
<rss version="2.0">
	<channel>
		<title>The Joint Commission Journal on Quality and Patient Safety</title>
		<link>http://www.jcrinc.com</link>
		<description>Blog</description>
		<language>en-us     </language>
		
		
				<item>
					<title>February 2012 issue of The Joint Commission Journal on Quality and Patient Safety </title> 
					<link>http://www.jcrinc.com/Blog/2012/1/26/February-2012-issue-of-The-Joint-Commission-Journal-on-Quality-and-Patient-Safety/</link> 
					<description><![CDATA[
		
				
						
								
										
												Now available for your online access is the February 2012 issue of The Joint Commission Journal on Quality and Patient Safety. Here is a look at this issue:
										
								
						
				
				
						
						PERFORMANCE IMPROVEMENT
				
		
		
				Spreading a Medication Administration Intervention Organizationwide in Six Hospitals 
		
		Spreading a quality improvement collaborative’s one-year intervention from two pilot units to all inpatient units in six hospitals led to improvement in medication administration accuracy for the pilot and spread units.
		
				Improving Venous Thromboembolism Prevention Processes and Outcomes at a Community Hospital
		
		
		Standardization of venous thromboembolism (VTE) risk assessment and prophylaxis prescribing practices across surgical and medical specialties in a community hospital increased VTE  prophylaxis use resulted in a significant decrease in the number of hospital-acquired VTE events between 2008 and 2010  (p = .035).
		
				INFECTION PREVENTION AND CONTROL
		
		
				Estimated Costs Associated with Improving Influenza Vaccination for Health Care Personnel in a Multihospital Health System
		
		
		A health care system’s 11 hospitals conducted an education and publicity campaign to provide nonphysician health care personnel influenza vaccine free of charge at mass vaccination clinics. The average costs per vaccinated employee were modest compared with the costs typically associated with influenza-related absenteeism. 
		
				
						PERFORMANCE MEASURES
		
		
				Ongoing Professional Performance Evaluation (OPPE) Using Automatically Captured Electronic Anesthesia Data 
		
		A large academic center providing anesthesia services for more than 49,000 procedures each year created an Ongoing Professional Practice Evaluation (OPPE) process that uses readily available, automatically captured electronic information from its anesthesia information management system. 
		
				
						HEALTH CARE DISPARITIES
		
		
				Impact of an Easy-Access Telephonic Interpreter Program in the Acute Care Setting: An Evaluation of a Quality Improvement Intervention 
		
		A dual-handset phone with 24-hour access to professional telephonic interpretation was placed at the bedside of all patients on a hospital’s general medicine floor. The total number of telephonic interpretations and the rate of telephonic interpreter use per LEP patient increased significantly; the increases were sustained one year later. 
		
				
						RESEARCH METHODS
		
		
				Accelerating What Works: Using Qualitative Research Methods in Developing a Change Package for a Learning Collaborative
		
		
		A central element of a learning (quality improvement) collaborative is the change package—a catalogue of strategies, change concepts, and action steps—but little guidance is available on how to develop it. The approach taken by a patient safety and clinical pharmacy services collaborative can serve as a model for other collaboratives and individual organizations.
]]></description> 
					<pubDate>Thu, 26 Jan 2012 16:15:22 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2012/1/26/February-2012-issue-of-The-Joint-Commission-Journal-on-Quality-and-Patient-Safety/Default\.aspx</guid>
				</item>
			
				<item>
					<title>January 2012 Issue Available Online!</title> 
					<link>http://www.jcrinc.com/Blog/2012/1/3/January-2012-Issue-Available-Online/</link> 
					<description><![CDATA[
		Now available for your online access is the January 2012 issue of The Joint Commission Journal on Quality and Patient Safety. Here is a look at this issue:
		
				HEALTH PROFESSIONS EDUCATION
				Designing Education to Improve CareFive levels for defining and developing competence apply to physicians, nurses, and other members of an interprofessional QI team: novice, advanced beginner, competent, proficient, and expert. Each level entails certain skills and knowledge for health professions students to achieve before entering practice.
		
				INFORMATION TECHNOLOGY
				Using Information Technology to Improve Adult Immunization Delivery in an Integrated Urban Health SystemIn an immunization improvement project undertaken in a safety-net health care system, use of a clinical decision support system improved immunization rates in adults 65 years of age or older and in younger adults with diabetes or chronic obstructive pulmonary disease. The project may serve as a model for improved delivery of other preventive health services.
		
				MEDICATION SAFETY
				A Review of Verbal Order Policies in Acute Care Hospitals
				A stratified random sample of verbal and telephone order policy documents abstracted from 40 acute care settings indicated variability in practice, as well as contradictory policies within the same hospital. Careful review and updating of hospital policies is necessary to ensure that they are internally consistent and optimize patient safety. 
		
				FORUM
				Secondary Uses of Electronic Health Record Data: Benefits and Barriers
				In the primary use of health data, patient health information in electronic health records (EHRs) directly informs each individual’s care. In secondary use, patient data would be aggregated to improve health care delivery, yet several technological and policy barriers may slow implementation—but may be amenable to intervention.
		
				TOOL TUTORIAL
				Using the Opportunity Estimator Tool to Improve Engagement in a Quality and Safety InterventionTeams throughout the United States participating in a program to reduce central line-associated bloodstream infections (CLABSIs) are using the Opportunity Estimator. This Web-based tool translates CLABSI-related data into “opportunity estimates” of the patient lives and money that could be saved by reducing these infections. 
		“Designing Education to Improve Care” is adapted from A chapter for educators: Designing ways for students to learn to improve care. (Chapter 10) in Ogrinc GS, et al. Fundamentals of Health Care Improvement: A Guide to Improving your Patients’ Care, 2nd ed. Oak Brook, IL: Joint Commission Resources, 2011, 157–179. 
		 
]]></description> 
					<pubDate>Tue, 03 Jan 2012 20:16:47 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2012/1/3/January-2012-Issue-Available-Online/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The July 2011 Issue of The Joint Commission Journal on Quality and Patient Safety Is Now Out</title> 
					<link>http://www.jcrinc.com/Blog/2011/6/21/The-July-2011-Issue-of-The-Joint-Commission-Journal-on-Quality-and-Patient-Safety-Is-Now-Out/</link> 
					<description><![CDATA[
		Here is a look at the issue:
		
				Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action
				Stephanie A. Terezakis, M.D.; Peter Pronovost, M.D., Ph.D.; Kendra Harris, M.D., M.Sc.; Theodore DeWeese, M.D.; Eric Ford, Ph.D.A radiation oncology department has undertaken a variety of risk identification and mitigation strategies. However, coordination across multiple radiation oncology departments, as in a national reporting system and a database for radiation-related errors, is needed.
		
				Improving Follow-Up of High-Risk Psychiatry Outpatients at Resident Year-End Transfer
				John Q. Young, M.D., M.P.P.; Zoe Pringle, M.S.W.; Robert M. Wachter, M.D.Most of the elements of a multifaceted intervention implemented to improve follow-up of high-risk psychiatry outpatients should be relevant to other disciplines and specialties—such as such as pediatrics, internal medicine, and family medicine—that experience year-end resident transfers.
		
				The Need for Performance Measures on Testing for Latent Tuberculosis Infection in Primary Care
				Cynthia Tschampl, M.A.; John Bernardo, M.D.; Thomas Garvey, J.D., M.D.; Deborah Garnick, Sc.D.The proposed set of performance measures is intended to have a positive impact on secondary prevention of tuberculosis (TB). Successful treatment for latent TB infection reduces the likelihood by 90% that TB will reactivate to cause disease and transmission. 
		
				An Inpatient Fall Prevention Initiative in a Tertiary Care Hospital
				Jeffrey Weinberg, M.D., M.B.A.; Donna Proske, R.N., M.S.; Anita Szerszen, D.O.; Karen Lefkovic, R.N.; Carol Cline, R.N., M.P.A.; Suzanne El-Sayegh, M.D.; Mark Jarrett, M.D., M.B.A.; Kera F. Weiserbs, M.H.S., Ph.D.For a tertiary care hospital implementing a fall prevention initiative, fall rates decreased from April 2006 through March 2010 (1,098,471 inpatient-days) by 63.9%, and fall-related injuries also decreased significantly.
		
				Adopting Real-Time Surveillance Dashboards as a Component of an Enterprisewide Medication Safety Strategy
				Lemuel R. Waitman, Ph.D.; Ira E. Phillips, M.A.; Allison B. McCoy, M.S., Ph.D.; Ioana Danciu, B.S.; Robert M. Halpenny, M.S.; Cori L. Nelsen, Pharm.D.; Daniel C. Johnson, Pharm.D., B.C.P.S.; John M. Starmer, M.D., M.M.H.C.; Josh F. Peterson, M.D., M.P.H.Pharmacist use of the surveillance dashboards led to numerous patient safety–related interventions, such as notifying the clinical team about suboptimal medication orders, incorrect drug dose adjustments, or inadequate monitoring.
		
				The Meaningful Use Regulations in Information Technology: What Do They Mean for Quality Improvement in Hospitals?
				Sarah K. Abbett, M.D., M.P.H.; David W. Bates, M.D., M.Sc.; Allen Kachalia, M.D., J.D.If provider organizations are serious about improving quality and efficiency, they must advance their electronic health record capabilities far beyond just meeting the U.S. federal regulations. 
		To view the July 2011 issue of The Joint Commission Journal on Quality and Patient Safety, please click here: 
		
				http://www.ingentaconnect.com/content/jcaho/jcjqs/2011/00000037/00000007 
				For technical support, please contact help@ingenta.com.  I hope you enjoy the issue. Feel free to e-mail the authors if you want to comment on any of the articles or, perhaps at a later time when you are involved in a project for which the article is then particularly relevant and need additional information.  
		
				
						Joint Commission Resources Quality and Safety Network (JCRQSN) Video Series
				
		
		I also wanted to let you know about the Joint Commission Resources Quality and Safety Network (JCRQSN) Video Series. JCRQSN is a monthly series of video conference training sessions produced by Joint Commission Resources (JCR) in partnership with The Wellness Network. JCR, as the accredited provider, develops the series based on learning needs and key trends in patient safety and quality care.  For example, June 23, 2011, is the premier date for the following broadcast, which will be available on the satellite network and online:• Restraint Use and Preventing Patient Falls 
		
				
				Find out more about JCRQSN 
		
]]></description> 
					<pubDate>Tue, 21 Jun 2011 15:42:04 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/6/21/The-July-2011-Issue-of-The-Joint-Commission-Journal-on-Quality-and-Patient-Safety-Is-Now-Out/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Joint Commission Annual Conference on Quality &amp;amp; Patient Safety: Leading Ideas in Quality &amp;amp; Safety</title> 
					<link>http://www.jcrinc.com/Blog/2011/5/20/Joint-Commission-Annual-Conference-on-Quality-Patient-Safety-Leading-Ideas-in-Quality-Safety/</link> 
					<description><![CDATA[
		To follow up on my blog from April 13, 2001, “Overcoming Challenges and Implementing Solutions,” I wanted to let you know that you can still register for the Joint Commission Annual Conference on Quality and Patient Safety, “Come Together – A Gathering of Leading Ideas in Quality and Safety,” which will be held June 8–10 in Chicago. Faculty will provide best case practices, solutions, obstacles for overcoming challenges, and tools for implementing solutions. Registration at an early bird rate is still available—until May 31, 2011. I hope to be able to meet you there; you can ask for me at the registration booth. Click here for more information, including registration: http://www.jcrinc.com/Conferences-and-Seminars/Annual-Conference-on-Quality-and-Patient-Safety/2903/ 
]]></description> 
					<pubDate>Fri, 20 May 2011 17:07:07 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/5/20/Joint-Commission-Annual-Conference-on-Quality-Patient-Safety-Leading-Ideas-in-Quality-Safety/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Managing Conflict Within Health Care Organizations as a Patient Safety Imperative </title> 
					<link>http://www.jcrinc.com/Blog/2011/5/17/Managing-Conflict-Within-Health-Care-Organizations-as-a-Patient-Safety-Imperative/</link> 
					<description><![CDATA[
		
				
						This week, Debra Gerardi, the author, along with Charity Scott, of a two-part article that appeared in the February 2011 issue of the Journal—“A Strategic Approach for Managing Conflict in Hospitals: Responding to the Joint Commission Leadership Standard, Parts 1 and 2” (access part 1 here and part 2 here)— provides some additional reflections. We welcome your comments.
		As Charity Scott and I state in the article, the Joint Commission’s leadership standard for conflict management in hospitals, LD.02.04.01 (“The hospital manages conflict between leadership groups to protect the quality and safety of care”)1 underscores the significant impact of relational dynamics on patient safety and quality of care and the critical need for a strategic approach to conflict in health care organizations.2
		The recent publication of data relating to the prevalence and costs associated with medical errors and adverse events highlights the need for focused attention on the culture within health care organizations. In one study, for example, the researchers estimated that the annual cost of measurable medical errors that harm patients was $17.1 billion in 2008.3 In addition, other researchers found that the methods commonly used to detect adverse events missed 90% of those events; they extrapolated the reviewed data to suggest that adverse events occurred in one third of hospital admissions.4 Although progress is being made, significant challenges remain for organization leaders who seek to improve outcomes and position themselves for the shift in reimbursement from volume to value of services that is proposed by the Affordable Care Act5—specifically, through the Hospital Value-Based Purchasing Program. Addressing the underlying culture of health care and the impact that relational dynamics have on improving safety are key areas of focus for health care leaders who are serious about improving safety.
		In our two-part article, we outline an approach for addressing conflict strategically that includes managing conflict among leadership groups.2,6  As we state in the article, improving the capacity of health professionals to engage effectively in conflict and work collaboratively is increasingly important as production pressures increase and care delivery becomes more complex. Whether conflicts openly threaten a major disruption of hospital operations or whether unresolved conflicts lurk beneath the surface of daily interactions, unaddressed conflict can undermine a hospital’s efforts to ensure safe, high-quality patient care.
		In the past three months I have been involved in several cases in which poor patient outcomes are occurring within hospitals but with little reporting by staff because of fear of blame and retaliation. When reporting does occur, there is little follow-up by leadership because of a limited capacity to work through conflict and fear of escalating the conflict to a formal legal dispute involving physicians or other staff. Loss of trust in the leadership was common in each case, and the conflicts in the units were directly related to unresolved conflict among the leaders themselves. 
		In March 2011, Charity Scott and I had the opportunity to speak to members of the American Bar Association’s Health Law and Dispute Resolution sections at their annual meetings about the role that attorneys and mediators can play in supporting the shift toward nonadversarial approaches to dispute resolution. Lawyers must support the efforts of organizational leadership in better managing day-to-day conflict as a component of safer care and as an aspect of strategic positioning for delivery of accountable care. This represents a much greater role for the legal profession than tort reform, as it asks lawyers to recognize the impact that punitive and adversarial approaches have on trust within the organization and open reporting by health professionals. Shifting the culture of health care will take a collaborative effort by both the legal and health care professions if we are to improve the level of conflict competence within health care organizations as a key aspect of patient safety. Strategically incorporating efforts to address the relational dynamics among health professionals and leadership groups is a first step.
		
				
				References1. The Joint Commission: 2011 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2010.2. Scott C., Gerardi D.: A strategic approach for managing conflict in hospitals: Responding to the Joint Commission Leadership Standard, Part 1. Jt Comm J Qual Patient Saf 37:59-69, Feb. 20113. Van Den Bos J., et al.: The $17.1 billion problem: The annual cost of measurable medical errors. Health Aff(Millwood) 30:596-603, Apr. 2011..4. Classen D., et al.:   ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff(Millwood)30:581-589, Apr. 2011. .5. H.R.  3590. The Patient Protection and Affordable Care Act (PPACA) of 2010, Public Law 111–148, Mar. 23, 2011. http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf  (accessed May 12, 2011).6. Scott C., Gerardi D.: A strategic approach for managing conflict in hospittals: Responding to the Joint Commission Leadership Standard, Part 2. Jt Comm J Qual Patient Saf 37:70-80, Feb. 2011.
		 
]]></description> 
					<pubDate>Tue, 17 May 2011 15:21:06 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/5/17/Managing-Conflict-Within-Health-Care-Organizations-as-a-Patient-Safety-Imperative/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Further Progress in Standardizing Hospital Discharge Planning at the Mayo Clinic</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/14/Further-Progress-in-Standardizing-Hospital-Discharge-Planning-at-the-Mayo-Clinic/</link> 
					<description><![CDATA[
		
				
						Early this year, in
				Standardizing Hospital Discharge Planning at the Mayo Clinic
				,  Diane E. Holland and Michele A. Hemann at the Mayo Clinic reported how discharge planning–practice changes, entailing deployment of nurse specialists and the use of two specially developed electronic tools, resulted in a clinically meaningful decrease in length of stay for older patients at greater risk for complex discharge plans. In the postscript section of the article, the authors noted that the electronic tools—the evidence-based Early Screen for Discharge Planning (ESDP) decision support tool and the comprehensive discharge planning assessment format—have been incorporated into hospitalized patients’ electronic medical records. As a guest contributor to the Journal blog, Dr. Holland follows up with a report below on continued progress since the article. We welcome your comments. 
		We have been reworking our electronic discharge planning documentation to improve access to communications regarding transitions of care. In one enhancement, we identify a newly developed electronic note as a “discharge planning note,” regardless of the discipline involved in creating the note, thereby allowing discharge planning (DP)—related documentation to be grouped when sorting by note type. The DP note captures all documentation for each patient over time into a common aggregate view, which includes a (1) the current continuing care needs, (2) the plan to address the need, and (3) the clinicians involved in the planning process. The DP note also provides the capability to follow the history of plans to address a given patient need. For example, if a patient requires assistance with dressing changes, and the plan to change the dressing after discharge involves a referral to a home health care agency, clicking on the current plan will bring into view all related previous plan notes (for example, “spouse attempted to learn dressing change but was unable”). This helps clinicians to understand what has occurred as part of the planning process over time to address patient needs.
		In additional DP studies at Mayo, we have found that patients with high (that is, ≥ 10) ESDP scores report more unmet needs after discharge than patients with low ESDP scores—providing further evidence that patients with high scores probably should be targeted for hospital discharge planning services. (As we stated in the article, a cut-point score of 10 or more indicates that a referral to the DP team is warranted.) In addition, patients report fewer unmet needs when a standardized discharge planning assessment format is used as part of the discharge planning process. A study is in progress to determine “how much” discharge planning (or what steps in the DP process) can be accomplished within the first 24 hours of a patient’s stay in an intensive care unit.
]]></description> 
					<pubDate>Thu, 14 Apr 2011 20:56:37 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/4/14/Further-Progress-in-Standardizing-Hospital-Discharge-Planning-at-the-Mayo-Clinic/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Overcoming Challenges and Implementing Solutions</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/13/Overcoming-Challenges-and-Implementing-Solutions/</link> 
					<description><![CDATA[
		As you may know, The Joint Commission Annual Conference on Quality and Patient Safety, “Come Together – A Gathering of Leading Ideas in Quality and Safety,” will be held June 8–10 in Chicago. This conference will focus on how health care executives can seek to improve quality and reduce errors, contain costs, increase productivity, enhance execution, achieve organizational greatness, and build leaders throughout their organization.  Faculty will provide best case practices, obstacles for overcoming challenges, and tools for implementing solutions.  Headline speakers include Joint Commission President Mark Chassin, M.D., M.P.P, M.P.H.; Fred Lee, author of “If Disney Ran Your Hospital: 9½ Things You Would Do Differently;” James Reason, Professor Emeritus of Psychology, University of Manchester, United Kingdom, whose talk will address “Human Factors in Patient Safety – Retrospect and Prospect;”  and Jane L. Holl,  Medical Director for Patient Safety, Children's Memorial Hospital Feinberg School of Medicine, Northwestern University, Chicago, who will speak on “Assessing and Improving Pediatric Patient Safety and Quality of Care Through In-Situ Simulation.” I myself am looking forward to meeting Dr. Reason, who contributed the Foreword to the recent book, The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm (see editor Albert Wu’s guest blog on December 14, 2010). I hope to be able to meet you there, too! Click here for more information, including registration: http://www.jcrinc.com/Conferences-and-Seminars/Annual-Conference-on-Quality-and-Patient-Safety/2903/.
]]></description> 
					<pubDate>Wed, 13 Apr 2011 22:17:57 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/4/13/Overcoming-Challenges-and-Implementing-Solutions/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Joint Commission Releases Animated Speak Up Videos for Patient Participation in Health Care</title> 
					<link>http://www.jcrinc.com/Blog/2011/3/14/Joint-Commission-Releases-Animated-Speak-Up-Videos-for-Patient-Participation-in-Health-Care/</link> 
					<description><![CDATA[
		
				On March 9, 2011, in celebration of National Patient Safety Awareness Week,  Joint Commission Online announced the release of the first in a series of animated Speak Up™ videos, “Prevent Errors in Your Care,” to encourage patients to speak up and be active participants in their health care. Produced by The Joint Commission, these entertaining 60-second videos are intended as public service announcements and will air on The Joint Commission’s YouTube channel (http://www.youtube.com/user/TheJointCommission) and in other venues. As reported in the announcement, since its launch in 2002, the Speak Up program has grown to include 16 campaign brochures and three posters, as well as Spanish-language versions of all brochures. 
		We welcome your comments and articles on your own efforts to promote patient and family participation in the quality and safety of care.   
		 
		 
		 
]]></description> 
					<pubDate>Mon, 14 Mar 2011 15:31:46 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/3/14/Joint-Commission-Releases-Animated-Speak-Up-Videos-for-Patient-Participation-in-Health-Care/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Talking to Patients About Their Goals of Care  </title> 
					<link>http://www.jcrinc.com/Blog/2011/2/15/Talking-to-Patients-About-Their-Goals-of-Care/</link> 
					<description><![CDATA[
		
				
						This week, Lauris Kaldjian, who, along with Ann Broderick, contributed an article, 
				
						“Developing a Policy for Do Not Resuscitate Orders Within a Framework of Goals of Care,” 
				 guests on the Journal blog. In the article, the authors describe why and how the University of Iowa Ethics Committee changed the policy on DNR decisions by placing DNR orders and end-of-life discussions within an encompassing framework of goals of care. Dr. Kaldjian follows up on the article to report on other work that he and his colleagues have undertaken in exploring goals of care with their patients. We welcome your comments. In exploring how putting do not resuscitate orders in a broader context can help patients make decisions about them, we have been interested in learning more about how hospitalized patients understand goals of care. We simply tell patients, “Please tell me your goals of care for this hospitalization.”  In one of our studies, we asked this question of 135 general medical patients.1 While 117 of the patients were able to respond to the question, 1 patient could not, and the remaining 17 (13%) patients were instead able to answer the simple follow-up question, “What are you expecting will be accomplished during this hospitalization?”  This degree of understanding is encouraging, for it suggests that the term “goals of care” can be comprehended by patients and is not merely a concept useful for clinicians.  We have also explored how the answers that patients give to open-ended questions about their goals fit within a framework of goals of care that have been documented in the literature. To pursue this question, we conducted a study to determine whether clinicians can categorize patients’ spontaneously articulated goals of care using six goals from a structured literature review. We then compared clinicians’ categorizations of patients’ open-ended responses with the most important goals of care that the patients articulated in answer to a series of closed-ended questions.2 The results from this study helped us understand some of the differences between open-ended and closed-ended styles of communication when discussing goals of care. For example, clinicians identified an average of 2 goals within each open-ended patient response. By contrast, when the patients were given seven possible goal options, presented one after another in a closed-ended fashion, patients affirmed an average of 5 goals. This finding and other observations suggest that how patients are asked about their goals may influence what they say and how many goals they list. Using open-ended questions to solicit patients’ goals of care has the advantage of identifying goals that are in the forefront of their minds and allows those goals to be articulated in a patient’s own words.  Using a sequence of closed-ended questions about specific goals allows patients to affirm or deny a range of preferences that may clarify and possibly test the meaning of their initial reply to an open-ended question.  On the basis of this work, we believe that clinicians would do well to use both open-ended and closed-ended questions when talking with their patients about goals of care.  
		
				References1.  Kaldjian L.C., et al.: Code status discussions and goals of care among hospitalized adults. J Med Ethics 35:338–-342, Jun. 2009. 2.  Haberer T.H., et al.: Goals of care among hospitalized patients: A validation study.  Am J Hosp Palliat Care Nov. 21, 2010 [Epub ahead of print].
]]></description> 
					<pubDate>Tue, 15 Feb 2011 21:07:36 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/2/15/Talking-to-Patients-About-Their-Goals-of-Care/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Praise and Critiques for Using Human Factors Engineering to Improve Patient Safety: Problem Solving </title> 
					<link>http://www.jcrinc.com/Blog/2011/2/15/Praise-and-Critiques-for-Using-Human-Factors-Engineering-to-Improve-Patient-Safety-Problem-Solving-on-the-Front-Line-Second-Edition/</link> 
					<description><![CDATA[
		
				
				This week, John W. Gosbee, M.D., M.S., and Laura Lin Gosbee, M.A.Sc., editors of a new JCR book,
				Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second Edition
				, follow up on their guest blog on September 4, 2010 about the book to share two reviews and comment on an issue raised by one of the reviewers. You can join in the discussion by posting below or by sending an email to 
				
						sberman@jcrinc.com
				
				. 
		
		We have been fortunate to have a few nice reviews on the book so far; Ayse P. Gurses’s appeared in the Human Factors & Ergonomics Society’s Health Care Technical Group Newsletter, and Ed Israelski’s, in Biomedical Instrumentation & Technology. Both reviews and our responses can be found in our Human Factors Engineering and Healthcare Blog, http://redforestconsulting.com/blog/, where we also expand on the ideas and tools introduced in the book. 
		We certainly appreciate the positive feedback in these reviews, such as Israelski’s statement that the book “provides an excellent introduction to human factors engineering (HFE) with a variety of useful teaching resources and informative case studies.” Yet along with the congratulations, many authors also appreciate the constructive feedback that book reviews can contain. For example, we all have blind spots or misconceptions for which reviewers can provide learning opportunities. Israelski commented that we were “too narrow” in our “description of what constitutes a good HF engineer, since “many of the most successful HF engineers did not come from pure HFE academic backgrounds.” In Chapter 4, “Finding and Using Human Factors Engineering Expertise,” we noted, “Many HFE professionals have a graduate degree, which will likely be in engineering or psychology—but their field of study is HFE, and their program will consist of human factors course work along with, typically, a thesis or research project.” Israelski is right in saying that practitioners can arise from non-HFE academic programs. Accordingly, we wish to confirm that formal, academic training in HFE is not sufficient to make a HFE practitioner. Melding the knowledge of HFE concepts with the skills in HFE tools is the crucial thing. The fact that the terminology often overlaps with that of other disciplines makes this a difficult arena to easily and clearly define. Even in academia this is muddled. You could have human factors–type courses in three separate colleges—engineering, psychology, and computer science. In addition, the accounts that the four HFE professionals currently working in health care settings provide about their own backgrounds (in Chapters 6–9) well illustrates a wide variety of educational preparation. To conclude, in rereading Chapter 4, we can now see how Israelski, and perhaps others, could misinterpret our position. We welcome other readers’ comments about other issues in promoting the application of HFE to improve patient safety in the health care setting, which, after all, is the goal of the book.
		 
		 
		. 
]]></description> 
					<pubDate>Tue, 15 Feb 2011 17:36:45 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/2/15/Praise-and-Critiques-for-Using-Human-Factors-Engineering-to-Improve-Patient-Safety-Problem-Solving-on-the-Front-Line-Second-Edition/Default\.aspx</guid>
				</item>
			
				<item>
					<title>2010 John M. Eisenberg Patient Safety and Quality Award Recipients Announced </title> 
					<link>http://www.jcrinc.com/Blog/2011/1/14/2010-John-M-Eisenberg-Patient-Safety-and-Quality-Award-Recipients-Announced/</link> 
					<description><![CDATA[
		
				As you may have noticed, on January 12, 2011, Joint Commission Online reported the recipients of the 2010 John M. Eisenberg Patient Safety and Quality Award, as announced by The Quality Forum (NQF) and The Joint Commission.The patient safety awards program, launched in 2002 by TNQF and The Joint Commission, honors John M. Eisenberg, M.D., M.B.A., former administrator of the Agency for Healthcare Research and Quality (AHRQ), who was known for his passionate advocacy for patient safety and health care quality.
		The winners are:
		• John H. Eichhorn, M.D., (Individual Achievement category), University of Kentucky, Lexington, Kentucky, is recognized for his contributions which have led to dramatic and sustained reductions in catastrophic intra-operative anesthesia accidents.  • James L. Reinertsen, M.D., (Individual Achievement category), The Reinertsen Group, Alta, Wyoming, is recognized for his life-long leadership in improving health care quality and safety in medical groups, hospitals, and health systems. Washington State Hospital Association, Seattle (Innovation in Patient Safety and Quality at the National Level category) is recognized for its Safe Tables Learning Collaborative program. • The Children’s Hospital at Providence Newborn Intensive Care Unit, Anchorage, Alaska, (Innovation in Patient Safety and Quality at the Local Level category) is recognized for its multiyear quality improvement project to eliminate catheter-related blood stream infection (CRBSI) in the neonatal intensive care unit. 
		
				I am pleased to be working with the Eisenberg Award recipients, as I have done since 2002, on representing in the Journal the work for which they are being honored. Please watch for more details in the May 2011 issue. 
		 
]]></description> 
					<pubDate>Fri, 14 Jan 2011 19:47:15 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/1/14/2010-John-M-Eisenberg-Patient-Safety-and-Quality-Award-Recipients-Announced/Default\.aspx</guid>
				</item>
			
				<item>
					<title>An Update on the &quot;forYou Team&quot;</title> 
					<link>http://www.jcrinc.com/Blog/2011/1/14/An-Update-on-the-forYou-Team/</link> 
					<description><![CDATA[
		
				
						This week, Laura Hirschinger, a co-author of “Caring for Our Own: Deploying a Systemwide Second Rapid Response Team,” which appeared in the May 2010 issue, guests on the Journal blog. As Hirschinger and her co-authors reported in the article, they and colleagues developed a unique rapid response system to provide social, psychological, emotional, and professional support for health care providers who are “second victims”—persons traumatized as a result of their involvement in an unanticipated adverse event, medical error, or patient-related injury. Ms. Hirschinger takes this opportunity to provide readers an update on their progress since the article. We welcome your comments. As we reported in the article, the first forYOUTeam at University of Missouri Health Care (MUHC) was launched in March of 2009, with 51 clinicians representing various disciplines trained in the role of one-on-one crisis intervention. After assessing our high-risk clinical areas and teams, we realized that we needed additional team members in those areas to spread understanding of the second-victim phenomenon and ensure easy access to one-on-one support services for clinical areas, with rapid turnaround time. The areas that we began recruiting included vascular surgery, the neonatal intensive care unit (NICU), case management, the acute medical floor, and members of our rapid response team. As a result, our forYOUTeam expanded its membership on April 26, 2010, when 48 staff members joined the existing peer support team. The total membership now represents various professional types, hospital units, and shifts to help represent high-risk clinical areas from across the MUHC system.  Currently we have a total of 80 team members who remain actively involved in the monthly meetings and assist with one-on-one activations of the forYOUTeam.
		Since the article’s publication, the forYOUTeam has become increasingly busy with ongoing surveillance and Tier 2 (in which guidance and nurturance is provided for previously identified second victims) one-on-one deployments. To date we have a total of 115 Tier 2 one-on-one activations with trained forYOU Team members. The average encounter has lasted 24 minutes.  There have been a total of 13 team debriefings, lasting an average of 67 minutes and attended by an average of 15 health care professionals.  With our ongoing surveillance, our team members have found that they are seen as the unit experts and have been asked by unit managers and supervisors for guidance.  We have tracked this type of encounter as a mentoring session and have documented 13 mentoring opportunities. 
		One of the biggest challenges that we experience is the ability to effectively capture the total number of encounters by our trained members. Individuals selected for the role of peer supporter seem to have a natural tendency to provide support and guidance to a colleague in distress.  Therefore, using the one-on-one intervention support techniques seems to be natural to them and they do not identify this exchange of information as an “encounter” event.  One way we try to assist the team members in identifying encounters is by reviewing and discussing activations during our monthly team meetings. This gives the team members an opportunity to self-report the encounters that they might not otherwise reported, which the team can then discuss. Given this limitation, we realize that reported activation numbers do not truly represent the team’s full impact. The authors are hopeful that this type of supportive atmosphere in the aftermath of an unanticipated clinical event will become more common place as a natural response as opposed to an official “activation.” 
		During the first 22 months of the forYOU Team’s existence, it has evolved in many ways.  Individuals interested in becoming involved and members of the support team have brought diverse backgrounds, which help the forYOU Team evolve into a stronger supportive network. These individuals include a licensed counselor, an administrator with a Master of Divinity degree, and a human resource representative with a registered nurse background.  With these new partnerships, we are working to expand the knowledge base of our peer supporters and provide additional resources for team mentoring.  In addition to the team member resources, the forYOUTeam has also evolved into incorporating several “subcommittees” of special interest. These groups include peer supporters who are more passionate about assisting staff in specific clinical situations—such as one-on-one support for staff members who experience a blood exposure while providing clinical care—or in, for example, supporting colleagues in the aftermath of the death of a staff member or staff members who are returning to work after a work-related injury. Plans are underway to develop an additional group of medical staff peers who are interested in providing support when a colleague is going through the litigation process. We are planning a third training session for fall 2011 and anxiously wait to see how the forYOU Team will continue to grow and evolve.
		 
		 
		 
		
				 
]]></description> 
					<pubDate>Fri, 14 Jan 2011 19:40:32 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2011/1/14/An-Update-on-the-forYou-Team/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Now Published! The Value of Close Calls in Improving Patient Safety</title> 
					<link>http://www.jcrinc.com/Blog/2010/12/14/Now-Published-The-Value-of-Close-Calls-in-Improving-Patient-Safety-Learning-How-to-Avoid-and-Mitigate-Patient-Harm/</link> 
					<description><![CDATA[
		
				
						This week, Joint Commission Resources is publishing The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm, which I have had the privilege of working on with Albert Wu, M.D., M.P.H., a member of the Journal’s Editorial Advisory Board. Because close calls, often also termed near misses, don’t raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning. Dr. Wu recruited all of the expert tutorial authors and the 15 detailed case studies, each of which shows how the health care organizations used a close call to identify, investigate, and solve patient safety problems.  
		
				In the book’s Foreword, James Reason, Ph.D., the renowned expert in human error, states that close calls are “free lessons” about how patient harm occurs. “Chronicling, analyzing, debating, and disseminating stories about close calls are prerequisites for achieving the unrelenting vigilance and informed wariness that are vital steps along the path to improving patient safety.”
		
		
				I am also pleased that the book has received advance praise from Robert M. Wachter, M.D. (“This superb book tells us why analyzing close calls is so important to patient safety and shows us how to do it. It should be on the bookshelf of everyone interested in keeping patients safe.”), Evan M. Benjamin, M.D. (“This succinct and focused book, which demonstrates how close calls have been used to solve safety problems, is a must read for anyone with responsibility for patient safety”), and Charles Vincent, Ph.D. (“Learning from close calls is critical to safety but hard to do in practice. This book brings the concepts and ideas to life in rich examples that reveal the errors, the system failures, the heroic recoveries, and the many roads to system safety. It is invaluable for all clinical teams as they seek to put principles into practice to ensure the safety of their patients.”) 
				
		
		You can learn more about the book, which is available in print or as a PDF, and find ordering information at http://www.jcrinc.com/Books-and-E-books/VNM10/2152/. I asked Dr. Wu for his own reflections on his role as editor of the book. We welcome your comments. It is often said that it is very difficult to get physicians to change their behavior. For example, What is the best way to get a physician to follow a clinical practice guideline? Answer—Enlist them to help write one. In editing this book, I experienced a similar phenomenon. Although I had more than a passing knowledge of close calls before I embarked on the book, I soon found myself paying much closer attention to them in my clinical practice and teaching. Early this year, when I encountered a mix-up in insulin dosing— in which the patient adopted a much lower dose than intended—I quickly clarified the dosage but then went on to entered this close-call case into our in-house incident reporting system. I then followed up with a conversation with our patient safety officer. Someone needed to know about this! Thinking about close calls on virtually a daily basis has given gave me a greater appreciation of the spectrum of the etiology and patient harm involved in errors and adverse events. It has also sold me on the importance of an integrated approach to addressing incidents and to managing risk. Health care organizations, like all organizations, need to be aware of the hazards that exist within their systems. They should exploit information as it comes to them, whether as close calls and incidents that cause harm as well as other wisdom from workers at multiple levels of the organization. Armed with this knowledge, they can prioritize and intervene. Because intervention does not necessarily lead to improvement, it is also crucial to evaluate the impact of those interventions. Organizations also need to be mindful of the need to disclose close-call incidents to patients and to provide necessary first aid to clinicians who may be the second victims of adverse events, as my colleagues and I advise in Chapter 5, “Disclosing Close Calls to Patients and Their Families.” We still need practical approaches and strategies to prioritize hazards, investigate efficiently, intervene effectively, and determine if the changes we make actually make care safer. 
		 
]]></description> 
					<pubDate>Tue, 14 Dec 2010 19:51:53 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/12/14/Now-Published-The-Value-of-Close-Calls-in-Improving-Patient-Safety-Learning-How-to-Avoid-and-Mitigate-Patient-Harm/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Reflections on Adapting a Quality of Care Model for Global Implementation </title> 
					<link>http://www.jcrinc.com/Blog/2010/12/7/Reflections-on-Adapting-a-Quality-of-Care-Model-for-Global-Implementation/</link> 
					<description><![CDATA[
		
				
						This week, Bruce D. Agins, M.D., M.P.H., a co-author of "
				
						Pediatric HIVQUAL-T: Measuring and Improving the Quality of Pediatric HIV Care in Thailand, 2005-2007
				
				,”  in the December  2010 issue, guests on the Journal blog. The article describes the implementation of Pediatric HIVQUAL-T, a model for performance measurement and quality improvement (QI) of pediatric HIV care which was adapted from the U.S. HIVQUAL model by incorporating Thai national guidelines as standards. I asked Dr. Agins for his reflections on progress made in the near-20 years since 1992, when he and his colleagues started the New York State HIV-specific quality of care program. In an article in the 1995 issue of the Journal (then known as The Joint Commission Journal on Quality Improvement), they stated that the program could serve as a model for quality monitoring programs for other chronic illnesses and in diversified settings  We welcome your comments.
		When the New York State (NYS) Quality of Care program was launched in 1992, our goal, as it is now, focused on improving the quality of care for people living with HIV/AIDS, an approach that is logically synchronized with the needs of HIV infected patients both locally and globally. In retrospect, the international application of the HIVQUAL model would have seemed a natural extension of our work in NYS, but in truth, it required an adaptation of our approach and process of engagement. In addition to a focus on local guidelines and the needs and challenges in each implementing country, we had to modify our methods to a public health model within a specific political context and a single-payer system, which creates unique opportunities while still allowing for parallels between our respective state and national government systems.Much like our early efforts in NYS, where achieving buy-in from clinicians and service providers was not immediate, key stakeholders needed to be persuaded about the integrity of the framework. Building systems and processes for quality care in diverse international settings, particularly where access to resources varies, remains a critical challenge. HIVQUAL Thailand has achieved great success because the program is government-led, based on national guidelines, and conducted by a cadre of dedicated local staff. Funding also encouraged visionary health systems leadership at Thailand’s  Ministry of Public Health and the U.S. Centers for Disease Control and Prevention, which who co-led the implementation of their Global AIDS program.
		The pediatric HIVQUAL-Thailand model represents the first effort at adaptation for pediatrics. HIVQUAL/HEALTHQUAL programs in Uganda, Haiti, and Guyana, now also include pediatric measures. Our experience with this model demonstrates the adaptability of our approach and reinforces the transition now underway from HIVQUAL to HEALTHQUAL, which reflects our expanded focus on a public health approach to quality management. 
		
				 
]]></description> 
					<pubDate>Tue, 07 Dec 2010 17:30:26 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/12/7/Reflections-on-Adapting-a-Quality-of-Care-Model-for-Global-Implementation/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Preventing Suicide Outside Mental Health Units </title> 
					<link>http://www.jcrinc.com/Blog/2010/11/23/Preventing-Suicide-Outside-Mental-Health-Units/</link> 
					<description><![CDATA[
		
				
				A new Joint Commission
				Sentinel Event Alert
				urges greater attention to the risk of suicide for nonpsychiatric patients in emergency departments (EDs) and medical/surgical inpatient units and recommends education for caregivers about warning signs that may indicate when these patients are contemplating harming themselves. The Alert cautions that many patients who kill themselves in general hospital units do not have a psychiatric history or a history of suicidal attempts. The Alert suggests that hospitals take a series of specific steps, including educating staff about suicide risks factors and warning signs that may indicate imminent action, empowering staff to call a mental health professional or resource person if changes in a patient are noted.
		
				Peter Mills, a Journal Editorial Advisory Board member and the author of many Journal articles and a previous blog, was among the experts interviewed for the Alert. Dr. Mills guests again on the  Journal Blog to provide an overview of his work on preventing inpatient suicide outside mental health units.
		
				In 2003, the American Psychiatric Association reported that approximately 1,500 suicides take place in inpatient hospital units in the United States each year.1 My colleagues and I have been studying inpatient suicide in Veterans Heath Association (VA) hospitals for several years. Our initial study of inpatient suicide in mental health units2 led us to develop a Mental Health Environment of Care Checklist for reviewing inpatient mental health units for suicide hazards, such as anchor points for hanging.3,4 Data from these studies indicate that although approximately 50% of completed suicides and serious suicide attempts occur on mental health units, 50% occur in other areas of the hospital. Figure 1 displays the locations of inpatient suicides and suicide attempts that were reported in the VA between December 1999 and December 2009; note that the ED and acute care or medical units are the second and third most common location. In analyzing the root cause analysis reports of these events, we found that for medical units, the most common root causes were “problems with communication of suicidal risk,” “need for staff education on suicide assessment and treatment,” “need for improved suicide assessment,” and “poor system for managing suicidal patients.” For EDs, the most common root causes were “poor communication of suicide risk,” “lack of available staff,” “poor contraband search,” and “problems with the physical layout in the ED.” These identified root causes underline the need for clear communication during handoffs and between the mental health staff evaluating the patient and the medical staff members caring for the patient on the unit. In addition, medical staff would benefit from a better understanding of suicide assessment and specific protocols for managing these patients on their units. Finally, we recommend the use of a standardized checklist to evaluate the environment of care,4 in any area in which suicidal patients will be left unattended, especially sleeping rooms and bathrooms, which are the highest-risk areas. 
		
				
				References1. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(11 suppl.):1-60, Nov. 2003. Erratum in: Am J Psychiatry 161:776, Apr. 2004.2. Mills P.D., et al.: Inpatient suicide and suicide attempts in Veterans Affairs Hospitals. Jt Comm J Qual Patient Saf 34:482-488, Aug. 2008.3. Mills P.D., et al.: A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf 36:87-93, Feb. 2010.4. U.S. Department of Veterans Affairs: VA National Center for Patient Safety Mental Health Environment of Care Checklist (last accessed Nov. 23, 2010; or contact Peter.Mills@va.gov)
		
				Figure 1. Location of Inpatient Suicide Attempts and Completions in VA, December 1999–December 2009 (N = 350)  
]]></description> 
					<pubDate>Tue, 23 Nov 2010 19:53:41 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/11/23/Preventing-Suicide-Outside-Mental-Health-Units/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The Danger of “Rogue” Health Care Workers</title> 
					<link>http://www.jcrinc.com/Blog/2010/11/18/The-Danger-of-Rogue-Health-Care-Workers/</link> 
					<description><![CDATA[
		
				
				In a previous blog, 
				
						“Addressing Violence in Health Care Facilities,”
				
				Kenneth W. Kizer and Beatrice C. Yorker, authors of the Journal article, “Health Care Serial Murder: A Patient Safety Orphan,"  commended The Joint Commission for its Sentinel Event Alert, Preventing Violence in the Health Care Setting.Dr George Lundberg, in a recent online column, “Murder in Your Hospital,” cited the Kizer and Yorker article, which discussed the often overlooked patient safety aspects of health care serial murder (HCSM).  Lundberg encourages readers to alert their institutions to the potential of healthcare murders as a patient safety issue. I am pleased to have Yorker provide additional comments. We welcome your own comments on how your own institutions are addressing this issue.
		Thanks to Dr. George Lundberg for highlighting our finding that the number of cases of serial murder by health care professionals, while rare, is quite alarming.  And we agree with his call to raise awareness about this patient safety issue at the facility level. We would like to go further—by raising awareness of “rogue” health care providers who intentionally harm their patients. New HCSM cases continue to occur, particularly in Europe (where they are called health care serial killings).  
		I continue to receive calls from attorneys and hospital administrators when they have an index of suspicion that a specific health care provider is linked to adverse patient outcomes. I also receive requests from hospitals, risk managers, and professional schools to provide education in this area. My presentation, “Crime in Hospitals,” addresses serial murder, attempted murder (causing a cardiopulmonary arrest which is resuscitated), sexual assault, child pornography, and diversion of patient drugs.  As part of raising awareness of this patient safety issue, I show footage of covert video surveillance of parents who smother and otherwise harm their children as a result of Munchausen Syndrome by Proxy (MSBP; making a dependent in one’s care ill for the purpose of gaining medical attention), another underdetected crime that can occur in a hospital.  Watching graphic cold-blooded acts toward defenseless victims play out on videotape is a real eye-opener for an audience of health care providers who, like the general public, are reluctant to believe such behavior is possible for a person in a caring role. There is a significant psychodynamic overlap between MSBP and serial murder in hospitals.  Dr. Herbert Schrier and Judith Libow, who authored the text, Hurting for Love: Munchausen by Proxy Syndrome (1993), used the case study of Genene Jones, a nurse serial killer who suffered from Munchausen Syndrome (making oneself ill for the purpose of gaining medical attention) as also fitting the description of MSBP. Although most MSBP involves mothers making their own children ill, many of the nurse serial killers are simply using their patients (instead of their own child) as a handy victim to create a critical incident to gain attention.  In both MSBP and HCSM, many patients die as a result of the inflicted medical crisis. 
		I recently met Detective Edward Nordskog, an arson/explosives expert with the Los Angeles County Sheriff, who is writing a book on serial arsonists. He says that there are more than 1,300 documented convictions of firefighter arsonists, and that almost all are serial offenders.  Each has his or her own reason for starting fires, but the main motives are the "hero/vanity" motive, while some have the "spite/revenge" motive, and a very special few have a bit of a sexual motive. Nordskog noted that Munchhausen Syndrome dynamics seemed evident in some of the arsonists but are more common in a subgroup he referred to as the "wannabes"—phony firefighters.  In his research, he found that the closest criminal to a firefighter arsonist is the nurse/murderer.  Many of these types have been victims of multiple crimes or, less frequently, their families have been crime victims or accident victims. 
		This information is very relevant to our research on HCSM, as some of the convicted nurse serial murderers did have a history of setting fires. Several of these murderers made family members in their care ill, sometimes injecting them with the same medication used on their patient victims. One nurse made bomb threats against the hospital during the investigation, and another smeared feces in the nursing dormitory. Others have fabricated sexual assaults or other crimes on themselves.  A nurse who confessed to injecting his patients to cause codes has stated that he was motivated by the respect he received from his colleagues because he performed well in a code.  He added “I am like those firefighters who set fires.” Interestingly, fire fighters and nurses are consistently rated as the most trusted professionals by consumer groups. Another reason to raise awareness about HCSM is that the fields of health care and fire protection may attract people with a propensity to create critical incidents.  
]]></description> 
					<pubDate>Thu, 18 Nov 2010 22:42:59 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/11/18/The-Danger-of-Rogue-Health-Care-Workers/Default\.aspx</guid>
				</item>
			
				<item>
					<title>What’s Next for the “Necessary First Steps” on Medication Reconciliation?</title> 
					<link>http://www.jcrinc.com/Blog/2010/11/11/What’s-Next-for-the-“Necessary-First-Steps”-on-Medication-Reconciliation/</link> 
					<description><![CDATA[
		The November 2010 issue of the Journal includes a white paper prepared for the Society of Hospital Medicine which addresses the issues in medication reconciliation and their potential solutions. The article, “Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant, and Implementable: A Consensus Statement on Key Principles and Necessary First Steps,” authored by Jeffrey L. Greenwald and colleagues, identifies 10 key areas requiring further attention to move medication reconciliation forward as an important element of patient safety. The authors also suggest “first steps” that should be taken for each of the areas. For example, for the first key area, “Achieve Consensus on the Definition of Medication and Reconciliation,” the suggested first step is as follows: “A consortium of clinical, quality, and regulatory stakeholders should work to achieve consensus on the definition for medication and the intent and expectations for the reconciliation process.”
		I am interested in what hospitals and other organizations can do now to respond to the white paper and otherwise get involved in addressing the key areas—or any other quality or safety issues raised in Journal articles? In other words, what are the “next steps?” There is as yet no effort to follow up on the actions called for in the article, but health care organizations can take many of the suggested first steps by (1) examining their current medication reconciliation processes; and (2) identifying partnerships with community, public health, and other professional organizations to improve cross-continuum care outside the hospital, engage the patients in settings where they spend the majority of their lives (not the hospital or other clinical settings), and use social marketing (which emphasizes social responsibility and the benefits of adopting change)  to get the message out. I welcome your comments about the “first steps” that you and your organization are taking, either on your own or in partnership with other organizations.
]]></description> 
					<pubDate>Thu, 11 Nov 2010 22:16:46 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/11/11/What’s-Next-for-the-“Necessary-First-Steps”-on-Medication-Reconciliation/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Using the Push/Pull Point-of-Dispensing (POD) Vaccination Model: Update on the 2010–2011 Season</title> 
					<link>http://www.jcrinc.com/Blog/2010/10/26/Using-the-Push/Pull-Point-of-Dispensing-POD-Vaccination-Model-Update-on-the-2010–2011-Season/</link> 
					<description><![CDATA[
		
				
						This week, Robert S. Crupi, the lead author of 
				
						“Linking Emergency Preparedness and Health Care Worker Vaccination Against Influenza: A Novel Approach,”
				
				 which appears in the November 2010 issue, guests on the Journal blog. In the article, Dr. Crupi, Chairman of the Department of Emergency Medicine, Flushing Hospital Medical Center, Flushing, New York, and his colleagues describe how they adopted a push/pull point-of-dispensing (POD) model for vaccination that was derived from emergency preparedness planning for mass vaccination and/or prophylaxis to respond to an infectious disease outbreak, whether occurring naturally or due to bioterrorism.  We welcome your comments.
		In an effort to improve health care worker (HCW) vaccination rates for the 2010–2011 influenza vaccination season, the Flushing Hospital Medical Center has again used the push/pull point-of-dispensing (POD) vaccination model. As we explain in the article, we did not report on the 2009–2010 vaccination season, given the unusual circumstances of that influenza season. 
		
				As compared to the 2008–2009 vaccination season, in which we reached 72% of the employees were reached in two days (with 54% of those reached accepting vaccination), on October 6–7, 2010, we reached 82% employees (with 65% of them accepting vaccination). We believe that the improvement in outcomes reflects the efficiencies gained from continued drilling of our emergency preparedness model. Data collected for the 2010–2011 HCW influenza vaccination season will be shared with the Centers for Disease Control and Prevention (CDC) through our participation in the CDC-sponsored Healthcare Personnel Influenza Vaccination Coverage Pilot project in collaboration with the New York City Department of Health and Mental Hygiene (see Protocol for Pilot Test of CDC-Sponsored Measure for Reporting HCP Influenza Vaccination Coverage and Information for Pilot Test Sites).
		 
]]></description> 
					<pubDate>Tue, 26 Oct 2010 16:07:47 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/10/26/Using-the-Push/Pull-Point-of-Dispensing-POD-Vaccination-Model-Update-on-the-2010–2011-Season/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Joint Commission Center for Transforming Healthcare’s Hand-off Communications Solutions</title> 
					<link>http://www.jcrinc.com/Blog/2010/10/26/Joint-Commission-Center-for-Transforming-Healthcare’s-Hand-off-Communications-Solutions/</link> 
					<description><![CDATA[
		On October 21, the Joint Commission Center for Transforming Healthcare released its second set of solutions, which focus on improving hand-off communications (transitions in care).  The first set of solutions, which were pilot tested, addressed hand hygiene compliance, as I discussed in an earlier blog. 
		Ten leading U.S. hospitals and health care systems teamed up with the Center in August 2009 to use Robust Process Improvement™ (RPI) methods—including Lean Six Sigma and change management—to find the causes of and put a stop to these dangerous and potentially deadly breakdowns in patient care. All the hand-off communications solutions that were developed by the Center and its participating hospitals are listed on the Center’s Web site. In early 2011, the targeted solutions for hand-off communications will be pilot tested to prove their effectiveness in demographically diverse hospitals and other care settings. They will be added to the Targeted Solutions Tool™ (TST)—which provides a step-by-step process to measure performance, identify barriers to excellent performance, and implement proven solutions—in the second half of 2011. 
		The Journal has featured many articles on hand-off communications in the past, including the following papers this year:• Coles G., et al.: Three kinds of proactive risk analyses for health care (Aug. 2010)• Bernstein J.L., et al.: Improved physician work flow after integrating sign-out notes into the electronic medical record (Feb. 2010)• Anderson J., et al.: The Veterans Affairs shift change physician-to-physician handoff project (Feb. 2010)• Patterson E.S., Wears R.L.: Patient handoffs: standardized and reliable measurement tools remain elusive (Feb. 2010)
		We welcome your comments on your experiences in developing and implementing solutions to problems in hand-off communications. 
]]></description> 
					<pubDate>Tue, 26 Oct 2010 15:34:14 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/10/26/Joint-Commission-Center-for-Transforming-Healthcare’s-Hand-off-Communications-Solutions/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The Joint Commission’s Annual Report Highlights Progress </title> 
					<link>http://www.jcrinc.com/Blog/2010/9/22/The-Joint-Commission’s-Annual-Report-Highlights-Progress/</link> 
					<description><![CDATA[
		Today—September 22, 2010—The Joint Commission released its annual quality and safety report, Improving America’s Hospitals: The Joint Commission’s Report on Quality and Safety 2010. According to the report, accredited hospitals in the United States are providing higher-quality, evidence-based care for heart attack, pneumonia, surgical care, and children’s asthma care. This fifth-annual report shows continual improvement during an eight-year period on what The Joint Commission calls accountability measures—a new designation for measures that meet four criteria (research, proximity, accuracy, and adverse effects) designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement.  
		For example, the result for heart attack care improved from 88.6% in 2002 to 97.7% in 2009. A 97.7% score means that hospitals provided an evidence-based heart attack treatment such as aspirin at arrival and beta-blockers at discharge 977 times for every 1,000 opportunities to do so.
		
				In addition to focusing on accountability measures, this report represents an effort to clearly demonstrate the impact that performance measures have on improving patient outcomes. Specific expectations for performance on accountability measures will be included in hospital accreditation standards by 2012.  
		As you may recall, the September 2010 issue of the Journal featured an article, “Improving and Sustaining Core Measure Performance Through Effective Accountability of Clinical Microsystems in an Academic Medical Center,” on how Stanford Hospitals & Clinics improved performance on core measures, with an increase in the 24-metric composite compliance score from 62% in 2006 to 90% in 2010—gains that have been sustained.
		We welcome your comments on the report and on your own experiences in improving your results on The Joint Commission’s accountability measures. 
]]></description> 
					<pubDate>Thu, 23 Sep 2010 05:14:18 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/9/22/The-Joint-Commission’s-Annual-Report-Highlights-Progress/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The Joint Commission Launches Targeted Solutions Tool™</title> 
					<link>http://www.jcrinc.com/Blog/2010/9/16/The-Joint-Commission-Launches-Targeted-Solutions-Tool™/</link> 
					<description><![CDATA[
		As you may know, on September 13, 2010, The Joint Commission launched its Targeted Solutions Tool™ (TST), which encapsulates the work of the Joint Commission Center for Transforming Healthcare. 
		The TST is an interactive tool that simplifies the process for solving the most persistent health care quality and safety problems that exist within our health care system—such as hand hygiene compliance, the Center’s first project. The tool provides a step-by-step process to measure performance, identify barriers to excellent performance, and implement proven solutions. For more information about the TST, including a fact sheet and Frequently Asked Questions (FAQs), visit the Center for Transforming Healthcare Web site. 
		The Joint Commission will host a free 60-minute teleconference on the TST on Wednesday, October 13, at 1:00 p.m. Central Time. Information about the call and how to sign-up will be provided on accredited organizations’ Connect extranet site one week prior to the call. 
		
				Also, Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission, discusses the Center and the TST in an interview in the October 2010 issue of the Journal. We welcome your comments—and even an article—on your experiences in using the TST to customize the improvement solutions to address the most important causes in your own organizations. 
]]></description> 
					<pubDate>Thu, 16 Sep 2010 07:45:09 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/9/16/The-Joint-Commission-Launches-Targeted-Solutions-Tool™/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Editors of New JCR Book on Human Factors Engineering Discuss Recent Work </title> 
					<link>http://www.jcrinc.com/Blog/2010/9/4/Editors-of-New-JCR-Book-on-Human-Factors-Engineering-Discuss-Recent-Work/</link> 
					<description><![CDATA[
		
				This week, John W. Gosbee, M.D., M.S., and Laura Lin Gosbee, M.A.Sc., editors of a new JCR book, Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second Edition, and longtime contributors to the Journal, discuss their recent work. You can reach the Gosbees at info@redforestconsulting.com. 
		
				Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second Edition, provides health care organizations with information that can help them to “jump start” the use human factors engineering (HFE) in their patient safety efforts.  There is a customized primer about the essentials of HFE principles and methods for physicians, nurses, risk managers, and other health care professionals. In addition, case-study chapters provide ready-made templates on how to train your work force, who to hire, and what kind of problems and projects are impacted.
		Recently, both of us have continued to apply our own lessons.  Laura is working with applied researchers in Toronto to evaluate the effectiveness of various methods for differentiating look-alike drug names.  This work is similar to an FDA public workshop in June on effective methods for validating improvements to drug labeling and packaging.  As panelist, John provided his input on types and timing of HFE methods.  John continued in his sixth year as instructor for a University of Wisconsin summer course on teaching HFE to health care personnel, where the class was filled again with nurses, pharmacists, doctors, and biomedical engineers from around the country.  We continue to value the importance of collaborating with clinicians.  One of Laura’s recent collaborations resulted in a paper in Critical Care Medicine on HFE aspects of infection control to be published this month.   
		We hope you enjoy the book. Read more about it here. Let us know what you think of it by posting below or by sending us an email. 
		
				 
]]></description> 
					<pubDate>Sat, 04 Sep 2010 06:27:39 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/9/4/Editors-of-New-JCR-Book-on-Human-Factors-Engineering-Discuss-Recent-Work/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Addressing the Issue of Violence in Health Care Facilities</title> 
					<link>http://www.jcrinc.com/Blog/2010/6/17/Addressing-the-Issue-of-Violence-in-Health-Care-Facilities/</link> 
					<description><![CDATA[
		
				
						A new Joint Commission Sentinel Event Alert, Preventing Violence in the Health Care Setting, warns that health care organizations and their patients and visitors are now confronting steadily increasing rates of crime, including assault, rape, and murder. The Alert advises that while it is imperative to control access to the facility and maintain ongoing surveillance of the grounds, administrators must be alert to the potential for violence to patients by health care staff members. The stressful environment, together with failure to recognize and respond to warning signs such as behavioral changes, mental health issues, personal crises, drug or alcohol use, and disciplinary action or termination, can elevate the risk of a staff member becoming violent towards a patient. The Alert lists 13 suggested actions that health care organizations can take to prevent violence.  I asked Kenneth W. Kizer and Beatrice C. Yorker, authors of a recent Journal article, “Health Care Serial Murder: A Patient Safety Orphan," to comment on the Alert. We welcome your own comments. 
		We applaud The Joint Commission for issuing its recent Sentinel Event Alert. A variety of data indeed indicates that instances of physical violence in health care settings are occurring more frequently and that such occurrences are sometimes difficult to recognize. 
		
				While the focus of our article was on the specific problem of health care serial murder, the issues and challenges, as well as the recommendations on the actions that should be taken to better address this problem, are applicable to health care-related violence in general.  In light of recent civil litigation claiming that hospitals have a “duty to warn” other hospitals if a nurse or health care employee has been suspected and/or investigated for adverse patient outcomes,1 we suggest that health care risk management practices be reviewed and modified, if needed, so that they encourage and support hospitals and other health care organizations in their efforts to provide honest and complete employee evaluations.  
		Further, covert video surveillance, a tool cited in the Alert, may be useful in health care settings, notwithstanding the issues raised by its use. Yorker concluded that covert video surveillance does not violate one’s constitutional right to privacy in situations involving patient safety and in which vigilance is expected as part of the standard of care. It has been found to be effective in deterring and preventing some types of health care harm (for example, in cases of Munchausen Syndrome by proxy).2 In addition to physical violence, other types of intentional health care harm, such as medical-identity theft and intended health-privacy breaches, performance of unnecessary medical interventions for financial or other nonmedical reasons, and illegal harvesting of body parts, are clearly on the rise. Hopefully, the Joint Commission will address them in a subsequent Alert.
		As disturbing as it may be to think that some health care providers might intentionally harm patients, the regrettable reality is that for a variety of reasons, some do. It is time to recognize that it is too easy for rogue health care workers to commit crimes against patients. As we argued in our article, as an enterprise, health care needs to take a more proactive and concerted approach to preventing such occurrences.
		
				References1. In re: Charles Cullen (2010 N.J.) - Court of Common Pleas, Lehigh County #2005-C-3330.
		2. Yorker B.C.: Covert video surveillance of Munchausen Syndrome by proxy: The exigent circumstances exception. Health Matrix Clevel  5:325-346, Summer 1995. 
		
				 
]]></description> 
					<pubDate>Thu, 17 Jun 2010 10:05:20 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/6/17/Addressing-the-Issue-of-Violence-in-Health-Care-Facilities/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Safety of Test Result Follow-Up: Challenges, Progress, and More Challenges</title> 
					<link>http://www.jcrinc.com/Blog/2010/5/15/Safety-of-Test-Result-Follow-Up-Challenges-Progress-and-More-Challenges/</link> 
					<description><![CDATA[
		
				This week, Hardeep Singh and Meena S. Vij, the authors of 
				
						“Eight Recommendations for Policies for Communicating Abnormal Test Results,” 
				which appeared in the May 2010 issue, are guests on the Journal blog. The evidence- and experience-based recommendations provided in the article are intended to help organizations ensure safe and timely abnormal test-result communication. The article was accompanied by an editorial, “Eight Questions for Getting Beyond ‘Getting Results,’” by Gordon D. Schiff, to which Dr. Singh now responds. We welcome your comments.
		We thank Dr. Schiff for commenting on our recommendations for policies for better test-result communication and for envisioning the next steps for this work. As he points out, improving test-result communication is often presumed to be an easy fix to prevent diagnostic errors. In reality, as we both have described, this “low-hanging fruit” continues to elude us. 
		Implementation of new policies and monitoring communication outcomes and processes over time, are essential to advancing this field. Thus, Questions 1–3 and 6 are integral to the portfolio of our future work. As Dr. Schiff suggests, we now have baseline data and reliable methods for measuring outcomes. However, we approach longitudinal assessment with a measure of caution. Identifying which improvements, if any, were related to our policy itself is an ongoing challenge within a system that is subject to many other internal and external influences at both local and national levels. 
		Regarding Question 4, we fully agree that there is potential to overwhelm busy clinicians with test-result notifications. This is precisely the reason that the types of subcritical test results that Dr. Schiff discusses are not always communicated verbally to clinicians. Our own policy provides one example of how to prioritize handling of critical and abnormal findings to address the “signal-to-noise ratio” problem. Meanwhile, we agree that it is also important to carefully consider the timing and mode of test-result delivery to patients themselves (Question 7). We believe that the Department of Veterans Affairs (VA) has already taken the lead by initiating the VHA Directive mentioned in the article; specific patient-centered language is a part of this document.
		Whom to notify and how (Question 5), are complex questions that our policy also attempts to address. Currently, we are unaware of any other institutions in the United States that have similarly detailed protocols in place. Our policy not only provides general guidance for patient ownership to providers who “just ordered the test” but also sets an example for others to follow by elaborating detailed protocols in the Appendix. Although we do not claim to have an optimal solution, we believe that raising the concern about test-result follow-up responsibility is a necessary start. For instance, in the example provided by Dr. Schiff, the surgical consultant might object to following up on the renal mass on the MRI but may be more likely to accept the responsibility for personally notifying the patient’s primary care physician to ensure follow-up.  We encourage others to develop clear, detailed safeguards pending the development of truly “fail-safe” systems.   
		Finally, we agree that our ultimate goals lie beyond merely “getting” test results (Question 8). As we have seen in our previous work, test results are missed even in systems that virtually guarantee their delivery to providers. Thus, one apparent “fix” in the communication process exposes problems elsewhere in the test-result life cycle. While having effective policies and protocols for communication are a start, questions about the “newly” discovered complicated problems are now informing our research agenda. Indeed, the road ahead is not so smooth as we once thought, and it is sure to keep us in this line of work for years to come. 
]]></description> 
					<pubDate>Sat, 15 May 2010 09:46:44 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/5/15/Safety-of-Test-Result-Follow-Up-Challenges-Progress-and-More-Challenges/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The Joint Commission Annual Conference on Quality and Patient Safety:</title> 
					<link>http://www.jcrinc.com/Blog/2010/4/30/The-Joint-Commission-Annual-Conference-on-Quality-and-Patient-Safety/</link> 
					<description><![CDATA[
		
				
						
								A Preview of "Evidence-Informed Value Improvement"
						
						
						As you may know, The Joint Commission Annual Conference on Quality and Patient Safety will be held June 23–25 in Chicago. This conference will focus on organizational greatness and decisions and actions for health care executives seeking to improve quality, reduce errors, contain costs, increase productivity, sharpen execution, and to build leaders throughout their organization.   Participants will hear practical application of improvements from successful organizations that have driven change to sustain organizational greatness. Headline speakers include Joint Commission President Mark Chassin, M.D., M.P.P, M.P.H.; John J. Nance, J.D., a world-renown broadcast analyst and advocate for safety in aviation and health care; and John Øvretveit, Ph.D., M.H.S.M., a member of the Journal’s Editorial Advisory Board who has devoted much of his career to studying how health care organizations improve. Click here for registration information: 
				
						http://www.jcrinc.com/Conferences-and-Seminars/The-Joint-Commission-Annual-Conference-on-Quality-and-Patient-Safety/1979/
				
				
		
		
				I was curious about Dr. Øvretveit’s talk, "Leading Evidence-Informed Value Improvement," and so I recently “chatted” with him (by e-mail). He and I welcome your comments—and hope to see you at the conference.
				
				
		
		
				
						What is Evidence-Informed Value Improvement?
				
				When an organization makes a value improvement, it makes changes that increase the quality of a service relative to the costs of providing the service. For example, antibiotic prophylaxis before surgery reduces postsurgical infections and improves clinical outcomes. But it also reduces costs because treatment of postsurgical complications such as infections takes time and resources and is not reimbursed. 
		Most value improvements reduce patient suffering and reduce waste. But there are some that add quality at a small cost—not to realize future savings, but to generate more revenue—for example, by remote monitoring of patients at home that is made possible by investments already made in the information technology system for other purposes. The “evidence-informed” part comes from experience reported elsewhere, such as in the Journal and other published research, conference presentations, or listserve discussions. This experiential evidence helps us to make improvements in a more effective way as we draw on the “lessons learned” by others. Reports that describe the setting and the steps taken also help us to determine whether the same improvement might or might not be feasible to implement in our own setting. 
		
				
						We hear a lot about value these days. Like value-based purchasing, is this a way to arrive at a "value" measuring stick so organizations can determine how to allocate their resources for improvement? 
				
				For me the most important aspect of the “value” idea is to connect quality and finance for both health care providers and purchasers. At present, buying and selling is done mostly on the basis of cost and volume, with very iittle attention paid to quality, which often is not measured and made part of the contract. Evidence-based value improvement can help purchasers move from volume-based purchasing—where lowest price/highest volume is the only consideration and quality is either assumed or ignored—to value-based purchasing, which relates price to quality. Now, the challenge is to develop valid, service-specific measures of quality that efficiently capture and report data. Evidence-based value improvement approaches also helps providers prioritize their quality and safety improvement activities on the basis of the anticipated return on their investment, thereby aligning the clinical operations with strategic goals. 
		
				
						What is to guard against organizations simply devoting improvement resources that are already measured by the Centers for Medicare & Medicaid Services (CMS) clinical performance measures?
				
				No pay for never events and other pay-for-performance initiatives are already moving organizations in the direction of value-based purchasing. Organizations will focus resources on avoiding these events and work to improve quality for those items that are measured and linked to payments, which is what those schemes are designed to do. The problem is, as you say, that some organizations may divert resources from other quality activities that are more effective and do more good for other patients. This is why a broad range of measures are needed, and why we need to further assess the ultimate impact of these schemes on quality. You have to start somewhere.   How would evidence-informed value improvement affect continuity and coordination of care, which go beyond patient conditions or procedures?You have hit on a subject dear to my heart and that I am working on now—the tremendous waste in systems due poor communications and coordination between providers. I am sure that some of the greatest value improvements can be made in improving connections between organizations and between clinical services and shifts within organizations. 
		As you know, patient handoffs are very problematic, in terms of the costs of inefficiency and the risk of adverse events. Improvements in communication and coordination in general, and specifically in handoffs, can usually be carried out at low cost and reduce considerable waste—for the next stage down the line. The problem, then, is that the people making the improvement often do not always realize the savings. Evidence-informed value improvement should help make the costs and savings associated with improvements plain for all to see. For more on this subject, read Dr. Øvretveit’s “Does Improving Quality Save Money?”
		
				 
]]></description> 
					<pubDate>Sat, 01 May 2010 03:50:18 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/4/30/The-Joint-Commission-Annual-Conference-on-Quality-and-Patient-Safety/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Improving Tdap Vaccination Rates: A Case Study</title> 
					<link>http://www.jcrinc.com/Blog/2010/4/9/Improving-Tdap-Vaccination-Rates-A-Case-Study/</link> 
					<description><![CDATA[
		
				A recent issue of 
				
						The Joint Commission Online 
				included a call for strategies to improve tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates in health care organizations. The Joint Commission is asking health care organizations to share their approaches for implementing vaccination programs for patients and health care workers. The information will be considered for inclusion in an educational monograph that will be available free of charge later this year on the Joint Commission's Web site. Organizations are asked to complete the online survey by April 26, 2010. This week, Tina Q. Tan, the lead author of 
				
						Pertussis and Patient Safety: Implementing Tdap Vaccine Recommendations in Hospitals,  
				which appears in the April 2010 issue,  guests on the Journal blog. Dr. Tan and her co-author Melvin V. Gerbie describe efforts at two hospitals in Chicago—Prentice Women’s Hospital and Children's Memorial Hospital—to increase postpartum use of Tdap vaccine and to replace the tetanus and diphtheria toxoids (Td) booster with Tdap vaccine in emergency department (ED) settings. The authors also call attention to the need for vaccination of health care personnel.  Dr. Tan follows up on the article to provide some updates on progress. We welcome your comments.
		Since the vaccination program was instituted in June 2008, more than 18,200 doses of Tdap vaccine have been administered to postpartum women. We recently administered a patient survey, which, as we stated in the article, we were developing at the request of the Chicago Department of Public Health to assess patient acceptance and barriers to acceptance of Tdap vaccine. Some 1,087 postpartum women completed this brief, anonymous, self-administered survey in a six-month period (from August 1, 2009 to February 28, 2010). Some 79% of the respondents received a dose of postpartum Tdap vaccine and 7% had previously received a dose of Tdap vaccine before becoming pregnant; overall, 86% of the women were vaccinated with Tdap. The most common reasons cited for receiving Tdap vaccine were to protect their infant from pertussis disease and to protect themselves from pertussis disease or the need for a tetanus vaccine.
		For the 14% of women who declined vaccine, the major reasons for not receiving the vaccine were a preference to receive the vaccine at their primary care physician’s office, concerns about vaccine side effects, perception of not being at risk for pertussis, and a distrust of vaccines. More than 96% of the respondents, regardless of whether or not they received the postpartum Tdap vaccine, felt that the hospital’s offer of the vaccine was a worthwhile and valuable service. Further analysis of the survey data is ongoing. Children’s Memorial Hospital’s emergency room program of administering Tdap vaccine for wound prophylaxis continues, with no changes in the protocol, as do monitoring and evaluation of the program.
]]></description> 
					<pubDate>Sat, 10 Apr 2010 04:14:23 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/4/9/Improving-Tdap-Vaccination-Rates-A-Case-Study/Default\.aspx</guid>
				</item>
			
				<item>
					<title>An Emergency Department Clinical Information System: Continuing Improvement and Benefits  </title> 
					<link>http://www.jcrinc.com/Blog/2010/3/31/An-Emergency-Department-Clinical-Information-System-Continuing-Improvement-and-Benefits/</link> 
					<description><![CDATA[
		
				
						This week, Kevin M. Baumlin, the lead author of "
				
						Clinical Information System and Process Redesign Improves Emergency Department Efficiency
				
				” in the April 2010 issue, guests on the Journal blog. Dr. Baumlin’s article describes how Mount Sinai Medical Center, a hospital in Manhattan, coordinated a variety of efforts—including changes in patient registration, order entry, and results retrieval—with the implementation of a fully integrated emergency department information system, leading to significant decreases in length of stay and door-to-doctor, doctor-to-disposition, and radiology turnaround times. Dr. Baumlin follows up on the article to provide some updates on continued progress—and spread. We welcome your comments.
				
				Since implementing our comprehensive emergency department information system (EDIS), the team at Mount Sinai has enhanced and refined it to better meet the needs of patients and staff. We will publish our recent findings on our financial return1 and our experience in integrating clinical decision support into the information system2 soon.   Some improvements since we initially implemented EDIS include changing the sequence of the clinical content sections in the “electronic view” so that it is consistent with nurses’ and physicians’ preferences. For example, we have found that nurses prefer to navigate from triage to allergies, past medical history, current medications, nurse assessment, nursing procedures, physician history of present illness (HPI), physician assessment, and plan. The preferred sequence for physicians is as follows: call-in information, triage, allergies, current medications past medical history, MD HPI, review of symptoms (ROS), physical examination, laboratory interpretation, physician assessment and plan, physician procedures, nurse assessment, and nurse procedure. The difference may seem small but the users reported this to be a large improvement. We have also added doses, including units with approved abbreviations (that is, excluding the Joint Commission “Do Not Use" List) to our most commonly used medication order sets. This has led to a marked decrease in free-text medication orders, thus enabling us to disband our free-text oversight committee. Another benefit of implementing the EDIS has been the use of the data to support multiple projects for reporting in peer-reviewed publications. More importantly, EDIS has given us the ability to gather data so that we can participate in multicenter studies3,4 and build a consortium of researchers to define and improve care for patients in hospitals across the United States.In 2007 we were able to reproduce our success in implementing EDIS at our sister institution, Mount Sinai Hospital of Queens. With an ED volume or 50,000 and extreme physical plant restrictions, the site was in dire need of improved efficiency but still needed to meet the needs of its multicultural community. We planned and implemented EDIS in less than six months, with immediate results. We have also been able to advise several other community and academic sites (including George Washington University Hospital ED) in their review and implementation of their own information systems.The methodology for work-flow documentation, as we described in the article, is .simple and transportable—and, regardless of the specific information system used, requires only a spreadsheet and identification of roles and systems (that is, paper or computer program) used to carry out a function. One enduring lesson, as we described in the article, is that optimization of work flow, reflecting staff members’ input, must go hand in hand with implementation of any information system. References1.  Shapiro J.S., et al.: Implementation of an emergency department information system at an urban academic center: Results in rapid return on investment. Acad Emerg Med, in press.2.  Melnick T., et al.: Translation of the American College of Emergency Physicians Clinical Policy on Syncope using computerized clinical decision support. Int J Emerg Med, in press. 3.  McCarthy M.L., et al.: The emergency department occupancy rate: A simple measure of emergency department crowding? Ann Emerg Med 51:15-24, Oct. 31, 2007, epub Nov. 5, 2007. 
		4. Hoot N.R, et al.: Forecasting emergency department crowding: An external, multi-center evaluation. Ann Emerg Med 54:514-522, Oct. 2009. Epub Aug. 29, 2009. 
		
				 
]]></description> 
					<pubDate>Thu, 01 Apr 2010 05:03:51 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/3/31/An-Emergency-Department-Clinical-Information-System-Continuing-Improvement-and-Benefits/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Medication Administration Article Circulates Across Switzerland</title> 
					<link>http://www.jcrinc.com/Blog/2010/3/26/Medication-Administration-Article-Circulates-Across-Switzerland/</link> 
					<description><![CDATA[
		
				To follow up on the previous blog, I have recently learned that Dr. David Schwappach, the Scientific Head of the Swiss Patient Safety Foundation, has selected the Kliger et al. article, “Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy” (December 2009 issue of the Journal), as “Paper of the Month.” This means that the foundation has informed its approximately 3,000 listserv recipients of the article and has provided an extended summary and discussion of the article in French and German, which has also been reprinted in several German-language journals. 
		Dr. Schwappach told me that the article “tackles a very well-known problem and presents a clear, practice-oriented intervention and builds on the expertise of frontline staff.” He continued, “A few years ago, when I was developing a study in oncology medication administration safety, for a few days I observed the processes and conditions under which nurses prepare chemotherapy drugs. I was stunned by the working conditions in which the nurses' efforts tried to maintain their concentration while everybody was coming in and out the room, talking to each other, requesting information, and interrupting the highly sensitive medication preparation processes. I felt that we are working with drugs of the future under conditions of the early 20th century. 
		The Kliger et al. article, I felt, needs to be spread to the front line! For me, one of its main messages is, “We can make a difference! And sometimes, straightforward solutions work!”  He added that he has already received word from many professionals responsible for medication administration safety in hospitals and nursing homes that they are involved in similar projects or are thinking about translating the intervention described in the article to their own institutions. Well, spread of good practices is what the Journal is all about, and I would like to hear your own accounts of how spread is working for you. 
		
				 
]]></description> 
					<pubDate>Sat, 27 Mar 2010 05:54:54 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/3/26/Medication-Administration-Article-Circulates-Across-Switzerland/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Building in Strategic Communication as Key to Leadership in Improvement</title> 
					<link>http://www.jcrinc.com/Blog/2010/3/24/Building-in-Strategic-Communication-as-Key-to-Leadership-in-Improvement/</link> 
					<description><![CDATA[
		
				
						This week, Julie Kliger, lead author of 
				
						“Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy,”
				
				which appeared in the December 2009 issue, guests on the Journal blog. As you will recall, the article reported how a 36-month demonstration program led to a 87.7% reduction in medication administration errors—increasing medication administration accuracy to 98% at six Bay Area hospitals. An expanded cohort of 56 units in 9 hospitals showed similar results during the course of 13 months, from September 2008 to October 2009. Ms. Kliger follows up on the article to discuss the critical role of strategic communication in the medication administration project and to preview the current project on sepsis. We welcome your comments.
		
				Change management and leadership are hot topics throughout the health care sector, as they have been for some time. At the University of California, San Francisco Center for the Health Professions, the Integrated Nurse Leadership Program (INLP) has demonstrated the importance of empowering capable frontline clinical staff—who have the creativity, insight, and expertise to drive sustainable change from the bottom up. 
		The demonstration program described in the article used the INLP model of quality improvement (QI)—a holistic leadership training program that, as we reported, “leads clinicians through an entire process of QI, during which participants learn to innovate, test innovations, diffuse innovations throughout the hospital, and embed innovations in hospital policies and daily practice.” The critical term here is holistic. Effective leadership requires a broad skill set that is beyond most frontline clinicians—for example, conflict resolution, lateral-level management, coalition building, and delegation. Nurses attended seminars, received one-on-one coaching, and implemented inter-session “homework” assignments at their institutions. 
		Nurses need the skills and authority to redesign processes, test potential solutions, and measure results, all of which were part of the INLP program. But that is not enough—our program also included training in a strategic communications component because change management, to be effective and sustainable, requires institutional buy-in. 
		We found that communication was essential to moving the program forward. Nurses were often challenged to communicate the purpose and importance of the program to peers, as well as potential allies and detractors in other departments. Keeping the program going required institutional buy-in and culture change, neither of which was possible without developing a compelling message and then delivering it effectively throughout the institution.
		It is important to distinguish “strategic communications” from tactical initiatives (for example, SBAR [Situation-Background-Assessment-Recommendation]). Most tactical programs narrowly seek to improve technical skill relative to specific clinical tasks. However, task-based communication is very different from the kind of strategic message delivery practiced by professional communicators. The strategic communication portion of the curriculum included new skills, such as developing targeted messages, building programmatic outreach strategies, and creating an identity (a brand and tag line) for the change initiative. For example, nurse teams at several hospitals developed comprehensive branding programs, including a logo, slogan, posters, and t-shirts. These branding efforts allowed for clear, consistent message delivery and helped build institutional momentum behind their initiatives. One hospital used an informal event strategy—a “trolley” with program literature and refreshments—that they wheeled out once a month, visiting a different floor each month.
		Most important, nurse teams were trained to identify key audiences and their core personal and professional concerns so that they could develop targeted messages that were relevant and meaningful and reflected respect for each individual’s point of view. Such customization of the program message to address individual concerns was critical to overcoming objections and gaining participation.  
		I believe that this focus on strategic communication was instrumental in the success of our leadership program. It made our teams more effective in achieving targets, sustaining change, and spreading redesigned best practices throughout the hospitals. We are applying the same holistic leadership approach, including the strategic communications component, to early goal-directed therapy (EGDT) in the treatment of severe sepsis. The sepsis program is targeting a 15% reduction in sepsis mortality in approximately 60 units, at the same nine hospitals in the Bay Area. However, whereas medication administration was an “event-based” challenge, sepsis is a diagnostic- and treatment-based challenge. The  sepsis program, which centers on a regimented EGDT protocol, requires higher institutional commitment and more systematic coordination across multiple departments, making effective communication an even greater challenge—and an even more important potential solution.
		 
]]></description> 
					<pubDate>Thu, 25 Mar 2010 05:40:03 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/3/24/Building-in-Strategic-Communication-as-Key-to-Leadership-in-Improvement/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Incident Reporting Still Lacking Among Many Doctors-in-Training   </title> 
					<link>http://www.jcrinc.com/Blog/2010/3/13/Incident-Reporting-Still-Lacking-Among-Many-Doctors-in-Training/</link> 
					<description><![CDATA[
		To follow up on my previous blog, the deficiencies in patient safety education described in the Lucian Leape Institute report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, are reflected in another Journal article—cited yesterday in an article in the New York Times, “Learning to Keep Patients Safe in a Culture of Fear” (http://www.nytimes.com/2010/03/11/health/11chen.html?emc=tnt&tntemail1=y). Lia Logio and Rangaraj Ramanujam found that doctors-in-training (residents and  fellows) may still be reluctant to report errors. “Medical Trainees’ Formal and Informal Incident Reporting Across a Five-Hospital Academic Medical Center” indicated that of 305 respondents who rotated through all five hospitals represented in the study, only 22.3%–31.5% knew how to locate an incident form, and only 6.2%–20% had completed at least one. The researchers recommend a number of strategies to improve incident reporting, from intensive role modeling by faculty to regularly informing residents about improvements resulting from incident reporting. Moreover, residents’ reporting behaviors seemed to be shaped by unique attributes of different hospitals—even within the same academic center. This led the researchers to suggest that individual hospitals encourage residents to report incidents and emphasize their role in improving the whole system.   
]]></description> 
					<pubDate>Sat, 13 Mar 2010 06:07:15 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/3/13/Incident-Reporting-Still-Lacking-Among-Many-Doctors-in-Training/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Quality and Patient Safety Education Needs for Physicians—and Nurses </title> 
					<link>http://www.jcrinc.com/Blog/2010/3/12/Quality-and-Patient-Safety-Education-Needs-for-Physicians—and-Nurses/</link> 
					<description><![CDATA[
		On March 11, 2010, the Lucian Leape Institute at the National Patient Safety Foundation released a report that finds that medical schools are failing to do an adequate job of “facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care,” resulting in greater risk to patients. Lucian L. Leape, M.D., chair of the Institute, stated, “Despite concerted efforts by many conscientious health care organizations and health professionals to improve and implement safer practices, health care remains fundamentally unsafe….The result is that patient safety still remains one of the nation’s most solvable public health challenges.” Dennis S. O’Leary, M.D., President Emeritus of The Joint Commission and a leader of the initiative, remarked, “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.” The report calls for major education reform at the medical school and residency training program levels. Unmet Needs: Teaching Physicians to Provide Safe Patient Care is available at http://www.npsf.org/LLI-Unmet-Needs-Report/.  
		This report calls to mind a recent article in the Journal, “New Nurses’ Views of Quality Improvement Education,” by Christine Kovner, New York University, and colleagues, which suggests deficiencies in nursing education. Of 436 newly licensed registered nurses, 38.6%  thought they were “poorly” or “very poorly” prepared in their nursing education programs to implement quality improvement measures or “had never heard of” the term quality improvement. Similarly, 41.7% of the respondents thought they were “not at all prepared” to use national patient safety resources. 
		In response to the report, Dr. Kovner states, “Our colleagues in medical schools share some of the same problems that we have in nursing education. I think we can learn from one another and together ensure that the next generation of nurses and physicians have the knowledge and skills to provide safe patient care. We at New York University are collaborating with our medical school colleagues to improve our students' patient safety knowledge and skills. “
		The Journal is committed to disseminating health care organizations’ efforts to educate the health professions in quality and patient safety and, in general, to  promote a culture of patient safety and safe practices among physicians, nurses, other staff—and patients and their families. 
]]></description> 
					<pubDate>Sat, 13 Mar 2010 03:51:50 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/3/12/Quality-and-Patient-Safety-Education-Needs-for-Physicians—and-Nurses/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Radiation Hazards and Challenges in Reporting Adverse Events: A Human Factors Perspective </title> 
					<link>http://www.jcrinc.com/Blog/2010/3/5/Radiation-Hazards-and-Challenges-in-Reporting-Adverse-Events-A-Human-Factors-Perspective/</link> 
					<description><![CDATA[
		
				
						
						In his January 29, 2010 guest blog, Kurt Herzer commented on the two recent investigative articles in the New York Times on the incidence and impact of rare accidents in radiation therapy. Shortly after, the American Society for Radiation Oncology issued a six-point plan for improving safety and quality and reducing the chances of medical errors—including working with other stakeholders to create a database for the reporting of linear accelerator– and computed tomography–based medical errors. This week, Emily S. Patterson, Ph.D., Ohio State University Medical Center, School of Allied Medical Professions, and a member of the Journal’s Editorial Advisory Board, discusses challenges faced in the reporting of adverse events.We welcome your comments.The New York Times articles have served as a wake-up call for the human suffering that results from negative, unintended consequences of using increasingly complex technology in a largely unregulated, competitive marketplace to perform potentially life-saving radiation treatments. A particularly troublesome aspect of these stories is the potential for overradiated and underradiated patients to suffer harm that goes undetected for years, and likely in many cases, forever. The articles, as well as Kurt Herzer, proposed increase reporting and monitoring of adverse events as one solution. Although certainly an increased understanding of the hazards and patterns in incidents would be extremely helpful in improving patient safety, I agree with him that achieving this “will require vision, creativity, and collaboration.” The patients’ stories in the New York Times articles hint at some of the challenges that I believe will be faced in effectively harnessing the potential of reporting systems to improve patient safety. First, there are substantial issues in obtaining high-quality data.   Many have noted that there is no such thing as a “mandatory” reporting system—all reporting systems are, at some level of analysis, voluntary. In addition, particularly with such horrific patient outcomes, there will predictably be enormous pressure to concurrently use the data for “accountability” purposes. Experience suggests that a single breach of confidentiality directly and immediately results in a widespread lack of trust that reporting is safe, thereby eroding the volume and quality of data. This lack of trust creates  pressure to blame individuals and recommend sanctions, training, or revised policies and procedures—at the expense of attention to systemic flaws. Hospitals will be concerned about lawsuits and loss of reputation, device companies will be concerned about loss of market share and lawsuits, health care providers will be concerned about losing their ability to provide health care and maintain their employment, and the administration personnel of the reporting systems themselves will be concerned about their own ability to keep their employment in the face of criticism for failing to appropriately communicate issues and intervene, even when their sphere of influence over device design and regulation is limited. Finally, it is likely that access to the richly detailed stories, even if they are obtainable, will be highly limited because of concerns about breaching confidentiality of the reporters for “outsiders” interested in analyzing the data.  A second challenge area is data analysis. Because “tags” of some kind will be needed to organize the collected data, an easy pathway will be to create summary statistics using those tags. The tags will need to be easily understood by those entering the data, by definition, so it is unlikely that they will be in a language conducive to recognizing patterns that reveal how to improve systems. For example, the geographic region in which incidents occurred are not as informative as learning that fail-safe mechanisms are lacking in automated filter placement software, but it is unlikely that such a tag would be used to classify cases from the outset. Similarly, outcome-based tags, such as whether a patient was overradiated to the point of mortality within six months, are probably not the best grouping for finding patterns, since processes and outcomes are not necessarily correlated.  
		The most important recommendation that I can give for a reporting system is to have at a minimum one full-time dedicated Ph.D.-level human factors engineer and one full-time M.S.-level usability specialist on staff conducting analyses on cases that are found to be related on the basis of searching text within the report itself, not just the tagged fields. To truly understand the reported cases, these specialists should have continuous access to all devices in the field and be able to replicate reported issues with phantom patients. Even independent of reported incidents, these personnel could conduct heuristic evaluations, usability testing, multidevice integration testing, and systematic identification of potential hazards (as Kurt Herzer described in his blog, and, earlier, in his article, “A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.”  In just this way, previously unknown hazards have been discovered in the past that were believed impossible by the device manufacturers, such as an IV pump that allowed free flow of medications when in demo mode and a handheld device for wireless medication administration that corrupted electronic medical record databases.  
		Finally, the largest challenge for adverse event—or error—reporting is the fact that it is a fundamentally slow and painful approach to improving systems. Can it be done? Probably. But let me suggest an alternative on the basis of my highly positive experiences with the Veterans Health Administration’s (VHA’s) Office of Information Patient Safety Program Office (PSPO) reporting system for information technology issues. Although this system does ask whether a patient was harmed based on the reported safety concern, it is not a required data field. Instead, reports mainly emphasize “unsafe conditions”: that are attributed to software design concerns, such as information technology that allowed primary care providers who had been terminated to be assigned to new patients. This framing, in addition to reducing barriers to reporting, has also lent itself to easier tracking of whether reported issues were related and had been addressed and has reduced incentives for manufacturers to deny that changes are needed. Another reason why improving systems is so difficult is that, in some legal cases, changes made to devices have been used as evidence of wrongdoing—because if a change was needed, perhaps it wasn’t safe before, leading to the response, “The device worked as intended. It was human error.”
		 
]]></description> 
					<pubDate>Sat, 06 Mar 2010 04:05:35 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/3/5/Radiation-Hazards-and-Challenges-in-Reporting-Adverse-Events-A-Human-Factors-Perspective/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The Joint Commission Invites Eisenberg Award Nominations</title> 
					<link>http://www.jcrinc.com/Blog/2010/2/24/The-Joint-Commission-Invites-Eisenberg-Award-Nominations/</link> 
					<description><![CDATA[
		
				
						As you may know, The Joint Commission has recently invited nominations for the 2010 John M. Eisenberg Patient Safety and Quality Award. Information about the awards and the and nomination process can be found at 
				
						http://www.jointcommission.org/PatientSafety/EisenbergAward/
				
				.
		
		Every year since 2002, when John M. Eisenberg died, it has been an honored tradition for the Journal to devote space in its December issue to the recipients of the John M. Eisenberg Patient Safety and Quality Award. For the introduction to the recipients featured in the December 2009 issue, please click here to view the article.
		With the approach of autumn, I am always anxious to hear which individuals and organizations the Eisenberg Awards Panel has chosen to recognize. Through the years, we have featured interviews with a wide variety of leaders who have indeed “made significant and lasting contributions to improving patient safety and health care quality.” For example, in that first year, I had the pleasure of interviewing David W. Bates, M.D., M.Sc., who was honored for "his cutting-edge research in using information technology to measure and improve patient safety, particularly in the area of medication safety." (Dr. Bates went on to nominate two other recipients of an Eisenberg award—Jerry H. Gurwitz, M.D., and Tejal Gandhi, M.D., M.P.H.) In 2004, Kaveh G. Shojania, M.D., and Robert M. Wachter, M.D., described the evolution of the “case-based approach to educating practitioners, provider organization leaders, policy makers, and patients about patient safety issues”—for which they were recognized—in their article, “The Face of Errors.” In their effort to engage clinicians in patient safety—which was then just newly established as a subject of policy and research—they reasoned that clinicians might respond more to case studies of dramatic adverse events than they would to statistics. This case-based approach has become so commonplace that I decided to include a link to the article here for you to read (or revisit) the article. For me, it remains unique and among the most memorable papers during my tenure with the Journal.
		We have also published instructive articles by the organizations that, through a specific initiative or project, “made an important contribution to patient safety and health care quality in the areas of research or system innovation.” For example, in the December 2009 issue, the Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality described a quality improvement collaborative’s work on central line–associated bloodstream infections, and Mercy Hospital Anderson, Cincinnati, reported how it developed and implemented an automated early warning system to predict the patient's likelihood of deterioration. 
		I hope you all will identify your and your colleagues’ achievements and recent innovative work in improving quality and patient safety and share your experience with the Eisenberg Awards—and the  Journal!  (Award submissions will be due at The Joint Commission on April 12, 2010.) 
]]></description> 
					<pubDate>Thu, 25 Feb 2010 04:15:46 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/2/24/The-Joint-Commission-Invites-Eisenberg-Award-Nominations/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Reducing Inpatient Suicide Hazards at Veterans Administration Hospitals </title> 
					<link>http://www.jcrinc.com/Blog/2010/2/12/Reducing-Inpatient-Suicide-Hazards-at-Veterans-Administration-Hospitals/</link> 
					<description><![CDATA[
		
				
						This week, Peter Mills, the senior author of " A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals,” which appears in the February 2010 issue, guests on the Journal blog. In the article, Dr Mills and his colleagues report on the first study to examine the implementation and effectiveness of a standardized checklist for mental health units. Dr. Mills, a member of the Journal’s Editorial Advisory Board,  provides an update on recent data concerning the findings across the 113 VA facilities that have been using the checklist. The Journal welcomes your comments.As we reported in the article on the first year’s experience, 113 VA facilities used the Mental Health Environment of Care Checklist (http://www.patientsafety.gov/SafetyTopics.html#mheocc), which was designed to review the environment of care in mental health units in VA hospitals and identify environmental hazards for suicidal patients. As of the end of fiscal year 2008 (October 31, 2008), 7,642 hazards had been identified, of which 5,834 (76.3%) had been abated. Throughout 2009 and into 2010, VA facilities have continued to use the checklist to evaluate their mental health units on a quarterly basis. As this process has unfolded, we have worked with manufacturers to develop specialized products for use in mental health facilities and have made recommendations to the field.  At the same time, new hazards have been identified and communicated to the field, and the checklist has been updated accordingly. By the end of fiscal year 2009 (October 31, 2009), the facilities had identified 9,786 hazards—reflecting 2,144 new hazards, of which 8,298 (84.8%) have been abated (see table). I would like to emphasize that while there are still 13 level-5 (“critical”) and 380 level-4 (“serious”) hazards that have not been abated, all these hazards have a specific mitigation plan to reduce the risk of the hazard to patients on the unit. For example, areas with the identified hazards are locked or continuously observed while patients are present. All facilities with level-4 hazards are required to submit a plan to mitigate any hazards that will not be abated in a timely manner, and all level-5 hazards are to be abated or mitigated within 24 hours. In this way, the hazard is reduced immediately even for hazards that may require new construction or significant environmental changes to resolve. The fact that more than 2000 new hazards were identified in our mental health units in the second years of the checklist’s use suggests that as the more obvious hazards such as anchor points and security issues are identified and abated, the staff begins to recognize more subtle hazards, such as suffocation using plastic material from shower curtains and the potential to shut lanyards in the sides of doors to hang. Also, as incidents happen in our facilities we are able to alert all facilities in our system to the causes and potential hazards to look for.     Table. Status of Hazards by Risk Level 
		
				
						
								
										
												
														
																Risk Level
														
												
										
										
												
														
																
																		    Not Abated
														
												
										
										
												
														
																  
														
												
												
														
																
																		     Abated
														
												
										
										
												
														
																     Total
														
												
										
								
								
										
												
														1
												
										
										
												
														309
												
										
										
												
														1855
												
										
										
												
														2164
												
										
								
								
										
												
														2
												
										
										
												
														485
												
										
										
												
														2170
												
										
										
												
														2655
												
										
								
								
										
												
														3
												
										
										
												
														301
												
										
										
												
														1897
												
										
										
												
														2198
												
										
								
								
										
												
														4
												
										
										
												
														380
												
										
										
												
														2221
												
										
										
												
														2601
												
										
								
								
										
												
														5
												
										
										
												
														
																13
														
												
										
										
												
														
																155
														
												
										
										
												
														168
												
										
								
								
										
												
														
																Grand Total
														
												
										
										
												
														
																1,488
														
												
										
										
												
														
																8,298
														
												
										
										
												
														9,786
												
										
								
						
				
		
		
				
				
		
		 
]]></description> 
					<pubDate>Fri, 12 Feb 2010 16:11:41 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/2/12/Reducing-Inpatient-Suicide-Hazards-at-Veterans-Administration-Hospitals/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Reflections on Integrating Electronically Generated Sign-out Documents into the EMR</title> 
					<link>http://www.jcrinc.com/Blog/2010/2/4/Reflections/</link> 
					<description><![CDATA[
		
				
						A Case Where What Is Good for Doctors May Also Be Good for Patients
				
				
						
						
						
				
		
		
				
						This week, Jonathan A. Bernstein, the lead author of “Improved Physician Work Flow after Integrating Sign-out Notes into the Electronic Medical Record,” which appears in the February 2010 issue, guests on the Journal blog. As the authors reported in the article, in Spring 2006 they developed an electronic, printable sign-out report within the electronic medical record (EMR) system at Lucile Packard Children’s Hospital. Dr. Bernstein takes this opportunity to reflect on some of the issues in developing and implementing this clinical care tool. We welcome your comments. 
		The team of physicians and software developers that had built this tool was very excited about what it could do. Practitioners would be able to remotely access and update sign-out documents that would be automatically updated with pertinent patient information from the EMR. Yet, we wondered if anyone would put the new tool to use. 
		
				To spur adoption, we announced the new tool’s arrival by e-mail to the housestaff, subspecialty fellows, and attending staff. Then we hit the pavement. Members of the development team met with the housestaff as a group and conducted a tutorial on the sign-out documents. During the following weeks, we went unit to unit, performing impromptu demonstrations. A co-author, Dr. Longhurst—an attending who was on service in late Spring—and his resident team were among the first to make regular use of the integrated sign-out tool. We also met with nurses, case managers, and social workers to let them know about the tool and to gather suggestions for how it might be helpful to them. Still, adoption in the first month was slow.
		
				As shown in the article (Figure 2, page 75), use of the sign-out documents picked up dramatically in the second month after going live. Within several months, the new sign-out documents were in regular use throughout much of the hospital. However, in reviewing usage logs, we saw clearly that use was very infrequent in our neonatal intensive care unit (NICU). Discussions with providers in the NICU identified several barriers to adoption in this setting, which largely centered on  formatting of the printed version of the report. Because of the relatively high census, the sign-out reports were too cumbersome on paper. In Summer 2008, a NICU hospitalist, Dr. Jon Palma, took on the task of adopting the electronic sign-out tool for use on neonatal patients. He led the construction of a neonatal specific sign-out report, which went live in October 2008. This report used much of the underlying engineering of the initial sign-out tool but was modified to match the functionality and formatting of a stand-alone electronic sign-out tool that had been developed by neonatology fellow Dr. Ash Sangoram for use in the NICU. Dr. Palma is currently preparing a manuscript describing the adoption and impact of the NICU EMR integrated sign-out documents.
		In addition to the positive impact on provider work flow, as we described in the article, the adoption of EMR integrated printable sign-out reports and the more recently developed neonatal sign-out report, have helped to build significant good will towards the EMR and computerized provider order entry at our institution. End users have seen the tools as examples of how the hospital’s IT department could be responsive to the day-to-day needs of care providers.
		
				With the experience of nearly four years and tens of thousands of electronically generated sign-out reports behind us, we can report an exceptionally positive experience with their adoption. We have heard from colleagues at the University of Washington that recent efforts at EMR integration of their electronic sign-out system have also been very well received there. Tailoring hospital IT services to the needs of care providers can improve the work experience of care providers and be a source of good will towards EMR-centered patient care and safety initiatives.
]]></description> 
					<pubDate>Thu, 04 Feb 2010 17:02:11 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/2/4/Reflections/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Identifying and Mitigating Hazards in Radiation Therapy</title> 
					<link>http://www.jcrinc.com/Blog/2010/1/29/Identifying-and-Mitigating-Hazards-in-Radiation-Therapy/</link> 
					<description><![CDATA[
		
				2:22:04 PM
		
		 
		
				
						This week, I asked Kurt R. Herzer, Marshall Scholar, University of Oxford, and Woodrow Wilson Research Fellow, Johns Hopkins University, to guest on the Journal blog. Mr. Herzer comments on two recent investigative articles in the New York Times reporting on the incidence and impact of rare accidents in radiation therapy, many of which can cause irreversible patient harm and even death (http://www.nytimes.com/2010/01/24/health/24radiation.html; http://www.nytimes.com/2010/01/27/us/27radiation.html?ref=health. Mr. Herzer was the lead author of “A practical framework for patient care teams to prospectively identify and mitigate clinical hazards,” which appeared in the February 2009 issue. Mr. Herzer welcomes your  comments.As the scope and possibilities of radiation treatment expand, so too should our attention to delivering it safely. With more than 50% of American cancer patients receiving some form of radiation therapy and the average lifetime dose of diagnostic radiation seven-fold what it was 30 years ago, systems must exist to manage the complexity introduced by these new life-saving treatments.
		The New York Times articles articulate the debilitating consequences of errors in radiation treatment through several patient stories. The patients suffering this undue harm experienced severe and unremitting pain, burns, deafness, visual impairment, loss of the ability to swallow, and death. Although these severe and regrettable cases might be rare, the factors that precipitated the hazards that led to them may be common. James Reason’s model of error causation provides a useful conceptual model for understanding how clinical hazards emerge and lead to patient harm. Active failures are short-lived but can have a direct impact on the resilience of system defenses. They are often the result of unsafe acts committed by providers. Latent failures, in contrast, arise from organizational culture, policies, and management decisions and can lead to error-prone conditions in the work environment or have a long-term crippling effect on system defenses. Indeed, the New York Times investigation found that in the case of radiation, “software flaws, faulty programming, poor safety procedures, or inadequate staffing and training” could be sources of error. 
		The New York Times articles also raise several pertinent questions. How do hospitals, patient care teams, and individual clinicians manage the potential hazards created by the influx of technological innovation? Is reading a manual or going through limited training in the use of the devise or therapy enough? What is the best way to train residents and students in the use of these technologies? With a theory like Reason’s in mind, an approach is needed that is both rigorous in indentifying and mitigating hazards before patients are harmed and feasible for bustling hospitals and busy clinicians to use.
		Our article in the Journal described a framework to prospectively identify and mitigate hazards that met both these criteria. This framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; the correction or elimination of the hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability. All these steps are described in detail in the Journal article.
		Bridging theory and practice, we applied this framework through three case examples, one of which was intraoperative radiation therapy (IORT). IORT involves delivering localized, high-dose-rate radiation to a tumor or tumor bed during a surgical procedure, requiring specialized brachytherapy equipment and a specialized shielded operating room (OR).  In introducing IORT to our institution for the first time, we used this framework to uncover unknown hazards before patients could receive the therapy. A human simulator was used for the in situ simulations, which were conducted in the same OR we would use for all of our patients, and real radiation was applied and measured. The simulation identified 20 potential hazards in the patient care process, some serious enough to substantially harm or kill a patient should they occur. These included such problems as the calibration of OR radiation meters, fixing the OR door to avoid radiation leaks, developing ways to remotely manage anesthesia, and standardizing language that was clear for both the clinicians and physicists participating in IORT cases. After all hazards were mitigated, and a multispecialty protocol and checklist were developed for IORT cases, patients were admitted to receive the surgical procedure and the therapy. Since its inception, nearly 30 patients have received IORT, and there have been no incidents, adverse events, or errors, and the protocol and safety procedures developed using this framework were consistently used for every case. This package model can be widely adapted by other institutions for the safe delivery of radiological procedures.
		While this approach may be useful at a hospital level for protecting patients, at the macro level creating transparency in the problems associated with radiation treatment by reporting and monitoring incidents can help create a shared learning community for hospitals and radiation specialists to learn from one another. Achieving this will require vision, creativity, and collaboration. My colleagues and I look forward to the discussion that ensues. 
		
				
		
]]></description> 
					<pubDate>Fri, 29 Jan 2010 18:22:33 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/1/29/Identifying-and-Mitigating-Hazards-in-Radiation-Therapy/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Adding a Layer of Safety Through Rapid Response Systems </title> 
					<link>http://www.jcrinc.com/Blog/2010/1/22/Adding-a-Layer-of-Safety-Through-Rapid-Response-Systems/</link> 
					<description><![CDATA[
		
				
						
								This week, Michael DeVita, M.D., chief editor of the Journal’s department Rapid Response Systems: The Stories, which began in the July 2006 issue, guests on the blog. Dr DeVita, Professor of both Critical and Internal Medicine in the University of Pittsburgh’s School of Medicine and Executive Vice President of Medical Affairs for West Penn Allegheny Health System, reflects on the state of the art—and science—of rapid response systems. Please feel free to provide your own comments on rapid response systems or to report on your own experience (in the department).
				
		
		
				
						 
				
		
		
				The field of rapid response systems (RRSs) is heating up further. The Joint Commission’s requirement that hospitals have a “process for recognizing and responding as soon as possible” to a patient’s worsening condition (Standard PC.02.01.19) is promoting dissemination. When we started this department, very few journals were accepting manuscripts for publication on the topic. Now, authors are publishing their findings in a wide range of journals, and some major journals have published either original data or meta-analyses. As a result, the field is maturing rapidly, with new applications for response teams, as well as a new recognition of the importance of event detection and prevention. We continue to see that virtually all reported RRSs have all four components of the system: event detection and response triggering (afferent limb), planned event response team (efferent limb), quality analysis, and administrative oversight and maintenance. 
		
		
				
						 
				
		
		
				Yet RRSs are not without controversy. For example, in a recent article, Chan and colleagues (Archives of Internal Medicine, Jan. 11, 2010) concluded that the data supporting RRSs are not "robust." In a Critical Care Medicine article a year earlier, Chen and colleagues reanalyzed the data from the MERIT trial originally reported in Lancet. They concluded that as the response rate increases, mortality decreases. We expect the debate to continue for some time. 
		
		
				
						
								 
								 
						
				
		
		
				I am optimistic about the increasing impact of RRSs. As I visit various organizations, it is not unusual for me to find a new type of response team or other tweak that improves their RRSs. Hospitals have applied  the RRS principles to find lost or eloped patients, deal with dangerous psychiatric crises, or support the psychological or emotional needs of staff members. The Journal encourages hospitals to report their RRS findings in this department. We accept not only case reports but any research in the field that you seek to disseminate effectively. We hope that as innovators contribute their results to the department, they may be emulated and may have their results tested by others. Only in this way can we learn the true impact of RRSs in promoting patient safety. 
		
		
				
						 
				
		
		
				There is another way to "be the first on your block" to hear about new methods or resolve problems with your current RRS: attend the only international annual conference in the field. The Sixth Annual International Meeting on Rapid Response Systems will be held in Pittsburgh on May 10–11. As usual, faculty from around the world will be available to present their most recent work, explore controversies, and answer questions. The program is aimed at nurses, physicians, and administrators, as well as both trainees and those who have completed their formal education. For information about abstracts and registration, see 
				
						http://www.rapidresponsesystem.org
				
				.
		
		
				
						
						
				 
		
				As the RRS column progresses into its fourth year, we will continue to select stories that provide new insights into how the RRS can add to your clinical care environment and provide an added layer of safety for your patients, their families, and your staff. We hope to hear more from you as you push the boundaries of how the system can be used. 
		
		
				
						 
				
		
		
				
						 
				
		
]]></description> 
					<pubDate>Fri, 22 Jan 2010 16:28:24 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/1/22/Adding-a-Layer-of-Safety-Through-Rapid-Response-Systems/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Emerging Issues with the VA Shift Handoff Tool </title> 
					<link>http://www.jcrinc.com/Blog/2010/1/14/Emerging-Issues-with-the-VA-Shift-Handoff-Tool/</link> 
					<description><![CDATA[
		
				
						
								
										This week, Peter Kaboli, the senior author of “The Veterans Affairs Shift Change Physician-to-Physician Handoff Project,” which appears in the February 2010 issue, guests on the 
						
				
				
						
								Journal blog. The development team designed an electronic medical record (EMR) handoff tool to provide a standardized approach to handoff communications and improve on previous handoff methods. As Dr. Kaboli and his co-authors noted in the article, a final version of the software was incorporated into the national EMR software program and made available to all Department of Veterans Affairs medical centers in June 2008. Dr. Kaboli takes this opportunity to reflect on some of the issues that have emerged since the rollout. The Journal 
						
						
								
										welcomes your comments.
								
						
				
		
		
				
						
								The VA Shift Handoff Tool became available to all VAMCs in June 2008 as a new function to the VA Computerized Patient Record System (CPRS). The rollout included notices by email, listserves, and other updates at all 129 VAMCs. There have been no formal surveys of adoption, so all reports have been anecdotal to the development team. A number of observations have been made: 
						
				
		
		
				
						
								
										
												
														
																
																		• More widespread adoption by medicine than surgery or psychiatry services.  The reason for this is unclear. However, one VAMC surgery program, which did not feel that the automatic fields met their requirements, preferred to have residents continue to enter information into a spreadsheet.  
														
												
										
								
								
										
												
														
														
												 
								
								
										
												
														
																
																		
																				
																						• 
																				
																		Medicine services that adopted the Shift Handoff Tool have used it for both housestaff and staff attendings (especially hospitalists) for their handoff communication. By report, after the tool was adopted it has been continuously used. One minor recommended modification was to move the “code status” line into another box to allow another column for free text. However, program modifications are difficult to request, and the development team was told that it was not a priority at this time.   
														
												
										
								
								
										
												
														
														
												 
								
								
										
												
														
																
																		
																				
																						• 
																				
																		In the past 2 months, one significant problem developed in at least 7 VAMCs.  The program works properly, but when the physician sends the tool to the printer, it prints out 50 blank pages. Because covering physicians need a paper copy to carry with them, they had to return to their prior system, which in turn highlighted how valuable the Shift Handoff Tool had become. The programming team is working on the problem and hopes to have it corrected soon.   
														
												
										
								
						
				
				
						
								
										
												
												
												
												
										
								
								 
						
				
		
		
				
						
								The next step in the tool’s continual development is to better understand how it can be integrated with nursing change-of-shift.  Because handoff communication between providers is not part of the medical record, nurses do not have access to this information. However, there are obvious reasons why nurses would want to know what physicians are signing-out to each other.  Likewise, there is important information that nurses sign-out to one another that would be important for physicians. Ongoing work at the Iowa City VAMC and VA National Patient Safety Center in Ann Arbor is exploring how to optimally integrate the flow of information between nurses and physicians using an EMR.   
						
				
		
		
				
						
								
										 
								
						
				
		
		
				
						
								
										 
										
										
								
						
				
		
]]></description> 
					<pubDate>Thu, 14 Jan 2010 19:41:36 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2010/1/14/Emerging-Issues-with-the-VA-Shift-Handoff-Tool/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Additional Reflections on Preventing Venous Thromboembolism</title> 
					<link>http://www.jcrinc.com/Blog/2009/10/29/Additional-Reflections-on-Preventing-Venous-Thromboembolism/</link> 
					<description><![CDATA[
		
				
				
		
		
				
						This week, Alpesh Amin, author (with Steven Deitelzweig) of “Optimizing the Prevention of Venous Thromboembolism: Recent Quality Initiatives and Strategies to Drive Improvement,” which published in the November 2009 issue, guests on the blog. In the article, they review the quality indicators, public reporting initiatives, incentive programs, and “negative reimbursement” that are designed to help hospitals improve venous thromboembolism (VTE) prevention. In this blog, Dr. Amin reflects on some recent developments since writing the article. The Journal welcomes your comments. What quality initiatives and strategies have you found helpful in optimizing VTE prevention practices?  
		As a serious, treatable complication, deep venous thrombosis (DVT/VTE) has been added as a Centers for Medicare & Medicaid Services (CMS) nursing- sensitive measure, failure to rescue—which highlights the importance of accountability of every member of the health care team in achieving quality outcomes. Readmission rates are emerging as another important issue. Patients who had a hospital-acquired VTE are likely to be readmitted over one third of the time. A Niagara Health Quality Coalition analysis suggests that there are 87,000 potentially preventable readmissions with VTE within 30 days in the Medicare population (http://www.myhealthfinder.com/cmsletter063009.pdf).   The Leapfrog Group hospitals were asked in March 2008 to sign an agreement to not bill for “never events.” States have implemented legislation to require reporting of events, and California has imposed fines for occurrence of “never events” in 2007. Medicare is working on not making additional payment for DVT or pulmonary embolism that develops during the hospital stay. Finally, the continuum of care is important to achieve quality of care. As we stated in the article, National Quality Forum Safe Practice 28 recommends that each patient be evaluated, and periodically thereafter, for the risk of developing VTE. It also recommends that evidence-based methods of appropriate thromboprophylaxis be used if required. One important point is that the concept of ensuring assessment “periodically thereafter” reflects the fact that patient status changes during the hospitalization and after, and so does one’s risk for VTE. For example, renal function and procedure-based mobility changes during the hospitalization could affect approaches to VTE prevention. Our practice must be more continuous and longitudinal in terms of assessment and use of evidence-based practices to ensure the highest-possible quality outcomes for our patients.
		 
		 
		
				
		
]]></description> 
					<pubDate>Thu, 29 Oct 2009 17:06:32 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/10/29/Additional-Reflections-on-Preventing-Venous-Thromboembolism/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Hand Hygiene Leads to More Preventive Efforts </title> 
					<link>http://www.jcrinc.com/Blog/2009/10/16/Hand-Hygiene-Leads-to-More-Preventive-Efforts/</link> 
					<description><![CDATA[
		
				
				
						This week, Mark Bittle, lead author of "Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care,” which appeared in the October 2009 issue, guests on the blog .In the article, Dr. Bittle and Suzanne LaMarche describe how involving the patient is a simple and cost-effective way to monitor hand hygiene in the ambulatory setting. In this blog, Dr. Bittle reflects on how hand hygiene efforts at the Johns Hopkins Outpatient Center have now led to other preventive measures in the outpatient clinical practice setting. The Journal welcomes your comments about this blog and your own experiences in monitoring hand hygiene compliance, influenza vaccination, or other preventive efforts.   The hand hygiene compliance monitoring project has recently sparked interest among members of the Johns Hopkins Hospital’s ambulatory quality and patient safety task force in the need to implement other preventive measures in our specialty practices. Hand hygiene, after all, represents a prevention practice. For example, we have also begun an initiative whereby we have requested our specialty practices to screen all patients for influenza vaccination. Essentially, at each encounter, the practices ask patients if they have had a flu vaccination and, if not, would they want one. Prevention is one of the keys to reducing the burden of illness, and reducing the burden of illness is one of the fundamental factors to reducing increases in health care expenditures. Yet, this process of asking specialists to screen for a preventive measure has met with some considerable resistance. Much of this resistance reflects the perception that prevention is somehow the sole purview of primary care physicians and implementing this five-question screening process will negatively impact productivity. Given the importance of screening for hand washing and other essential prevention services, we hope to gain practices’ cooperation to build appropriate prevention screening into every clinical encounter, regardless of the provider’s specialty.   Editor’s note: Staying current with this blog is easier now than ever with our new RSS feed. Click here to find out more.  
]]></description> 
					<pubDate>Fri, 16 Oct 2009 22:45:08 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/10/16/Hand-Hygiene-Leads-to-More-Preventive-Efforts/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Coaching Physicians Involved in Disclosure Cases</title> 
					<link>http://www.jcrinc.com/Blog/2009/10/9/Coaching-Physicians-Involved-in-Disclosure-Cases/</link> 
					<description><![CDATA[
		
				
						 This week, Randy Peto, lead author of "One System’s Journey in Creating a Disclosure and Apology Program,” which appeared in the October 2009 issue, guests on the blog. In the article, Dr. Peto and his colleagues describe the disclosure and apology program at the four-hospital Baystate Health system. In this blog, Dr. Peto discusses his experience, which occurred while the article was in press, in coaching a physician who was involved in a serious unanticipated outcome. The Journal welcomes your comments about this blog and your own experiences in the disclosure process.
				  We recently experienced a very serious unanticipated outcome for a patient undergoing an elective surgical procedure. The family was immediately informed of the situation, followed by a conversation the next day and a few short subsequent phone conversations. The exact cause of the unanticipated outcome was unclear. One of the physicians involved informed our risk management office of the case. A departmental colleague of the physician suggested that he also talk to me, as medical director for quality and patient safety, to gain additional feedback and advice about the best ways to proceed.   At the physician’s suggestion, we held our first meeting offsite at a location in which he was comfortable. He was clearly troubled by the seriousness of the outcome, particularly by the fact that at the time we didn’t yet know what caused the outcome. We spent about 3 hours together. I did more listening than talking.  The physician had run through the case multiple times in his head, trying to make sense of it all. He described the emotional impact of the case on himself and his family. We tried to anticipate what the patient’s family was feeling at this point in time, knowing that we’d never fully be able to put ourselves “in their shoes.”  We talked about the strain in waiting for additional data to be collected, including a root cause analysis and additional investigations. Amid the myriad events and unanswered questions following the adverse outcome, he seemed to gain some comfort from hearing me recite the four “wants/needs” of patients & families after an adverse event: 1)      To learn what happened 2)      To make the situation right as much as possible 3)      To receive an apology (if warranted) 4)      To change the system to reduce the risk of similar events happening to future patients   During the next few weeks, we had shorter conversations, some by e-mail and some in person. Additional data trickled in from the subsequent investigations.  The evolution and speed of the process (especially the early steps) were clearly not seamless to him, and he has provided some recommendations on how we might improve our disclosure infrastructure. For example, he stated that assistance should be provided in coordinating the communication and paperwork required in the immediate aftermath of a serious event—at a time when the medical team is emotionally traumatized.   The final investigation concluded that the outcome was not preventable, given the information known at the start of the surgical procedure. At this point, our conversations focused on planning for the major meeting with the family to present a comprehensive overview of the investigation’s findings and to provide an opportunity to ask questions. We talked both about the big things, as we again tried to anticipate how the family might be feeling a few weeks after the adverse event, as well as the small things, such as arranging for a comfortable room for an extended conversation. The major disclosure session with the family went well. The door was left open for future discussions, but no follow-up meetings were scheduled or have since occurred.   In developing our disclosure and apology program, we provided intensive training to some physicians to become “communication consultants.” We have not used those physicians extensively since the training, in part because of the historical comfort risk managers have gained in that consultant role. As for my own role as a communication consultant, I’ll probably learn my true worth in this process only after more difficult cases involving errors on the part of the hospital/clinicians and/or families who react to an adverse event in a challenging fashion. But it was reassuring to have my first disclosure “case” turn out reasonably well, despite the horrible outcome to the patient.   Editor’s note: Staying current with this blog is easier now than ever with our new RSS feed. Click here to find out more. 
		
		
]]></description> 
					<pubDate>Fri, 09 Oct 2009 18:17:21 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/10/9/Coaching-Physicians-Involved-in-Disclosure-Cases/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Why Policy Should Not Precede the Science: The Case of Briefings and Debriefings </title> 
					<link>http://www.jcrinc.com/Blog/2009/10/1/Why-Policy-Should-Not-Precede-the-Science-The-Case-of-Briefings-and-Debriefings/</link> 
					<description><![CDATA[
		
				
						This week, Sean Berenholtz, the lead author of “Implementing Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center,” which appeared in the July 2009 issue, guests on the Journal blog. Briefings and debriefings involve a discussion among all members of the surgical team before incision and then before leaving the OR. Drawing on 37,113 briefings and debriefings, Berenholtz and his colleagues demonstrated that it was feasible to implement OR briefings and debriefings in a large, busy hospital and that physicians and nurses perceived that briefings and debriefings were associated with improved interdisciplinary communication and teamwork in the operating room (OR). Dr. Berenholtz takes this opportunity to reflect on some of the issues in implementing briefings and debriefings. He and I welcome readers' questions and comments. 
		
		Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR. A number of tools have been adopted in health care from the aviation industry, and briefings and debriefings are but one example.  
		Although we did not evaluate the impact on clinical or economic outcomes, our study builds on a growing body of literature that suggests that briefings and debriefings in the OR and other structured communication tools may indeed improve patient outcomes. Since the inception of this study, for example, Haynes et al. (Jan. 29, 2009 New England Journal of Medicine) published the results of the World Health Organization (WHO) Safe Surgery Saves Lives program. In the WHO study, investigators prospectively collected data on clinical outcomes from 3,733 consecutive adult patients before the introduction of the Surgical Safety Checklist and 3955 patients undergoing noncardiac surgery after checklist implementation. The checklist was an integral part of a required sign-in before the procedure and a sign-out before leaving the OR. The authors report a significant 47% (1.5% pre to 0.8% post) reduction in mortality and a 36% (11% pre to 7% post) reduction in complications after introduction of the checklist.
		Based in large part on the WHO study and other smaller studies, many organizations and professional societies are now advocating the routine use of briefings and debriefings in the OR. While these studies and others evaluating the potential role of briefings and debriefings, including checklists, seem promising, there are many unanswered questions. For example, do briefings and debriefings reduce patient complications and mortality? Frankly, it doesn’t seem plausible that a checklist decreases mortality by nearly 50%. In other words, for every two patients who would have died, one patient did not die as a result of checklist implementation.  
		Many other implementation questions also remain unanswered. Who should lead the briefing and debriefing? Who should be included? When should a briefing be conducted relative to timing of patient induction and surgical incision? When should a debriefing be conducted relative to the timing of surgical closure and leaving the OR? Should the briefing and debriefing consist of yes/no questions, open-ended questions, or a combination of both? Should briefings and debriefings be modified based on the patient population and/or surgical procedure? To date, the answers to these questions are not known.
		While the pressure to improve perioperative quality and safety is increasing, I would hope that we don’t repeat mistakes of the recent past. Perhaps two lessons from recent announcements that mandated time-outs have done little to nothing to change wrong-sided surgery in the United States are worth mentioning. First, policy should follow the science, not precede the science. More research is needed to inform policies before briefings and debriefings are mandated.  Second, while checklists and other structured tools are an easy answer, this isn’t about checklists. To achieve substantive and sustainable improvements in the quality and safety of patient care, we need to focus on systems of care; engage local interdisciplinary teams to assume ownership of the problem; centralize support for technical work, including robust data collection and data quality control efforts; encourage local adaptation of the intervention, improve culture; and encourage social networking among organizations. Only then will we make progress. 
]]></description> 
					<pubDate>Thu, 01 Oct 2009 19:45:51 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/10/1/Why-Policy-Should-Not-Precede-the-Science-The-Case-of-Briefings-and-Debriefings/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Issues and Trends in Rapid Response Systems</title> 
					<link>http://www.jcrinc.com/Blog/2009/9/29/Issues-and-Trends-in-Rapid-Response-Systems/</link> 
					<description><![CDATA[
		
				The Journal has been running articles in Rapid Response Systems: The Stories, since this department premiered in July 2006. As Michael DeVita, the chief editor of the series then remarked (see article, attached), we launched the series “to provide a resource to those who are just getting started or are interested in advancing their programs already underway.” I encourage you, as he did then, to report your own experiences with rapid response systems, thereby contributing to a learning community. This week, Drs. Ajay D. Rao (Brigham and Women’s Hospital, Boston), Ken Hillman (University of New South Wales, Liverpool Hospital, Sydney, Australia), Anne Lippert (Danish Institute for Medical Simulation, Copenhagen), Andreas Hvarfner (Lund University Hospital, Sweden), and Rinaldo Bellomo (Austin Hospital, Victoria, Australia) join Dr. DeVita in providing a brief overview of the two-day 5th International Symposium on Rapid Response Systems and Medical Emergency Teams, which took place in scenic Copenhagen, in May 2009. We welcome your comments—and your own reports on using rapid response systems.
		
				This year’s conference, which carried the theme, “Bridging The Gap Between Patient Needs And Resources,” reflected an exciting increase in the quality of the research reported. This was the first time that the conference, directed by Anne Lippert and Andreas Hvarfner, was held outside of North America, keeping with the intention to represent the international work being done in this field. 
		
		
				On Day 1, Michael DeVita “set the scene” by informing the audience as to the great headway that has been made in the growing field of rapid response systems (RRS) and medical emergency teams (METs), along with potential future pathways for research. Presentations then followed, organized by three separate tracks—Novice, Research, and Education. Highlights included a series of new sessions exploring the contribution of social sciences to effective METs. For example, Susan Scott (University of Missouri Health System, Columbia), reported on the success of a novel use of a RRS to provide support to the health case workers– physicians, nurses, therapists, students, volunteers, and so on—who are considered the so-called second victims of a patient crisis, often experiencing anxiety, stress, and even guilt when a patient decompensates or dies. 
		
		
				In another session, emphasis was placed on the afferent-efferent arms of the RRS model. The afferent arm focuses on the detection of the event, and the efferent arm refers to the team’s response to the event. Many studies have shown that implementation of an effective RRS involves optimizing both arms of the loop. This session provided the audience a reminder of the importance of the linking of the two arms. 
		
		
				In a session about the quality of research pertaining to RRS, Max Bell (Karolinska Institute) highlighted the need for better data collection and analysis in research. As RRSs move past the “why we do it” and “how to do it” and phase, more robust inquiry is needed as to what makes the system work and what models appear to be the most effective in which environments.  
		
		
				On Day 2, in summarizing the previous day’s events, Rinaldo Bellomo commented the importance of education to developing RRSs. In addition, he spoke of how young the field was and the need for better ways to identify patients at risk of a deteriorating condition. This was followed by a panel debate with interactive audience voting on the question: “Should the patient themselves or relatives be allowed to activate the RRS?” The audience verdict was mixed, with those in favor of family activation stating that additional inputs to trigger the system will likely decrease the well-documented rate of failure to trigger a response. In addition, sociologically, it was felt that incorporating the family into the healing team was beneficial. Those opposed were concerned about the potential for overtriggering of responses. Another pro/con seminar addressed whether continuous vital sign monitoring should be offered to all patients in the hospital, as opposed to using only intermittent data collected by staff. Those in favor felt that continuous monitoring is needed to reliably detect all crisis events; those opposed were concerned about cost and false-positive alarm rates. 
		
		
				Day 2 included several sessions on pediatric RRSs. Some highlights include a presentation from the St James’ Hospital in Leeds (U.K.) on the need for a pediatric warning score.  Data shown included results from close to 14,000 encounters and the need for more clinical evaluation of the scoring system. The system is age based and was effective in predicting risk for in-hospital mortality. 
		
		
				In the afternoon, attendees had the privilege of listening to the three award-winning posters of the conference. The first presentation was from Dr. Catherine Jones (Wake Forest University Medical Center), “Mandatory Rapid Response Activation Improves Quality of Care.” This was followed by an excellent study from the pediatric world about “Pediatric Medical Emergency Teams Decrease Rate of Code Blue, PICU Readmissions, and PICU Mortality” from Afrothite Kotsakis (The Hospital for Sick Children, Toronto). The last presentation was an intriguing study by a team from the University of Pittsburgh Medical Center on possible prevention of patients found pulseless and apneic in the hospital.
		
		
				In a concluding talk, “Where Are We Heading?”, Ken Hillman touched on the importance of in-house physicians and hospitalists and how their involvement will likely be contributory to future success of RRSs. He emphasized the changing role of the house staff in the modern setting of RRS and METs. As was noted in some breakout sessions later on, there is the concept that RRS and METs might take away from the learning experience of young physicians, along with duty hours implemented in the U.S. and on their way to being implemented in Europe. On the other hand, additional staff supervision might improve the learning experience during critical patient events while at the same time improve outcome. There are little data on these considerations as yet. In addition, he reminded the attendees about the value of reinvestigating age-old dogmatic monitoring methods that do not provide as valuable data as once thought with regards to medical emergencies. For example, an electrocardiogram is unlikely to predict an evolving crisis and can fail to detect respiratory, neurological, or circulatory events. (The conference returns to Pittsburgh in May 2010). 
		
		
				
				 
]]></description> 
					<pubDate>Tue, 29 Sep 2009 23:30:09 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/9/29/Issues-and-Trends-in-Rapid-Response-Systems/Default\.aspx</guid>
				</item>
			
				<item>
					<title>How to Sustain the New Practice–and Continuous Quality Improvement—After the Initial Success? </title> 
					<link>http://www.jcrinc.com/Blog/2009/9/17/How-to-Sustain-the-New-Practice–and-Continuous-Quality-Improvement—After-the-Initial-Success/</link> 
					<description><![CDATA[
		
				
						
				
				This week, John Q. Young, author (with Robert M. Wachter) of “Applying Toyota Production System Principles to a Psychiatric Hospital: Making Transfers Safer and More Timely,” which appeared in the September 2009 issue, guests on the blog. As you may remember, they described how Langley Porter Psychiatric Hospital and Clinics at the University of California San Francisco School of Medicine  used Toyota Production System principles to achieve sustained improvements in patient transfers to the outpatient medication management clinics from all other inpatient and outpatient services. As detailed in the article, the new transfer process included the use of templated (and HIPAA compliant)  e-mail communications to apprise the sending clinicians of the status of the transfer request. In this Blog, 41 months into implementation, Dr. Young discusses a recent setback in executing this part of the process. We would like to hear from you–What has worked for you to sustain new practices and continuous  quality improvement (CQI). What hasn’t?
				
				Recently, I received several anxious e-mails and voice mails from inpatient- and outpatient-service clinicians about the status of referral requests to our outpatient medication clinics. I was annoyed and concerned that these referring clinicians were not being informed of the status of their transfer requests in a timely manner. In an effort to improve communication during transitions in care and to treat referring clinicians as “internal customers,” we had developed a standardized e-mail communication just for this situation. This e-mail was to be sent to the referring clinician to let him or her know whether a transfer request had been accepted. So why wasn’t this happening? 
		
				I immediately spoke with one of our 3 frontline administrative staff in the Adult Psychiatry Clinic. She explained that the staff had in fact stopped sending this standardized communication to the referring clinicians. They apparently had made this decision on their own because they felt it was no longer necessary, given how quickly they now process transfers—in 1 to 2 days rather than 3 weeks. While from their standpoint, this decision made a lot of sense, the bigger picture had gotten lost. 
		We were able to quickly troubleshoot the problem. The staff realized how important the communication was to the referring clinician and saw the value in resuming the practice. The discussion even led to an improvement in the standardized communication—we added the date/time of the first appointment to the e-mail!. 
		But even as we were fixing the problem, I saw in myself and in our organization the tendency to move away from a “continuous improvement” mindset to one that pays attention only when there is a crisis. And how difficult it can be to discuss behavioral lapses such as the failure to continue to use e-mails without blaming or feeling really annoyed. In fact, we had recently expanded our weekly QI meetings with core staff to include staff from several other administrative units (or microsystems)—in part to bring other parts of the organization into a more explicit QI approach. But in the process, the meetings became less about collaboratively identifying opportunities to learn and improve and more about leadership informing staff about what needs to be done better or differently. 
		This seems to be a major challenge for many of the units at Langley Porter. How do we embed CQI into their processes and culture? And how do we develop practices and cultures that sustain and persist even when the initial leader is no longer there? For our part, we have reestablished regular meetings for the Adult Psychiatry Clinic—the 3 administrative staff, the practice manager, and clinic director. We have focused the meetings on empowering staff to identify problems and solve them collaboratively. We're off to a great start. The team has identified several issues to address right off, including how to redistribute clinical and administrative tasks with one of the staff now on medical leave. 
		
				
		
]]></description> 
					<pubDate>Thu, 17 Sep 2009 18:10:17 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/9/17/How-to-Sustain-the-New-Practice–and-Continuous-Quality-Improvement—After-the-Initial-Success/Default\.aspx</guid>
				</item>
			
				<item>
					<title>The Joint Commission Launches its Center for Transforming Healthcare </title> 
					<link>http://www.jcrinc.com/Blog/2009/9/10/The-Joint-Commission-Launches-its-Center-for-Transforming-Healthcare/</link> 
					<description><![CDATA[
		Today, at the National Press Club in Washington, D.C., The Joint Commission announced its Center for Transforming Healthcare. In a letter sent to more than 16,000 accredited health care organizations or programs across the United States, Mark R. Chassin, M.D., M.P.P., M.P.H., President of The Joint Commission, stated, “The Center is developing solutions by using the same Robust Process Improvement™ (RPI) methods—including Lean Six Sigma and change management—that other industries have long relied on to improve quality, safety and efficiency.” The Center is intended to “provide knowledge and practices that will help transform health care into a high-reliability industry, with rates of adverse events and breakdowns in routine safety processes comparable to air travel or nuclear energy.” 
		In its first initiative, The Center is working with a group of hospitals and health systems in developing solutions to improve hand hygiene and reduce preventable health care–associated infections, with initiatives also planned for handoff communications and wrong site surgery. The Center will spread the lessons learned to the rest of the health care system. More specifically, it will provide assessment tools to measure the magnitude of the problem and the causes, as well as packaged interventions customized for the identified causes. 
		You can learn more about The Center and its initiatives at its Web site, http://www.centerfortransforminghealthcare.org. I invite Journal readers to share their own stories, either informally on the Blog or in an article, about their ongoing work in hand hygiene, handoff communications, wrong site surgery, and other important areas. (Please don’t miss the article by Mark Bittle and Susan LaMarash, “Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care,” which will shortly appear in the November issue.) 
		 
]]></description> 
					<pubDate>Thu, 10 Sep 2009 20:14:25 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/9/10/The-Joint-Commission-Launches-its-Center-for-Transforming-Healthcare/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Using an Electronic Medical Record for Continuity of Care </title> 
					<link>http://www.jcrinc.com/Blog/2009/8/13/Using-an-Electronic-Medical-Record-for-Continuity-of-Care/</link> 
					<description><![CDATA[
		
				
						This week, Allen Hsiao, the lead author of  “Dropping the Baton During the Handoff from ED to Primary Care: Pediatric Asthma Continuity Errors,” which appears in the September 2009 issue, guests on the Journal blog. As part of the AHRQ-sponsored “Electronic Records to Improve Care for Children” (ERICCA) project, the authors examined the handoff of care for asthmatic children between the ED and the primary care providers in a traditional paper-based documentation system. Despite the great efforts to achieve continuity using phone calls and paper faxes, the authors found that all too often, “batons” are dropped in this important transition of care, with errors in continuity of information and continuity of care. The Journal invites your own comments on any progress on continuity of information or care that you’ve been able to make at your own organizations. Continuity has been seen as a necessary attribute of high-quality care and is especially important for and valued by vulnerable populations such as inner-city children with asthma. Patients who have continuous relationships with their primary care physicians have substantially decreased risk of emergency department visits and hospitalization. The ERICCA project successfully deployed an electronic medical record into the pediatric emergency department of Yale-New Haven Children’s Hospital to be used for discharge instructions and prescriptions. Primary care providers at the two community health centers cited in the article, as well as others, now receive information through electronic faxing and can also view the instructions and medication lists online through an online portal. This has greatly improved continuity of information. Because the project also implemented the electronic medical record in the pediatric respiratory medicine clinic, an added bonus is the emergency department can now share an electronic medication list with them; providers at both ends know exactly when an inhaler was refilled or when the last course of steroids was prescribed. 
		With the U.S. government’s recent big push for electronic medical records in ambulatory and hospital settings, we should soon be able to greatly diminish continuity errors. It will take work to pass critical information between different systems, but getting off of paper and transmitting the information electronically is half the battle. We sincerely hope that physicians soon won’t have to “practice in the dark”—not knowing a patient’s history or medications or that he or she was recently treated in an emergency department.  
		
				 
]]></description> 
					<pubDate>Thu, 13 Aug 2009 22:26:16 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/8/13/Using-an-Electronic-Medical-Record-for-Continuity-of-Care/Default\.aspx</guid>
				</item>
			
				<item>
					<title>What Does the U.S. House Bill Say About Hospital Complications and Payment?</title> 
					<link>http://www.jcrinc.com/Blog/2009/7/23/What-Does-the-US-House-Bill-Say-About-Hospital-Complications-and-Payment/</link> 
					<description><![CDATA[
		
				
						This week, Richard Averill, the lead author of Forum, “Hospital Complications: Linking Payment Reduction to Preventability,” which appeared in the May 2009 issue, guests on the Journal blog. As you’ll recall, in the article, Mr. Averill and his colleagues proposed that the Center for Medicare & Medicaid Services (CMS) policy of denying payment for certain in-hospital complications should be modified, given that complications are not always preventable. I was curious about the implications of the current U.S. House of Representatives health care reform bill, America’s Affordable Health Choices Act, released on July 14, 2009, in terms of  provisions for payment reductions for hospital readmissions. So I asked Mr. Averill. He and I welcome your reactions or questions. 
		The current House bill that contains payment reform relating to the payment for readmissions states that payment adjustments for readmissions shall not apply to readmissions that are "unrelated to the prior admission." This is a definition stated in the negative but by implication any readmission for which there is a payment reduction must be related to the prior admission. The equivalent language in the Deficit Reduction Act of 2005 (P.L. 109-171) related to payment reductions for inpatient complications states that payment reductions should apply only to those complications that could "reasonably have been prevented." Although the wording is different, it is clear that the intent is the same. Congress wants pay for performance–related payment reductions for complications and readmissions to apply only in those circumstances in which there is a  clinically reasonable presumption that the complication or readmission could have been prevented. 
		As we discussed in “Hospital Complications: Linking Payment Reduction to Preventability,” the method of implementing the payment reductions is critical to the success of the payment reform. The payment adjustment for complications has been implemented on a case-by-case basis, which essentially limited the complications included to those complications that were virtually always preventable. As a result, the payment reductions for complications have had a negligible financial impact on Medicare expenditures. Fortunately, the proposed payment adjustments for readmissions in the current House Bill are based on the number of excess readmissions in a hospital and are not implemented on a case-by-case basis. A case-by-case payment reduction would have an inherent implied accusation that care provided to an individual patient was substandard. Focusing on risk-adjusted hospital readmission rates as the basis of determining pay-for-performance payment reductions has avoided the defensive responses evoked by a case-by-case approach.  Because readmissions are often the result of problems in the care processes relating to coordination and communication between the hospital and postdischarge care providers, a focus on systematic differences in readmission rates across hospitals is appropriate.(You can find the complete House Bill at http://edlabor.house.gov/blog/2009/07/americas-affordable-health-choices-act.shtml).  
]]></description> 
					<pubDate>Thu, 23 Jul 2009 18:42:49 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/7/23/What-Does-the-US-House-Bill-Say-About-Hospital-Complications-and-Payment/Default\.aspx</guid>
				</item>
			
				<item>
					<title>More on Implementing E-Surveys (a Practical Enhancement to Tracer Methodology)</title> 
					<link>http://www.jcrinc.com/Blog/2009/7/17/More-on-Implementing-E-Surveys-a-Practical-Enhancement-to-Tracer-Methodology/</link> 
					<description><![CDATA[
		
				This week, Frederick North, the lead author of  a Tool Tutorial, “E-Surveys as a Practical Enhancement to Tracer Methodology for Continuous Joint Commission Accreditation Readiness, “which appears in the August 2009 issue, guests on the Journal blog. In the article’s conclusion, the authors stated, “We now have regular interdisciplinary group meetings with physician, nursing, secretarial, appointment, and clinical assistant leadership to plan ongoing updates and assessments on the basis of the tracer and E-survey data. We prioritize our actions depending on the tracer results and additional information from E-surveys.”  Dr. North wanted to take this opportunity to spell out how the interdisciplinary meetings fit into the overall E-survey process and to provide a process summary to guide readers who are planning to implement the E-surveys in their own organizations. Dr. North, who can be reached at North.Frederick@mayo.edu, welcomes readers’ questions, about the software necessary for the E-survey. 
		We’ve learned that monthly interdisciplinary leadership meetings to plan and discuss the E-surveys are essential for their success. The meetings are useful not only to communicate results but to engage leadership by eliciting their ideas for interventions. We’ve found that several key processes involved in the E-surveys benefit from leadership input. In the meetings, we regularly address items 6 though 11 in the process summary, as well as item 2—final content validation of the questions. 
		
				Process Summary for E-surveys 1. Evaluate the tracer deficiency to see if a survey question can be constructed to test for a more general knowledge deficiency2. Construct a question which is understandable, has an agreed upon meaning, and accurately tests for the deficiency3. Access the current available resources (online and otherwise) to make sure the information necessary to answer the question is readily available4. Construct and disseminate the E-survey: include the correct answers for last week’s E-survey, where to find more information on the standard or policy, and any additional motivational material5. Download and summarize E-survey results by staff subgroup6. Communicate results to staff leadership7. Decide the percent correct rate above which no further action is initiated8. Decide which staff types need an intervention based on the E-survey data9. Plan the intervention (by staff subgroup if needed)10. Decide when to retest11. If the tracer deficiency cannot be tested with an E-survey then plan an intervention to remedy the deficiency 
		 
]]></description> 
					<pubDate>Fri, 17 Jul 2009 22:14:24 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/7/17/More-on-Implementing-E-Surveys-a-Practical-Enhancement-to-Tracer-Methodology/Default\.aspx</guid>
				</item>
			
				<item>
					<title>On Developing and Adapting Tools</title> 
					<link>http://www.jcrinc.com/Blog/2009/7/10/On-Developing-and-Adapting-Tools/</link> 
					<description><![CDATA[
		Quality and patient safety professionals and clinicians need to have useful and efficient tools at their disposal to collect data to identify opportunities for improvement and to then address them. In an article in the October 2008 issue of the Journal, “Developing Process-Support Tools for Patient Safety: Finding the Balance Between Validity and Feasibility,” Jill Marsteller and her coauthors at the Quality and Safety Research Group at Johns Hopkins described their strategy for developing tools. At that point, the group had developed 10 tools, almost all of which were represented in a Journal article.  (They followed up with another article, “Team-Based Daily Goals Sheet for a Non–ICU Setting,“ in the current issue.) 
		The tools and all the improvement methods and strategies represented in the pages of the Journal are made available so that you, our readers, can use them, adapting them to the context of your own organizations. Although we can’t all develop tools, we can all try to use them. And if we can’t  all find the time to submit an article, then why not use the blog as a forum on how an improvement tool—or method or strategy—has worked? 
		As always, I look forward to hearing your reactions and ideas.
]]></description> 
					<pubDate>Fri, 10 Jul 2009 14:32:28 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/7/10/On-Developing-and-Adapting-Tools/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Thinking about Patient Safety for Chronically Ill Outpatients</title> 
					<link>http://www.jcrinc.com/Blog/2009/7/2/Thinking-about-Patient-Safety-for-Chronically-Ill-Outpatients/</link> 
					<description><![CDATA[
		
				
				
		
		 
		
				
						This week, Urmimala Sarkar, the lead author of “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care,” which appears in the July 2009 issue, guests on the Journal blog. She reflects on the origins of the article and on the need to engage patients, especially the large population of patients with chronic conditions, in improving safety. Dr. Sarkar and I welcome your own reactions.While most prior research has focused on patient safety in the hospital setting—that is, medical errors during hospital stays—we argue in our article that more attention should be paid to ambulatory populations with chronic diseases. Unlike acute care settings, where patients receive care from trained teams of clinicians guided by protocols, the outpatient setting involves patients performing the day-to-day management of their chronic conditions themselves. 
		
				I started thinking about these issues during my training. As a resident, I saw a new patient in my primary care clinic, just discharged from the hospital, and found that she was taking literally four times the maximum dose of her blood pressure medication, an ACE inhibitor. There were a host of factors at work. For one thing, there was a formulary change at our health system, so she had two different medicines from the same class. One should have replaced the other, but that was not communicated to her. Then, when she was discharged from the hospital, she was given an entirely new set of medicines, but she did not realize she should stop the medications she had at home. When she came to see me, she was clearly overwhelmed and unable to name her medications or describe her regimen. After I pieced it together, I sent her for blood tests, which showed new kidney failure from the medication overdose. I had to send her right back to the hospital. This example highlights some of the problems that we tried to touch on in article—transitions in care, inadequate communication between providers, and limited health literacy—all leading to medication confusion.  
		As a primary care provider myself, I think it’s crucial to keep in mind how complex our patients’ interactions with the health care system are. I don’t think it’s coincidental that current patient safety efforts focus more on inpatient issues. The issues raised in the ambulatory setting are much less amenable to any “quick fix” by providers, administrators, or even accreditors. For outpatient chronic disease safety, we need to engage patients to improve safety, and we still have a lot to learn about how to do that.
		 
]]></description> 
					<pubDate>Thu, 02 Jul 2009 21:47:53 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/7/2/Thinking-about-Patient-Safety-for-Chronically-Ill-Outpatients/Default\.aspx</guid>
				</item>
			
				<item>
					<title>On Planning Improvement Projects as if Publishing</title> 
					<link>http://www.jcrinc.com/Blog/2009/6/22/On-Planning-Improvement-Projects-as-if-Publishing/</link> 
					<description><![CDATA[
		In my recent blog regarding the new Joint Commission Resources book, A Guide to The Joint Commission's Medication Management Standards, Second Edition. I noted Brigham and Women's Hospital (Boston)'s efforts to improve medication safety. I recently had the opportunity to chat with the hospital's executive director of pharmacy, Bill Churchill, who took the lead with his team in writing the chapter. I asked how the decision to publish an article (or chapter) on an improvement project affects the way that project is planned and conducted—if the decision is made before the project starts—or could affect how they do subsequent projects.
		
				For Bill, when he and his colleagues decide they want to publish a paper, they are "much more deliberate about defining the project and its goals, end points, and measures." For example, for a simple project on the impact of the presence of a pharmacy in the emergency department to review medication orders, he was involved in several months of meetings "to identify all the steps that we had to take,  to know what we were going to study, to identify processes that we were going to use for data collection," and so on. On the other hand, he added, if he and his colleagues were just going to plan and implement the intervention without intent to publish, "we would have just briefly discussed what we're doing it, why we're doing it," and then gotten started. 
		
				After further conversation, Bill advised to "plan as if you were publishing, especially if you are working with other sites, because you would have to standardize the process and measures anyway." Such preparation, the thinking goes, would probably make for a better project whether published or not: "When you go into a process improvement project and focus on implementation, you can miss the opportunity to include certain data if you don't think through all phases in the same way that you would if you had done a  research study." For example, after writing up the improvement project on bar-code administration for their Medication Management chapter, he realized that they should have established a mechanism to collect ongoing data on the number of errors prevented in the pharmacy using bar-code-based technology in their dispensing process—which he will now collect for their next project on the topic.
		
				I would be very interested in your own reflections on how an improvement project changes when you’ve decided to try to publish.     
		 
		 
]]></description> 
					<pubDate>Mon, 22 Jun 2009 20:13:52 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/6/22/On-Planning-Improvement-Projects-as-if-Publishing/Default\.aspx</guid>
				</item>
			
				<item>
					<title>A Guide to Medication Management Standards</title> 
					<link>http://www.jcrinc.com/Blog/2009/6/15/A-Guide-to-Medication-Management-Standards/</link> 
					<description><![CDATA[
		We at Joint Commission Resources have just published A Guide to The Joint Commission’s Medication Management Standards, Second Edition. In developing the book, I asked a number of hospitals and other health care organizations to describe medication management practices that they improved to address The Joint Commission standards. I vetted the topics to ensure that they would provide educational assistance where our customers have indicated that they needed it most—in improving the organization’s medication management system in general and, specifically, in ensuring safe medication administration, including self-administered medications and patient-controlled analgesia; managing high-risk medications; and storing and securing medications.
		Brigham and Women’s Hospital (Boston)’s efforts to improve its medication management system are described in detail in the book. In a systems approach, every organization member, from hospital and medical staff to executive leadership, is dedicated to patient safety, and a patient safety team oversees creation of the “safest possible environment” for patients and staff through seven initiatives,” one of which is “improve medication safety.” As Jeannell H. Mansur, R.Ph., Pharm.D., states in the Foreword, this hospital and the other organizations represented in the book share what calls “an evident passion for medication safety.” She asks, “Is medication safety identified as a top priority for your own organization?” If not, what have you tried to do about it? We’d like to know—and will treat the information anonymously, if requested. Also, what challenges or issues in medication safety would you like to see addressed in the Journal? 
]]></description> 
					<pubDate>Mon, 15 Jun 2009 21:34:19 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/6/15/A-Guide-to-Medication-Management-Standards/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Antibiotic Resistance</title> 
					<link>http://www.jcrinc.com/Blog/2009/6/9/Antibiotic-Resistance/</link> 
					<description><![CDATA[Have you heard about the Joint Commission Resources audioconference scheduled for June 12, 2 p.m. C.S. T., on Reducing Antibiotic Resistance and Multidrug-Resistant Organisms? Hospital executives and their leadership teams are invited to learn more about the clinical and financial cost of antibiotic resistance and effective prevention and control techniques. (Registration can be conducted at http://www.surveymonkey.com/s.aspx?sm=CCXJbEtXOO8sTsh4DQ_2fkmQ_3d_3d) That reminded me about an article and editorial on antibiotic resistance that we published in the Journal that are well worth revisiting. Gordon Schiff and colleagues, in describing their experience in a national collaborative, Improving Inpatient Antibiotic Prescribing, commented, “Antimicrobials are unique, being the only class of drug therapy that affects not only the patient to whom it is prescribed but other current and future patients as well.” Schiff and colleagues provided detailed, practical suggestions for action within six categories—adopting a general approach to improving antibiotic prescribing, rethinking guidelines, getting the message out and changes implemented, building viable linkages to leverage change, improving measurement, and promoting nondrug strategies and patients’ roles in treating and preventing infection. What have other organizations done lately to achieve “good antimicrobial stewardship?” Click here to view the article "The Search for Good Antimicrobial Stewardship" Click here to view the article "Improving Inpatient Antibiotic Prescribing: Insights from Participation in a National Collaborative"]]></description> 
					<pubDate>Tue, 09 Jun 2009 17:21:50 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/6/9/Antibiotic-Resistance/Default\.aspx</guid>
				</item>
			
				<item>
					<title>Guest Blog: Laura Damshroder</title> 
					<link>http://www.jcrinc.com/Blog/2009/4/30/Guest-Blog-Laura-Damshroder/</link> 
					<description><![CDATA[
		
				
						
								
										
										
												
														
												
										
								Frequently, I will be asking authors of articles published in The Joint Commission Journal on Quality and Patient Safety to “guest” on the blog to provide “the story behind the story.” Laura Damshroder, one of the authors of “How Active Resisters and Organizational Constipators Affect Health Care–Acquired Infection Prevention Efforts” (May 2009) issue was kind enough to provide her reflections. Laura and I welcome your own reactions. 
				
				
						
						
								
										
								
						
				
		
		
				
						
								Many U.S. hospitals have not consistently implemented practices for preventing health care-acquired infections, even practices with the highest grade of evidence available.* In our study, we explored the kinds of barriers people encounter in their organizations when attempting to implement infection prevention practices. We based our findings on analysis of more than 950 pages of verbatim transcripts from interviews (phone and in-person) with people who are involved with implementing evidence-based practices to prevent health care-acquired infections in their hospital. As you know from the article, we consistently heard about the barriers presented by people who actively resist change and by “organizational constipators”—mid- to high-level executives who act as insidious barriers to change. In presenting our findings at conferences, we have found that this term triggers an immediate understanding among audiences of what we are talking about. It deeply resonates with many people who work in hospitals, who then recount their frustration when confronted with organizational constipators in their own organizations. 
						
				
		
		
				
						
								
										 
								
						
				
		
		
				
						
								We believe this phenomenon is not limited to infection prevention. All too often, it’s the elephant in the room that no one talks about. However, as our study suggests, the first step in addressing these barriers is to simply acknowledge that they exist. Then, use strategies or incentives to get active resistors and constipators on board with the change effort. Work-arounds also can be used but are generally only a short-term solution. Ultimately, though, leaders need to be called in to ensure that these individuals cannot block change; either through reorganization or letting them go. One highly-placed executive, in responding to our results, said, the “key role of the senior leader [then] is to ensure implementation and efficient movement through the system to serve as a sort of organizational laxative.” This would surely be an effective antidote against organizational constipators. 
						
				
		
		
				
						
								
										 
								
						
				
		
		
				
						
								Does the role of organizational constipator or active resistor resonate with you? If so, what kinds of attempts been made to overcome these barriers to implementing change? Have any of them worked? 
						
				
		
		
				
						
								 
						
				
		
		
				* Krein S.L., et al., Translating infection prevention evidence into practice using quantitative and qualitative research. Am J Infect Control 34: 507-512, Oct. 2006, and Krein S.L., et al.: Preventing ventilator-associated pneumonia in the United States: A multicenter mixed-methods study. Infect Control Hosp Epidemiol 299:933-940, Oct. 2008. 
		
]]></description> 
					<pubDate>Thu, 30 Apr 2009 21:39:07 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/4/30/Guest-Blog-Laura-Damshroder/Default\.aspx</guid>
				</item>
			
				<item>
					<title>An Introduction</title> 
					<link>http://www.jcrinc.com/Blog/2009/4/21/An-Introduction/</link> 
					<description><![CDATA[
		
				
						
								Greetings! I’m Steven Berman. For 20 years, I’ve had the privilege to not only witness but also participate in the tremendous growth of the field of quality and patient safety in health care. When I first started, the Joint Commission—in fact it was still the Joint Commission on Accreditation of Hospitals—journal was called Quality Review Bulletin. Later, we called it our Journal on Quality Improvement, and in 2005 we chose the current name to reflect the burgeoning expansion of interest in patient safety.
						
				
		
		
				
						
								
										 
								
						
				
		
		
				
						
								I certainly never planned to “specialize” in quality in health care—which, after all, hadn’t yet emerged as a field in its own right—or even to be an editor. Most of my education and training was in clinical psychology, but while I enjoyed doing diagnostic assessments, I was skittish about being a therapist. In hindsight, I believe I’ve helped many more people by not becoming a therapist than I possibly could have otherwise! Ironically, even as an editor, I still find myself doing assessments (of manuscripts), and, with the indispensable help of the editorial advisory board and other reviewers, arriving at a “treatment” or “improvement” plan. 
						
				
		
		
				
						
								
										 
								
						
				
		
		
				
						
								
										
												
														
																Soon after I started at the Journal, I learned that improvement intervention papers would be most helpful if they provided enough step-by-step, “how-we-did-it” detail to enable readers to adapt the methods, strategies, and approaches to their own settings. The Journal’s credo has always been, if it worked elsewhere, why not try it “at home”? So I am always asking authors to explain not just what they did and why but how, and to describe what they themselves would have liked to have known before starting the improvement project. 
														
												
										
										
												
														
																
																		 
																
														
												
										
										
												
														
																It is especially exciting that this blog provides the opportunity to really enable the Journal to fulfill its mission as a “forum for practical approaches to improving quality and safety in health care.” You, the readers, as well as the editorial advisory board members and the authors themselves, can now share opinions, concerns, and ideas about issues and approaches in improving quality and patient safety. For example, authors can provide the behind-the-scenes stories, provide updates or other insights that didn’t make it to press, and respond to some of the questions that readers have asked them since the article’s publication. Readers perhaps not ready to write an entire journal article can try out their own suggestions and comments about the ways they’ve come up with to improve quality and patient safety. I’d like to also ask all readers—whether researchers, consultants, administrators, clinicians, or quality improvement professionals—to briefly describe a quality and patient safety issue you’re currently trying to address—and then see how this “community“ reacts. 
														
												
										
										
												
														
																
																		 
																
														
												
										
										
												
														
																So watch this space; it is yours.
																  
																 
														
														
																
																
														
												
										
								
						
				
		
]]></description> 
					<pubDate>Tue, 21 Apr 2009 18:00:01 GMT</pubDate>
					<guid isPermaLink="false">http://www.jcrinc.com~/Blog/2009/4/21/An-Introduction/Default\.aspx</guid>
				</item>
			
	</channel>
</rss>
