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Improving Guardianship Process for Inpatients Lacking Medical Decision-Making Capacity

Added on August 26, 2014 in General News, Press Releases

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(Oak Brook, Ill.) Joint Commission Resources today announced the release of the September 2014 issue of The Joint Commission Journal on Quality and Patient Safety. The issue features “A Clinical Pathway for Guardianship at Dartmouth-Hitchcock Medical Center,” by Jasper J. Chen, M.D., M.P.H., M.B.A., M.Sc.P.P., M.Sc.H.P.P.F., and co-authors, which describes the development of a guardianship process for inpatients who lack medical decision-making capacity and are unwilling to be discharged and returned home to be cared for by a proxy decision maker. 

A multidisciplinary quality improvement team at Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, mapped the DHMC guardianship process and analyzed causes for delays. Specific interventions were then designed and implemented to address identified improvement areas. Through the creation of a clinical pathway, the interventions helped DHMC standardize the guardianship process to improve tracking of patients. Details such as guardianship hearing dates and assignments were included.  

The DHMC team identified 26 guardianship patients during a two-year period (May 1, 2011–May 1, 2013). These patients incurred charges totaling an estimated $4 million, for an average of more than $150,000 per patient. Using the clinical pathway for guardianship, DHMC decreased the length of medically unnecessary hospitalizations from an average of 27.8 to 11.3 days. In addition, 214.5 medically unnecessary days were avoided for the last 13 of the 26 patients, saving more than $1.2 million in reduced charges during the two-year period. 

In an accompanying editorial, Mary Faith Marshall, Ph.D., discusses how current approaches to clinical decision making for guardianship patients have ethical, legal and institutional pitfalls. Moral distress can run high in guardianship situations, which place clinicians in direct conflict of interest with the patients they serve. Dr. Marshall encourages clinicians to advise and advocate for—rather than represent—their patients. 

The remaining articles from the September 2014 issue are:

Reporting Systems

Impact of a Reengineered Electronic Error-Reporting System on Medication Event Reporting and Care Process Improvements at an Urban Medical Center
Donald McKaig, R.Ph., CDOE; Christine Collins, R.Ph., M.B.A.; Khaled A. Elsaid, Pharm.D., Ph.D.

The cornerstone of an effective patient safety program is the voluntary reporting of actual and near-miss events to enable the evaluation and modification of processes of care. At a 719-bed multidisciplinary urban medical center, a reengineered error-reporting system replaced another commercially available system. Events are routed for peer review in the patient care area where the error occurred and to other involved departments. Following implementation, reporting of prevented errors and errors reaching the patient with no resultant harm significantly increased—an improvement in reporting that lasted for 26 months.

Infection Prevention and Control

Implementation and Impact of an Automated Group Monitoring and Feedback System to Promote Hand Hygiene Among Health Care PersonnelLaurie J. Conway, RN, M.Phil., CIC; Linda Riley, RN, M.Ed., CIC; Lisa Saiman, M.D., M.P.H.; Bevin Cohen, M.P.H.; Paul Alper, B.A.; Elaine L. Larson, RN, Ph.D., FAAN, CIC

An automated group monitoring and feedback system was implemented from January 2012 through March 2013 at a 140-bed community hospital. Feedback, in the form of graphical reports, was provided during the intervention period but not the baseline and rollout periods. After the feedback began, hand hygiene compliance increased—but only by four hand hygiene events per inpatient per day—and was not sustained. Measurement and implementation challenges included obtaining accurate census and staffing data, engendering confidence in the system, disseminating information in the reports, and using the data to drive improvement.

Patient-Centered Care

Use of CAHPS Patient Experience Surveys to Assess the Impact of Health Care InnovationsRobin M. Weinick, Ph.D.; Denise D. Quigley, Ph.D.; Lauren A. Mayer, Ph.D.; Clarissa D. Sellers, M.P.H.

Despite the widespread use of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®), knowledge about its use in assessing the impact of quality improvement efforts is limited. In a study on the use of patient experience surveys in assessing the impact of innovations, the 201 innovation profiles identified on the Agency for Healthcare Research and Quality’s Health Care Innovations Exchange website that included patient experience as an outcome were analyzed. Fewer than half of the innovations used a patient experience measure. Although innovations targeting quality improvement are often evaluated using surveys, there is considerable untapped potential for using CAHPS to assess their effectiveness.

Department Interview

An Interview with Paul O’Neill

Mr. O’Neill, the former chairman and CEO of Alcoa and the 72nd Secretary of the US Treasury, discusses the lessons in developing a safety culture at Alcoa for patient and health care worker safety.

Interviewed by Meghan Pillow, RN, CCRN 


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