Will Medicare’s New Efficiency Measurement Harm Patient Safety?
While facing rising Medicare costs and ever-present budget challenges, federal officials are focused on lowering Medicare costs. As part of the federal Affordable Care Act, Medicare is beginning to measure efficiency and per-patient costs to evaluate hospitals and will adjust its payments to them accordingly. The change has angered several hospital administrators and has patient advocates asking whether Medicare’s focus on low costs will improve or damage patient safety and medical care.
“Per Beneficiary” Medicare Spending
Medicare will track hospital efficiency based on “Medicare spending per beneficiary,” equivalent for other measures used for tracking infection rates of surgery patients and mortality rates of heart-attack patients. The intended purpose of the measure is to improve the quality and efficiency of health care by tying Medicare payments to the performance of health-care providers.
In addition to expenses brought on during a patient’s hospitalization, the cost of any medical treatment occurring three days before hospitalization and 90 days after discharge also will be tacked on to the hospitals’ bills for Medicare measurement purposes. Medicare officials claim that using such a long duration should encourage hospitals to coordinate care in an efficient manner over an extended period of time.
Federal officials offered an example of the Medicare spending per beneficiary measurement, which was simplified and republished by The New York Times. In the simplified example, if Medicare spends an average of $9,125 per Medicare beneficiary at one hospital, and the comparable cost at every U.S. hospital is $12,467, the single hospital would receive a higher score for efficiency.
This efficiency score would then be combined with scores from other measures to create an overall performance score for that hospital. Medicare will then use the overall performance scores to determine a higher or lower percentage to be paid for each claim the hospital files. This system, known as value-based purchasing, rewards and distributes more funds to higher-performing hospitals. Full details of the measure are still being finalized, but Medicare began computing performance scores in July 2011 and plans to implement the value-based purchasing system by October 2012.
Concerns Rise Over the Quality of Patient Care
Unsurprisingly, many hospital administrators dislike the notion of being held accountable for expenses arising from care beyond the walls of their facilities. They say they have very little influence over medical treatment occurring after a patient has been discharged and essentially no control over the treatment a patient receives before being admitted.
Additionally, teaching hospitals may earn lower efficiency scores and be penalized by the value-based purchasing system because they often treat patients with more severe conditions, which adds to the cost of treatment. Medicare officials claim that efficiency data will be adjusted to consider factors such as patients’ ages and the severity of their illnesses. Regardless, president of the Greater New York Hospital Association, Kenneth E. Raske, says the efficiency measure “tends to discriminate against inner-city hospitals with large numbers of immigrant, poor and uninsured patients.”
Many in medical community have agreed that paying hospitals based on performance is important, but implementing the right measures of performance is crucial. President of the Federation of American Hospitals, Charles N. Kahn III, says officials are “off track” in holding hospitals responsible for what Medicare ends up spending on patients nearly three months after discharge.
Further, numerous hospital administrators and patient-safety advocates are concerned about the long-term ramifications of a measure that emphasizes low costs rather than quality outcomes, especially in regards to patient safety. For example, the focus on lower costs could result in fewer diagnostic tests being ordered and performed, potentially leading to missed or incorrect diagnoses. Especially in cases where early detection and quick treatment are vital to recovery, such cost-cutting measures could put the very life of a patient at stake.
Health IT to Have a Bigger Role in Improving Patient Safety
According to a recent commentary published in The Journal of the American Medical Association, advances in technology will lead health information technology to play a bigger role in improving patient safety. More specifically, wider adoption of electronic health records (EHRs), as well as computerized provider order entry (CPOE), clinical decision support (CDS) and barcode medication administration, will play increasingly important roles in addressing the Joint Commission’s National Patient Safety Goals.
EHRs and related health IT have been marketed as tools to enhance patient safety, but the promise remains largely unfulfilled at the present time, wrote co-authors Ryan P. Radecki, MD, department of emergency medicine, East Carolina University Brody School of Medicine, in Greenville, N.C., and Dean F. Sittig, PhD, professor at The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics, in their commentary titled “Application of Electronic Health Records to the Joint Commission’s 2011 National Patient Safety Goals.”
The authors offered the following example: EHRs with CDS interventions integrated into CPOE have been shown to improve clinicians’ performance on process metrics, yet their effect on patient outcomes has yet to be seen.
Joint Commission Pushing EHR Adoption
The Joint Commission’s National Patient Safety Goals for 2011 include correctly identifying patients, delivering test results more quickly and accurately, ensuring that medications are labeled correctly, examining medications for potential adverse reactions, preventing and reducing infections, and identifying patients who may be at risk of suicide.
Improving the rate at which EHRs can be used to address patient safety issues would involve implementing the National Patient Safety Goals into the existing criteria for EHR certification.
The authors stated, “The 2011 National Patient Safety Goals provide high-yield guidance to EHR certification and oversight bodies who should refine their criteria for meaningful use to include incentives for development and use of tools to enhance safety. As with all computer-based interventions, incorporation of EHRs into routine clinical workflow is critical; their effectiveness depends on appropriate maintenance, effective user training, periodic institutional self-assessment of EHR safety and effectiveness, and clinically focused policies to support their use.”
They concluded, “Although EHRs by no means represent all necessary mechanisms to address critical safety problems, they can provide tools to help organizations improve their performance.”
Hospital Checklists Reduce Hospital-Acquired Infections
According to the New York Times, the fourth-leading cause of death in the United States is hospital-acquired infections (nosocomial infections). Nosocomial infections are infections, such as pneumonia, that patients contract while receiving treatment in hospitals. These infections cost the U.S. healthcare system over $40 billion every year.
Hospitals across the nation are taking steps to decrease the prevalence of nosocomial infections, making incredible progress in some areas. Yet, studies show there is still a long way to go.
Safety Checklists Prove Effective
An experiment conducted in 2003 in Michigan demonstrated the effectiveness of a simple checklist in reducing certain types of patient infections. To reduce the occurrence of central-line catheter infections, the Michigan Health and Hospital Association required 103 intensive-care units to use a five-point checklist when inserting catheters into patients. The results were incredible: the median rate of infection dropped to zero and remained at zero throughout 15 months of follow-up monitoring.
The same hospitals implemented a similar checklist method to reduce ventilator-associated pneumonia. Again, by using the checklist method, the hospitals were successful in eliminating this infection, reducing the median infection rate to zero.
Risks of Hospital-Acquired Infections
Despite the success of checklists in reducing hospital-acquired infections, there is still great room for improvement. One of the main causes of nosocomial infections is the hospital workers’ failure to wash their hands frequently enough. A study published in the American Journal of Medicine Quality revealed that most hospitals have hand-washing rates below 50 percent. The study also showed that medical personnel in intensive care units only wash their hands one quarter as often as they should.
Atul Gawande, author of The Checklist Manifesto, says implementing checklist systems in more hospitals nationwide will help improve rates of basic tasks such as hand washing. He says hospital checklists work well for several key reasons. First, lists are reminders to busy hospital personnel who may overlook a step in a routine procedure when doing many things at once. Second, lists instill a sense of responsibility among the people involved in performing a procedure; everyone is responsible for the success or failure of the procedure. Each person has the right and the duty to say something if someone is skipping a step on the checklist.
AAMI Cite Alarm Management among Top 10 Biomedical Challenges
In a recent survey conducted by the Association for the Advancement of Medical Instrumentation (AAMI), clinical engineers and biomedical engineering technicians were asked to report the biggest biomedical challenges they see in their hospitals. Interfacing devices and information systems were the top challenges, but managing alarm systems and computerized IT systems were also ranked highly (#3 and #2, respectively).
The information was collected through a research survey conducted in November 2010 by Stratton Research. There were 418 responses to the survey, which was sent to more than 2,500 hospital biomedical technicians and clinical engineers. The results were published in the March/April 2011 issue of the Biomedical Instrumentation & Technology. Clinical engineers and hospital professionals discussed the findings at the recent AAMI conference held on June 27.
The top 10 biomedical challenges were:
- Interfacing between devices and information systems
- Maintaining computerized IT systems
- Managing alarms
- Maintaining and processing endoscopes
- Broken connectors
- Wireless management
- Battery management
- Problems with patient monitors
- Problems with dialysis equipment
- Managing the radiation dose from CT
“In terms of solutions to these challenges, clinical engineering veterans and other professionals hit the same broad themes: better education and training, stronger and communication and cooperation among departments, and often a need for standards,” stated Paul W. Kelley, CBET, of Washington Hospital Healthcare System in Fremont, Calif.
“The successful implementation of interoperability requires defined objectives and measurable goals”, noted Carol Davis-Smith, CCE, Premier Healthcare Alliance in Charlotte, N.C., “as well as a complete and well-maintained physical inventory of the applicable items included in the network.” Davis-Smith recommended prioritizing and making data-driven decisions when implementing interoperable devices.
“What we’re finding out there in the community, is that one, our basic CMO mass inventory is not clean. We need to get that cleaned up, and the reason being, because we need to have IT collect this really granular data about each of those individual devices, what can talk and what cannot talk, to what extent does it talk and how does it talk,” Davis-Smith said. “Bringing this level of granularity might be an ice-breaker in the IT department.”
Kelley said, “We learned [from the survey] that IT plays a huge role in biomedical engineering, as three of the top 10 challenges are IT-related. The IT department, clinical engineers, clinicians and vendors have to work together. Healthcare is most definitely a team sport.”
Related to interoperability, alarm management was also a strong focus of Monday’s discussion. Managing alarms has become a widespread issue—gaining media exposure with stories in The Boston Globe, The Washington Post, CBS Nightly News, and National Public Radio—as hospitals are attempting to manage the alarm fatigue caused by the countless visual and audible alarms directed at nurses each day.
“In terms of the top 10 medical device challenges, it really interacts with so many of the other challenges: interfacing, computer updates, broken connectors, patient monitors,” said J. Tobey Clark, CCE, of the University of Vermont in Burlington. “All of those other hazards directly impact clinical alarms.”
Clark said that sounds are actually just a portion of the problem. He said caregivers cannot recognize more than six different alarm sounds and have difficulty distinguishing between high- and low-priority alarms.
“This clinical alarm problem is very complex,” he said. “The stumbling block is human limitations. Because it’s a complex problem, you need a complex solution,” Clark said. “We need a multi-disciplinary approach to resolve this problem. False alarms and nuisance alarms [are] by far the biggest problems that lead to alarm fatigue.”
The issue of clinical alarm fatigue will be the focus of an upcoming AAMI summit in Herndon, Virginia, Oct. 4-5.
ONC to Penalize EHR Accreditors for Poor Performance
The Office of the National Coordinator for Health IT (ONC) has proposed a new method to penalize accreditors that oversee organizations that certify electronic health record (EHR) products when the accreditors engage in improper conduct or perform their duties poorly. To clarify, the ONC plans to select only one approved accreditation organization every three years to oversee smaller bodies that will certify EHR products for use by healthcare providers.
This makes authorized accreditors very important for EHR certification programs because healthcare providers will be relying upon EHR certification bodies to help meet meaningful use requirements.
The rule proposed by the ONC explains both the conduct violations and the possible consequences that could be levied against authorized accreditors and details the ONC’s process for disciplining poor performers, including the possibility of replacement due to conduct violations.
Under the ONC’s permanent certification program, which will be implemented on January 1, 2012, the accreditor must ensure that the authorized certification bodies follow reliable methods of surveillance of vendor products. According to the proposed provisions, conduct violations include fraud, withholding or altering information that would indicate fraud, falsifying accreditations of certifying organizations, and failure to perform in a satisfactory manner.
The ONC will be able to assess the accreditor’s performance through the annual reports made by the certifying organizations which will detail EHR product surveillance. The surveillance results will include feedback from the accreditor as well.
The permanent program will make EHR certification more thorough and reliable than the temporary processes currently used to approve EHRs. Temporary testing and certification will cease on December 31, 2011.
“We believe that a removal process would protect the integrity of the permanent certification program and maintain public confidence in the program,” the ONC said in the proposed rule, which was published in the May 31 Federal Register. The proposed rule is open to public comments until August 1.
Nurse Messaging Improves Nurses’ Efficiency and Patient Satisfaction
Nurses spend most of their time working on documentation, care coordination, and medication administration. In order to complete these tasks along with the necessary dictation and charting, nurses must constantly be on the move throughout the hospital. Unfortunately, this leaves nurses with very little time to interact with their patients, usually less than 5 minutes per patient for each hour during a shift.
To help ease the burden on nurses and improve relationships with patients, many hospitals are incorporating nurse messaging into their communications plan. With this type of setup, nurses can send and receive calls or text messages on their wireless phones as they travel throughout the hospital.
Hospitals that implement a wireless nurse messaging system typically see immediate benefits for their nurses and their patients. Messaging software can be connected to devices within patient rooms so that nurses can receive alert messages on their phones detailing them about the patient’s condition or actions. Since caregivers can receive and respond to alerts more quickly with messaging, the risk of “never events” (such as patient falls or pressure ulcers) is reduced.
Text messages can convey simple task requests more quickly than voice communications; thus, messaging saves time for caregivers because many clinical communications do not require extended voice interaction.
Also, since wireless messaging allows nurses to receive specific patient care alerts and updates on the go, messaging improves nursing workflow. For example, because they are receiving alert messages on their phones in real-time, nurses are able to prioritize the alerts, ensuring that the speed and quality of care given corresponds to each patient’s level of need. Similarly, the wireless phones can be programmed to sound different alert tones to signify different levels of urgency. Some hospitals have reported seeing nursing efficiency improve by nearly 25% within the first three months of implementing a wireless messaging system.
Unit secretaries and operators can greatly benefit from wireless messaging systems as well. Incoming patient calls can be screened and forwarded, or the operator can send the nurse a message which identifies the patient’s need. From their desk, operators can also message physicians or housekeeping to keep the processes of patient admission and discharge running smoothly. Instead of calling back and forth between patients, nurses, and physicians, wireless messaging systems allow operators to generate or forward concise messages to the appropriate caregiver quickly.
Messaging can also greatly improve patient satisfaction. When nurses become more efficient they gain more time to interact with their patients. The patients perceive their nurses as being more attentive to their needs and, consequently, are more likely to view their experience as a positive one. The time nurses spend with their patients is incredibly valuable; time spent in positive communication with patients affects not only patient satisfaction, but nurses’ job satisfaction as well.
Dalcon Team Attends KIRK Commercial and Technical Partner Event 2011
Every year Kirk invites its partners to the company’s headquarters in Denmark to improve partner relationships and encourage the development of interoperability of solutions. Members of the Dalcon team will be in attendance this year.
Kirk is a manufacturer of DECT wireless handsets and solutions, including the 7020 and 7040 series made specifically for healthcare.
At the event Dalcon will be showing Dalcon Alert, Dalcon’s Patient Care Notification and Alarm Management system. Wireless phones are an important part of the Dalcon Alert solution, and though Dalcon Alert is device agnostic, Dalcon advocates the use of Kirk healthcare specific wireless handsets.
15 Percent of Nursing Homes Fail to Meet Infection Control Standards
15 Percent of Nursing Homes Fail to Meet Infection Control Standards. A new study published in this month’s issue of the American Journal of Infection Control reveals that 15% of US nursing homes receive deficiency citations for infection control each year.
The study, which was carried out by a team of researchers from the University of Pittsburgh’s Graduate School of Public Health, analyzed deficiency citation data collected for the purpose of Medicare/Medicaid certification between 2000 and 2007. The data represented approximately 100,000 observations of roughly 16,000 nursing homes. Collectively, the analyzed data represents 96% of all nursing homes in the United States. The team noted a strong correlation between low staffing rates and infection control deficiency citations.
Infections are the Leading Cause of Nursing Home Deaths
The leading cause of morbidity and mortality in nursing homes, infections are responsible for nearly 400,000 deaths each year. Several states have enacted legislation applying to infection prevention practices in long-term care facilities. For example, Illinois lawmakers are close to passing legislation which would require an “infection preventionist” in every nursing facility. Despite increased political and media attention, raw empirical data is lacking on the subject.
The Centers for Medicare and Medicaid Services (CMS) requires nursing homes to be certified before receiving reimbursement from Medicare or Medicaid. As part of the certification process, facilities that fail to meet certain standards are issued deficiency citations. This study only examined the deficiency citation for infection control requirements, which is also known as F-Tag 441.
Infection Rates Connected to Low Staffing Levels
The authors of the study state, “Our analysis may provide some clues as to the reason for the persistent infection control problems in nursing homes. Most significantly, the issue of staffing is very prominent in our findings; that is, for all three caregivers examined (i.e., nurse aides, LPNs and RNs) low staffing levels are associated with F-Tag 441 citations. With low staffing levels, these caregivers are likely hurried and may skimp on infection control measures, such as hand hygiene.”
The authors summarize their observations saying, “The high number of deficiency citations for infection control problems identified in this study suggests the need for increased emphasis on these programs in nursing homes to protect vulnerable elders.”
New Patient Safety Initiative Advocates Culture of Safety
The United States’ new $1 billion patient safety initiative, Partnership for Patients, promises to save over 60,000 lives and over $10 billion in Medicare costs by the end of 2013 by focusing on reducing medical errors in hospitals.
Achieving the ambitious goals of the new Partnership for Patients program is not a matter of telling physicians, nurses, and other clinicians to be more careful, Donald Berwick, MD, administrator of the Centers for Medicare and Medicaid Services (CMS) says that achieving the program’s lofty goals is not a matter of reprimanding and retraining caregivers, but is rather an issue of reworking the system in which these caregivers operate.
Culture of Safety Enhances Patient Safety
“The workforce is not the problem,” says Dr. Berwick. “Doctors and nurses…want to offer safe care. They learned ‘do no harm’ in their training. In spite of that, patients get injured because of defects in the care system.”
Dr. Berwick points out that personal blame works against the culture of safety that hospitals need to establish in order to improve patient safety: “Blame and accusations are not the answers. Teamwork and improvement are the answers. Commercial air travel didn’t get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”
Understanding the complex systems-design challenges of addressing typical problems such as patient falls, the new federal program is assembling a versatile coalition of experts from groups such as the American Medical Association and the American Nurses Association, as well as leaders from major hospitals, employers, health plan experts, unions, patient advocates, and state and federal agencies.
Specific Objectives of the Patient Safety Initiative
There are two main objectives of Partnership for Patients. The first objective is to reduce the number of hospital-acquired conditions (HACs) by 40% by the end of 2013 compared with 2010. The second objective is to reduce hospital readmissions by 20% by improving follow-up care after discharge—sometimes described as “healing without complication.”
To reach these objectives the new Innovation Center at CMS will invest nearly $500 million in pilot projects aimed at reducing HACs and improving patient hand-offs. Initially, these projects will target nine common medical errors and complications including pressure ulcers, adverse drug reactions, surgical site infections, and childbirth complications.
CMS’s new Community-Based Care Transition Program will award another $500 million to community organizations that partner with hospitals to provide comprehensive follow-up care within 24 hours of a patient’s discharge from the hospital. “We know that if a patient’s primary care physician receives their discharge papers within 24 hours, the likelihood of a hospital readmission will be reduced,” says American Medical Association President Cecil Wilson, MD.
Partnership for Patients will analyze “best practices” from hospitals and institutions known for their patient safety practices and then share these practices with other organizations. As Dr. Berwick quips, “If there, why not everywhere?”
Dr. Berwick says it’s important to note that Partnership for Patients addresses the hotly debated issue of rising healthcare costs. “The options are either to cut care or improve care,” He says. “I’m against cutting. I’m for improving. Doing it right costs less than doing it wrong.”
Convening the First International Patient Safety Congress
On April 21, 2011 the First International Patient Safety Congress was inaugurated in Hyderabad, the capital city of Andhra Pradesh, India. Hosted by the Apollo Hospitals Group, the two-day conference was inaugurated by Dr. Preetha Reddy, MD, Apollo Hospitals Group.
The main purpose of the congress was to discuss how proactive system design in healthcare can improve patient safety. The multi-disciplinary lectures and sessions involved participants from all aspects of the healthcare continuum, including administrative and clinical leaders, practitioners, healthcare academics, healthcare regulators, caregivers, and patients.
Key lectures were delivered on the following topics:
- Patient Safety Priorities in Healthcare
- Framework – A Safety Imperative
- Focus on Monitoring & Analysis
- 4 Essentials of Patient Safety – The Challenges Faced
- Best Practices in Patient Safety
- Panel Discussion on Nursing
Dr. Reddy emphasized in her address to the congress that patient safety is a global duty which should be cultivated within every healthcare system. She said, “It is for the first time we have come together to address this issue, which focuses on the reporting, analysis and prevention of medical error that might lead to adverse situations. A challenging global issue both for developed and developing countries, patient safety also helps in defining quality healthcare. We have to come forward to train and educate people about patient safety which is a very important aspect for any healthcare provider.”
She stated that meeting those goals helps healthcare providers guarantee a safe healthcare environment for their patients. She also stressed that accreditation with groups such as the Joint Commission is vital to making a real improvement in patient safety within any healthcare organization.
Incident Reporting Emphasized
During her remarks on patient safety, Ann Jacobson, ED, from Joint Commission International (JCI) said: “To promote Patient Safety, practitioners should identify problem areas in a hospital and thereafter develop practices to correct these errors. A global Incident Reporting System and evidence-based Patient Safety solutions should be part of Standard Operating Procedures. Sentinel events should also be tracked. JCI-accredited hospitals have a mandate to conduct a root cause analysis of any sentinel event within 45 days of occurrence. All these procedures will go a long way in ensuring better Patient Safety outcomes.”
The World Health Organization called patient safety an international concern, citing that 1 out of every 10 patients worldwide is affected by medical errors. “It is with this background that Apollo Hospital Group accords the highest priority to the safety and quality of care for each of its patients. The Patient Safety Model was first launched in a few Apollo Hospitals and has now evolved and been adopted across all the hospitals within the Apollo Group, in India and overseas,” said Ms. Sangita Reddy, ED – Operations, Apollo Hospitals Group.
Apollo was incredibly pleased with the number and variety of professionals who attended the congress including more than 600 delegates from reputable healthcare organizations, healthcare institutions, and professional societies from across the globe. Based on the number of participants and optimistic about its ability to improve patient safety, the congress also announced plans to assemble a Patient Safety Coalition of healthcare leaders, experts, and innovators in the near future.
