A distinguished gentleman who looks to be in his 60s is asking the question. He and I are sitting across from each other at the end of a long, dark mahogany conference table.

I don’t remember how I came to be here. I probably look a bit confused.

“John. Tell me… How would you do that?”

Now I remember. I’m interviewing for the position of Chief Quality Officer (CQO). I’m ten minutes into an interview with the Chair of the Board of Directors. His name is Samuel.

That’s quite a broad question, Sam.

Clarify the question for me. You want me to describe how I would build an ideal quality improvement program? For a hospital like this? Are there any financial constraints?

“I’d just like to hear your opinion on what a really good program looks like. Let’s not worry too much about budgets. But keep it within the realm of possibility.”

A Great Hospital Quality Improvement Program

OK. I’ll tell you what I think. And I’ll try to keep it brief and fairly high level.

I’m making the following assumptions:

• We’re talking about the quality program at a stand alone general full-service hospital.
• I am going to include patient safety as part of overall quality program.
• I’m assuming that this program will need to meet all of the required reporting demands of CMS and other regulatory bodies.

“That sounds good,” Sam replies.

OK, then let me start with the basics.

First, I’ll define what I mean by quality improvement.

We’re talking about a program designed to support the hospital’s efforts to deliver medical care to patients that is:

• Undeniably effective and evidence-based,
• Timely, and
• Error free.

I’ll describe my design of a basic quality program. However, in the real world, the design process would be collaborative. It would involve multiple conversations with stakeholders from the local community, and possibly some outside experts.

Culture

The underpinnings of the program will start with the culture of the organization. Quality and safety must be built into the fabric of the culture of the hospital.

That means that the hospital mission addresses quality and safety. And the values of the organization will also include a commitment to quality.

Furthermore, the QI program itself would have its mission, values and vision. They would be defined by the hospital leadership, with input from all stakeholders, including patient representatives.

The Board of Directors will approve them. And everyone working at the hospital will need to acknowledge and sign off on the mission, vision and values. That includes the employees and non-employed medical staff members and independent contractors working at the facility.

The cultural aspects must include evidence that teamwork and effective communication are valued. We will implement the list of Safe Practices from the National Quality Forum.

Credentialing

Next, we will ensure that team members believe in quality and continuous learning. Hiring will involve an assessment of the commitment of potential hires to quality and safety.

Of course, all necessary licensing and credentialing will be followed.  An excellent quality program starts by involving motivated and engaged team members. Whether it's environmental services, phlebotomists, CNAs, lab and imaging technologists, nurses, pharmacists, or physicians, we will ensure that they all have the best credentials and a demonstrated ability to provide excellent care.

That sets the stage for building a great program.

Metrics

A great hospital quality improvement program has the ability to measure, report and improve important measures of quality and safety. So, next, I would define for the organization how quality is going to be quantified. 

We will need to implement tools to monitor our performance. In order to clearly define the tools we need, the expertise we need, and the structure to put this program in place, we need to define the metrics that will demonstrate our success or failure.

Ideally, we will track every outcome and process measure that experts agree define quality in the hospital setting. Off the top of my head, the following are generally recognized as important outcomes to track and report:

• Overall mortality rate, expressed as mortality index.
• Mortality rate for high volume conditions like heart failure, COPD and pneumonia. The top 20 by volume would be a good start.
• Complication rates for the top 20 procedures (by volume), such as total joints and other inpatient procedures.
• 30-day readmission rates for the top 20 medical, and top 20 surgical, diagnoses.
• Compliance rates for process measures (such as CMS core measures and other important lead measures).
• Selected patient safety measures (including Sentinel Events and Never Events).
• Selected AHRQ Inpatient Quality Measures.
• Length of Stay (overall, and for specific high volume diagnoses).
• Medication Errors.
• Additional measures, as indicated by comparing the Leapfrog National Measures Crosswalk and other published guidelines to what is already in place.

Measurement Tools

Given the list of measures that we must monitor, I will lead a team to identify the best measurement tools. If there are tools that can integrate with our EMR, I will focus on those. Otherwise, I will find tools(s) that will provide as much of the needed data as possible. The tools will need to provide risk-adjusted outcomes and rates for process measures. It will need to be as affordable as possible.

Such tools might include those provided by The Advisory Board, Premier, Quantros and others. Without automation of these measurements, they become very difficult to follow and compare to benchmarks.

People

In addition to leadership by the CMO or CQO, we will need an experienced, knowledgeable, clinical expert to lead the quality and safety department or division. He or she will have the appropriate attitude, experience and training to ensure success in this position.

Other expertise needed within the department will include:

• Regulatory (CMS, TJC or DNV, and state regulatory departments);
• Quality processes, including process improvement, quality improvement, and patient safety;
• Sentinel events and root cause analysis;
• Infection prevention;
• Medication safety;
• Data analysis, decision support and statistical analysis;
• Continuing medical education;
• Super-user for any measurement tools installed; and,
• Coding and documentation as it relates to quality and safety reporting.

Structure

We will need to assign the activities to the appropriate teams and create a REPORTING structure. We can start with a structure that looks like this, and adjust it to suit our needs:

In a small facility, one person might handle multiple duties. As the organization gets larger, the duties will need to be managed by a larger team.

I will place management of continuing medical education as part of the QI division. In this way, the majority of educational content for physicians will be designed to address gaps in care or patient safety.

Process

The Quality Committee, which is a subcommittee of the Board, will oversee all of the activities. So, there will need to be several scorecards that the board can review in order to easily monitor our performance.

The membership of the committee will include select board members, the CEO, COO, CQO, CMO, QI & PS Director, Pharmacy Director, Nursing Director, representatives from CME and  Infection Prevention, and members of the medical staff from each of the large departments (e.g., medicine, surgery, etc.).

Several subcommittees will report directly to the QI Committee:

• CME
• P & T/Medication Safety
• Readmissions
• Quality Team (tracking mortality, complications, core measures)
• Patient Safety
• Infection Prevention
• Code of Conduct

Each of these subcommittees will be monitoring outcomes and creating teams to address specific gaps in performance. The subcommittees might need specific teams for certain projects or for certain high risk units.

Here is how the COMMITTEE structure might look:

Reporting

Each SUBCOMMITTEE and TEAM will develop its own scorecards for reporting the ongoing performance being addressed. Minutes of each meeting and scorecards for each TEAM will be sent to its SUBCOMMITTEE. Each SUBCOMMITTEE, in turn, will report to the Quality and Safety Committee.

The CQO will present quarterly quality and safety reports to the senior executive team and the Board of Directors.

That structure ensures accountability of the organization to the community, via the Board.

Peer Review

Notice, Sam, that this model has not addressed the formal physician peer review process. But that must be included as part of the re-credentialing process for physicians.

My recommendation is that medical staff peer review be done by a multidisciplinary committee, with members from each medical staff department appointed by the chair. Cases will be reviewed, based on screening criteria for each department. Also, cases can be referred to the peer review committee as needed.

Some of those cases will also be reviewed through the sentinel event or QI process as well. The physicians will be invited to participate when their case is being discussed.

So, Sam, that’s what I consider to be a starting point for a good program.

In addition to the what I've already mentioned, we will:

• address new opportunities as they arise,
• focus on continually improving the quality of the care,
• take a multidisciplinary approach,
• integrate education into the process, and
• evaluate the culture through regular cultural surveys.

Wrapping Up a Great Hospital Quality Improvement Program

Sam replies, “That sound like a really sound plan. Thanks for taking the time to describe it.

“I think we’re out of time, so I’ll bring you to your next interview. Best of luck and thanks for coming in to meet with us today.”

I'm walking toward the door when, suddenly, I hear a distant ringing. The ringing becomes louder and louder.

Where is it coming from?

I open my eyes. The alarm on my cell phone is ringing. And I’m in my pajamas, in bed. I'm so preoccupied with my upcoming job search that I was dreaming about an interview!

Some of those ideas about a quality program were pretty good, though.

I jump out of bed to find a pen and paper to jot the ideas down!

Next Steps

What have I forgotten in my dream-induced quality plan? Let me know in the Comments.

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He explained that it was something they had not experienced before. They were upset that such an event could occur at their facility. He asked me to describe what I knew about hospital sentinel events and share some of my experiences.

Here is a short list of what I told him:

• In the hospital setting, a sentinel event is a specific term defined by The Joint Commission. It is a very serious, uncommon patient safety event that occurs when multiple systems break down that  results in harm to a patient.
• Not to minimize what may have happened at his facility, I told him that every hospital experiences sentinel events.
• Because they are so serious, in addition to harming a patient, they often result in upset staff and physicians, and angry patients and families. Allegations of medical negligence and potential public relations problems can occur following such an occurrrence.

I also explained that a good-sized community hospital might experience 6 to 12 sentinel events annually, in my opinion.

He seemed a bit shocked by that estimate.

I reminded him not all SEs are of the same severity. There is a difference between a “never event” such as wrong site surgery or a fire occurring in the operating room, and a medication error that causes temporary, albeit serious, harm to a patient.

Recent TJC Statistics on Hospital Sentinel Events

TJC has developed its approach to defining, identifying, analyzing and reporting sentinel events over several decades. Part of that process includes the voluntary reporting of sentinel events by accredited hospitals. When reporting the SE, most hospitals follow-up with TJC by submitting the results of its root cause analysis of the event.

We adopted a policy of reporting almost every sentinel event to TJC that we experienced. We believed that the additional support and coaching provided by TJC following our RCAs were very valuable. Also, it could be embarrassing if our board or the public discovered that there had been a serious SE that had not been reported to TJC, if and when it came to light.

This type of voluntary reporting allows TJC to track trends in SE occurrences and to promote preventive measures to reduce their occurrence. According to published TJC reports, for each of the past five years, about 900 such events were self-reported. There were another 200 or more that were reported to TJC in other ways (anonymous reports, media reports, etc.).

If we assume that as few as 5% to 10% of SEs are reported to TJC, then there are probably 9,000 to 18,000 such events annually in U.S. hospitals; more if you include less serious occurrences. With about 5,000 non-psychiatric, non-federal hospitals in the U.S., that would equate to 2 to 4 serious events per year per hospital.

There is a fairly consistent pattern to the types of events seen in hospitals.

[table id=6 /]

These numbers are probably skewed by the fact that retained FB and wrong site surgery are very obvious and easily measurable. But other events are more subjective with regard to their seriousness and reportability. For example, it is doubtful that every organization defines a “serious medication error” in the same way. Some will have a higher threshold for reporting such events than others.

There is also a fairly consistent pattern to the types of outcomes each year.

[table id=7 /]

Responding to Sentinel Events

When a sentinel event is identified, the appropriate response is to perform a root cause analysis (RCA). The RCA process was developed first in the field of engineering in the 1950s. It’s development is often attributed to Sakichi Toyoda, the founder of the Toyota Corporation.

The concept of sentinel events and RCAs were not applied to medical care until decades later. But their use is now widespread, being promoted by both TJC and the Centers for Medicare and Medicaid (CMS) as a way to learn from and prevent future patient safety breakdowns.

Most physicians do not welcome being asked to participate in an RCA, however. They are time-consuming. And the atmosphere of an RCA meeting can be intimidating and uncomfortable as participants frankly describe breakdowns leading to a patient's harm.

Why Pay Attention to Sentinel Events

Given that sentinel events have the effects mentioned above (patient harm, liability, increased costs, psychological trauma to involved professionals), it should be clear that these events must be addressed aggressively.

As a hospital leader responsible for patient quality and safety, here are some of the reasons I believe medical staff leaders and physician executives should become experts at recognizing and investigating a sentinel event:

1. Leaders Can Demystify the Process.

Because sentinel events and ensuing RCAs are, thankfully, uncommon, most healthcare workers rarely become involved. It is therefore essential that the leaders in an organisation remove the fear of being part of an RCA, and effectively communicate the need to openly, and in a blame-free manner, try to identify the root causes of an event.

While the core expertise in running an RCA may lie in Quality or Patient Safety Staff, the physician executive must feel comfortable with the process. He or she can then help to encourage others involved in an SE to provide feedback and input.

2. Leaders Promote a Culture of Safety.

The culture of an organization is often described as “how we do things around here.” Physician leaders must set the agenda AND model the behaviors that promote such a culture of patient safety. This culture has the following characteristics:

• Employees are empowered to question unsafe practices;
• Everyone understands that healthcare is prone to error;
• Lifelong learning and continuous improvement are valued; and,
• Teamwork is crucial to improving safety.

3. Leaders Enable and Support Improved Patient Care.

Identifying a sentinel event, performing a root cause analysis, and instituting corrective measures based on the RCA will reduce the likelihood of occurrence in the future. This will make your hospital a safer place for your patients.

4. Leaders Foster Downstream Benefits.

Better patient care means less rework, lower liability costs, and better staff morale. A safe high quality hospital fosters pride in caregivers, medical staff and board, and better standing in the community. By avoiding staff turnover and expensive lawsuits, there is a positive financial result in the long run.

5. Only Physician Leaders Can Fully Engage Other Physicians in the Process.

I wrote about the challenges of achieving and maintaining physician engagement in Become a Physician Leader and Save the Medical Profession. It can be quite difficult for non-physician CEOs, Quality Directors and other hospital management to speak the physician's language and enroll them in patient safety initiatives, including an RCA following a sentinel event.

None of us wants to accept the occurrence of hospital sentinel events. Hence, it should be our goal to promote the aggressive investigation of and learning from sentinel events.

How Can Leaders Help?

Here are some things we can do to help the process:

• Make time to participate in and co-lead RCAs if possible.
• Bring learnings from completed RCAs to the medical staff for discussion and feedback.
• Provide education about SEs and RCAs to your hospital board.
• Provide the board with an annual summary of RCAs that lists the nature of the events and the changes implemented to reduce or eliminate their occurrence in the future.

Next Steps

If you are not already involved with RCAs, seek out the professional at your organization that oversees identification of sentinel events. This might be the Director of Quality, or Patient Safety, or Risk Management. Then talk with them. Ask about the process if you're not already involved. And ask if you can sit through a root cause analysis or two to understand the process better.

Review These Additional Resources

Here is the TJC Sentinel Event Policy and List of Sentinel Events.

For an overview of the root cause analysis process go to Guidance for Performing Root Cause Analysis from CMS.

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The CEO and the Board of Trustees (or Directors) definitely want to see meaningful reports about hospital performance. They truly want to see that performance is improving. Along with positive financial results, nothing will make the CEO and board happier than seeing that quality can be measured, is at an acceptable level, and is improving.

There are many ways to collect, analyze and present such data. I am going to show you how to prepare quality reports that my board found useful and interesting. Several of my board members told me that they really looked forward to seeing these reports.

First, Some Basics

Anyone who works in the quality arena will take the following caveats as a “given.” But for those who are just starting, here are some things to keep in mind.

It is not easy to reliably measure quality. And for hospitals, we generally do not measure “chart-level” outcomes. Our quality measurements are limited by the fact that we use billing data to collect mortality, complications, length of stay and other quality outcome measures.

UB-04 Billing Form

However, there is more than two decades of work by universities and quality vendors validating the use of billing information to measure outcomes. These researchers have produced an approach to quantify outcomes and apply statistical methods to the process. This enables us to compare the performance of facilities across the country. These methodologies are the same as those used by CMS and private quality reporting organizations such as Truven Health Analytics and HealthGrades.

You should verify that the following requirements are in place before you try to create reports like the ones I describe:

1. Your organization has a quality measurement tool that is interfaced to all of the necessary hospital systems.
2. The tool accurately draws data such as date of admission, date of discharge or death, source of the patient, destination on discharge, length of stay, etc.
3. The system(s) have the ability to distinguish between medical conditions that were present on admission (POA) from those that arose during a hospital stay.
4. Your hospital has robust medical records, coding and billing departments that accurately assign CPT codes, ICD-10 codes, and DRGs. You must be confident that those codes comply with the definitions from CMS and other quality agencies.
5. You have staff in the quality department that is knowledgable and can pull the outcome reports you need.

Other Considerations

The systems that I’m describing perform risk-adjustment of the data. It is therefore valid to compare outcomes to other organizations. In addition to reporting risk-adjusted rates, the outcomes are also expressed in one of two ways:

1. As an index, defined as the ratio of the observed rate over expected rate. If the observed and expected rates are the same, then this ratio is 1.0. A higher ratio indicates a rate worse than expected. A lower ratio than 1.0 indicates a better than expected rate.
2. As the difference between the actual and expected rates. If the difference is a positive number, the actual rate is worse than expected. If it is less that zero (a negative number) the rate is lower/better than expected.

Finally, most systems will also indicate whether the difference or ratio is statistically significant, and at what level of significance. When considering quality comparisons, we want to know differences at the 75th and 90th percentile. In research studies a significance level of 95% is desired. But we want to err on the side of identifying opportunities for improving quality. And we ignore opportunities with a significance of less than the 75th percentile, because they are more likely a result of chance alone.

Bringing It All Together to Prepare Quality Reports

As complicated as all of that sounds, the majority of hospitals have systems that meet those requirements. They can produce risk-adjusted outcomes and deviations from expected. And they can apply statistical testing for any of the high volume diagnoses. This allows us to prepare quality reports for our medical staff, our executive team and our board.

Using these systems, the quality department can create a report for the high volume diagnoses that lists the mortality, morbidity (complications), readmissions and length of stay.

I usually break these reports into two main categories. I produce one report that focuses on the mortality and length of stay for serious medical conditions. In this way, I can show the CEO and board a report that addresses pure quality (mortality) and a combination of quality and utilization (LOS).

For the high volume surgical or procedural admissions, since the mortality rates are very low, I find it more useful to present the morbidity (complication) rates and LOS data.

Start With a Spreadsheet

I use Microsoft Excel to create the data table and the graphs. But most spreadsheet software should work as well. I copy them to Microsoft PowerPoint for my presentation. I keep the slides as simple as possible. Usually, I include a minimum of labels so the information is clear. Yet I try to be parsimonious: showing everything that is needed, but nothing that is not needed.

Creating the bar graphs is simple: just highlight two columns (the list of diagnoses and the outcomes) and select the type of bar graph from the drop down menu. I generally use 2-D graphs for simplicity. Then, I save the charts on a separate page so that I can easily copy them to my slides.

The “bubble graph” is created by highlighting the three columns to be included (LOS, mortality and volume columns in this case), then choosing the prefered style from the “Scatter or Bubble Chart” option.

An example of a table that includes all of the information needed for these graphs follows. Note that these are completely fictional data that I generated for demonstration purposes only. But the information I present will look very much like this table, but for a larger number of conditions (20 or 25).

Using the information from the table, I create a bar graph to show the spread of outcomes from best to worst (in this case, lowest to highest mortality and LOS indexes). To do so requires sorting the data (lowest to highest) before creating each chart. Here is how those graphs would look:

Preparing the Bubble Graph

Finally, in order to bring it all together when I prepare quality reports, I combine all of the information into a single graph. This graph displays a grid showing the mortality index, the LOS index and the volume of cases. That graph is shown below.

I usually add small labels for each bubble indicating which diagnosis it represents. [Those must be added manually using individual text boxes. I did not do it for this post to save time. – VPE] I should also note that most of this work was delegated to a capable quality improvement nurse once I had created the first few iterations of these reports.

When I was presenting these data regularly for our board (twice a year), I would show the previous results and the current results. And I would skip through the bar graphs quickly, since all of that information was also incorporated into the bubble graph. But I wanted the board to understand where the bubble graph information came from.

Then I would just leave that bubble graph up on the screen while I discussed the great results of conditions sitting in the bottom left quadrant. And I would point out that it is possible to have great outcomes and a short length of stay (contrary to the opinions of some of my medical staff colleagues).

I would then describe the challenges of the conditions in the top right quadrant. And I would outline the procedures we had instituted to address the excess mortality and/or LOS. I might also comment on how we would prioritize working on the largest bubbles in the top right quadrant because they represented more cases.

Other Steps

It is best to preview these presentations with your CEO and senior executive team. That way, you can better anticipate questions the board may ask. And it gives you an opportunity to engage other team members in your quality improvement efforts.

You can combine any two variables (plus the volumes) to create similar slides. In addition to mortality and LOS, I would present a bubble graph of morbidity and LOS as noted above, or incorporate readmission rates. You may want to apply this method of analysis to metrics from patient safety or infection control. Even the finance team can find a use for these types of graphics.

Next Steps

Get creative and come up with some other combinations. Once you create some charts, why don’t you include a picture in the COMMENTS below, or just describe what you have created.

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Pharmacy

Medication administration is one of the most important functions of a hospital. Safe, effective and timely administration of medications requires coordination of multiple hospital staff departments, integration of electronic medical records, implementation of pharmacy automation, and monitoring and managing drug costs.

The triad of professionals responsible for the selection and delivery of medications consists of the physician, nurse and pharmacist. These highly educated professionals each contributes critical expertise to medication delivery. The integration of the physician/nurse/pharmacist triad is the secret to safe medication delivery.

Those three professionals each work in domains with unique challenges and cultures. Thus, when they bring to bear their particular skills and tools, they optimize the patient's outcome.

Value of the Physician Executive

The physician is an expert in selecting the medication needed to treat a given patient. The nurse is the expert in safely administering the medication and monitoring the patient for intended benefits and adverse effects. The pharmacist is the expert at monitoring the process, delivering the medication to the bedside and providing needed support and advice, especially when polypharmacy is involved.

The Physician Executive is in the best position to understand the process and facilitate coordination of the stakeholders. Some of the critical aspects that must be led are:

• Developing guidelines and protocols that drive medication selection.
• Facilitating discussions needed to create a formulary that is appropriate, yet manageable in size, cost and complexity.
• Mediating between physicians and pharmacists when constraints are placed on the use of high cost medications.
• Advising about which functions can be delegated to technicians and which require direct doctorate-level pharmacists.
• Promoting the collaboration between the pharmacy and quality improvement departments.
• Balancing the costs and benefits of new pharmacy-led initiatives such as:
  • Deployment of clinical pharmacists to the emergency department and other units such as intensive care;
  • Diabetes management services to adjust insulin doses for inpatients; and
  • Anticoagulation clinics to adjust warfarin dosing.

Practical Considerations

How can the VPMA or CMO best help the pharmacy to deliver on its mission? Here are a few suggestions to consider.

1. Promote a culture of accountability, teamwork and safety within the department. This will require the selection and nurturing of a very skilled pharmacy director.
2. Lead your physician and nursing colleagues by example. Commit time and resources to measuring outcomes, participating in teams, and presenting pharmacy concerns to medical staff and executive leadership.
3. Remain current with important medication safety issues by monitoring publications from:
   • Institute for Safe Medication Practices
   • American Society of Hospital Pharmacists
   • American Hospital Association (see Quality Advisory on Medication Safety)

One-on-Ones

Finally, as with all of your direct reports, you will meet with your pharmacy director on a weekly or biweekly basis. During those meetings, the following topics should be addressed (not necessarily at every meeting):

1. Review of goals for the year. Are milestones being met? How can you facilitate them?
2. Review staffing. Is the pharmacy fully staffed? Are there open positions? How are those being addressed?
3. Budget updates. How are expenses running compared to budget, especially staffing and drug costs?
4. Medication safety reporting. What are the number and nature of medication errors for the past reporting period? Were they preventable?
5. Formulary requests. Are any pending? Review the agenda for the next Pharmacy and Therapeutics meeting. Do physicians need to be contacted prior to the next meeting?
6. Summary of cost reductions resulting from clinical pharmacy interventions.
7. Director’s performance review (at least quarterly).

Conclusion

The physician executive can have a positive impact on patient care. This will be achieved by enabling the pharmacists to fully apply their expertise and by promoting the physician/nurse/pharmacist triad.

Next Steps

If you are a VPMA or CMO and do not currently oversee the pharmacy functions, become more involved in the department.

• Attend P and T Committee meetings.
• Support the efforts of the Pharmacy Department to engage physicians.
• Promote new clinical pharmacy initiatives that will enhance medication safety.

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I found these best practices to be a good source of goals for the pharmacy director. If there was a recommendation that we had not implemented, the director and I would add it to his goals for the upcoming year. The CMO should be a strong advocate for medication safety.

2016 – 2017 Medication Safety Best Practices

In the most recent list of best practices, there were updates to two of the first six practices (from the 2014 – 2015 list), and five new recommendations. Here is a summary of all 11 best practices.

The Original 6 Best Practices

1. Dispense vinCRIStine (and other vinca alkaloids) in a minibag of a compatible solution and
   not in a syringe. This one is unchanged. The purpose for this practice is to prevent intrathecal infusion of these medications, which can lead to disability and death.
2. Implement practices to prevent the administration of daily methotrexate dosing when the amounts are meant to be given weekly. The revision allowed for a manual process when an EMR was unable to provide a hard stop to avoid a mistake.
3. Measure and record patient weights with each encounter, rather than using reported weights. And report all weights in metric units. The revision involved using the actual weight rather than a reported weight.
4. All oral liquids, if not available in single dose packaging, should be administered in an oral syringe only. This helps to prevent administering oral liquids intravenously because an oral syringe cannot be attached to parenteral tubing.
5. Purchase and use oral dosing devices labeled in metric units only (to avoid confusion with ounces or teaspoon labels).
6. Eliminate glacial acetic acid from the hospital. This is to avoid accidental use of this caustic chemical, when vinegar or 0.25% acetic acid is called for.

5 New ISMP Best Practices

1.  Segregate, sequester, and differentiate all neuromuscular blocking agents from other medications, wherever they are stored. This best practice was implemented to avoid accidental administration of an NMB when ventilatory assistance is not readily available.
2. Administer high-alert intravenous medication infusions via a programmable infusion pump utilizing dose error-reduction software. This allows hospital-wide dosing limits to be followed. These smart pumps have been available for ten years. But some hospitals still have not deployed them.
3. Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available, with clear instructions for administration. This addresses the issue of delays in administration of antidotes and reversal agents that can lead to injury and death.
4. Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy. This practice was adopted in order to eliminate high volume IV infusions of sterile water, which can cause hemolysis and death.
5. When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients (medications and diluents) are added, including confirmation of the proper amount of each ingredient prior to its addition to the final container. This best practice was added because of continued reports of compounding errors associated with patient deaths.

These 11 best practices, along with much more detailed implementation advice, can be found in the recent ISMP Best Practices for Hospitals.

Implementation

Many of these practices may already be in place at your facilities. If not, then bring the list of best practices to your Pharmacy and Therapeutics Committee (or equivalent) and follow this process:

1. The pharmacy director or clinical pharmacist should provide a summary of the practices not yet in place.
2. Select the most important best practice and set a timeline for implementation.
3. Identify who needs to be involved in implementation. In addition to the pharmacy staff, you may need to obtain input from the medical staff, nursing staff, other ancillary personnel, the purchasing department, operating room staff, and others.
4. For any best practice that requires a major capital investment (such as the smart pumps), be sure to add it to the budget process, if it's not possible to proceed as a non-budgeted item.
5. Develop check lists to support implementation and reports to monitor progress.
6. Report on the implementation progress at each subsequent meeting, with one member serving as the lead on the project.
7. Educate and communicate with anyone that will be affected by the changes – use newsletters, meetings and emails to get the word out.
8. Then go live with your new best practices!

Next Steps

Check out the ISMP report and discuss it at your next Pharmacy and Therapeutics meeting. Then take your plans for implementing any new best practices to your CEO, CFO and Senior Executive meetings. For major projects, such as purchase of smart infusion pumps for an entire hospital, integrate the process into your capital budget process. Consider adding these goals to your pharmacy director's annual list of management goals.

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He had been on the board for several years, and had an intimate knowledge of the performance of the hospital. He knew many of the local medical staff. His wife had once worked for the hospital.

At one point in our brief conversation he said, “ You know, John, I really look forward to your quality reports. We all do. The board members like to know that things are going well. We also want to know when there are potential problems, and the steps taken to address them.”

I thanked him and promised that I would continue to keep the board informed, and he went on his way. Over the years, other board members mentioned similar sentiments. They were very interested in how the organization was addressing quality and safety.

Historical Perspective

Thirty years ago, hospital boards spent most of their time reviewing financial reports, statistics about patient volumes, new programs, and capital investments in equipment or the physical plant.

But over the past few decades, there has been an increasing emphasis in healthcare on measuring and improving quality and safety. Hospital and health system boards are well aware of this evolution. They are interested in assuring that their organization is meeting its mission to provide safe, high quality care to its patients.

Simultaneously, quality, safety, infection control, risk management and decision support departments have grown in size and sophistication. The number of reports describing outcome and process measures has also grown. Many of these are of great interest to your board of directors. And physician executives, like the chief quality officer and the chief medical officer, have stepped up to lead that process.

The 7 Hospital Board Reports

The following is a list of some of the reports I have personally provided to our board. These always generated discussion and good questions.

1. Review of Hospital Compare Data

These reports include an overall star rating, core measure performance, complications, readmissions and mortality. Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) is also posted on the Hospital Compare website.

There is probably too much information to present at one sitting. Note that some of the information is presented annually, while some is available quarterly. Since this information is available to the public, it is very important for the board to be aware of current rankings and trends.

2. Annual HealthGrades Summary

HealthGrades applies its own risk adjustment and analysis to publicly available data and generates an annual comparison of the hospitals and physicians each year. It analyzes the data to generate one- three- and five-star ratings (below average, average and above average, respectively) for several clinical conditions.

My board found it useful to review a grid that I developed to summarize the star rating for each item each year. The grid included a row for each measure. Each column included the star rating for that measure in a given year. I also included a total for each column of the number of five-star and one-star ratings.

3. Annual or Quarterly Quality Review

Using a quality improvement tool that extracts information from the coding and billing information, most hospitals can generate risk adjusted outcomes for its most common discharge diagnoses. We would generally review risk-adjusted length of stay, complication rates and mortality rates for our top 20 (by volume) diagnoses.

I would summarize these data by creating a bar graph that presented the observed over expected ratios, from highest (worse performance) to lowest (best performance) for the measures noted above. I might then compare year the results from the previous year to the current year.

4. Sentinel Event Summary

Every hospital and health system experiences sentinel events. Large systems probably count more than a dozen or so, if they are honest with themselves. In addition to the events that meet the CMS definition, there are also near misses that deserve a root cause analysis (RCA). In a hospital setting, these sentinel events may include the administration of the wrong medication, an unexpected death, wrong site surgery, patient suicide or a fire in the operating room.

During the root cause analysis of an error that threatened the life or limb of a patient, the RCA team will identify the proximate causes, the contributing factors and the root causes of the untoward event. For the board's purposes, it can be useful to summarize each year's RCAs. Place each event into a specific category and review the root causes that were identified and the plans for addressing each.

5. Patient Safety Update

I discussed the patient safety indicators when I discussed how to deliver patient safety. These events consist of uncommon occurrences, especially during or following surgery. Because their rates are so low, be prepared to answer questions about why they occurred and what steps are being taken to prevent them in the future.

These are best shown in tabular format, which includes historical information by year for each PSI and the national averages. The goal for most PSIs is for none to occur, unlike quality indicators in which is generally some baseline rate due to unavoidable patient factors.

6. Annual Review of Behavioral Issues

Due to the widespread recognition that so-called “disruptive behaviors” by physicians threaten good patient care, many hospitals have developed a plan for reducing such incidents. This includes the adoption of a universal code of conduct (or code of behavior) and creating escalating consequences for violating the code. There is usually a committee to oversee the process and investigate the validity of alleged violations of the code by physicians.

Our organization created a physician-led multidisciplinary team that reported to the Medical Executive Committee (MEC). It investigated allegations of inappropriate behaviors. The team was able to interview and provide education to those with minor violations of the code of conduct. When serious violations were confirmed, they were sent to the MEC for action.

Once each year, I presented a summary to the board that listed the nature of the confirmed violations and the actions taken. I also presented a graph depicting the number of annual investigations, which showed the declining rate of occurrences after the program was put in place.

7. Infection Control Updates

You should be producing a monthly report that describes the incidence of serious hospital acquired infections. This is usually reported in the form of a dashboard. This can be rolled up to an annual summary and then trended over several years for review by the board.

In Summary

Health system and hospital board members want to see more than just financial reports. They genuinely want to know that the care being provided is good, and that it is improving. These seven reports will provide your board with a good sense of the quality and patient safety being delivered at your institution.

I would really like to hear your additions. What reports have you presented, or seen presented? Which of them seemed to produce the greatest discussion and questions? Please share in the COMMENTS.

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Let’s imagine that your team has selected a WIG. And the goal is written in the format of “from X to Y by when.” According to the authors of 4DX, the next step is to develop lead measures. Lead measures, if implemented, will result in improvements in the lag measure.

Consider an enterprise in which the WIG is “increase our sales of widgets from $50,000 per month to $75,000 per month.” The sales team knows that a certain percentage of calls on customers results in eventual sales. The lead and lag measurements might be written as follows.

• Lag measurement = monthly sales (goal is $75,000)
• Lead measurement = number of monthly sales calls

If chosen correctly, an improvement in the lead measure will result in an improvement in the lag measure. One of the common failings of goal implementation is to track the lag goal, but fail to create measurable lead metrics. It is the lead measures that can be tracked and shared with the team on a regular basis as a way to enhance execution.

However, in order to progress on a goal a team maintain focus on the goal, even as the daily whirlwind continues around us.

In their book, the authors spend a fair amount of time describing the process for maintaining that focus. It includes weekly meetings in which the lead and lag measures are reviewed using a scoreboard. The meetings involve everyone that has an impact on the goals. And it aims to maintain accountability of the team's success by making commitments and reporting on those commitments. This is what a scoreboard might look like:

How the Disciplines of Execution = Quality Improvement

The lead measures and lag measures described by the authors are very similar to what are called process measures and outcome measures in the field of Quality Improvement. The process measures are sometimes called core measures when referring to The Joint Commission-required quality metrics.

Core measures are specific process measures defined by TJC (and CMS) that hospitals must measure and report. They are used to measure compliance with quality monitoring programs, some of which determine adjustments to Medicare payments. Core measures are generally scientifically supported interventions that have been shown to improve outcomes.

When trying to measure and compare outcomes of hospitals, process measures became popular for several reasons:

• They are more timely. Measuring beta blocker or aspirin use for acute myocardial infarction can be measured and tracked in near real-time. Measuring, risk adjusting and reporting mortality or complications for patients with acute MI is slower.
• There is a greater range in performance of process measures. Improvements become obvious more quickly. Tracking compliance rate for a process measure from 60% to 99% seems more meaningful than demonstrating a small reduction in mortality from 3.0% to 2.5%.
• The process or core measures generally correlate well with the outcome measures. Demonstrating higher compliance with process measures usually predicts better results for outcomes.

Example: Ventilator Associated Pneumonia

My primary reason for discussing 4DX is to help physician executive understand how to translate goals into results. But I think it might be helpful to use a clinical example to demonstrate some of these principles. As physicians, we understand these principles pretty well, and they can easily be applied to business examples in the healthcare setting.

Ventilator associated pneumonia (VAP) is a subset of nosocomial or hospital acquired pneumonias. It falls under the general category of healthcare associated infections (HAIs), which is a subset of hospital acquired conditions:

Hierarchy of Hospital Acquired Conditions

If we want to improve this entire cascade of hospital complication, we need a team to address each one. If we focus on VAPs, we can see that the lag measure is the VAP rate, which must be measured reported, discussed and addressed. It is generally measured and calculated as follows:

[# of VAPs (meeting specific criteria)/Ventilator days] X 1,000

It is reported as VAPs per thousand patient days. The numerator can be measured manually via logs, or pulled from an EMR, as long as documentation and coding are consistent and accurate. Tracking ventilator days is generally done manually.

Lead or Process Measures for VAP

The process measures that have been shown to affect VAP outcomes are as follows:

• Elevation of the head of the bed (30 – 45 degrees)
• Daily sedative interruption and assessment for extubation
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis
• Daily oral care with chlorhexidine

These metrics need to be manually observed and recorded in the units where ventilated patients are treated. There are checklists that can be used to help ensure compliance. An intensive educational program will need to be presented to staff to achieve understanding and “buy-in” to the project.

Achieving 100% compliance with the performance of these lead measures results in drastic reduction in the lag measure of VAPs per thousand ventilator days. Below are examples of real trends following the institution of VAP bundles and weekly quality improvement meetings in an anonymous organization.

Percent Patients in ICU with Ventilator Bundle

Average Stay of Patients

VAP in ICU

To achieve these results, however, the same principles that 4DX describes must be followed:

• Create a scorecard with weekly tracking of the process and outcome measures.
• Focus on the process by meeting weekly so that the whirlwind can be shut out – if non-WIG items come up, deal with them in another venue.
• During the weekly meetings
  • Follow-up on the previous meeting’s commitments
  • Review the dashboard
  • Make individual commitments to be reported on at the next meeting.

Final Thoughts

4DX provides much more detail about the process for implementing the 4 Disciplines of Execution. I find it very interesting that effective quality improvement methods closely mirror the detailed approach to executing strategic goals outlined in 4DX.

Physicians involved in QI and Patient Safety Initiatives should feel comfortable translating those skills to selecting and achieving management goals if they chose a career in hospital management.

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The CEO and board were very proud of the designation. We all were. It was a welcome recognition of all of the hard work we had been doing.

Our executive team met on our usual Wednesday operations meeting shortly thereafter. We reviewed the data presented with the award, and determined that several factors had come together to help us achieve it.

We had started an aggressive length of stay initiative about 3 years prior. In addition, we had implemented a nurse documentation and coding program.

Finally, we had implemented a quality measurement tool from CareScience (now owned by Premier and called QualityAdvisor) several years earlier. And we were collaborating with our affiliate hospital, Rush University Medical Center, to work on quality projects together. We had seen some impressive improvements in mortality and complication rates, and reductions in length of stay as a result of some of the projects.

The metrics being considered have changed significantly since then. When this all started, present on admission (POA) coding had not been implemented, so it was very difficult to distinguish co-morbidities from complications when analyzing closed charts. And CMS core measures were not yet being tracked. A lot has changed.

In July of this year, I wrote a post that described the steps for achieving Truven's Top 100 Hospital status. In it, I listed the metrics that Truven used to rank almost 3,000 U.S. hospitals using its balanced scorecard. The list of hospital performance measures had changed little over the previous decade.

When I reviewed the methodology for the 2016 report, I found several significant changes in the performance measures. The notes also mentioned that there are more changes to come.

Top Hospital Performance Measures

Here is the list of measures used to rank hospitals in the most recent release of the Top 100 list:

1. Risk-adjusted mortality index

This is a measure of survival in your hospital compared to other hospitals.

2. Risk-adjusted complications index

This is a measure of “error-free” care.

3. Core measures mean percent

This item has been used in the past. It is based on hospital use of care guidelines from CMS. But the core measures change over time. In 2015, Truven used core measures for heart attack (AMI), heart failure (HF), pneumonia, and surgical care. In 2016, Truven switched to core measures for stroke care and blood clot prevention.

4. 30-day risk-adjusted mortality rate for AMI, HF, COPD, pneumonia and stroke

This is unchanged from 2015, except for expansion to include COPD and stroke.

5. 30-day risk-adjusted readmission rate for AMI, HF, COPD, pneumonia, hip/knee arthroplasty and stroke

This is unchanged from 2015, except for expansion to include COPD and stroke.

6. Severity-adjusted average length of stay (ALOS)

This is a measure of efficiency and indirectly of quality. Patients with complications remain in the hospital longer. And those with extended stays tend to experience complications such as falls and infections.

7. Mean emergency department (ED) throughput

This is a new hospital performance measure. It is calculated by averaging the mean throughput times for door to admission, door to discharge, and time to receipt of analgesics for fracture care.

8. Case mix-/wage-adjusted expense per discharge

This is a measure of cost efficiency.

9. Medicare spend per beneficiary (MSPB) Index

This is a somewhat new measure. It is adjusted for various factors. It is used to compare the cost of care from 3 days prior, to 30 days after, the index admission.

10. Adjusted operating profit margin

The most basic financial metric, operating margin is a measure of management's ability to operate within current fiscal restraints.

11. HCAHPS score

The  Hospital Consumer Assessment of Healthcare Providers and Systems is a patient satisfaction survey required by CMS. The Truven measure is based on the patient overall hospital rating question only.

Note the following changes:

• The patient safety index was removed. According to Truven, it eliminated this measure because of “concerns that many of the metrics reflect inaccurate coding and documentation rather than adverse patient safety incidents.”
• Truven changed the way it applies the POA (present on admission) indicator. It accepted all principal diagnoses as POA. And it accepted any secondary diagnosis as POA across the board if more than 50% of hospitals coded the diagnosis as POA.
• The mortality risk model excludes all records from mortality measures in which ICD-9 code v49.86 is present on admission (POA).

Other Considerations

My observations for optimizing hospital performance under this balanced scorecard are as follows:

1. As usual, risk-adjustment is a big deal. Risk-adjustment is what determines how actual hospital performance looks when compared to expected performance. The more complete the risk-adjustment, the better your hospital performance will look. And missing appropriate risk-adjustment information will make your outcomes look crappy.
2. Risk-adjustment depends on capturing secondary diagnoses, especially those present on admission. So, it is critical that physicians include all treated and historical diagnoses on the admitting history. It is also helpful for nurse documentation specialists to identify any missed diagnoses by reviewing old records and other information.
3. There are many inclusion and exclusion criteria for the performance measures. These should be well understood and identified when present. The best example is the accurate identification of DNR status. The v49.86 code must be present in the record so that terminally ill patients are NOT included in mortality calculations by Truven.
4. It is crucial that someone on your team understands the methodology. Then you can educate other team members about changes in the measures and issues described above.

Why I Like Truven's Top 100 Balanced Scorecard

Some physicians do not like rankings like these. They believe it promotes gaming the system, rather than improving care.

But, if we don't have validated, published quality metrics, how will we know if we are underperforming? And how will our patients know? And what incentive will we have to change, if it is not demonstration of our performance gaps?

I also like the idea that this scorecard includes quality, satisfaction and financial performance. What better way to demonstrate to our stakeholders that we are doing a good job, than by demonstrating that our care is good, our length of stay is low, our patient experience is positive and our financial performance is superior?

Finally, I like the fact that of the current measures, the Chief Medical Officer should have direct oversight of the first five or six, and will influence the others.

Next Steps

Take a minute to scan through the methodology section of Truven Top Hospitals 2016 if you're interested in learning more.

Contact Truven Health Analytics to find out how your hospital balanced scorecard looks.

For more of my thoughts on healthcare and leadership Subscribe here.

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The post Shape Your Hospital Performance Measures and Boost Your Reputation appeared first on NonClinical Physicians.

patient safety

Patient safety can sometimes be a nebulous concept. Like quality, it is difficult to define, but most of us recognize it when we see it.

I was standing in a conference room, trying to explain to a group of vocal physicians why we needed to approve a Code of Conduct for the medical staff. It was one of our quarterly medical staff meetings, so there were a good number of physicians present.

Some of the physicians were concerned that such a code would be used to punish passionate and otherwise well-meaning physicians who became angry in the heat of a stressful situation. Another group felt that any new set of rules would jeopardize their autonomy.

That word, autonomy, had been used countless times to argue against various bylaws changes over the years. The thinking was that physician autonomy was sufficient to ensure quality of care.

Of course, that had been proven untrue many times. The quality improvement and patient safety literature repeatedly demonstrates that system breakdowns cause harm even when the most brilliant and dedicated physician is caring for patients.

Many of the staff members begrudgingly came to agree with the need for approving the code. This was primarily due to a fear of being accused of creating a hostile work environment. Very few had come to recognize the main concern that I had: that this was a serious patient safety issue.

The Code of Conduct had already been approved by the Medical Executive Committee. Members were convinced by a cultural survey completed earlier in the year. The survey demonstrated that staff, from pharmacists and nurses, to radiology techs and housekeepers, were hesitant to express concerns about potential safety issues. They would avoid calling physicians with important patient information, because of poor treatment during previous interactions.

I recalled several patients over the years, mostly in intensive care units, that I believe were harmed due to delays in contacting physicians. Most of those occurred before the implementation of in-house intensivists. But similar events still occur in recovery units and observation units in many hospitals due to delays in calling physicians.

So, the code of conduct is an integral piece of the patient safety puzzle. And its main purpose was to try to address the cultural and communication aspects of patient safety.

patient safety system failure

Definition of Patient Safety

The Institute of Medicine at one point defined patient safety as the “freedom from accidental injury.” My definition of patient safety is as follows: the discipline that is devoted to avoiding unexpected or avoidable harm to patients. 

Quality improvement and patient safety address similar issues, but I draw a distinction between the two. Generally, quality improvement involves the use of evidence-based care to optimize medical care. For example, reducing the length of stay or mortality rate for community acquired pneumonia by consistently selecting the appropriate antibiotic. If inappropriate antibiotic selection results in a poor outcome, then a quality issue has occurred.

Patient safety has to do with avoiding harm caused my mistakes or by breakdowns in communication, hand-offs, and other system failures. In the pneumonia example, if the wrong antibiotic is dispensed to the patient because of a similarity in name and labeling of the medication, then a patient safety issue has been identified.

Other examples of patient safety, as opposed to quality, issues in this case could be:

• hand-off communication: the antibiotic is ordered in the ER but never given because the orders from the ER EMR (electronic medical record) do not transfer to the inpatient EMR;
• disruptive communication: the physician hangs up on a phone call before the nurse can perform the read back, who then orders the wrong medication;
• medication error: the nurse administers an inappropriate medication because the dispensing cabinet was stocked improperly;
• preventable infection: patient develops C. difficile infection while hospitalized because of improperly followed infection prevention policies.

Addressing Patient Safety

Facing this topic can seem daunting, because there are so many potential safety issues, especially in the hospital setting. But I think the physician leader can use the following checklist when trying to devour the “elephant” of patient safety (one  bite at a time, of course). These steps follow an approach  similar to what I recommended for Becoming a Top 100 Hospital.

patient safety team

 1. Create a multidisciplinary Patient Safety Committee if you do not already have one.

This committee will typically include representation from the following areas:

• Executive team
• Medical staff
• Nursing
• Pharmacy
• Quality Improvement
• Risk Management
• Infection Prevention
• Informatics
• Case Management
• Documentation and Coding
• Medical Records

Additional participants can be pulled in as the need arises. The team will need a charter and a chair. A champion from the medical staff may also be assigned.

2. Use national safety organizations to guide you to the top patient safety issues to consider.

These organization have spent millions of dollars determining which indicators are valid and have measurable impact on patient outcomes. Besides, your organization will ultimately be graded on how well it performs on these measures, which are generally reported to the public in some fashion.

Some of the entities that can provide direction include:

• the Institute for Healthcare Improvement
• the Centers for Medicare and Medicaid
• the National Quality Forum
• the Agency for Healthcare Research and Quality

After reviewing the material provided by each of these entities, move to the next step.

3. Select patient safety indicators (PSIs) to measure.

I would recommend starting with the AHRQ measures. They are well-defined and already included in most hospital quality measurement tools. Here is the list of AHRQ PSIs (including a link to each PSI's technical specification):

• PSI 02 Death Rate in Low-Mortality Diagnosis Related Groups (DRGs)
• PSI 03 Pressure Ulcer Rate
• PSI 04 Death Rate among Surgical Inpatients with Serious Treatable Conditions
• PSI 05 Retained Surgical Item or Unretrieved Device Fragment Count
• PSI 06 Iatrogenic Pneumothorax Rate
• PSI 07 Central Venous Catheter-Related Blood Stream Infection Rate
• PSI 08 In Hospital Fall with Hip Fracture Rate
• PSI 09 Perioperative Hemorrhage or Hematoma Rate
• PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis
• PSI 11 Postoperative Respiratory Failure Rate
• PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound Dehiscence Rate
• PSI 15 Accidental Puncture or Laceration Rate
• PSI 16 Transfusion Reaction Count
• PSI 17 Birth Trauma Rate – Injury to Neonate
• PSI 18 Obstetric Trauma Rate – Vaginal Delivery With Instrument
• PSI 19 Obstetric Trauma Rate-Vaginal Delivery Without Instrument
• PSI 21 Retained Surgical Item or Unretrieved Device Fragment Rate
• PSI 22 Iatrogenic Pneumothorax Rate
• PSI 23 Central Venous Catheter-Related Blood Stream Infection Rate
• PSI 24 Postoperative Wound Dehiscence Rate
• PSI 25 Accidental Puncture or Laceration Rate
• PSI 26 Transfusion Reaction Rate
• PSI 27 Perioperative Hemorrhage or Hematoma Rate

Be certain that your team understands the definition of each measure. As I explained in How to Slash Your Hospital Mortality Rate you need to be certain that adverse events actually meet the definition before being counted in the measure.

safety dashboard

4. Create a dashboard that compares quarterly results to an external benchmark or goal.

Track the metrics back over the prior 8 or 10 quarters. This will allow for identifying trends that need to be addressed. Select the PSI with the biggest opportunity or potential impact for improvement. Begin a concerted effort to work on it. Develop an annual goal and milestones to track.

5. Present regular updates to the executive team and then the board of directors.

This helps to keep everyone involved and serves to create urgency when measures do not meet expectations. Be prepared to define the various terms and use the opportunity to educate the executive team and board about patient safety concepts.

6. Address other supporting issues that will enhance patient safety efforts.

These include:

• Coordinate regular surveys to measure the achievement of a culture of safety
• Oversight of root cause analyses done in response to sentinel events or never events
• Development of an educational patient safety curriculum for all constituents
• Attending conferences to enhance the team's learning and to network with others
• Join regional and national patient safety collaboratives or patient safety organizations
• Consider implementing Patient Safety Walkrounds

Addressing these issues will help to put your organization on strong footing when it comes to improving patient safety.

What questions or comments do you have about patient safety?

The post Six Steps for Delivering Outstanding Patient Safety appeared first on NonClinical Physicians.

But there is more to achieving a low mortality rate than just hiring good staff and implementing evidence-based care. Hospital mortality rankings are heavily dependent on rating agency rules and documentation practices.

Rules Matter

I was nine years old and obsessed with bowling. Maybe it was because Don Carter had become so popular. Perhaps it was the curiosity generated by the sound of bowling balls crashing into the pins at an alley only 2 blocks from my home. I had only bowled on a few occasions. But I knew that my dad had bowled in a league when he was a young man.

I begged him to sign me up for a league. On a lazy Saturday morning, after weeks of cajoling, he did just that and left me there to enjoy the games. I selected a ball and some bowling shoes.

I was assigned to a team and began bowling with the other kids in turn. I knock down a few pins and occasionally made a spare or a strike. But my score was hideous. When it was all over, I had three games with scores in the mid-double digits. Our team did poorly. I headed home disappointed and confused.

It turned out that there was something called a “foul line” and a rule against crossing it when throwing the ball. To this day, I don't understand why nobody explained that to me. It wasn't until much later that I figured it out.

But I learned a valuable lesson. Understand the rules or you will surely lose the game!

Hacking Mortality Rate Data

When you start digging, you'll find many rules when defining, measuring and reporting mortality rates. The rules vary depending on whether you're talking about rates published by CMS, Truven, HealthGrades or some other entity. And all of the reported scores use data sets originally designed for billing purposes.

Understanding and applying the appropriate rules makes a BIG difference in playing the game of published mortality rates.

Coding and Documentation

Hospital quality reporting is based on information from closed patient records. For Medicare patients, there are strict rules on the number and order of codes that can be used. In late 2007, “present on admission” (POA) modifiers were implemented. This helps to distinguish whether a co-morbid diagnosis is pre-existing or new (and possibly a complication of care).

The UB-04 Billing Form contains almost every determinant of the mortality rate calculation. Aspects that affect the patient's actual risk for mortality include:

• Patient origin (home, nursing home, hospice, etc.)
• Demographics (age, gender, race)
• Discharge status (alive to home, nursing home, etc. or expired)
• Admitting diagnosis
• Secondary diagnoses
• POA indicators

The first step is to assign the most appropriate admitting diagnosis. You don't want to mis-classify a patient with sepsis as having pyelonephritis or pneumonia. The latter conditions have a much lower expected mortality rate than sepsis patients.

Sometimes secondary diagnoses are missed. This is evidenced by a medication being listed in the patient's medical history without any corresponding diagnosis on the problem list.

Risk Adjustment

When hospital mortality rates are compared and ranked, it is not based on raw mortality rates, but on risk-adjusted rates. Risk adjusted rates are calculated by taking into account each patient's demographic information, admission diagnosis, secondary diagnoses and so forth. Hospitals are ranked by comparing the ratios of actual to expected rates.

All things being equal, the organization that captures more co-morbid diagnoses in its documentation and coding will demonstrate a lower risk-adjusted mortality rate. And it is not just a matter of listing more secondary diagnoses. The POA indicators must be accurately assigned so that pre-existing conditions do not appear to be complications of care.

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria also greatly influence quality metrics. If you don't know that a heart failure patient with an AICD (automatic implantable cardioverter-defibrillator) is excluded from mortality calculations, and you fail to document the presence of such a device in a deceased patient, your rate will look higher than it should. There are multiple such criteria for each diagnosis. There is some overlap, but each rating agency has its unique set of rules.

Discharge to Hospice

It is not uncommon for a terminally ill patient to be admitted to a hospital. When it becomes clear that supportive care is indicated, hospice care may be instituted. If the patient qualifies for in-patient hospice care, discharging the patient from an acute hospital status (general inpatient care or G.I.P.) to a contracted hospice bed will prevent the patient from being counted as an inpatient death. Without actually removing such patients from the hospital, you can put a process in place to change the status.

Solutions

Your reported mortality rates can improve dramatically if you do the following:

• Create a physician-led, nursing-based documentation and coding initiative if you don't already have one. Do as much concurrent coding as possible so that you fully capture all diagnoses and the POA status of each. These initiatives more than cover their costs through improved reimbursements and play a major role in reducing published mortality rates.
• Create a team of coders, case managers, documentation specialists and quality professionals to review charts of patients prior to billing to clarify any documentation and coding issues. Assign one or two persons to become experts in the rules used to calculate quality metrics by the various quality rating agencies.
• Review the charts of all patients expiring in the hospital to ensure that all of the above concerns are addressed.
• Begin your efforts with heart failure, pneumonia, COPD, acute myocardial infarction and stroke. If necessary, develop quality committees for each diagnosis that address mortality, complications and readmissions. Expand them later to include overall hospital mortality.

By understanding the rules of the game, your hospital mortality rate will improve dramatically.

What other methods have you used to improve quality ratings at your facility?

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