ResourcesHilton ChicagoChicago, ILwww.jcrinc.com

June 20-21

Innovating to Improve Health CareInstitute for Healthcare ImprovementHyatt Harborside HotelBoston, MAwww.ihi.org

June 27-29

APIC Annual ConferenceAssociation for Professionals in Infection Control andEpidemiologyBaltimore Convention CenterBaltimore, MDhttp://conference.apic.org

July 11-12

Business Intelligence & Analytics forHealthcare8th Annual Healthcare UnboundThe Center for Business InnovationManchester Grand Hyattwww.tcbi.org

August 15-18

The Quality ColloquiumHeld on the campus of Harvard UniversityCambridge, MAwww.qualitycolloquium.com/

September 12-14

Patient Safety Strategy WorkshopJohns Hopkins Center for Innovation in Quality Patient CareBaltimore, MDwww.regonline.com/safetystrategy

September 12-16

Forces of Change: New Strategies forthe Evolving Health Care MarketplaceHarvard School of Public HealthBoston, MAhttps://ccpe.sph.harvard.edu/Forces

October 16-19

ASHRM Annual Conference &ExhibitionAmerican Society for Healthcare Risk ManagementPhoenix Convention CenterPhoenix,AZwww.ashrm.org

October 19-21

Connected Health SymposiumCenter for Connected HealthBoston Park Plaza Hotel & TowersBoston, MAwww.connected-health.org

A D V E R T I S E R S ’ I N D E XA D V E R T I S E R S ’ I N D E X

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