Are hospital quality/safety metrics used by payers & accrediting organizations getting ahead of the science of q/s measurement? (I)

Back in the day one of our system’s community hospitals achieved the top rating for obstetrics from one of the for-profit hospital rating companies and then, before it could be stopped, bought an obstetrics marketing package from the company. This was cherry-picking since the hospital did not receive marketable ratings on the company’s other clinical categories.


Look at the web sites of the three hospitals nearest to you and compare how they post hospital safety and quality report card information.

Find additional models of patient safety/ quality not based mostly on available Medicare data.

PREQUEL: Hospital web site archeology.

“It sure seems like there’s been a lot of bad news for and about hospitals — specifically, about their protections for patients’ safety.

Driving the news:

•             A WebMD/Georgia Health News investigation found a third of the country’s hospitals have violated basic federal rules for providing emergency care.

•             Baylor St. Luke’s Medical Center is now drawing scrutiny for poor outcomes with its liver and lung transplants, after ProPublica and the Houston Chronicle highlighted failures with heart transplants.

•             Kids at the Johns Hopkins children’s hospital in Florida are dying “at an alarming rate,” the Tampa Bay Times recently reported.

•             The federal government is threatening to end Medicare and Medicaid funding at Vanderbilt University Medical Center after a patient died from getting the wrong medication.

•             A large Detroit hospital faces the same threat due to dirty surgical equipment.

What they’re saying: “We are unnecessarily killing thousands of people every year because hospital quality is not what it should be,” says Leah Binder, CEO of the Leapfrog Group, an organization that grades hospital care.

•             “There’s lots of ratings that will say, ‘This is the No. 1 hospital, this is the great hospital list.’ But what we also need are ratings on where not to go,” Binder says. “But there’s some risk to exposing and embarrassing any part of that.”” (A)

Physician Licensing

“In Louisiana, Larry Mitchell Isaacs, MD, gave up his medical license in the face of discipline, after he removed an allegedly healthy kidney during what was supposed to be colon surgery.

In California, he mistakenly removed a woman’s fallopian tube. According to medical board records, he thought it was her appendix — which already was gone. More surgeries on the woman followed, including one in which he allegedly left her intestine unconnected.

Facing state sanctions, he surrendered his license there, too.

In New York, where regulators were moving to take action based on his California problems, he also agreed to give up his license.

But in Ohio, he has found a home.

There, his medical license remains unblemished, allowing Isaacs to work at an urgent care clinic in the Cincinnati area.” (B)

“Look up the Wisconsin medical license for John Kidd, MD.

All that is posted is a document that says he gave up his Wisconsin license in 2012 because he had moved to New York and didn’t plan to practice again in the state.

Look up Kidd’s license in New York and there is no indication of any allegations of poor care or wrongdoing against him there — or anywhere else in the country.

But, documents obtained by the Milwaukee Journal Sentinel, USA Today, and MedPage Today offer a different picture.

They show Kidd was terminated in 2010 by his employer, a business that provides anesthesiology services for Theda Clark Regional Medical Center in Neenah, Wis., after a series of alleged incidents earlier that year:

When a patient had trouble breathing, Kidd would not help a nurse and doctor who had rushed to the patient’s aid.

When a patient who was having a limb amputated complained of pain and discomfort, Kidd was on his cellphone and did not respond promptly.

A nurse thought he was once impaired at work and smelled of alcohol…

Kidd, 53, is one of more than 250 doctors who surrendered their medical license since 2012, but who were still able to practice in another state, an investigation by the news organizations found.” (C)

“The Medical Board of California has begun monitoring warning letters sent by the FDA to physicians engaged in potentially harmful practices, following a Milwaukee Journal Sentinel/MedPage Today report earlier this year about the failure of states to act on allegations raised in the letters.

That investigation found that 73 physicians around the country with active medical licenses had been the subject of FDA warning letters alleging serious problems over a five-year period, but only one had been disciplined.

The warnings involved fertility clinics that didn’t test donors of eggs and sperm for communicable diseases; researchers who didn’t follow rules designed to protect patients who volunteer for trials of drugs and devices; physicians who pushed dubious treatments and supplements to unwitting customers; and a mammography clinic faulted for inadequate quality control testing…

“The Board reviews the letters and if they contain information regarding physicians licensed by the Board, the Board looks into the matter,” he said in a recent email. The practice began in June, but only now is being confirmed…” (D)

“When it comes to improving the nation’s broken system of physician discipline, many advocates say the starting point should be fixing something that was created to do the job in the first place.

In 1986, Congress created the National Practitioner Data Bank (NPDB), pledging it would improve healthcare and reduce fraud and abuse. The data bank records all sorts of things: malpractice payments, disciplinary action, restrictions of hospital privileges, and other transgressions.

There are just three problems:

The system can be gamed, so not all problem physicians appear on the list.

State medical boards don’t always check the data bank.

And, the information is off limits to those who are most at risk: patients….

Here is a look at five other ways to improve the system:

1. The Problem: Uneven discipline. A physician who holds licenses in multiple states can lose a license in one, but get lesser or no discipline in another…

2. The Problem: Dead letters. When the FDA performs investigations and sends warning letters to physicians — a rare step that indicates serious matters — the letters typically go only to the physician. Copies are rarely sent to medical boards in the states where the physicians are licensed…

3. The Problem: Cryptic surrenders. In some cases, a physician facing discipline agrees to surrender his or her license prior to a hearing or formal charge. That can keep potential problems out of the public eye…

4. The Problem: Inconsistent data. State medical boards vary dramatically when it comes to the information they include on their websites about a physician’s background…

5. The Problem: Medicare payments. Physicians who lose their licenses in one state, or who are banned from a state Medicaid program due to problems such as fraud or putting patients in harm’s way, can still collect money from the taxpayer-financed Medicare program.” (E)

The Joint Commission

“Facts about the National Patient Safety Goals

In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program

The first set of NPSGs was effective January 1, 2003

The NPSGs were established to help accredited organizations address specific areas of concern in regard to patient safety

Development of the Goals

Following a solicitation of input from practitioners, provider organizations, purchasers, consumer groups and other stakeholders, The Joint Commission determines the highest priority patient safety issues and how best to address them, including as a NPSG. The Joint Commission also determines whether a goal is applicable to a specific accreditation program and, if so, tailors the goal to be program-specific.” (F)

“The Joint Commission (TJC) requires compliance with standards that will result in continuous improvement in support of safe, high quality care. Accreditation surveys, mid-cycle performance reviews, self-assessments, and plans for corrective action all drive your organization to achieving continuously higher levels of quality of care and patient safety.

QPS consultants can guide your organizations through the intricacies of TJC accreditation process as well as the CMS survey. We are subject matter experts in the accreditation process for organizations that provide behavioral health care and substance abuse treatment.  We have substantial professional experience with accreditation and regulatory surveys for organizations that provide behavioral health care and an in-depth knowledge of the standards being reviewed. QPS consultants can partner with your organization to achieve or maintain your honored status of accreditation.” (G)

“The Trump administration is weighing whether to continue approving hospital and health-accreditation groups that also have consulting arms, following potential conflicts of interest raised in an article in The Wall Street Journal.

The disclosure came in an announcement by the Centers for Medicare and Medicaid Services that it is seeking input on possible conflicts of interest.” (H)

Quality Measures Linked to Physician Reimbursement

“Physician reimbursement increasingly depends upon measures of healthcare quality. Physicians who fall short on quality measures now face financial penalties. But it might be quality measures, themselves, that are falling short, according to a study conducted by the American College of Physicians.

The study involved a panel of people with expertise in evidence-based medicine. Panelists were asked to evaluate the validity of quality measures being used by either Medicare, the National Committee for Quality Assurance, or the National Quality Forum. It is typically measures from these three groups that are used to determine physician quality report cards, and Medicare plans to use its measures to influence reimbursement for individual clinicians…

How do quality measures from these three groups stack up? The experts reviewed each measure and determined whether it was valid, uncertain, or invalid. They looked at 86 quality measures that Medicare will use as part of its MIPS program (an acronym for Merit-based Incentive Payment System). Barely more than a third of these measures were valid. The measures from NCQA and NQF came out better, with 60% and half being judged valid, respectively. But that still leaves a huge number of quality measures that are either uncertain or out and out invalid…

Their results strongly suggest that the use of quality measures, by payers and accrediting organizations, has gotten ahead of the science of quality measurement.” (I)

Electronic Medical Record Algorithms

“Several patients seen in our practice recently were significantly and dramatically transformed by the electronic health record (EHR). And not in a good way.

Take, for instance, the patient whose outside chart was reviewed when she showed up in our office for a follow-up appointment after an emergency department visit.

The notes from the emergency department providers, including a scribe and the attending physician, described her in the following way:

“This 67-year-old woman with morphine sulfate presented after a fall with injury to her head.”

Throughout the documentation, they kept referring to her as a patient with morphine sulfate.

For a while, as I read through it, my eyes skimmed over this, and it didn’t really register as something I needed to pay attention to.

Perhaps they were taking note of the fact that she had morphine sulfate with her when she arrived, had taken morphine sulfate before the fall, or was requesting morphine sulfate to ease her pain.

Only after diving deeper into her past medical history in our own chart did I realize that someone must’ve typed “MS”, and the computer auto-corrected and somehow turned that into morphine sulfate, instead of multiple sclerosis.

I’m not sure how their system works, but most of the functionality of EHRs that has been created to prevent medical confusion from abbreviations offers you a choice of what it thinks you’re looking for, the most obvious or most common diagnoses usually typed by physicians.

So maybe the system saw “MS” and offered up morphine sulfate, multiple sclerosis, mitral stenosis, myasthenic syndrome, magnesium sulfate. Pick one.

Or maybe their system just turned “MS” into morphine sulfate without giving them any choice.” (J)

“Patients often struggle to have errors in their medical records corrected, according to a recent CNBC report.

About 70 percent of patient records have wrong information, sociologist Ross Koppel, PhD, told CNBC.

For one patient — 20-year-old Morgan Gleason — the errors in her medical record claimed she had twice given birth and was diabetic. But she’s never been pregnant, nor been diagnosed with diabetes, she told CNBC.

When Ms. Gleason tried to have her records corrected, the hospital insisted she was wrong, she said. In fact, the hospital told Ms. Gleason that if she hadn’t given her physician the information, it wouldn’t have been in her chart in the first place. It wasn’t until Ms. Gleason made a written request for a correction of her record that changes were made.” (K)

“When Liz Tidyman’s elderly parents moved across the country to be closer to their children and grandchildren years ago, they carried their medical records with them in a couple of brown cardboard folders tied with string.

Two days after their arrival, Tidyman’s father fell, which hadn’t happened before, and went to a hospital for an evaluation.

In the waiting room, Tidyman opened the folder. “Very soon I saw that there were pages and pages of notes that referred to a different person with the same name — a person whose medical conditions were much more complicated and numerous than my father’s,” she said.

Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future. “That was a wake-up call,” she said…

In the worst-case scenario, an incorrect diagnosis, scan or lab result may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment. This, too, is something that Tidyman’s father encountered soon after moving from Massachusetts to Washington. (Her parents have since passed away.)

When both his new primary care physician and cardiologist asked about kidney cancer — a condition he didn’t have — Tidyman reviewed materials from her father’s emergency room visit. There, she saw that “renal cell carcinoma” (kidney cancer) was listed instead of “basal cell carcinoma” (skin cancer) — an illness her father had mentioned while describing his medical history.

“It was a transcription error; something we clearly had to fix,” Tidyman said.”  (L)

“Health systems use numerous methods to exchange patient medical records, but providers continue to rely heavily on the old-fashioned approach of mail or fax, according to new federal data on interoperability.

Nearly three-quarters of non-federal acute care hospitals routinely use fax or mail to receive summary of care records from providers outside their system, according to new data released by the Office of the National Coordinator for Health IT. Two-thirds of health systems use fax or mail to send records…

But hospitals also employ a wide variety of methods to exchange records. Nearly 80% of hospitals used more than one electronic method to send records in 2017. However, a quarter of hospitals are not receiving records electronically at all…

The number of methods used is a detriment to health systems, ONC concluded, adding that its Trusted Exchange Framework could help streamline those options.

“The number of exchange methods hospitals need to ensure that they have information electronically available and subsequently used, contributes to the complexity and costs of exchange,” the agency wrote. “These complexities and increased costs are often cited as barriers to interoperability. Efforts, such as the Trusted Exchange Framework, might help to simplify the exchange of health information through the use of health information networks.”” (M)

Hospital Report Cards

“Consumers are getting “mixed messages” from the CMS Hospital Compare website and penalties levied by the Hospital Readmissions Reduction Program, undermining their ability to shop for quality care, according to a study in The American Journal of Managed Care.

The researchers compared hospital grades posted on Hospital Compare for heart failure and acute myocardial infarction readmissions with the HF and AMI scores for excess readmissions used to set penalties under HRRP. They also looked at how often hospitals were penalized for just one or two of the five HRRP conditions, since the penalty program affects a hospital’s sum Medicare payments.

Of 2,956 hospitals, 92% were deemed “no different” than the national HF readmissions rate on Hospital Compare, yet nearly half (49%) scored high for HF readmissions under HRRP and 87% received an overall readmissions penalty.” (N)

Emergency Medicine Physicians/ Sleep Deprivation

 “Sleep deprivation and fatigue have plagued emergency room physicians for decades but apparent widespread use of sleeping aid medications entails risks.

A recent study found more than half of ER physicians reported actively using a sleeping aid medication. Sleeping aid medications pose risks to physician wellbeing such as rebound insomnia. Negative cognitive effects of sleeping aid medications can last hours after awakening. Use of sleeping aid medication among emergency department physicians is likely far more common than previously reported, recent research shows. Fatigue has been linked to cognitive impairment among ER physicians but sleeping aid medication is a problematic solution. Sleeping aid medication fails to induce normal sleep stages and their progression to natural sleep, and health concerns have implications for physician wellbeing such as rebound insomnia after discontinuance of medications…. The most commonly used medication was a nonbenzodiazepine hypnotic such as Ambien…

ER physicians need the same kind of duty-hour restrictions that were established for medicine residents by the accrediting agency for graduate education,.. (O)

Stethoscopes Carry Bacteria

“DNA from an abundance of bacteria linked to healthcare-associated infections, including Staphylococcus, was found on stethoscopes carried by healthcare professionals in the ICU, and cleaning only led to a modest reduction, researchers found.

On a set of 40 stethoscopes in use in an ICU, all 40 had a high abundance of Staphylococcus DNA, with “definitive” S. aureus DNA present on 24 of 40 stethoscopes tested, reported Ronald G. Collman, MD, of the University of Pennsylvania (UPenn) Perelman School of Medicine in Philadelphia, and colleagues.

Moreover, while cleaning the stethoscopes reduced the amount of bacterial DNA, it did not completely bring all stethoscopes in use in the ICU to the level of “clean,” the authors wrote in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America…

The CDC, in its guidelines for disinfection, state that “medical equipment surfaces” such as stethoscopes should be disinfected with an EPA-registered low- or intermediate-level disinfectant, with these guidelines adding that “use of a disinfectant will provide antimicrobial activity that is likely to be achieved with minimal additional cost or work.”  (P)


“In 2009, Steve Burrows’ mom, Judie, went in for hip replacement surgery. She came out with brain damage and mobility issues after a weeks-long coma that would change her and her family’s life…

What happened to Judie is complicated, but it essentially began with massive blood loss.

“In the end, that’s really how this whole thing started,” Burrows says in an interview with NPR’s Lulu Garcia-Navarro. “She lost over half the blood in her body.”

After her surgery, she was put into recovery and left alone with what’s called an electronic intensive care unit, or eICU.

With a series of monitoring tools that usually include microphones, video cameras and alarms, eICUs are meant to provide the 24-hour monitoring that many patients require after a major medical emergency.

“This [eICU] didn’t notice my mom was in a coma for at least a day and a half and I wanted to talk to the ICU doctor who was there that night,” Burrows says. “We were told there was no doctor there. I said ‘Well that’s insane, what do you mean?’ ”

He says there were doctors monitoring the cameras out by the airport in Milwaukee and they were supposed to be the safety net for his mother.

Burrows says that when he asked whether the camera was on, the head of the ICU told him it wasn’t because of patient privacy issues…. (Q)

Assuming blame for a medical error may help patients and families heal.

Dr Tigard admits that not all medical errors are preventable. He uses the example of a nurse in an oncology unit responsible for the care of 5 patients because of understaffing at the hospital. In this scenario, 2 patients suddenly need life-saving interventions at the same time. The nurse is able to save only one patient, while the other dies. Although she may be tempted to blame the system, Dr Tigard contends that the nurse should apologize to the family, as it offers the best chance of healing…

“That means medical errors are now the third-leading cause of death in the country — yes, the third-leading cause of death of all people. The number of lives that are lost each day to a medical error, a preventable error, is equivalent to a 747 going down daily,”

Arnold’s work is focused on reducing those errors, particularly in medical emergency situations involving children. The simulation center, which moved into a new, $95-million, 225,000-sq.-ft. Johns Hopkins All Children’s Research and Education Building this fall, features 15 simulation rooms, a dozen hightech mannequins and education space for medical personnel to test their skills in simulated emergencies and learn from the experiences.

 “The technology here, all the computers to run the mannequins, that’s just the tool,” Arnold says. “What it all provides is an opportunity for our providers to become really experts, to hone their skills, not only their clinical skills and their procedural skills, but most importantly their behavioral and communication skills.””  (R)

Let Hospital Patients Sleep!

 “If part of a hospital stay is to recover from a procedure or illness, why is it so hard to get any rest?

There is more noise and light than is conducive for sleep. And nurses and others visit frequently to give medications, take vitals, draw blood or perform tests and checkups — in many cases waking patients to do so…

Peter Ubel understands the problem as both a physician and patient. When he spent a night in the hospital recovering from surgery in 2013, he was interrupted multiple times by blood draws, vital sign checks, other lab tests, as well as by the beeping of machines. “Not an hour went by without some kind of disruption,” said Dr. Ubel, a physician with Duke University. “It’s a terrible way to start recovery.”

It’s more than annoying — such disruptions can harm patients. Short sleep durations are associated with reduced immune function, delirium, hypertension and mood disorders. Hospital conditions, including sleep disruptions, may contribute to “posthospital syndrome” — the period of vulnerability to a host of health problems after hospitalization that are not related to the reason for that hospitalization…

Solutions aren’t hard to fathom. Dr. Ubel listed some in 2013. Hospital workers could coordinate so that one disruption serves multiple needs: a blood draw and a vitals check at the same time instead of two hours apart. Or they could allow patients’ needs to guide schedules. If a patient is at low risk and can go six or eight hours without a vitals check, for example, perhaps don’t do that check once every four hours…”  (S)

Are physicians aware of how much they don’t know?

His epiphany on the subject came in 1984, when he was a resident at Washington University’s Barnes Hospital in St. Louis, Mo. “We had a difficult case, and it was clear doctors had little understanding of [a particular] test result” dealing with prothrombin time, said Laposata, who now chairs the pathology department at the University of Texas Medical Branch at Galveston. As a result, they ended up needlessly giving blood to an 8-year-old boy who was getting a tonsillectomy; the blood turned out to be contaminated with HIV — a disease that was still a mystery at the time. The boy developed HIV and later died.

Upon finishing his residency, Laposata went to work at the University of Pennsylvania, where he became director of the coagulation lab there. “I said, ‘We’re not going to just send [test] results; we’re going to put an interpretative paragraph underneath the numbers,'” he explained. “We did it for 3 months and then I got a surprise visit from the chief of hematology, [who] comes to me and says, ‘Stop doing that.’ I said, ‘Why?’ and he said, ‘Hematology fellows are not seeing cases because you’re giving the diagnosis too soon.'”

When Laposata suggested that a quicker diagnosis was a good thing, the hematology chief replied, “Not for me, because without fellows, we don’t have research projects.” “I said, ‘I thought the patient comes first,’ but he said ‘No,'” said Laposata. “That was a shocker.”

He then went to work at Massachusetts General Hospital, where he became director of a lab. “I thought, ‘I’m going to go for it,'” Laposata said. “We have to change the paradigm for making diagnoses. We should have only experts providing opinions about different areas.”

So he started a diagnosis management team (DMT) for coagulation disorders, in which physicians who treated patients worked with lab experts to figure out the right tests to administer and to properly interpret the test results…”  (T)


“There are plenty of places in the diagnostic process where things can go wrong. But radiology is a frequent source of medical error that is ripe for reform, according to a new report.

Coverys, a Boston-based medical liability insurer, reviewed more than 10,600 malpractice claims from between 2013 and 2017 and found that nearly 600 named a radiologist explicitly. These cases often related to significant patient harm and delayed diagnosis of serious conditions, according to the group’s report…

 “Radiology has done a lot over the last several years to try and see if they can become a safer discipline,” Hanscom said. “They need to continue to press on a number of fronts—they are still finding themselves very much connected to these poor outcomes.”

The report identifies several ways that radiology teams can address the risk of medical errors, including:

•             Using clinical decision support • Having a clear protocol for bringing in a second opinion on a reading •                Building templates for reports and using clear language in them •             Ensuring that incidental findings worthy of follow-up are highlighted so they aren’t missed

Peer review is a key strategy, Hanscom said, especially since the interpretation stage is the riskiest. Getting a second opinion can ensure that nothing on a test result is missed and can prevent communication gaps, such as getting crucial information to the physician that can best use it.”  (U)

National Licensure

“National licensure of nurses, physicians and other healthcare professionals is an idea whose time has come. But it’s coming pretty slowly through painstaking state-by-state approval of interstate compacts.

The underlying issue is basic: Whether you’re in Maine or Arizona, Florida or Oregon, all patients deserve the same high quality of healthcare. That means quality standards for professionals who deliver patient care should be consistent no matter where you live.

There’s no evidence that healthcare professionals in one state are better or worse than in other states. Yet, in most parts of the country, healthcare professionals who can commute to several states in an hour or two must have separate licenses to work in each state.

There’s an important reason for national licensure: flexibility. Clinical workforce shortages don’t follow any geographic rules. Some rural areas have severe physician or nurse shortages, but others don’t. Some cities have an adequate supply of highly skilled nurses, while others face a near crisis. Specialties like OB-GYNs, telemetry nurses, pediatric physical therapists or family nurse practitioners can be sufficient or sparse in different parts of the same region. Healthcare professionals need to be able to go where they are needed quickly and efficiently.

Another reason for national licensure is telemedicine. The immense value of telemedicine in improving patient care is widely acknowledged. Yet, invisible barriers to telemedicine arise at state lines. We need to knock down those barriers.

One argument against national licensure has come from state proponents who say they need to protect patients from problem clinicians who might move from state to state to escape their records of misconduct. But, a national system, where each healthcare professional has only one record, would, in fact, make it easier to catch offenders and protect the patient…”  (V)

Competency Of Aging Physicians

“A set of guiding principles from an American Medical Association council on assessing the competency of senior/late career physicians failed to gain adoption at the AMA’s interim meeting here.

In a floor vote of 281-222 on Tuesday, delegates sent the report back to the Council on Medical Education, which issued the guiding principles. Some hospitals and health systems already require competency testing by older physicians, but there are currently no standards for these tests.

There are currently more than 120,000 practicing physicians 65 and older in the U.S., according to the council. Chairperson Carol Berkowitz, MD, stressed that the report does not mandate age-based competency testing. Instead, it sets out guidelines for any organization or hospital that decides to put in place a testing process to ensure it is “fair, evidence-based, and equitable.”.. (W)

Monitoring EMRs For Patient Safety

Scientists at a patient safety organization developed a way of monitoring EHRs to detect safety risks to hospitalized patients in real time, a method they described in Health Affairs on Monday.

The paper, published in a journal issue dedicated to patient safety, was based on a three-year pilot of a safety management system developed by the organization, Pascal Metrics.

Pascal says it is the first organization to apply machine learning to a dataset of EHR-based adverse event outcomes. The system, which Pascal tested at two community hospitals, can detect patient harm from real-time data and fires triggers that result in patient safety monitoring.

“This appears to be a genuine pivot away from retrospective reviews of patient safety incidents to real-time analysis,” said Jeff Smith, vice president for public policy at the American Medical Informatics Association.

While the study demonstrates the potential for use of real-time data, there were many false positives triggered by the system, noted Dean Sittig, a professor of bioinformatics at the University of Texas Health Sciences Center in Houston.

Until EHR systems become capable of limiting these false alarms, “systems like these will be untenable for all but the highest-staffed facilities,” Sittig said.

Hardeep Singh, a health IT expert at the Baylor College of Medicine, said that while the prototype in the article was good, the portfolio of triggers it used would be limited in detecting the various types of harm seen in hospitals. In addition, few hospitals have the bandwidth to work with sophisticated algorithms to detect or prevent patient harm, he said.” (X)

Preventing Patient Harm – The Conversational Nurse Model

“Imagine an 82-year-old patient – we’ll call him Mr. A — with severe congestive heart failure, bouncing in and out of the hospital with increased frailty. During one hospital admission, Mr. A’s cardiologist consults the palliative care team for symptom management and clarification of goals of care. Mr. A tells the palliative care team that what matters most to him is to return home to be with his wife. He does not want to be placed on a ventilator, nor does he want aggressive measures taken. He agrees to go to a skilled nursing facility (SNF) for strengthening but says that if his heart failure worsens, he wants to return home.

The palliative care consult notes are filed in the medical record, along with a form stating that Mr. A does not want aggressive measures taken. However, this form and the consult notes are lost during transfer to the SNF. Mr. A tells the SNF team that his goal is to get stronger, which is interpreted as wanting all measures taken. Two weeks later, Mr. A develops shortness of breath and confusion and is transferred to the hospital. Records from the SNF indicated that he wants all measures taken. He is put on a ventilator in the emergency department and dies a week later in the intensive care unit…

To address this in our own health system, Care New England in Rhode Island developed the Conversation Nurse model: a program for training nurses in conversational skills to conduct discussions with patients about serious illness and their goals for their care. Our Conversation Nurses meet with patients across the entire health care continuum and talk with them about their understanding of their illnesses and their goals for care as their diseases worsen. We have used this model to increase the workforce trained in serious illness care and have demonstrated the following outcomes: 1) Increased volume of palliative care consults in inpatient settings, 2) Increased documentation of advance directives in the home care agency population, 3) Decreased readmissions and increased hospice consults in skilled nursing facilities, and 4) Broad training of Accountable Care Organization (ACO) interprofessional teams. The model, which started in the inpatient setting and expanded into the community, has proven useful both in increasing the workforce trained in having conversations about serious illness and in optimizing use of finite physician resources.” (Y)

Preventing Patient Harm – The PST Model

That effort takes form in the PST model—primary, secondary and tertiary responses to adverse events that encompass both a proactive and a reactive approach, leaders at the system said at a session at the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Healthcare.

A safety mindset allowed the system to develop a series of interventions to prevent harms and to effectively address them should a safety lapse occur. Steps at the earliest level include adjusting hiring to bring in the best team members and offering training to enhance their skills in safety as needed.

Other proactive steps MedStar took include making safety central to the culture of its hospitals, tracking patient satisfaction to identify risks and offering standardized work processes.

To plan for “secondary” prevention, MedStar expanded its definition of harm from “serious safety event” to “serious unanticipated outcome.” Doing so allowed the system to monitor harms that may not be caused directly by providers, said Seth Krevat, M.D., assistant vice president for safety at MedStar.

That definition switch led the number of reports to increase significantly, providing a greater database for new initiatives, Krevat said. For example, in 2018 so far, 239 unanticipated outcomes have been reported, compared to 41 scenarios that would be considered “serious safety events.”

Further secondary steps taken by the hospital include diving deeper into claims data and patient surveys to flag issues and identify near misses. (Z)

Preventing Patient Harm – the Piedmont Healthcare model

“For one hospital in particular, a poor Leapfrog Hospital Safety Grade rating in 2014 became a launching pad for improved quality and safety.”When we got a ‘D’ from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn’t the fanatic level that we have now,” says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia

Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.In November 2018, six of Piedmont’s 11 hospitals received “A” grades in The Leapfrog Group’s Fall 2018 Hospital Safety Grade ratings

 From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%

One Piedmont hospital has not reported a hospital-acquired infection for more than a yearHamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.” (AA)

Postscript on Hospital Ratings

“Many organizations have started publishing hospital performance measures and report cards in recent years, growing out of the movement for improved quality and patient satisfaction, lower costs, and greater accountability and transparency. Among the organizations publishing these ratings and measures are government agencies, news organizations, healthcare accreditation and quality groups, and companies and not-for-profits focused on transparency. The emergence of these reviews has put pressure on hospital leaders to do what’s necessary to improve their scores.

But the various reports use significantly different methodologies and have different areas of focus, often producing sharply different ratings for the same hospitals during the same time period. Some hospital leaders say this makes it more difficult to know which areas to prioritize to improve their quality of care and rankings….

Reasonable people disagree on what measures are most important to include, which makes for significant differences in the various ratings, Jha said. One problem with that, though, is that hospitals can cherry-pick favorable ratings for marketing purposes, whether or not those ratings have much validity. “Anyone who wants to dodge accountability can hang their hat on some obscure rating that was good,” he said…

Some groups use a star rating system, some use a 1 to 100 percentage scale, and others use an academic-style A to F grading range. The groups also vary on how frequently they publish ratings, with some issuing reports annually and others offering more frequent updates.

The raters rely on data sets from the government, such as the Medicare Provider Analysis and Review and the Hospital Consumer Assessment of Healthcare Providers and Systems. Some create their own surveys and solicit voluntary responses from the hospitals. Others use diagnostic and procedure coding for specific diseases, conditions and services. But not all groups disclose how they weight the various quality measures in producing their final scores. “They have to create a distinct product,” Daugherty said.” (BB)

Did This Health Care Policy Do Harm?

“No patient leaves the hospital hoping to return soon. But a decade ago, one in five Medicare patients who were hospitalized for common conditions ended up back in the hospital within 30 days. Because roughly half of those cases were thought to be preventable, reducing hospital readmissions was seen by policymakers as a rare opportunity to improve the quality of care while reducing costs.

In 2010, the federal agency that oversees Medicare, the Centers for Medicare and Medicaid Services, established the Hospital Readmissions Reduction Program under the Affordable Care Act. Two years later, the program began imposing financial penalties on hospitals with high rates of readmission within 30 days of a hospitalization for pneumonia, heart attack or heart failure, a chronic condition in which the heart has difficulty pumping blood to the body.

At first, the reduction program seemed like the win-win that policymakers had hoped for. Readmission rates declined nationwide for target conditions. Medicare saved an estimated $10 billion because of the reduction in hospital admissions. Based on those results, many policymakers have called for expanding the program.

But a deeper look at the Hospital Readmissions Reduction Program reveals a few troubling trends. First, since the policy has been in place, patients returning to a hospital are more likely to be cared for in emergency rooms and observation units. This has raised concern that some hospitals may be avoiding readmissions, even for patients who would benefit most from inpatient care.

Second, safety-net hospitals with limited resources have been disproportionately punished by the program because they tend to care for more low-income patients who are at much higher risk of readmission. Financially penalizing these resource-poor hospitals may impede their ability to deliver good care.

Finally, and most concerning, there is growing evidence that while readmission rates are falling, death rates may be rising.” (CC)

Physician Burnout

“Studies have shown that medical errors are common in the United States healthcare system, representing a major source of inpatient deaths. Evidence indicates that physician burnout, characterized by exhaustion and cynicism, is associated with medical errors. Safety grades provide a summary reflection of the patient safety practices within a patient care setting (or “work unit”) intended to reduce these errors. However, the interactions among these patient safety practices, physician burnout, and medical errors have remained unknown.” (DD)

Physician Stress

“Surgeons under stress are far more likely to make mistakes on patients in the operating room, even if the stress is caused by a trivial source and lasts briefly, a Columbia University study finds.

The research shows that all it takes is a negative thought or a loud noise in the room to trigger moments of short-term stress for doctors, according to lead author Peter Dupont Grantcharov, a master’s student at the Data Science Institute at Columbia.

For the study, Grantcharov had Dr. Homero Rivas, Associate Professor of Surgery at Stanford Medical Center, wear a high-tech “smart shirt” under his scrubs during 25 surgical procedures, most of which were gastric bypasses… (EE)

NIH: antibiotic-resistant bacteria living in the plumbing

“Patients were infected with antibiotic-resistant bacteria living in the plumbing of the National Institutes of Health’s hospital in Bethesda, Md., contributing to at least three deaths in 2016.

A study published Wednesday in the New England Journal of Medicine found that, from 2006 to 2016, at least 12 patients at the NIH Clinical Center, which provides experimental therapies and hosts research trials, were infected with Sphingomonas koreensis, an uncommon bacteria. The paper, written by NIH researchers, suggests that the infections came from contaminated water pipes, where the bacteria may have been living since as early as 2004, soon after construction of a new clinical center building.” (FF)

“There could be a whole post dedicated to medical inaccuracies on Grey’s Anatomy or political impossibilities on Scandal, but we’re about to explore so much more than just technical knowledge (although, there will be some of that too). Even some of the most eagle-eyed fans missed these mistakes in Shondaland’s most beloved shows, from huge mistake in birthdates to tiny mistakes in continuity. Because we’ll be talking about many seasons of many shows, beware of spoilers, especially if you’re not caught up on Grey’s Anatomy and How To Get Away With Murder.

Here are the 20 Mistakes Fans Completely Missed In Shondaland Shows.” (GG)

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