November 2005
Dear Colleague:
An audio file and transcript is available from Premier's October Advisor Live audio program on SCIP (Surgical Care Improvement Project) featuring CMS's Drs. Dale Bratzler and David Hunt. It is not too late to register for the next program on November 30 to hear about the first year results of the CMS/Premier Hospital Quality Incentive Demonstration Project.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
News
- CMS/Premier Pay-for-Performance produces quality improvements among nation's hospitals
- Final measures released for CMS Surgical Care Improvement Project
- Long-awaited national pandemic influenza
plan is released - HCAHPS patient satisfaction survey released
for comment - Fire protection agencies agree on permitting hand sanitizers in corridors
- IHI offers leadership guide for patient safety
- Study finds use of real-time audits improve
patient safety - Perioperative oxygen reduces surgical site infections in clinical trial
- The impact of prescription-guided psychotropic medication on the elderly
Safety tools
- Multimedia safety tool kit for patient education
- On-line resources – bar coding, RFID and
patient safety - AHRQ slides – quality indicator tools
- Fact sheets and checklists – resources for cleanup from water damage, mold
- ASA Practice Advisory – reduce awareness
under anesthesia
CMS/Premier Pay-for-Performance produces quality improvements among nation's hospitals
"Pay-for-performance" can increase clinical quality and save lives, according to the first year of official data from a national project involving more than 260 hospitals. The Centers for Medicare and Medicaid Services (CMS) will pay $8.85 million in incentives to the top-performing hospitals in the project, which is managed by Premier, Inc.
Data from the first year of CMS/Premier Hospital Quality Incentive Demonstration (HQID), validated by CMS and reported publicly on November 14, 2005, demonstrated a significant improvement in the quality of care across five clinical focus areas as measured by 33 nationally standardized and widely accepted quality indicators. The average improvement across the clinical areas was 6.6 percent. These performance gains have outpaced those of hospitals involved in other national performance initiatives. Approximately 235 acute myocardial infarction (heart attack) patients were saved as a result of quality improvements in that related focus area alone.
Premier will be hosting an audio conference on November 30 to share the results of the first year of the demonstration project. To register for the conference go to Advisor Live.
Medicare is awarding $8.85 million to hospitals that achieved the highest levels of performance at the end of the first year of the project. This is the first time that Medicare has awarded actual monetary bonuses to health care providers in a pay-for-performance demonstration.
Premier's relationship with participants enabled implementation of effective, collaborative knowledge transfer programs supporting identification and dissemination of best practices of top performers, a key component to the rapid pace of performance improvement.
The financial component of the HQID will reward hospitals performing in the top 10 percent for a given clinical focus with an additional 2 percent bonus on their Medicare payments for patients in that clinical area. Hospitals in the second decile will receive a 1 percent bonus.
Unlike other performance improvement initiatives that only monitor processes of care associated with three focus areas, the HQID, which began in October 2003, tracks process and outcome measures in five clinical areas – acute myocardial infarction (AMI), heart failure, coronary artery bypass graft (CABG), pneumonia, and hip and knee replacement.
Composite quality scores, an aggregate of all quality measures, improved between the first and last quarters of the first year of the demonstration in all 5 clinical focus areas:
- From 87 percent to 91 percent for patients with acute myocardial infarction (heart attack).
- From 65 to 74 percent for patients with heart failure.
- From 69 percent to 79 percent for patients with pneumonia.
- From 85 percent to 90 percent for patients with coronary artery bypass graft.
- From 85 percent to 90 percent for patients with hip and knee replacement.
The range of variance among participating hospitals is closing, as those hospitals in the lower deciles continue to improve their quality scores and close the gap between themselves and the demonstration's top performers.
For a complete review of the demonstration, the year one results, and to view those hospitals ranking in the top 50 percent in each focus area, visit the HQI demonstration site.
Register for November 30 Advisor Live at: www.premierinc.com/advisorlive
HQI demonstration Web site: http://www.premierinc.com/qualitydemo
For more information about Premier Healthcare Informatics, visit: www.premierinc.com/informatics, or call 800.805.4608.
Final measures released for CMS Surgical Care Improvement Project
Premier hosted a 90-minute audioconference on October 26, 2005, as part of an Advisor Live series of calls on performance improvement, on the Centers for Medicare and Medicaid's (CMS) Surgical Care Improvement Project (SCIP). SCIP is a national voluntary partnership to improve surgical care. The faculty included Dr. Dale Bratzler, clinical coordinator for the Oklahoma Foundation for Medical Quality and the SCIP support center, and Dr. David Hunt, Medical Officer with the CMS Quality Improvement Group and member of SCIP steering committee. The faculty summarized the program plans and reviewed the rationale for selection of the final process and outcome measures that were released by CMS in mid-October, pointing out that the outcome measures are intended for internal performance improvement. SCIP is a multi-year national campaign and partnership aimed at reducing surgical complications by 25 percent by the year 2010.
An audio file and handouts including a summary of the call in a question/answer format for the October 26 program are available, along with information and registration for future Advisor Live programs on quality, safety and performance improvement. The programs are provided at no charge.
90-minute audio file (mp3) (9.65 MB)
Handouts/slides (.pdf) (314 KB)
Final SCIP measures (.pdf) (42 KB)
Narrative summary in Q &A format of call (.pdf) (142 KB)
Premier's Advisor Live Web site for listing and registration for upcoming programs: www.premierinc.com/advisorlive
Long-awaited national pandemic influenza plan
is released
President Bush's "National Strategy for Pandemic Influenza" released on November 1, 2005, outlines the characteristics of the pandemic and avian influenza threat and proposes $7.1 billion in funding to coordinate a federal response. The following day, a comprehensive plan with implementation details was released by the Department of Health and Human Services (HHS).
National Strategy for Pandemic Influenza. The administration's plan has three main elements: detecting outbreaks anywhere in the world; stockpiling vaccines and antiviral drugs while improving the ability to make new vaccines for a pandemic virus; and improving general readiness at the federal, state, and local levels. The strategy includes:
- $1.2 billion to purchase enough vaccine against the current strain of bird flu to protect 20 million Americans (vaccine under development). This includes sufficient vaccine for front-line emergency personnel and at-risk populations, including military personnel;
- $1 billion to stockpile more anti-viral drugs that lessen the severity of the flu symptoms;
- $2.8 billion to accelerate the development of cell-culture technology and increase the speed for the development of vaccines as new strains emerge. The goal is to have the manufacturing capability by 2010 to have enough vaccine for every American within six months of the beginning of a pandemic.
- $583 million for state and local governments to prepare emergency plans to respond to an outbreak.
HHS Pandemic Influenza Plan. On November 2, a comprehensive "HHS Pandemic Influenza Plan" was released by the Department of Health and Human Services, providing details of the strategy in two major sections – "Strategic Planning" and "Public Health Guidance." Hospitals and healthcare providers will find their interests addressed primarily in the Part 2 supplements – healthcare planning, infection control/isolation, vaccine distribution and use, and antiviral drug distribution and use.
World Health Organization (WHO) – Frequently asked questions about avian flu
WHO recently published a document, "Frequently Asked Questions about Avian Flu" on the
WHO Influenza Web
site that can be used to educate patients, workers, and the community about avian flu.
Official U.S. government Web site for pandemic flu
The official U.S. government Web site has been launched with information on pandemic
and avian flu.
Premier Safety Institute public health resources
on influenza
The Premier Safety Institute maintains key resources and links for pandemic or avian influenza,
hurricane "clean up," including re-occupation of healthcare facilities, West Nile virus and other
current public health issues on its Emergency and public health preparedness site. Also see
Influenza Resources for
more information.
National strategy for pandemic influenza (.pdf) (702 KB), or go to:
http://www.whitehouse.gov/homeland/
pandemic-influenza.html
HHS pandemic influenza plan: http://www.hhs.gov/pandemicflu/plan/
WHO influenza Web site: http://www.who.int/csr/disease/avian_influenza/en/
Download WHO FAQ on Avian Influenza (.pdf) (68 KB)
Premier's Emergency and public health
preparedness resources
HCAHPS patient satisfaction survey released
for comment
The final draft of the Centers for Medicare and Medicaid (CMS) "Hospital Consumer Assessment of Health Providers and Systems" (HCAHPS) survey instrument, the first national survey to collect uniform patient feedback on hospital care, has been published in the Federal Register for comments accepted through December 7, 2005.
Hospitals will voluntarily participate in HCAHPS, also known as Hospital CAHPS or the CAHPS Hospital Survey. The HCAHPS program will be implemented next year under the auspices of the Hospital Quality Alliance (HQA), a private/public partnership that includes the American Hospital Association, Federation of American Hospitals, Association of American Medical Colleges, Joint Commission on Accreditation of Healthcare Organizations, National Quality Forum, AARP, CMS/AHRQ, and other stakeholders that share a common interest in reporting on hospital quality. Results will be publicly reported on the Department of Health and Human Services' Hospital Compare Web site. The HCAHPS survey instrument is intended to provide a standardized instrument and data collection methodology for measuring patients' perspectives on hospital care. An independent analysis of the costs and benefits of the HCAHPS survey instrument, recommended by the National Quality Forum, is also available from CMS.
Detailed information on the HCAHPS survey instrument (.doc) (661 KB)
Hospital Compare Web site: http://www.hospitalcompare.hhs.gov/
Analysis of the survey (.pdf) (18 KB)
Fire protection agencies agree on permitting hand sanitizers in corridors
The International Code Council (ICC) has joined the National Fire Protection Agency (NFPA) and the Centers for Medicare and Medicaid Services (CMS) in permitting the use of alcohol-based hand rubs in healthcare facility corridors, aligning all fire safety-related organizations on this issue.
The agencies that have jurisdiction and enforce fire safety varies with each state. These include: the International Code Council (ICC), which enforces the International Fire Codes (IFC); the National Fire Protection Agency (NFPA), which enforces the Life Safety Codes; CMS, which enforces the NFPA codes; and the Joint Commission on Accreditation of Healthcare Organizations, which enforces state-adopted codes. Having all these agencies agree on the placement of alcohol-based hand rubs in the corridors of healthcare facilities aligns the national state and local fire agencies on this issue.
Implementation and enforcement
The final language that approves use of dispensers in hallways will be incorporated into the 2006
editions of the fire codes for each organization. Until the 2006 editions of the codes are published,
healthcare facilities should use the interim documents published by NFPA, CMS, and ICC regarding
expectations for safe use of alcohol-base hand rub products when discussing issues with state and
local fire safety organizations (also known as the authority having jurisdiction, or AHJ). The
American Society for Healthcare Engineering (ASHE) has provided details of the interim
approvals from each agency.
On a related note, suggested guidance for placement of dispensers in light of CMS specifications is provided as a FAQ courtesy of ASHE and the Premier Safety Institute.
ASHE Web site:
http://www.ashe.org/ashe/codes/handrub/
FAQ on placement of dispensers (.doc) (30 KB)
Background – see Premier Safety Share October 2005
IHI offers leadership guide for patient safety
A leadership guide offering eight steps for senior health care leaders to help their organizations achieve patient safety and high reliability is available from the Institute for Healthcare Improvement (IHI). "The Leadership Guide to Patient Safety: Resources and Tools for Establishing and Maintaining Patient Safety" introduces the concept of "reliability," defined as patients getting the intended tests, medications, information, and procedures at the appropriate time and in accordance with their values and preferences. Strategies for redesign of healthcare systems are presented using examples that IHI has gleaned from its experience in guiding organizations in improving patient safety. The eight steps include:
Step One:
Address strategic priorities, culture, and infrastructure
Step Two:
Engage key stakeholders
Step Three:
Communicate and build awareness
Step Four:
Establish, oversee, and communicate system-level aims
Step Five:
Strengthen reporting and analysis functions
Step Six:
Support staff and patients/families impacted by
medical errors
Step Seven:
Align system-wide activities and incentives
Step Eight:
Redesign systems and improve reliability
The IHI Leadership Guide contains resources and links to many additional tools and resources relating to the implementation of each of these steps.
The Leadership Guide to Patient Safety: Resources and Tools for Establishing and
Maintaining Patient Safety (.doc)
(308 KB)
IHI Web site:
http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/
Leadership/Literature
Study finds use of real-time audits improve
patient safety
A recent study concluded that real-time safety audits in an intensive care unit identified errors that were frequently undetected, such as equipment failures. Care processes that were especially error prone, including alarm settings, patient identification, hand hygiene, and labeling of syringes and tubing, were also identified. In the study, published in the August 2005 issue of the Journal Quality & Safety in Health Care, the real time audit and safety check list developed by a multidisciplinary group provided timely error detection and immediate feedback to front-line staff. Clinicians were reassured that the goal of the audits was to identify and correct problems, rather than assigning blame to any particular caregiver.
Results and recommendations. A number of important changes were made as a result of the auditing. These included a change in the patient identification system with the purchase of non-traumatic identification bands designed for use with neonates, and the development of NICU guidelines to ensure that pulse oximeter alarm settings were not set inappropriately high. Because a blameless culture of safety was stressed, staff was very accepting of the audits as major performance gaps were identified, study authors concluded.
August 2005 Journal Quality & Safety in Health Care (.doc)
(24 KB)
Perioperative oxygen reduces surgical site infections in clinical trial
Belda and colleagues from the University Clinic Hospital in Valencia, Spain, reported on the results of a double blinded, randomized control trial that found that the use of supplemental perioperative oxygen reduced the incidence of surgical site infections (SSI).
Published in the October 26, 2005, issue of the Journal of the American Medical Association, the study included 300 patients who were randomly assigned either 30 percent or 80 percent fraction of inspired oxygen (FIO2) intraoperatively and for six hours after surgery. Antibiotic administration and anesthesia were standardized across all patients. Surgical wounds were assessed daily and considered infected when they met the Centers for Disease Control and Prevention definition for infection. All infections diagnosed within the first 14 days after surgery were included in the study.
Results and conclusions. Thirty five patients (24.4 percent) were diagnosed with a SSI in the 30 percent FIO2 group and 22 patients (14.9 percent) in the 80 percent FIO2 group. The risk of SSI was 39 percent lower in the 80 percent FIO2 group. After logistic regression analysis, only the inspired oxygen and coexisting respiratory conditions were demonstrated to be significantly associated with the risk of infection. Patients with coexisting respiratory disease had a three-fold greater probability of SSI.
The authors concluded that supplemental 80 percent FIO2, with few risks and minimal cost, given during and for six hours after major colorectal surgery reduces SSI infection risk by a factor of two and is consistent with findings from one other appropriately designed randomized controlled trial.
Abstract supplemental perioperative oxygen and the risk of surgical wound infection (.doc) (25 KB)
The impact of prescription-guided psychotropic medication on the elderly
Geriatric patients are particularly vulnerable to adverse events related to the inappropriate use or excessive dosing of psychotropic medications, including over-sedation leading to delirium, falls and subsequent injury. The authors of "Guided prescription of psychotropic medications for geriatric inpatients" (Archives of Internal Medicine, April 2005) developed an automated decision support system as part of their computerized physician order entry system with recommended psychotropic medication selection and dosing for elderly inpatients.
Use of a computerized order entry system with decision support preceded a significant increase in recommended dose of prescription medications (from 19 percent to 29 percent) and a lower incidence of falls – 0.28 vs. 0.64 falls per 100 patient days.
Guided prescription abstract, Archives of Internal Medicine, April 2005 (.doc) (24 KB)
For more information, see Premier's Fall Prevention
Web module
Safety tools
- Multimedia safety tool kit for patient education
- On-line resources – bar coding, RFID and
patient safety - AHRQ slides – quality indicator tools
- Fact sheets and checklists – resources for cleanup from water damage, mold
- ASA Practice Advisory – reduce awareness
under anesthesia
Multimedia safety tool kit for patient education
A free multimedia safety tool kit is available and contains a five-minute, Web based version of the patient safety Emmi TM tool that explains the patient's role in preventing mistakes and infections in hospitals. The tool kit is sponsored by the American Society of Hospital Risk Management (ASHRM), Rightfield Solutions, the creators of Emmi patient education system, and the Health Research and Educational Trust (HRET) of the American Hospital Association. Hospitals can post this program on their Web sites for patients to view prior to coming to the hospital, or broadcast the two-minute version on an in-house television network. To view the program from the ASHRM patient safety tool kit, go to: www.emmisafety.com/ashrm. A press release (.pdf) (132 KB) provides additional details about the program and tool kit.
On-line resources – bar coding, RFID and
patient safety
Advances in technology are making it easier to improve patient safety. The September/October issue of Patient Safety and Quality Healthcare focuses on recent technology designed to reduce the risk of medical errors. Among the topics featured in this issue are bar coding to reduce medication errors, electronic medical records (EMR) and radio frequency identification (RFID) systems. The journal can be accessed at: www.psqh.com/sepoct05/tocc.html.
AHRQ slides – quality indicator tools
The first Agency for Healthcare Research and Quality (AHRQ) Quality Indicator (QI) users meeting recently provided an opportunity to discuss best practices relating to the new Pediatric Indicator Module. This module applies the AHRQ QI to improve population health using the AHRQ QI as a catalyst for quality improvement, implications of ICD-9-CM coding practices, the use of the AHRQ QI in the National Healthcare Quality Reports, methods for creating aggregate performance indices, and considerations in using the AHRQ QI for comparative reporting and pay-for-performance.
Using the AHRQ QIs for quality improvement and future directions were also discussed at the
initial meeting. Minutes from the meeting, as well as presentations from the speakers, are available
at:
http://qualityindicators.ahrq.gov/
usermeeting_presentations_2005.htm.
Fact sheets and checklists – resources for cleanup from water damage, mold
Reopening a facility. A fact sheet and checklist were recently developed by the Centers for Disease Control and Prevention to assist healthcare facilities with the tasks involved during clean-up and reopening following extensive water damage. "Remediation and Infection Control Considerations for Reopening Healthcare Facilities Closed due to Extensive Water and Wind Damage" notes that implementation of these measures is meant to be followed in accordance with state and local certification requirements, completion of building and fire inspections, and other relevant state or local regulations.
- Re-occupancy fact sheet (.pdf) (119 KB)
- Checklist (.doc) (137 KB)
- Checklist (.pdf) (135 KB)
Mold prevention. "Mold: Prevention Strategies and Possible Health Effects
in the Aftermath of Hurricanes Katrina and Rita" (.pdf) (163 KB)
and a mold table (.pdf)
(560 KB) includes population specific
recommendations for protection from exposure to mold in buildings flooded after hurricanes
by specific activity and risk factors, as well as information on how to identify and prevent
mold-related health effects. The documents include recommendations for control of mold exposure.
Additional key hurricane resources, including links and downloads, can be found at:
http://www.premierinc.com/quality-safety/tools-services/safety/topics/
disaster_readiness/hurricane.jsp. Resources are
listed by agency.
ASA Practice Advisory – reduce awareness
under anesthesia
The American Society of Anesthesiologists (ASA) has approved a practice advisory (.pdf) (226 KB) on anesthesia awareness intended to help anesthesiologists reduce the risk of unintended patient awareness under general anesthesia. The ASA reports that one to two out of every 1,000 patients receiving general anesthesia regains consciousness and may experience pain but have no ability to communicate with their physicians. The advisory recommends that physicians rely on multiple modalities for intraoperative monitoring for awareness, including clinical techniques and conventional monitoring. The recommendations also note that the decision to use a brain function monitor should be made on a case-by-case basis. Whether brain function monitoring should be used for all patients having general anesthesia remains controversial since the Joint Commission on Accreditation of Healthcare Organizations issued a sentinel event on anesthesia awareness last year (.doc) (55 KB).
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Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- Derek Kleckner, BA, Web master
About Premier
Premier, Inc. is a healthcare alliance entirely owned by 200 of the nations leading not-for-profit hospital and healthcare systems. These systems operate or are affiliated with 1,500 hospital facilities and hundreds of other healthcare sites. Premier provides an array of resources supporting health services delivery, including clinical and operational comparative data applications for quality/safety performance improvement, group purchasing and supply chain services, and insurance programs. The Centers for Medicare and Medicaid Services (CMS) has recently partnered with Premier for a three-year quality incentive demonstration project. Participating hospitals using Premier’s Perspective Online ™ database can receive recognition and additional Medicare payment when they meet or exceed specific quality measures.
