From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare


April 25, 2018 | Edit

On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…”

“Andy Slavitt, who served as the acting administrator for the Center for Medicare and Medicaid Services under President Barack Obama, warned late Friday night that Republicans may try to repeal and replace Obamacare once again before the 2018 midterm elections. “Republicans have been meeting in secret to bring back ACA repeal,” he writes…

… Santorum and others may think that there will be a “blue wave” in 2018 no matter what, so this may be the last time the GOP has the opportunity to get rid of Obamacare. And that might make Republicans desperate enough to try again.” (R)

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

In 2018, mostly under-the-radar, efforts are continuously underway to continue to undermine what’s left of ObamaCare.

“Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it…,

Congress has already repealed several unpopular parts of the law as part of last year’s tax legislation — most notably the individual mandate, which now expires at the end of this year, but also the Medicare cost-control board (known as the Independent Payment Advisor Board).

The executive branch has exerted its own influence on the law. In October of last year, President Trump signed an executive order calling for the expansion of association health plans and limited-duration insurance, in hopes of creating a secondary market for health plans that are cheaper and less regulated, and this year, the administration released extensive proposals for each. The administration also stopped paying the law’s cost-sharing reduction subsidies, which reimburse insurers for low-income beneficiaries. And the Department of Health and Human Services has begun allowing states to attach work requirements to Medicaid, making the program more bureaucratic, but possibly enticing red states that have so far declined to expand the program to do so…

Having failed in their repeal effort, Republicans are now in something of an arranged marriage with the health care law. These alterations are being made in a predictably haphazard fashion, with little in the way of guiding theory, but the cumulative effect is to turn Obamacare into a law that they can, if not love, at least learn to live with.”(A)

“Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options….

People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.

But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure.” (B)

“It’s been well documented that the Trump White House has filled federal agencies with bureaucrats whose life work is destroying the very agencies they’ve been assigned to. But one is in a better position than her fellows to threaten the health of millions of Americans—and she’s been working at that assiduously.

We’re talking about Seema Verma, who as administrator of the Centers for Medicare and Medicaid Services also is effectively the administrator of the Affordable Care Act. In the Trump administration, that has made her the point person for the Trump campaign to dismantle the act, preferably behind the scenes…

Still, Verma had spent enough time in the healthcare field that observers thought she might not be totally egregious as CMS administrator. But then, during her confirmation hearing in February 2017, she let on that she didn’t see why maternity coverage really needed to be mandated for all health policies, since “some women might want maternity coverage, and some women might not want it…

It wasn’t an auspicious start. But since then she has lived down to our expectations. Verma never has concealed her hostility to Medicaid — especially Medicaid expansion, a provision of the ACA. Her animosity is fueled at least in part by ignorance (willful or otherwise) about the program. Back in November, on the very day that voters in Maine and Virginia were demonstrating full-throated support at the polls for expanding Medicaid in their states, Verma was unspooling a string of misleading statistics and suspect assertions about the program to support a policy of rolling back enrollment.” (C)

“Passing two measures aimed at stabilizing the Affordable Care Act marketplaces by infusing insurers with more funds would lower monthly premiums by 20 to 40 percent and prompt an additional 3.2 million people to get covered, says an attention-grabbing independent analysis released yesterday by the firm Oliver Wyman.

These measures – which would pay insurers for extra cost-sharing discounts for the low-income and reimburse them for their most expensive customers – are currently stuck in political limbo as leaders on Capitol Hill consider whether to include them in a massive, must-pass spending bill next week.

The bills have become emblematic of inter and intraparty disputes over how to approach a world with most of the ACA still in place. Democrats are bitter that Republicans are still chipping away at parts of the law by repealing its individual mandate and changing other provisions through the executive branch…

And Republicans can’t even agree among themselves how to handle the law now that they’ve failed to entirely wipe it from the books. (D)

“Republicans campaigned for roughly a decade, promising voters they would dismantle former President Barack Obama’s landmark health care legislation; but one of their own senators is trying to keep it alive through the 2018 election cycle…

Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray, D-Wash., is using the deadline to sway leadership to include a proposal that would fund politically contentious Obamacare subsidies through 2019. The proposal would provide $10 billion a year for three years for these subsidies…

Additionally, the proposal would give states greater Obamacare waiver flexibility and would broaden consumer eligibility for “copper” plans. Abortion-covering health insurance plans would not receive subsidies under the proposal…

Republicans are either not thrilled about Alexander’s proposal, calling it a bad idea and one that could hurt the party going into 2018, or they think it could be one way to provide taxpayers some relief from the financial burdens Obamacare imposed.” (E)

“The House passed the $1.3-trillion omnibus spending package meant to keep the government running until Sept. 30 in a vote of 256-167, leaving the Senate barely 35 hours to get the same legislation approved by Friday at midnight to avert a shutdown.

The bill boosts funding for the National Institutes of Health, the CDC, and the Department of Veterans Affairs (VA) as well as other key agencies, but keeps funding flat for the Centers for Medicare and Medicaid Services…

The bill also does not include the health insurance stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins (R-Maine). They had wanted the omnibus package to include measures restoring for 3 years the cost-sharing reduction subsidies (monies that help insurers defray out-of-pocket costs for low-income enrollees), establishing 3 years of reinsurance (monies that help pay for the sickest of patients and keep premiums from spiking) at $10 billion per year, and streamlining the 1332 waiver process to allow states more flexibility in health plan design.” (F)

“The Trump administration hopes to move forward with a rule expanding alternatives to ObamaCare plans by this summer, Secretary of Labor Alex Acosta said Monday. The rule allows small businesses and self-employed individuals to band together to buy insurance as a group in what are known as association health plans. “We hope to have that by this summer,” Acosta said Monday during a tax reform event alongside President Trump in Florida.” (G)

“In 2012, the Supreme Court of the United States upheld Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority opinion. Many Obamacare opponents believe Roberts used contorted reasoning to save the law by labeling Obamacare’s individual mandate penalty a tax.

Now, six years later, 20 states have seized on the Roberts ruling to ask the courts again to undo Obamacare. These states filed a lawsuit indicating that because the December 2017 tax reform bill repealed the individual mandate penalty, there’s no longer any legal rationale for the mandate. They also argue that because there’s no “severability clause” in Obamacare, the entire law must be struck down.

If this sounds confusing, read on to unpack what’s going on with this latest attempt to undo Obamacare through the courts.

The Obamacare mandate was ruled a tax…

Opponents of the law argued Congress didn’t have the power to require individuals to purchase a product from private insurers, while the Obama administration argued authority for the mandate came from the Commerce Clause, which gives the federal government power to regulate commerce “among the several states.”” (H)

“Gov. Scott Walker has asked for a federal waiver to operate a state-based reinsurance plan designed to stabilize the state’s individual health insurance market and hold down premiums under the Affordable Care Act.

Following a 44 percent average spike in Obamacare premiums this year, Walker’s office estimates the $200 million program would lower premiums by 11 percent from what they otherwise would have been, amounting to a 5 percent decrease in premiums compared to 2018.

Under the plan, the state would pay $34 million for reinsurance in 2019, while $166 million would come from federal funds…

“We are taking action to address the challenges created by Obamacare and bring stability to the individual market,” Walker said. “Our Health Care Stability Plan provides a Wisconsin-based solution to help stabilize rising premiums in order to make health care more affordable for those purchasing in the individual market. With Washington D.C. failing to fix our nation’s health care system, Wisconsin must lead.” (I)

“The American Academy of Family Physicians and other doctor groups have unleashed detailed critiques of Trump’s effort to introduce cheaper health insurance with skimpier benefits….

“Insurers could reduce or eliminate certain essential health benefits to avoid vulnerable, expensive patients by excluding specific services,” AAFP board chair Dr. John Meigs, Jr., a family physician from Alabama wrote in a letter last week to U.S. Health and Human Services Secretary Alex Azar.

“In doing so, insurers could potentially make plans more expensive for people with long-term chronic conditions or with sudden medical emergencies,” Meigs said. “Inadequate benefits could leave this population with too little coverage to meet their health care needs.” (J)

“The Affordable Care Act (aka Obamacare) banned any hospital, doctor, or insurance company who receives federal funding from discriminating against or denying services based on sex; the Obama administration made it clear in 2016 that provision included transgender and gender-nonconforming patients…

These benefits and protections are heading for oblivion though, according to the Times. The Trump administration is pointing to a January 2017 ruling from a Texas federal judge who said the 2010 law did not cover gender identity or presentation.

“Congress did not understand ‘sex’ to include ‘gender identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said, Congress “adopted the binary definition of sex.” (K)

“As Republicans careen toward the midterms with tax reform under their belts and not much else, rumor has it that a small group of Republican senators are working with the White House and former Sen. Rick Santorum (R-Pa.) to revive the debate over ObamaCare repeal.

Their purpose is laudable. But, privately, conservatives across Capitol Hill are expressing concern that the proposal may not do enough to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or allow freedom to innovate outside the law’s stifling framework…

The bill’s premise — to devolve much of the health-care spending to the states — is a good starting point. But its implementing details are still unknown, leaving conservatives to wonder if the new bill will actually repeal ObamaCare and reform the health-care marketplace, or if it will simply recast much of the law’s worst elements with a few minor tweaks…

Voters are still waiting for a full repeal effort. Anything less will not suffice as a solution for candidates who will soon be elected on a message of repeal. Nor will it suffice for a party who has spent years making the same promise.” (L)

“Less than a year after the GOP gave up on its legislative effort to repeal the law, Democrats are going on offense on this issue, attacking Republicans for their votes as they hope to retake the House majority…

ObamaCare’s favorability in polls has improved since the repeal push last year, with more now favoring the law than not. A Kaiser Family Foundation poll in March found that 50 percent of the public favors the law, while 43 percent holds an unfavorable view.

GOP strategist Ford O’Connell said the political winds have shifted on the issue, turning ObamaCare into a subject Democrats want to tout and many Republicans want to duck.

“I don’t think it’s seen as a winning issue,” he said. “It’s also an issue that tends to fire up the Democratic base more so than the Republican base.”” (M)

“While Republican moves to overhaul Social Security, Medicare or Medicaid appear unlikely — at least for this year — Democrats are increasingly warning about the prospect because of the deficit concerns created by the tax plan. The GOP argues Democrats want to distract from the fact that they did not support the tax overhaul, the signature Republican achievement of Trump’s first year in office.

Democrats’ ability to sell voters on their vision for health care and warn about the possibility of cuts to Social Security and Medicare could prove crucial for candidates, such as Manchin, who are trying to win in red areas…

Polling suggests Trump and the GOP’s efforts to reshape the American health-care system have not resonated with voters. Thirty-six percent of respondents to the Economist/YouGov poll said they strongly disapprove of how the president has handled health care, compared with only 15 percent who said they strongly approve.” (N)

“People have voted with their enrollment decisions: A sizable number of Americans do not get insurance from their employers and value the coverage on Obamacare’s markets. That refutes the GOP myth that the program forces Americans to purchase junk insurance that they do not want. A recent Kaiser Family Foundation poll found that these consumers seek to guard against major medical costs, to gain the peace of mind that comes with insurance and to obtain coverage for chronic medical care, suggesting that the law serves important and durable needs.

Another fictional Republican claim is that Obamacare has been collapsing. A Kaiser study this year found that insurance markets stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This comports with findings from the Congressional Budget Office and a range of other independent analysts…

Obamacare continues to serve an important need. What’s sad to see is how easy it would be to make it even more useful, if Republicans would focus on improvement instead of sabotage.” (O)

“What’s the secret of Obamacare’s stability? The answer, although nobody will believe it, is that the people who designed the program were extremely smart. Political reality forced them to build a Rube Goldberg device, a complex scheme to achieve basically simple goals; every progressive health expert I know would have been happy to extend Medicare to everyone, but that just wasn’t going to happen. But they did manage to create a system that’s pretty robust to shocks, including the shock of a White House that wants to destroy it…

What this says to me is that if Republicans manage to hold on to Congress, they will make another all-out push to destroy the act — because they’ll know that it’s probably their last chance. Indeed, if they don’t kill Obamacare soon, the next step will probably be an enhanced program that lets Americans of all ages buy into Medicare.” (P)

“At the outset, Obamacare had three central features:

• Insurers could not charge higher prices to people with pre-existing conditions.

• Those without coverage had to pay a penalty to the government (the “mandate”).

• Low-income people would be eligible for subsidies.

The first two provisions were necessary to prevent the death spiral, and government couldn’t mandate insurance purchases without adding subsidies for the poor.

Despite a bumpy rollout and some frustrations over shrinking choices and rising prices at health care exchanges, Obamacare was working remarkably well by most important metrics. Program costs were much lower than expected, and the uninsured rate among nonelderly Americans fell sharply — from 18.2 percent in 2010 to only 10.3 percent in 2018.

This progress is now imperiled.

The mandate — by far the program’s least popular provision — was repealed as part of tax legislation passed in December 2017. And because economists predict that its absence will slowly rekindle the insurance death spiral, we’re forced back to the policy drawing board… (Q)


(A) The G.O.P. Accidentally Replaced Obamacare Without Repealing It, by Peter Suderman

(B) Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It., by Margot Sanger-Katz,

(C) How Trump’s Obamacare administrator is taking a hatchet to Obamacare, by Michael Hiltzik,

(D) The Health 202: Republicans could lower Obamacare premiums. But will they?, by Paige Winfield Cunningham,

(E) Senate May Fund Obamacare Subsidies With This Sneaky Move, by Robert Donachie,

(F) House Passes Spending Bill Without Obamacare Fix, by Shannon Firth

(G) Trump Official: Alternative to ObamaCare Plans Likely This Summer, by Peter Sullivan,

(H) States Take Another Run at Undoing Obamacare Through the Courts, by Christy Bieber,

(I) Amid rising Obamacare premiums, Walker seeks federal waiver for reinsurance program, by op 5 percent, by Lauren Anderson,

(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of Comment Deadline, by Bruce Japsen,

(K) Trump to Allow Anti-Trans Discrimination in Health Care, by BY NEAL BROVERMAN,

(L) Republicans have a long way to go toward fully repealing ObamaCare, by Rachel Bovard,

(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN,

(N) It’s not all about Trump: Democrats’ midterm chances ride on health care and Social Security, too, by Jacob Pramuk,

(O) Americans are sticking by Obamacare. If only the GOP would stop trying to kill it.,

(P) Obamacare’s Very Stable Genius, by Paul Krugman,

(Q) Back to the Health Policy Drawing Board, by ROBERT H. FRANK,

(R) Health Policy Expert Says Republicans Have ‘Secret’ Plan to Repeal Obamacare, by Cody Fenwick, 000000000000000

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Renaissance Master Caravaggio Didn’t Die of Syphilis, but of Sepsis,

Assignment: Learn everything you can about sepsis than make sure your local hospital uses Artificial Intelligence to diagnose (and even recommend treatment for) sepsis?

Less than one day after burying his beloved wife Barbara, former President George H.W. Bush was hospitalized in the intensive care unit with sepsis.

He recovered and left the hospital, but too often this potentially deadly condition takes lives.  In 2017 alone, 1 in 3 people who died in a hospital had sepsis.

The Centers for Disease Control tracks the disease and its complications.  Last year, it found at least 1.7 million cases diagnosed in the United States.

What is sepsis?  Sepsis is the body’s extreme response to common bacterial infections.  Things as simple as an infected skin cut, a urinary tract infection or illness affecting your lungs can trigger it. If you don’t get proper medical attention quickly, it can lead to tissue damage, organ failure and death.

It can strike anyone, but children, the elderly and those with chronic health problems are most at risk.

To help you know your risk and to avoid putting yourself or your family at risk, check out the CDC’s fact sheets on how to protect yourself. (W)

“Do not take that slight cut on your knee or a bruise on your elbow lightly for they can land your health in a complicated state called sepsis. Sepsis occurs when an existing infection causes the immune system to flare up intensely. As a result, your body swells up severely blocking the blood flow to your organs. While the symptoms take 24 -48 hours to manifest, do watch out for signs of fever, shortness of breath, unbearable pain, and a racy heart. Although bacterial infections are said to be the major cause of the disease, there are other culprits to watch out for.” (A)

Physicians will accept pathogen coverage of 80% to 90% from their preferred empiric antibiotic regimen when managing patients with mild and severe sepsis, respectively, from bacterial infections, survey results showed.

The survey of internal medicine physicians in Canada also showed that physicians perceived that their preferred empiric antibiotic regimen would cover 90% of the offending pathogens in each clinical scenario of sepsis.

Researchers said the findings could be used to inform clinical guidelines and improve prescribing practices.

According to Alex M. Cressman, MD, MSc, from the University of Toronto and Sunnybrook Health Sciences Center, and colleagues, prescribers must balance “early empiric antibiotic coverage and the antimicrobial stewardship goal of minimizing unnecessary broad-spectrum treatment” when choosing an antibiotic regimen. They suggested a need for treatment thresholds to aid physicians in choosing empiric antibiotic regimens for patients with serious bacterial infections.

 “Using a scenario-based survey of general internists and infectious disease specialists across Canada, we characterized physicians’ perceived likelihood of adequate coverage achieved by their preferred empiric antibiotic regimens for patients with mild and severe sepsis,” Cressman and colleagues wrote. “We also identified physicians’ minimum acceptable thresholds of adequate coverage for these patients.”..

According to Kollef and Burnham, treatment bundles can overlook important factors. Specifically, treatment bundles for sepsis tend not to assess antibiotic necessity, dosing strategies and antibiotic duration, and the in vitro activity of the antibiotic regimen. They highlighted the success that rapid molecular diagnostics has had in expediting patient evaluation for sepsis, ensuring effective, early antibiotic therapy and reducing the unnecessary use of broad-spectrum agents.

“Further work is needed to understand their work in a broader context that includes other front-line antibiotic prescribers,” Burnham and Kollef wrote. “Empiric antibiotic prescribing will continue to be a moving target, but with advances in [rapid molecular diagnostics], the ideal scenario of minimizing antibiotic use while maximizing excellent patient outcomes moves closer to realization, including in critically ill patients.” (B)

Hospitals have a hard time meeting the CMS’ sepsis treatment requirements.

The national average compliance rate for the Severe Sepsis and Septic Shock Early Management Bundle is barely 50%, according to the most recent data on Hospital Compare. The measure was adopted in July 2015 to improve hospitals’ identification and treatment of the life-threatening condition. More than 200,000 people die each year from sepsis.

WellSpan Health, an integrated delivery system based in York, Pa., has blown past that average, recently boasting an 85% compliance rate for the bundle. WellSpan executives credit a year-old quality improvement initiative that involves leveraging the electronic health record and a remote patient monitoring team to identify and treat patients with sepsis early…

To address alert fatigue, WellSpan established a remote surveillance team to monitor sepsis alerts and patients’ vital signs 24/7. The Central Alert Team operates much like air traffic controllers do, with the nurses monitoring patients at five hospitals, allowing them to review and intervene when necessary.

“The idea of the alert team is to facilitate early recognition and communication with the care team at the bedside, so they launch appropriate interventions,” Delaveris said.

Alerts go to the Clinical Alert Team rather than nurses at the bedside. Using patient record data on hand, nurses on the alert team will determine if an alert should be elevated to the next level. If so, they contact the patient’s physician or nurse directly to let them know the sepsis bundle should be activated.

Because the nurses only reach out to the bedside team when they see something amiss, the clinicians take their alerts seriously, Delaveris said. WellSpan also introduced the nurses to the clinicians they’d be working with so “it’s not just someone calling from the sky. We wanted to build a relationship and trust,” he added.

At least one registered nurse with intensive-care and emergency department experience is on duty at any given time monitoring patients for sepsis.

The nurses also continuously monitor the patients they see as at risk for sepsis to ensure the clinical team is following all of the bundle’s steps. WellSpan opted to use the bundle from the Surviving Sepsis Campaign, which is closely aligned with the CMS requirements. The bundle has multiple steps that need to be accomplished within designated time periods.” (C)

“Know the risks. Spot the signs. Act fast. Merit Health Wesley has worked for the past few years to integrate evidence-based clinical practices into the medical management of sepsis and reduce risk in the community by educating the public about the illness.

Merit Health Wesley is the first in Mississippi to achieve The Joint Commission’s Gold Seal of Approval for Sepsis Care.

“This achievement is a symbol of quality that reflects our hospital’s ongoing commitment to providing safe and effective patient care,” said Debbie Johnson, vice president of quality and clinical transformation and patient safety officer. “We endeavor to provide the highest quality of sepsis care through a comprehensive, multi-disciplinary approach to sepsis management and long term recovery.”

The sepsis management team at Merit Health Wesley has reduced the risk of sepsis by limiting the progression of sepsis. They are focusing on early diagnosis and rapid, efficient and effective treatment. Key elements of the hospital’s process are medical staff-approved sepsis protocols, a team approach with focused patient handoffs, regular reviews of designed process compliance, and accountability meetings to review outcomes. Merit Health Wesley chose to authenticate their best practices and process improvements by pursuing certification.

Since as many as 87 percent of sepsis cases start in the community, Merit Health Wesley has also implemented a community outreach and education plan. Patients and their families, nursing homes, emergency management staff and other care providers are educated to increase their awareness of sepsis and common early warning signs, as well as, evidenced based standards of care for rapid treatment, all key to improved outcomes and survival.” (D)

“Massachusetts Institute of Technology researchers have developed a machine-learning system that could help clinicians decide when to treat patients for sepsis in the emergency room.

Sepsis is one of the most common reasons for readmission to the hospital and one of the most common causes of death in the ICU. The researchers suggest that most of the ICU patients are admitted through the emergency room.

Treatment typically begins with antibiotics and IV fluids at a couple liters at a time, according to the researchers. Sepsis shock can happen if a patient’s body doesn’t respond well to treatment, which results in blood pressure dropping dangerously low with organ failure. Once that happens, the patient goes to ICU where clinicians can reduce and stop fluids to start vasopressor medications to raise and maintain blood pressure.

However, giving a patient fluids for too long could cause more organ damage. The researchers say that vasopressor intervention could be helpful and has previously been linked to improved mortality in septic shock. But administering vasopressors too early can cause heart arrhythmias and cell damage, leaving clinicians with an unclear answer on when to administer treatment.

MIT researchers have developed a model to alleviate that problem. The model learns from health data on emergency-care sepsis patients and can predict if a patient will need vasopressors within the next few hours.

In a study, the researchers compiled a dataset for ER sepsis patients. When they tested the algorithm, the model was able to predict the need for a vasopressor more than 80% of the time…

The machine-learning system could be used in a bedside monitor to track patients and send alerts to clinicians in the ER about when to start vasopressors and reduce fluids.

“This model would be a vigilance or surveillance system working in the background,” Thomas Heldt, the study’s co-author, said. “There are many cases of sepsis that [clinicians] clearly understand, or don’t need any support with. The patients might be so sick at initial presentation that the physicians know exactly what to do. But there’s also a ‘gray zone,’ where these kinds of tools become very important.”

Other models have been built to predict who is at risk of developing sepsis or when to administer vasopressors in the ICU. The MIT-developed model is the first one to be trained on data from the ER.

“[The ICU] is a later stage for most sepsis patients. The ER is the first point of patient contact, where you can make important decisions that can make a difference in outcome,” Heldt said…

 “The model basically takes a set of current vital signs, and a little bit of what the trajectory looks like, and determines that this current observation suggests this patient might need vasopressors, or this set of variables suggests this patient would not need them,” Prasad said.

The researchers hope to expand their work to make more tools that can predict in real-time if patients in the ER would initially be at risk for sepsis or septic shock.

“The idea is to integrate all these tools into one pipeline that will help manage care from when they first come into the ER,” said Prasad.

The researchers also say that the system could help clinicians in emergency room departments in major hospitals focus on patients who are most at-risk of developing sepsis.

“The problem with sepsis is the presentation of the patient often belies the seriousness of the underlying disease process,” Heldt said. “If someone comes in with weakness and doesn’t feel right, a little bit of fluids may often do the trick. But, in some cases, they have underlying sepsis and can deteriorate very quickly. We want to be able to tell which patients have become better and which are on a critical path if left untreated.” (E)

Jonathan Perlin, MD, president of clinical services and chief medical officer at HCA Healthcare, calls sepsis an “overwhelming infection” that can lead to severe organ failure and even death. He says the key to survival is early recognition and aggressive treatment.

“It’s a medical emergency that should be treated as aggressively as a heart attack or stroke,” Dr. Perlin said. “At HCA, we’re pleased to be able to rally the data of more than 28 million patients every year to help control sepsis, one of the most challenging diagnoses inflicted on patients, and ultimately, better inform patient improvements and outcomes.”..

For every hour of a delayed sepsis diagnosis, it increases the chance of death between 4 and 7 percent…

How does SPOT work?

Hospital computers, through “machine learning”, are trained by ingesting millions of data points on which patients do and do not develop sepsis. Those computers monitor clinical data every second of a patient’s hospitalization.  When a pattern of data consistent with sepsis risk occurs, it will signal with an alert to trained technicians who call a “code sepsis.”

The bedside nurse responds, begins evaluating the patient, and if sepsis is not “ruled out,” treatment begins immediately.

“SPOT is operating with 100 percent sensitivity, that is, all true sepsis positives have been identified,” he said, “allowing caregivers to fully focus on those patients who need intensive monitoring and support.”

More than 5,500 lives have been saved over the last three years as a result of the stop severe sepsis program, the national standard that relies on detecting sepsis at the cusp of deterioration, and HCA’s new technology SPOT.

“The doctors and nurses tell us there were some patients SPOT detected that we would’ve known about,” Perlin said. “More importantly, it told us time and again those patients we didn’t appreciate that were headed towards sepsis.”

HCA celebrated in August 1 million patients followed by SPOT. (F)

“Durham, N.C.-based Duke University Hospital in November will launch Sepsis Watch, a system that uses artificial intelligence to help identify patients in the early stages of sepsis, according to IEEE Spectrum.

Duke University Hospital will deploy the system in its emergency department before extending it to the general hospital floor and intensive care unit.

“The most important thing is to catch cases early, before they get to the ICU,” Suresh Balu, project lead and director of the Duke Institute for Health Innovation, told IEEE Spectrum.

The Sepsis Watch system can identify cases based on numerous variables, including vital signs, lab test results and medical histories. The AI’s training data consists of 50,000 patient records and more than 32 million data points. While operating, the system pulls information from medical records every five minutes to evaluate patients’ conditions, which offers real-time analytics physicians can’t provide.

When the AI system detects a patient who may be in the early stages of sepsis, it alerts a nurse on the hospital’s rapid-response team who will either dismiss the alert, place the patient on a watch list or contact a physician about starting treatment. The system will also walk staff through a sepsis treatment checklist using protocols outlined by the Surviving Sepsis Campaign.

“The model detects sepsis,” Mark Sendak, MD, physician and data scientist, told IEEE Spectrum. “But most of the application is focused on completing treatment.”

Electronic health records can help identify hospitalized patients at risk of death, according to a new study in The American Journal of Medicine.

Inpatients’ conditions can deteriorate quickly; the faster the intervention, the better the patient’s chances of survival. The researchers, from Arizona based Banner Health, created an algorithm that looked for at least two out of four systemic inflammatory response syndrome (SIRS) criteria, plus at least one of 14 acute organ dysfunction parameters. The algorithm continually sampled the EHR data in real time of 312,214 patients in 24 Banner Health hospitals, and contained an alert to notify the physician of the risk of death when a patient triggered it.

The alert identified a majority of the high risk patients within 48 hours of admission and enabled early and targeted medical intervention. The patients who triggered the alert had a “significantly high” chance of dying in that hospital stay compared to patients who didn’t trigger the alarm.” (G)

“.. the technology that goes by the name AI Clinician, described today in a paper in Nature Medicine, doesn’t diagnose—it makes decisions. It takes all the information about a patient with sepsis and recommends a course of treatment.

“It’s not mimicking the perceptual ability of the doctor, where the doctor sees certain symptoms and says the patient is going into septic shock,” says Aldo Faisal, an associate professor of bioengineering and computing at Imperial College London and one of the paper’s authors. “It’s really cognition that is captured here. We’re not just making the AI see like a doctor, we’re making it act like a doctor.”

The researchers didn’t try out their system on real patients; the technology isn’t ready for the clinic yet. Instead, they trained and tested AI Clinician on medical record databases from intensive care units (ICUs) in the United States. They first used 17,000 cases to teach the model about sepsis treatment, and then had it issue recommendations for 79,000 cases.

Overall, the treatments that the AI recommended were more likely to keep patients alive than those administered by the human doctors… 

Part of the treatment is to give patients intravenous fluids and drugs called vasopressors that constrict the blood vessels and increase blood pressure: These actions ensure that blood is reaching the organs. However, there’s considerable debate about how much to give, and when.

The researchers trained AI Clinician to issue recommendations on fluids and vasopressors. Gordon says these basic recommendations are just a start, and that the team has already been working on a model that includes more treatment factors…

Theoretically, an AI could control electronic pumps that deliver IV fluids and medications. “It would be the most personal doctor you can imagine, relentlessly watching over you,” Faisal says…

Essentially, reinforcement learning comes down to trial and error. The trainers establish a goal—such as winning a game, achieving a high score, or keeping a sepsis patient alive—and link it to a reward. (In this case, the AI was programmed to maximize credits, and it earned credits for each patient that stayed alive and lost credits for those that died.) The AI tries out a sequence of actions at random, and if it achieves its goal, it gets the payoff. Over many repetitions, it learns which combinations of actions are most likely to result in the reward.” (H)

“After finding inefficiencies and a high potential for error in their sepsis treatment process, University of Utah Health, a four-hospital system based in Salt Lake City, partnered with clinical communication solutions provider Spok to help improve sepsis response…

Dr. Horton began to identify problems in sepsis response while evaluating patients with fevers. “When I was consulting for a fever, I’d go see a patient, get into their chart and find they had abnormal vital signs that had been there for several days,” he said. “Our EHR imports those notes every day, but there were no discussions about those vital signs.”

At patient bedsides, nurses would take vital signs and continue this process for four or five other patients, making the first vital signs up to an hour old by the time they were entered into the computer. “If this was an emergent case, we’d already lost an hour,” Dr. Horton said. “There may not be communication about those vital signs, they may just sit in the computer waiting for the nurse to see them and a provider may not get back to them quickly.”

Some of the health system’s providers couldn’t put the pieces together to say it was sepsis, Dr. Horton said. “And as we started looking into it, we realized we had no real process in place at our institution to address sepsis as a leading cause of death.”

If there was a way to get the vital signs in the notes sent to a provider who knows what to do with them, the hospital could ensure patients aren’t slipping through the cracks, Dr. Horton said.

To address this issue, University of Utah Health leveraged their EHR system with Spok Care Connect, which takes the EHR’s sepsis alert or a critical test result and sends it to the right clinicians’ mobile device automatically.

The alert contains the information clinicians need to act right away, including who the patient is, their room number and their modified early warning score, or MEWS. MEWS is a physiological test that prevents delays in the intervention or transfer of critically ill patients. The alert is sent in seconds, allowing the care team to respond faster.

University of Utah Health’s EHR automatically uses vital signs entered to calculate the MEWS score. If the MEWS is sufficiently high, Spok sends that MEWS alert as a message to either the charge nurse or the rapid response team. When vitals are outside normal range, the recipients get a notification to begin intervention on that patient right away.

“What was helpful for us was having all our sepsis data in one place — we can look at the data and take it back to our providers to tell them what we’re seeing,” Dr. Horton said. “If you have an EHR-based algorithm, patients’ illness can be detected earlier on and resuscitated earlier on.”

The data University of Utah Health collected also allowed them to look at the odds of septic patients getting antibiotics within the first 24 hours, Dr. Horton said.

“For all sepsis patients, we saw a length of stay that was decreased by 10 percent and because of that our total direct cost decreased by 10 percent.”

“We can have the best hospital in the world, but if you don’t know what vital signs are, and if the vital signs aren’t entered into the computer in real time, then that patient is losing, and the institution is losing,” Dr. Horton said.” (I)

“.. a new alert system, pioneered by doctors at Cambridge University Hospitals and part of a two-year pilot, has led to a seven-fold increase in the number of patients getting life-saving drugs.

The alert system works by constantly analysing patients’ observations, as recorded by staff on handheld devices.

This includes temperature, pulse, blood pressure and level of consciousness taken at various stages as patients are assessed in A&E.

If the observations suggest a patient might have sepsis, a text message appears on the hand-held device and doctors can treat the patient.

The alert system was introduced at Addenbrookes Hospital in 2016. In July 2015, only 11 per cent of patients with possible sepsis were given antibiotics within an hour of arriving at A&E. This increased to 76 per cent by August 2016.” (J)

“New York state hospitals’ adherence to sepsis protocols increased and sepsis mortality declined after reporting became mandatory, researchers said.

The analysis of sepsis reporting data from 185 New York hospitals from April 2014 through June 2016 found that sepsis protocols were initiated in 81.3% of eligible patients, most often in emergency care settings.

Risk-adjusted deaths declined from 28.8% to 24.4% (P<0.001) among patients for whom a sepsis protocol was initiated, reported Mitchel M. Levy, MD, of Brown University/Rhode Island Hospital in Providence, and colleagues in the American Journal of Respiratory and Critical Care Medicine…

While hospitals have some flexibility in developing their sepsis protocols, the law requires:

•             Blood cultures followed by antibiotics and measurement of blood lactate levels within 3 hours of presentation in patients with severe sepsis (“3-hour bundle”)

•             Administration of intravenous fluids (30 cc/kg), vasopressors and re-measurement of lactate within 6 hours in patients with septic shock, defined as systolic pressure <90 mm Hg or lactate level ≥4 mmol/L (“6-hour bundle”)..

Greater hospital compliance with 3-hour and 6-hour bundles was associated with shorter length of hospital stay as well as with increased survival…(K)

“Despite the controversy, the proof in the literature is overwhelming,” he said. “The question I have when I debate this is, ‘Where would you want your loved one to be treated — at a hospital that is known to be continuously working toward meeting these measures or at a hospital that doesn’t agree with them?'”

Twenty-seven states fall below the national average for appropriate sepsis care, according to sepsis performance data added to CMS’ Hospital Compare website in July.

Nationally, the average percentage of patients who received appropriate care for severe sepsis and septic shock is 49 percent, according to Hospital Compare.

The sepsis performance measure is based on data from the first quarter of 2017 through the third quarter of 2017. The preview period for this change spanned from May 4 to June 2. The first full year of sepsis data will be available by October.

Here are the states ranked by the percentage of patients who received appropriate care for severe sepsis and septic shock, ordered from highest to lowest: • New York: 45 (L)

“Sepsis is a major cause of death in U.S. hospitals, yet timely and effective sepsis care can reduce the risk of death,” Chanu Rhee, MD, MPH, assistant professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, said during a presentation.

Previously, Infectious Disease News spoke with Konrad Reinhart, MD, chair of the Global Sepsis Alliance, about the global rise of sepsis. Although he said there have been improvements in coding standards in the last 5 years, before that “the medical system was not doing a good job of accounting for cases of sepsis.”

Rhee and colleagues found that the reliance on claims data may be hindering sepsis surveillance, research and quality improvement. Likewise, Rhee said variations in hospital diagnosis, documentation and coding practices may make it difficult to benchmark hospital sepsis outcomes using claims data.

“Administrative claims data have important limitations,” Rhee said. “We know they have low-to-moderate sensitivity when identifying sepsis and, more importantly, recent analyses have suggested that claims-based trends are biased by changing diagnosis and coding practices over time.”..

Rhee explained that varying claims data between hospitals limits its use when comparing sepsis rates and outcomes.

“I would be the first to acknowledge that there is no true gold standard for sepsis,” Rhee said. “However, the EHR clinical criteria, I believe, are more objective and consistent.” (M)

“The Sepsis Alliance is using the month of September to educate the public and care providers about the dangers of sepsis and the need to take quick action. By using the TIME acronym, it serves as a reminder to seek medical attention as soon as symptoms are present.

Temperature – Higher or lower than normal.

Infection – May have signs and symptoms of an infection.

Mental decline – Confused, sleepy, difficult to rouse.

Extremely ill – “I feel like I might die,” severe pain or discomfort.

If you have a combination of any of these symptoms, see your medical professional immediately, call 911, or go to a hospital with an advocate and mention concerns about sepsis.” (N)

“A local hospital is using a lighter approach to educate staff on a critical problem.

Nurses and doctors at Penn Presbyterian had to solve clues, just like an escape room game, to properly diagnose and treat a mock patient with sepsis – a life-threatening response to an infection. And to save him, they had an hour to complete all the tasks.

A nurse developed the exercise to make colleagues more aware of how to detect and treat sepsis.

And some of the equipment in the room was just used as a decoy – trying to make staffers more attentive and think as they would have to in a real-life situation. No doubt this will help them and their patients in the future. (O)

“I have been on active surveillance (AS) for prostate cancer since December 2010. But though I generally am a compliant patient, I increasingly have become resistant to MRIs and biopsies.

I have had five biopsies since 2010. Only a single core out of 60 has revealed any cancer — less than one millimeter back in 2010. It was never seen again.

In the beginning, I had annual biopsies; lately, I have been on a biopsy vacation.

When I heard about potential sepsis, I became uncertain about being needled.

I worry about the potential, though rare, for deadly infections. My hospital takes steps to prevent infections (they have a low rate in prostate biopsies, one infection in 6,000 patients vs one in 1,500 nationally), but sepsis is a killer.” (P)

“When someone is admitted to the hospital, they expect to get better. Instead, nearly 100,000 people in the United States are dying each year because of healthcare-associated infections (HAI), which is more than breast and prostate cancer fatalities combined.

Those who acquire HAIs but survive are forced to stay in the hospital for significantly longer than those who do not receive an infection, racking up medical bills that likely could have been avoided.

According to the Center for Disease Control (CDC), there are four common types of HACs:

Catheter-associated urinary tract infection (CAUTI): This is a type of infection that can occur in any part of the urinary system. The biggest risk factor for a CAUTI is using a catheter for too long. Doctors should remove them as soon as they are no longer needed to minimize this risk.

Central line-associated bloodstream infection (CLABSI): CLABSI is a serious infection that occurs when germs enter the bloodstream through a central line, which is a tube that doctors place near large veins to give medications or fluids or collect blood for testing.

Surgical site infection (SSI): An SSI is an infection that occurs after a surgical procedure at the part of the body where the surgery took place.

Ventilator-associated pneumonia (VAP): VAP is lung infection that develops in individuals while they are on ventilators to help them breathe.

Many HAIs are a result of a doctor failing to follow proper medical procedures. Making errors during surgery, using poor hand hygiene, using materials that are not sterile, improper insertion of a catheter or central line, and failure to remove devices in a timely manner are just some of the ways medical providers can cause HAIs.” (Q)

“Early Recognition of Sepsis across the Continuum. “To facilitate timely diagnosis and management, healthcare organizations across the continuum should have protocols for response when sepsis is suspected, much as they do for chest pain.”” (R)

“In a recent national survey of more than 1,300 EMS providers, the National Association of Emergency Medical Technicians (NAEMT) in association with the Sepsis Alliance found that although nearly all respondents (98%) consider sepsis a medical emergency, only about half (51%) feel very confident in their ability to recognize symptoms of sepsis—the body’s life-threatening response to an infection…

Unfortunately, more than one third of EMS providers surveyed say that sepsis isn’t a key priority within their organization, and 33% say their organization isn’t well prepared for patients with sepsis. Furthermore, 25% state that while they know patients have sepsis, physicians don’t like to diagnose them with it, and 58% say when patients are showing signs of sepsis, not all hospitals initiate a sepsis protocol.” (S)

“UK researchers have developed a test they say might quickly identify sepsis, a potentially fatal complication from an infection.

Scientists at Scotland’s University of Strathclyde developed an experimental microelectrode device that analyzes a patient’s blood and provides results as quickly as 2.5 minutes. Current testing methods for sepsis can take up to 72 hours.

This is important given that every hour without diagnosis and treatment increases the chance of dying.” (T)

Can You Really Get Sepsis from Trying on Shoes Without Socks?  (U)

Famed Renaissance painter Caravaggio didn’t die of syphilis, as some historians long thought.

Instead, it appears that the talented Italian artist — who had a reputation for gambling, drinking, sleeping with prostitutes and even murder — died of a sword wound that developed a nasty infection, leading to deadly condition called sepsis, a new study finds. Sepsis is the body’s overwhelming and life-threatening response to an infection.

A team of French and Italian scientists made the discovery by digging up and analyzing what they believe are the skeletal remains of the revolutionary painter, who died at age 39 in 1610. [Photos: Renaissance Husband’s Heart Buried with Wife]..

Over the years, historians have speculated how the artist died. Caravaggio had a fever at the time his death, prompting some to guess that he had malaria or even brucellosis, an infection that people can get from eating unpasteurized dairy products.

To investigate, the researchers searched the cemetery reported to hold Caravaggio’s remains. They looked for a skeleton that was about 5 feet, 4 inches (1.65 meters) tall and between 35 and 40 years of age.

Nine skeletons in the cemetery met these criteria, but only one dated to the beginning of the 17th century, according to radiocarbon dating, the researchers said. Even more revealing were the high levels of lead in the bones, “which was a discovery of great importance since Caravaggio was known to be careless when using lead for painting,” the researchers wrote in the study, published online Sept. 17 in the journal The Lancet.

The research team also analyzed the individual’s DNA and found that it matched the genetic profile of other men with the name Merisi or Merisio, who are believed to be Caravaggio’s relatives.

Satisfied they had Caravaggio’s remains, the researchers next analyzed his teeth and found the bacteria Staphylococcus aureus hiding within the remaining blood vessels of the artist’s teeth. This bacterial infection likely led to Caravaggio’s sepsis, the researchers said.

“[The cause of death] resulted from sepsis secondary to superinfection of wounds after a fight in Naples, a few days before the onset of symptoms,” they wrote in the study.” (V)

“The cost of treating patients who develop sepsis in the hospital rose by 20% in just three years, with hospitals spending $1.5 billion more last year than in 2015, according to a new analysis.” (X)


“…of the 1.5 million Americans who develop sepsis each year, nearly 260,000 die from it.”


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Syllabus. Health Care “Transformational” Management (2013)

BUS 9100:  Business and Society

Health Care “Transformational” Management 


 1. RESPONDING TO HEALTHCARE REFORM – A Strategy Guide for Health Care Leaders, By Daniel B/ McLaughlin, HAP  ACHE Management Series  Read one chapter per week starting with Chapter 1, Week

 2. Harvard Case Studies

The Cradle Dilemma, kel511

 Performance Management at Intermountain Healthcare, HBS 9-609-103

 Newton-Wellsley Hospital, HBS 9-609-088

 Evidence-Based Management, HBS R0601E

 What More Evidence Do You Need?, HBS R1005X

 Collaborating to Improve, HBS 9-608-054

 Jeanette Clough at Mount Auburn Hospital, HBS 9-406-068

 3. Additional readings posted on Blackboard; Web sites are also assigned for some sessions. 

 4. “Doctor, Did You Wash Your Hands?”  

Visiting Professors
(* Program Graduate)

Jeffrey Kraut*

Senior Vice President for Strategy of the North Shore-LIJ Health System and Associate Dean for Strategy for the Hofstra North Shore-LIJ School of Medicine

 – “North Shore-LIJ Health System’s strategy to  maintain  its leadership position under health care reform”?

Frank Goldstein*

Vice President, Physician Services, Meridian Health

 – “Converting hospital based physician practices from FFS to Patient Centered Medical Homes“

Annette Catino*

President & CEO, QualCare Alliance Networks, Inc.

– “Obamacare from the Payers perspective“

Carmine Asparro*

Principal in charge of the managed care consulting practice, OnPoint Partners

– “Provider and health plan strategies with Health Insurance Exchanges“

David Florman*

Partner of Florman Tannen LLC

–  “Population health management – organizational transformation in the health care reform era“

Jeffrey Menkes*

Senior Vice President ,System Network Development, Montefiore Medical Center

– “Lessons Learned as a  “seller” now “buyer” under Obamacare“

Joel Seligman

President and CEO of Northern Westchester Hospital

 – “Northern Westchester Hospital Center’s strategy to  maintain  its leadership position under health care reform“

Lee Perlman

Executive Vice President of Administration and Chief Financial Officer of the Greater New York Hospital Association;  President of GNYHA Ventures, Inc.; and CEO of Happtique

 – “Creating Value: GPOs and the Business and Politics of Health Care”

Section Objectives

To learn the basics about the American health care system

To understand the implications of the Affordable Care Act

To learn to use the Case Study method as an analytical tool

To start using an “evidence-based” approach to management

To  be a successful contributor in small group  meetings

To get comfortable  being a discussion leader

To meet and interact with industry leaders (your future bosses)

To begin a personal  career diary of  “Lessons Learned”

Section Paradigm

Using the CASE STUDY METHOD the course presentations by Professor Metsch and the Visiting Professors address COMPLEX PROBLEMS and the value of LESSONS LEARNED.

Case Study types: original Case Studies prepared by Prof. Metsch; Case Studies presented by senior health administrators (Visiting Professors); and iconic Harvard Case Studies.

Sessions are comprised of two complementary parts paired to integrate the Case Studies with Student Learning Outcomes and the Course Objectives. 

The Case Study Method

Cases attempt to reflect the various pressures and considerations that professionals of all varieties confront in the workplace.

Using complex, realistic open-ended problems as a focus, cases are designed to challenge you and help you develop and practice skills that you may need in your future careers.

Cases are also an excellent way to see how abstract principles learned in class are applied to real world situations.

Remember that case assignments involve a different kind of learning than other assignments. There is no one single answer and sometimes even the issue is deliberately not stated clearly.

Complex Problems

situations where the decision-maker must integrate or reconcile at least two competing priorities that may not be linear or complementary

having to reach agreement on goals while simultaneously evaluating options

where goals are clear but political support is not

where the definition of the problem keeps changing and consensus has to constantly be reestablished

where there are so many variables it is difficult to determine the actual possible outcomes

various combinations/ permutations of the above

Lessons Learned
  Start a diary of 3 Lessons Learned each week from the following categories:

•       –  the Visiting Professor and/ or ProfM 

•       –  the course text – RESPONDING TO HEALTHCARE REFORM

•       –  the articles posted on Blackboard or articles you find yourself

•       –  a Harvard Case Study (but only if different from the LLs you used in your 8 slide set)

•       –  an experience at work or elsewhere


                              •       USE 3 DIFFERENT CATEGORIES EACH WEEK!

•       For Week 12 use LLs from Final Case Study presentations ONLY (but not your own)     

                              •       Post on Blackboard after each class & email to 

•       then synthesize them into a Lessons Learned essay after the last class

Objective of Case Study Analysis =

To develop an evidence based theme (“thread”) through the slide set so the conclusion (“policy recommendation” or “project plan”) is accepted

How to Structure Your Harvard Case Study Homework Assignments
& Final Case Study Project

USING POWERPOINT (one slide on each of the following)

1.            Introduction, Situation, Background -This section describes the reason for the case study.

2.            Problem – This section states the main problems which need to be resolved. Some case studies include charts and graphs to illustrate key points.

3.            Questions/ Issues*

4.            Solution – This section describes the solution in detail, what changes were made, and the impact. Some case studies include charts and graphs to illustrate key solutions.

5.            Evaluation – This section recap the main benefits of the solution and the impact/ outcomes/ results. 

6.            Lessons Learned!

7.          Anchor Concepts

8.          Overlay 2013 ACA and “transformational” (if case was taking place today)

*Note: For final Student Case Presentations – #3  Questions/ Issues for class discussion before presenting #4 Solution

Week 1 – December 3rd

Case Study Method 1

Professor Metsch

“Project Management – The Hardest Part about Getting Started………… is Getting Started”

  (7 health care related vignettes with break-out groups to understand and practice case study analytics)

1.  Getting Started – “The First Day”

2.  Program Planning – Hoboken H1N1 “Swine Flu” Task Force

3.  Service Recovery – Hospital ER

4.  Professional Status – When the Nurse Wants to be Called “Doctor”

5/6.  Resource Allocation –  Food Sustainability Programs

7/8/9. NFP Board of Trustees – Program Evaluation, Changing Accreditation Agencies, New Service Opportunities

10. Joining a NFP Board of Trustees – What should you know?


Week 2 – December 10th

Case Study Method 2

Professor Metsch

Hudson Cradle,

Jubilee Center, &

Hudson County Child Abuse Prevention Center 

( 3 integrated health care related vignettes with break-out groups to further understand and practice case study analytics)

Homework*  The Cradle Dilemma kel511

(a health care related NFP CEO grapples with its “mission” in a turbulent environment)

Week 3 –December 17th

Case Study Method 3

Professor Metsch

Jersey City Medical Center (1989-2013)

( an original case study based on Dr. Metsch’s 17 year tenure as President and CEO of LibertyHealth/ Jersey City Medical Center, with break-out groups; to finish practicing case study analytics)



Jersey City Medical Center + Images of America + Len Vernon

Then scroll down and click on

Jersey City Medical Center – Google Books Result

Leonard F. Vernon – 2004 – ‎History

Leonard F. Vernon. IMAGES of America JERSEY CITY MEDICAL CENTER . 1,1 1.1 . . – . IMAGES of America JERSEY CITY MEDICAL CENTER Ono …

Week 4 – January 7th

Frank Goldstein

Vice President, Physician Services, Meridian Health

 – “Converting hospital based physician practices from FFS to Patient Centered Medical Homes”

(a case study on one system’s journey from fee-for-service to “population” health)

Homework*  Performance Management at Intermountain Healthcare HBS 9-609-103

(a mega system’s data driven approach to Medicare reimbursement) 

Week 5 – January 14th

Joel Seligman

President and CEO of Northern Westchester Hospital

 – “Northern Westchester Hospital Center’s strategy to  maintain  its leadership position under health care reform“

(A case study addressing the future of a high quality, free-standing, suburban community hospital)

Case Study Method 4 –

Professor Metsch

Restructuring a Failing Public Hospital in Hoboken

(a policy case study about how to stabilize a city-owned hospital)


New Jersey Commission on Rationalizing Health Care Resources, Final Report 2008

Commission on Health Care Facilities in the 21st Century

Week 6 – January 21st

Annette Catino

President & CEO, QualCare Alliance Networks, Inc.

– “Obamacare from the Payers perspective“

(Insurance Reform versus Healthcare Reform)

Homework * Newton-Wellesley Hospital HBS 9-609-088

(a CEO faces the challenge of multiple physician payment methods in one hospital)

Week 7 – January 28th

Jeffrey Kraut

Senior Vice President for Strategy of the North Shore-LIJ Health System and Associate Dean for Strategy for the Hofstra North Shore-LIJ School of Medicine

 – “North Shore-LIJ Health System’s strategy to  maintain  its leadership position under health care reform”?

(A case study on the transformation of the Health System’s clinical and business models to succeed under value-based health reform.)

Case Study Method 5

Professor Metsch

Evidence Based Decision Making

(fostering a framework for inter-disciplinary collaboration) 


Evidence-Based Management – HBS R0601E

What More Evidence Do You Need? – HBS R1005X

Week 8 – February 4th
David Florman

Partner of Florman Tannen LLC

–  “Population health management – organizational transformation in the health care reform era“

(a health care consultant presents case studies on organizational adaptation)

Homework*  Collaborating to Improve HBS 9-608-054

(a hospital Chief Medical Officer’s efforts to introduce a new quality paradigm)

Homework*  Collaborating to Improve HBS 9-608-054

(a hospital Chief Medical Officer’s efforts to introduce a new quality paradigm)

Week 9 – February 11th

Lee Perlman

Executive Vice President of Administration and Chief Financial Officer of the Greater New York Hospital Association;  President of GNYHA Ventures, Inc.; and CEO of Happtique

 – “Creating Value: GPOs and the Business and Politics of Health Care“

(a senior health care trade association executive discusses creating new revenue streams for its members)

Case Study Method 6

Professor Metsch

The role of the Board of Trustees  

(a series of vignettes on “best practices” of NFP Boards of Trustees)


Week 10 – February 18th

Carmine Asparro

Principal in charge of the managed care consulting practice, OnPoint Partners

– “Provider and health plan strategies with Health Insurance Exchanges“

(a health care consultant presents cases on client HIE strategies)

Homework *  Jeanette Clough at Mount Auburn Hospital HBS 9-406-068

(a hospital CEO leads a  financial “turn-around” then faces new sustainability challenges)

Week 11 – February 25th

Jeffrey Menkes

Senior Vice President ,System Network Development, Montefiore Medical Center

– “Lessons Learned as a  “seller” now “buyer” under Obamacare“

(a senior health system executive discusses “selling” a hospital to a system, now expanding the continuum of care for a mega-system)

Case Study Method 7

Professor Metsch

“Associated Camps”

(a case study of failed strategic planning)

Week 12 –March 4th  

Student Case Study Presentations

– Groups of 3 -set by the class –

(but different from Harvard groups and any groups from first trimester courses)


Due: January 7th

First PP Draft: February 4th

Second PP Draft: February 25th

Case Presentations: March 4th

Post Final on Blackboard on: March 5th

Week 13

Final Lessons Learned Essay ,

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Some CASE STUDIES by category

To view the full portfolio of cases go to

Doctor, Did You Wash Your Hands?™


When I was appointed President and CEO of LibertyHealth/ Jersey City Medical Center in 1989 one of our goals was to become a top tier New Jersey teaching hospital.

If Columbus had an advisory committee he would probably still be at the dock. (A)

The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER

We don’t know what we don’t know” (1) The challenge to emergency preparedness…..

Two years ago, while on vacation, my wife punctured her hand with a BBQ skewer. So she went to the nearest ER.

Confidential September 11, 2001 LESSONS LEARNED memorandum by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey gubernatorial campaign issue

Trust but Verify” (Ronald Reagan) – Four Lessons Learned as a junior CEO back in the day..

DON’T DEPEND ON ANYONE ELSE TO BRING THE COFFEE! & other Lessons Learned as a junior hospital CEO back in the day….

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)

“If you don’t have a seat at the table, you’re probably on the menu.”


From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare)

“It leaves us with two laws… Call the first one Obamacare… Call the second one Trumpcare”

The new health care Gold Standard” GawandeCare”

“…what would it look like if Amazon CEO Jeff Bezos took the helm of a major integrated (health care) delivery system?”

Case Study on Disruption/Disintermediation in health care (10 posts)


When physicians opt out of Medicare they should reimburse Medicare for paying for their training

The Mayo Clinic is discriminating against Medicare Patients. Unbelievable! Outrageous!

A Medicare Conundrum: Observation status – Readmission penalties – Hospitalist handoff to primary care physician.

Should physicians be afforded Mulligans for non-reimbursable Medicare readmissions?


“…really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.”

PUBLIC HEALTH administrators can transform monumental unique challenges to “rapid response” opportunities. Think: Hurricanes Florence and Michael, the California wildfires, the mysterious polio-like illness, the opioid epidemic, mass shootings, and immigrant family separation.

President signs “Right to Try Act” – “Despite good intentions – right to try legislation grants no rights.”

“Right-to-try should not be right-to-die-poorer”


Stop the name games! University hospitals and regional medical centers should live up to their billing *

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


Johns Hopkins All Children’s Hospital (St Petersburg, Florida) – problems in the hospital’s heart surgery unit

San Francisco General, a public hospital with San Francisco’s only trauma center, all commercial insurance is “out-of-network.”


You are a new member of the Board of University Medical Center and have been appointed chairperson of the Board’s Compliance Committee.

“…of the 1.5 million Americans who develop sepsis each year, nearly 260,000 die from it.” (A)


Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

Can/should health care workers be fired for using appropriately prescribed medical or legally purchased recreational marijuana?

“Concurrent” Surgeries – Is it OK for a surgeon to operate in different ORs at the same time?

There’s a growing movement in the United States to install video cameras in operating rooms…

Concierge medicine is the all the rage but rather should we be enraged about it?

Do you want to be treated by a stranger when you are admitted to the hospital? Every practicing physician should have hospital privileges.

It’s like the Wild, Wild West, the (physician specialty) turf wars…. (A)

“Two-thirds of beneficiary communication is more complex to read than Moby Dick…” Let’s start with EOBs!


On July 4th as we respect and admire hospital staff members who are working 24/7, it is interesting to look at hospital care during the Revolutionary War

President Garfield didn’t die from an assassin’s bullet, but rather from a doctor’s dirty hands.”

posts related to these posts can be found throughout

Doctor, Did You Wash Your Hands?™
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Method of Preparing “Raw” Contemporaneous Cases

A. Spend some time looking at the case format at

B. To identify CCCS topics sign-up for daily automatic health care news feeds. For example:


2. MedPageToday

3. Becker’s Hospital Review

4. Healthcare Dive

5. FierceHealthcare

6. New York Times

7. Hospital Association Daily News Clips

C. Set up Google Alerts for example I am currently following: telehealth, sepsis, AI, block chain, Medicare For All, EMRs, precision medicine)

D. Then create a folder for each topic

E. Then every day from your News Feeds select articles on your topics and move them to the appropriate folder.

F. When you are inspired to write a “case” start a Word document, then go to the case folder and select key points from the articles, and cut and paste them to the Word document. As well capture article title, author and hyperlink.

G. Move the key points around until you have created a story.

H. Then label each point A,B.C…and move article title, author and hyperlink to footnotes at the end of the case.

I. Then write an introduction to the case.

J. Questions to t

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Case Study Teaching

I am retired from teaching so I asked Professor “GOOGLE” about getting up-to-date on Case Study teaching. Here’s what I found.

The Case Method

Cases are narratives, situations, select data samplings, or statements that present unresolved and provocative issues, situations, or questions (Indiana University Teaching Handbook, 2005). The case method is a participatory, discussion-based way of learning where students gain skills in critical thinking, communication, and group dynamics. It is a type of problem-based learning.

What is the Case Study Method?

How the Case Method Creates Value

Often, executives are surprised to discover that the objective of the case study is not to reach consensus, but to understand how different people use the same information to arrive at diverse conclusions. When you begin to understand the context, you can appreciate the reasons why those decisions were made. You can prepare for case discussions in several ways.

Using Case Studies to Teach

Advantages to the use of case studies in class

A major advantage of teaching with case studies is that the students are actively engaged in figuring out the principles by abstracting from the examples. This develops their skills in: Problem solving; Analytical tools, quantitative and/or qualitative, depending on the case; Decision making in complex situations; Coping with ambiguities

Teaching Case Studies Online: A Resource List

It’s difficult to find a good set of resources for teaching online case studies. While researching how to structure and moderate online case studies for one of our faculty members, I put together a list of several resources. Hopefully, you’ll find these a helpful place to start as you are learning to teach using case studies online.

Top 10 Free Training Courses for Online Teachers

Whether you’re new to distance learning or an experienced online teacher, you can find free online training resources to fit your needs.

Are you a “face to face” classroom teacher considering shifting to online education?

Or are you an online teacher interested in the latest technology to make your online courses more effective?

For example, some online schools offer free training modules to help campus-based teachers learn how to transition to cyber-classrooms. Other organizations offer tips on designing online classes and teaching with technology.

And Amazon has a number of books to look at t T

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“President Garfield didn’t die from an assassin’s bullet, but rather from a doctor’s dirty hands.”

Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me. But not again before she left the room!
I reported this to the absentee owner!

Do you ask “Doctor, Did You Wash your Hands?” If not, why not?
Everyone knows, including our physicians, that proper hand washing is the most effective patient safety measure right?
Your physician and other clinicians (e.g. nurses, PTs, lab techs drawing blood) should wash their hands before and after each patient, both times in front of you.

First some history.
“Ignaz Semmelweis, a young Hungarian doctor working in the obstetrical ward of Vienna General Hospital in the late 1840s, was dismayed at the high death rate among his patients.
He had noticed that nearly 20% of the women under his and his colleagues’ care in “Division I” (physicians and male medical students) of the ward died shortly after childbirth. This phenomenon had come to be known as “childbed fever.” Alarmingly, Semmelweis noted that this death rate was four to five times greater than that in “Division II” (female midwifery students) of the ward.
One day, Semmelweis and some of his colleagues were in the autopsy room performing autopsies as they often did between deliveries. They were discussing their concerns about death rates from childbed fever.
One of Semmelweis’ friends was distracted by the conversation, and he punctured his finger with the scalpel. Days later, Semmelweis’ friend became quite sick, showing symptoms not unlike those of childbed fever. His friend’s ultimate death strengthened Semmelweis’ resolve to understand and prevent childbed fever.
In an effort to curtail the deaths in his ward due to childbed fever, Semmelweis instituted a strict hand washing policy amongst his colleagues in “Division I” of the ward. Everyone was required to wash their hands with chlorinated lime water prior to attending patients. Mortality rates immediately dropped from 18.3% to 1.3% in 1848 in Semmelweis’ division. (A)”

(1861) “…. Louis Pasteur was showing the world that microorganisms did indeed exist, that they acted on our world in myriad ways and that the ancient wisdom about “bad vapors” and spontaneous generation were wrong. Dead wrong. Prior to Pasteur and what would become known as “germ theory,” the prevailing theories held that organisms, like maggots and fleas, were spontaneously originated from other matter, like raw meat or diseased flesh…..
Pasteur is credited with opening the world’s eyes to the new science of microbiology and ushering in a brand new form of preventive medicine: immunization. …Building on what Pasteur was discovering, British surgeon Lister began to use this new germ theory to demonstrate the lifesaving value of disinfectant. Despite his skill at surgery, Lister knew that half his amputee patients would die of infection after the procedure…..
He began to treat his surgery equipment, before and after use, with carbolic acid. He also treated his patients’ wounds with it…..within two years, operative mortality decreased from nearly 50 percent to just 15 percent.” “Much of the greatness of Pasteur and Lister lies in their dogged persistence to spend 20 years convincing the rest of the medical world of the truth of their investigations,” ….. (B)

(1881) “What Dr. Towsend did next was something that Joseph Lister, despite years spent traveling the world, proving the source of infection and pleading with physicians to sterilize their hands and instruments, had been unable to prevent. As the president (Garfield) lay on the train station floor, one of the most germ-infested environments imaginable, Towsend inserted an unsterilized finger into the wound in his back, causing a small hemorrhage, and almost certainly introducing an infection that was far more lethal than Guiteau’s bullet.” (C)

“The shot in the back was not fatal, not hitting any vital organs. The bullet lodged behind the pancreas. “If they had just left him alone he almost certainly would have survived,” Millard said. Within minutes, doctors converged on the fallen president, using their fingers to poke and prod his open wounds. “Twelve different doctors inserted unsterilized fingers and instruments in Garfield’s back probing for this bullet,” Millard recounted, “and the first examination took place on the train station floor. I mean, you can’t imagine a more germ-infested environment.” American doctors at the time didn’t believe germs existed at all. And according to Dr. Jeffrey Reznick of the National Library of Medicine, they rejected the use of antiseptics pioneered by British surgeon Joseph Lister, for whom Listerine would later be named” (D)


“Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene….
“Why is it still so hard to get health care workers to wash their hands?
Active resisters are people who like doing things a certain way for the simple reason that things have always been done that way. During one site visit, an infectious diseases doctor involved in preventing infections told us:
Getting the surgeons to adopt things in general is problematic … they’re like baseball players, they’ve got superstitions…in their minds if it’s working, why should we change it.
But at least you know who these people are since they speak up at meetings and actively resist changing behavior.
The second type are what we termed organizational constipators. These individuals often have nothing against an initiative per se but simply enjoy exercising their power by refusing to change, albeit below the radar. The challenging aspect about organizational constipators is that the people above them think they are doing a good job, while those below them cannot believe they still have a job.
Yet another barrier we found in our research is that many hospitals have a culture of mediocrity rather than a culture of excellence. These hospitals are content to be just good enough. Leadership is generally ineffective. Overperformers are rewarded with more work.” (E)

“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (F)

“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (G)

“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. ” (H) (I)

“How dirty is your Qwerty?
It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips.
Sure, it may sound like a hypochondriac’s excuse to stay away from the office. But a growing body of research suggests that computer mice and keyboards are, in fact, prime real estate for germs.
It’s a phenomenon most recently illustrated by tests at a typical office environment in the United Kingdom. A consumer advocacy group commissioned the tests in which British microbiologist James Francis took a swab to 33 keyboards, a toilet seat and a toilet door handle at the publication’s London office in January.
Francis then tested the swabs to see what nasty germs he managed to pick up. He found that four of the keyboards tested were potential health hazards — and one had levels of germs five times higher than that found on the toilet seat.” (J)

“Question: I recently had an appointment with a medical specialist. I got called into the clinic room where I waited for the doctor; and I noticed a few “wash your hands” posters. When he came in, I swear he didn’t use the hand sanitizer. I couldn’t be sure. And I didn’t want to ask – but I was kind of grossed out. What should I have done? Is it okay to question the doctor about hand washing?
Answer: Your concerns about hand washing are certainly justified. Poor hand hygiene practices are largely to blame for the spread of germs within health care settings…
If you ever suspect that your doctor, nurse or other health care provider forgot to use the hand sanitizer, by all means raise the question. But, in reality, most patients in your situation are reluctant to do so.
“Very few people would ever be comfortable asking their health-care providers if they’ve cleaned their hands,” acknowledges Dr. Vearncombe. “Our patients feel very vulnerable,” she explains. “They are in an imbalanced power relationship with us, so it is really hard for them to ask.”
Indeed, some patients fear that their treatment could be jeopardized if they challenge the doctors and nurses on even routine matters such as hand hygiene. Their care will certainly not be affected, but it’s a worry for them nonetheless.
Surveys going back almost a decade found that Ontario patients didn’t want to be placed in the role of a police officer to ensure that doctors and nurses wash their hands.
As a result of these surveys, most of the hand-hygiene education in Ontario has focused on the health care providers themselves.
Since 2007-2008, Ontario hospitals have been required by provincial law to report their hand-hygiene rates. In some hospitals, such as Sunnybrook, designated staff members routinely observe interactions of health care providers with patients to track if they are actually washing their hands at the appropriate times.”
Before mandatory reporting took effect, a study carried out at a few hospitals had revealed that hand-hygiene compliance rates were “abysmally low,” notes Dr. Vearncombe.
The rate at Sunnybrook, for instance, was originally less than 40% – similar to many other hospitals. “We have made great increases in our hand-hygiene compliance, and the most recent results show our overall rate is now 87%.”..
A pilot study at Sunnybrook has been exploring what role patients could play.
Three of the hospital’s inpatient wards were selected for the pilot. As part of the study, an information card was placed on the bedside table whenever a room was cleaned and prepared for a new patient.
“This little card explained in lay language what to expect” when a health-care provider entered the patient’s room, says Dr. Vearncombe.
The cards stated that “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.”
The cards also included the catchphrases: It’s okay to ask staff, ‘Did You Clean Your Hands?’ and Reminders help everyone!
So, the next time you suspect a health-care worker may have skipped the hand sanitizer, don’t hold back. Everyone benefits when fewer germs are spread around.” (K)

“At Denver Health Medical Center, the CenTrak monitoring system is used on two of the medical-surgical wards, the medical intensive care unit, and the step-down care unit. On these particular units, all rooms are single occupancy.
All nurses and healthcare technicians on these floors, as well as those on the float team, have badges. Additionally, select hospitalists, intensivists and residents also have badges to track their personal electronic hand hygiene adherence.
“We monitor both waterless hand sanitizer and soap dispensers,” Young explained. “We have defined adherence with the technology to be performing hand hygiene within 60 seconds before or after entering the room and within 60 seconds before or after leaving the room.”
Denver Health has used the electronic hand hygiene monitoring system as a means to both effect and measure change in hand hygiene. For example, it has used electronic hand hygiene to study the effect of poster placement on hand hygiene habits. It also has provided individual feedback to staff members on their hand hygiene rates and studied the change in electronic hand hygiene over time.
The hospital has achieved quite a success with baseline hand hygiene adherence rates nearly doubling. While Denver Health measures multiple hand hygiene workflows, this particular example of improved compliance was in regard to its wash-in/wash-out protocol – the requirement for staff to wash their hands upon entering a room and again after their interaction with a patient.
“Using data from the electronic hand hygiene compliance system, Denver Health was able to properly audit hand hygiene processes and provide additional training and education to staff where needed most,” said Young.” (L)
“The 70-page report, “Guide to Hand Hygiene Programs for Infection Prevention,” outlines an eight-step multimodal program that hospitals can follow to ensure hand-hygiene program success.
“It’s when all those components of hand-hygiene programs are working together effectively that we see the biggest change,” Timothy Landers, R.N., lead editor of the guide, said in a report announcement. However, the report makes it clear that without one component–the full support of hospital leadership–programs will continue to fail.
“Leadership’s commitment to hand hygiene must be visible and engaging–to the organization and the public through formal communication, hand-hygiene education, promotions, and event sponsorship,” the report said.
In addition to leadership support, the guide also recommends that hospitals follow these steps:
Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug resistant pathogens.
Create a multidisciplinary design and response team led by a senior administrator to emphasize that the organization is committed to hand-hygiene compliance.
Provide ongoing education and training for staff, patients, families and visitors. The report suggests the use of instructive posters, pocket cards and brochures for training.
Ensure hand-hygiene resources are accessible throughout the organization, including patient care corridors and at the entrance and exit of patient rooms.
Reinforce hand-hygiene behavior and accountability. Some organizations have success conducting contests and recognizing healthcare workers who comply with the guidelines.
Provide reminders throughout the healthcare setting. For example, the report suggests organizations provide real-time feedback from observers, coworkers, patients and visitors.
Develop an ongoing monitoring program that includes feedback. Some organizations, the report said, post monthly compliance data on hospital units or their hospitals’ Web sites and discuss the findings with staff during meetings.” (M)

“Most evaluation reviews are generated after a major, life-threatening error occurs, which usually happens infrequently. Historically, when an evaluation determined that a process completed by personnel was deficient, problem-solving efforts focused on the identification of the specific individual(s) who “caused” the problem. Later, quality improvement efforts focused on developing a culture of safety and recognized that additional contributions to errors were due to complex, poorly designed systems. The advantage of an evaluation that reviews system problems is that it encourages health care professionals to report adverse events and near misses that might be preventable in the future, while balancing the identification of system problems with holding individual providers responsible for their everyday practices. Improvement is impossible without evaluation reports to provide data on the factors that contribute to mistakes and lead to subsequent individual and system changes that support safer practices.
An evaluation strategy examining process measures include the following examples:
Document staff use of maximum sterile barriers (cap, mask, sterile gown, sterile gloves, large sterile sheet) and aseptic technique for the insertion of central intravenous catheters or guidewire exchange.
Document timing of antibiotic prophylaxis when used in surgical patients (e.g., within 1 hour of incision).
Document if hand hygiene is performed and clean or sterile gloves are worn before assessing a catheter insertion site or changing a dressing on intravascular catheters.
Document time elapsed from when patient culture (microbiology and susceptibility) results are reported and when the appropriate isolation precautions are instituted (patient room placement, signs, PPE used, disposable equipment used, medical record documentation, etc.).
Ensure that staff (nurses, doctors, and housekeeping) enter a contact isolation room using the specified personal protective barriers (e.g., gloves, gown) on each entry.
Ensure that staff properly remove PPE after leaving a patient’s room.
Assess the annual rates of influenza vaccination for health care workers and other personnel eligible to receive vaccination; assess the rates of influenza vaccination for patients.
Ensure that needle disposal containers are no more than three-quarters full at time of disposal.
Periodically monitor and record adherence with the hand hygiene guidelines: the number of times personnel washed their hands divided by the number of hand-hygiene opportunities, computed by ward or by service. Provide feedback to personnel regarding their performance.
Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient days.
When outbreaks of infection occur, assess the adequacy of health care worker hand hygiene.
When a patient with a known colonization or infection with a multidrug-resistant organism (e.g., MRSA, VRE) is transferred to your facility, evaluate effectiveness of system notification to health care personnel in the receiving facility.
Record compliance with hospital policy for catheter-site dressing changes.” (N)

“Hospitals have several different options to consider when monitoring compliance.
• Direct observation: This method involves monitoring the actual hand hygiene actions of staff. It can be done manually – with an actual person doing the monitoring – or it can be done with the assistance of technology such as smartphone apps. The smartphone apps can improve the likelihood of making covert observations and reduce the instances of Hawthorne effect, which is a social occurrence in which individuals alter or improve their behavior in response to their awareness of being observed.
• Measuring product use: This is an indirect way of conducting observations by quantifying the amount of soap and sanitizer used. Mathematical models can be used to determine how many hand hygiene opportunities there were versus how often staff actually took advantage of these opportunities.
• Electronic monitoring: Several different types of sensors are now available to measure handwashing compliance. While they can be expensive, a major benefit of electronic monitoring is it can provide administrators with real-time feedback on compliance prior to a healthcare worker’s interaction with patients.” (O)

“More than 5,200 nurses and other caregivers in 71 units at 42 hospitals across multiple states were given a radio frequency identification (RFID) badge that recorded when they triggered the ubiquitous sanitizer dispensers typically placed near the entrance to a room. Researchers monitored the tracking for as long as three and half years, ending in August 2013. There were an estimated 20 million hand-washing opportunities to study. The researchers focused on “total daily usage per unit bed,” a calculation in which the number of times total dispensers in a given hospital unit were used each day was divided by the number of beds in that unit.
Nice Start…
Personal tracking did indeed trigger an initial improvement. The daily usage of dispensers jumped from an average of 28.4 times per day in the 17 days before the tracking commenced, to 46 times a day at launch. Workers who did not receive a badge did not show any change in hand-washing habits.
…But No Sustained Momentum
Hand-washing continued to improve for more than a year and a half, but then peaked at month 20. As the graph above shows, three years into the project, usage had backslid to where it was in the first month.
That said, the researchers calculate that it would be a full 10 years of waning compliance before hand hygiene habits fell to where they were before the monitoring program was introduced – though a sub-50 compliance rate is no one’s idea of optimal.
Clearly, technology in a vacuum is not the solution. “Managers cannot simply ‘monitor and forget,'” the researchers wrote. “There is a need for ongoing managerial interventions to sustain the benefits of monitoring.” (P)

“HyGreen Inc., Gainesville, Fla., provides just-in-time coaching to health care workers when they forget to wash, and records the information in real time, says Elena Fraser, vice president of sales and marketing. “The instant the health care worker dispenses the hand wash, both the light-emitting diode on the top of the HHCM sensor and the badge turn green. At the same time, a wireless signal documents the worker identification, time and location and sends that information to the database,” she explains.
When the health care worker steps into a zone that is created by a monitor over the patient bed, the monitor recognizes that the badge is green. Again, time, location and worker ID are transmitted to the database. If the health care worker forgets to wash his or her hands, the bed monitor will cause the badge to vibrate, which serves as a subtle reminder.” (Q)

“Vanderbilt already had a traditional hand-hygiene program in place, but it was doing little to improve hand-washing rates. So the doctors took a different approach, focusing on three important areas:
Training. Every single hospital employee received training on correct hand-washing protocol, from clerical workers to chief surgeons. The training program placed much of its focus on the direct link between hand-washing and hospital-acquired infections.
Communication. Peer-to-peer communication was key to making the program work. Staff members were encouraged to speak up and remind each other of correct hand-washing practices if they noticed lapses. If someone received a reminder, the only correct response was “Thank you.”
Shared accountability. All staffers were held equally accountable for their unit’s success with achieving high hand-washing rates, even if they were visiting surgeons. Designated employees were tasked with monitoring how closely everyone followed established protocols, and units that didn’t meet established targets were encouraged to boost their performance as a whole. Staffers were also rewarded based on their collective performance in improving hand-washing rates.” (R)

“The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands; before touching a patient; before clean/aseptic procedures; after body fluid exposure/risk; after touching a patient, and; after touching patient surroundings.” (S)

Few scientific studies have evaluated measurement techniques; a recent review of the reliability and validity of hand hygiene measures found that only 28% of research articles and guidelines related to hand hygiene measurement included any mention of reliability or validity. Methodology between studies varies a great deal, including how adherence or non-adherence is defined and how observations are carried out; in addition, sufficient details concerning the methods and criteria used are often lacking.
The following are some of the specific challenges to measuring hand hygiene adherence: • Contact with patients and their environment takes place in many locations within organizations. • Opportunities for hand hygiene occur 24 hours a day, 7 days a week, 365 days a year and involve both clinical and nonclinical staff. • The frequency of hand hygiene opportunities varies by type of care provided, unit, and patient factors. • Monitoring is often resource intensive; infection preventionists, quality improvement staff, and other health care workers (for example, nursing, respiratory therapy) face numerous competing demands for their time and expertise. • Observer bias (such as the Hawthorne effect) is difficult to eliminate.” (T)

It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse: Have you washed your hands?
Hospitals are encouraging patients to be more assertive, amid growing concern about infections that are resistant to antibiotics.
Strict hand hygiene measures are the gold standard for reducing infections associated with health care. Acquired primarily in hospitals but also in nursing homes, outpatient surgery centers and even doctor’s offices, they affect more than one million patients and are linked to nearly 100,000 deaths a year, according to the Centers for Disease Control and Prevention.
The CDC aims to engage both patients and caregivers in preventing dangerous hospital infections. Centers for Disease Control.
Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. (U)

(2013) “At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.” (V)

(2012) “But there are skeptics. “Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined? (W)

“Healthcare can benefit from the power of cameras to improve accountability,” Makary, Pawlik and Xu conclude. “In an era where 86% of nurses report having recently witnessed disruptive behavior at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement tool. If concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation.” (X)

(D) How doctors killed President Garfield,
(E) Hand Washing Stops Infections, So Why Do Health Care Workers Skip It?, by Sanjay Saint,
(F) What Zero Looks Like: Eliminating Hospital-Acquired Infections,
(G) Hospital-acquired infections rack up $9.8B a year, by Julie Bird,
(H) Guidelines for prevention of hospital acquired infections,
(I) Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene,
(J) Your Keyboard: Dirtier Than a Toilet, by Dan Childs,
(K) It’s okay to ask your doctor: “Did you wash your hands?”, by Paul Taylor,
(L) Denver hospital deploys hand hygiene monitoring system to boost adherence, by Bill Siwicki,
(M) An 8-step strategy to improve hand-hygiene, by Ana Mulero,
(N) Chapter 41Preventing Health Care–Associated Infections, by Amy S. Collins,
(O) A culture of support: 4 ways to improve hand hygiene compliance, by Brian Zimmerman,
(P) Hospital Hand Washing: The Limits of Electronic Monitoring, by Carla Fried,
(Q) Hand hygiene monitoring, by Neal Lorenzi,
(R) Hand washing: How one hospital achieved nearly 100% compliance, by Jess White,
(S) My 5 Moments for Hand Hygiene, World Health Organization
(X) (X)

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