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.”

More than 500 hospitals have committed to participate in the partnership, as well as numerous clinicians, employers, and patient-safety advocates, HHS said. Government estimates claim the program could help save 60,000 lives over the next three years and save up to $50 billion in Medicare costs during the next decade.

Initial funding of $500 million was made available recently as part of the Community-based Care Transitions Program, a provision of the healthcare reform law focused on improving readmission rates and transitions of care. According to HHS, the remaining sum of $500 million will be available through the CMS Innovation Center, supporting local projects that reduce hospital-acquired conditions (HACs).

“With new tools provided by the Affordable Care Act, we can aggressively implement programs that will help hospitals reduce preventable errors,” said CMS Administrator Dr. Donald Berwick, in the press release. “We will provide hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals and hospitals to support their efforts to reduce harm.”

Pushing for Widespread Involvement

Discussing how this initiative differs from previous ones focused on patient safety, Sister Carol Keehan, president and CEO of the Catholic Health Association, said HHS “is going after everyone,” rather than singling out a particular health system.
“The second thing that stands out is there are going to be consistent measurements and transparency about those measurements,” Keehan said. “And they’re going to share best practices—share tools—because people have done some really wonderful work around the country on various things.”  She added that stakeholders haven’t spent sufficient time documenting the methods and tools they’ve used to make changes and improvements.

When asked about the $500 million from the CMS Innovation Center to test different models of care, the center’s director, Dr. Richard Gilfillan, said official announcements regarding specific contracts will be made in the upcoming months.

Gilfillan said that demonstration projects will support a variety of network types and other activities to promote this effort among participating hospitals. He was optimistic, saying, “We’re going to find our way to engagement with every hospital in America.”

HHS said the partnership’s two highest goals are reducing the number of preventable HACs by 40% and reducing preventable complications occurring during care transitions by 20% by the end of 2013.

The proposed rule actually requires Medicaid nonpayment policies to adopt, at a minimum, Medicare’s current list of Hospital-Acquired Condition (HAC) guidelines, which include hospital acquired fall injuries and pressure ulcers, but also authorizes states to recognize unique PPCs under their applicable state plans, pending CMS approval through the state plan approval process. PPC is an umbrella term CMS created to signify conditions (inpatient and otherwise) states will not pay for.

The Reason for the Provider Preventable Conditions Rule

Prior to the proposed rule, since the Medicare HAC rule did not require state Medicaid programs to implement nonpayment policies for HACs, CMS had contacted Medicaid directors in 2008, encouraging them to modify nonpayment policies to reflect the Medicare HAC rule; however, subsequent review data showed great variation between nonpayment policies, with at least half of the policies exceeding Medicare’s HAC requirements. For this reason, the proposed rule seeks to provide a level of uniformity among Medicaid nonpayment policies.

The Rule’s HAC Reporting Guidelines

Under the proposed rule, states would also be able to identify the specific portion of a provider’s payment that arose from HAC treatment. CMS has stated that providers have no incentive to report conditions or events for nonpayment without clear and explicit reporting requirements. Therefore, the proposed rule would require provider self-reporting measures as well as systems within Medicaid programs that identify claims for nonpayment. CMS plans to utilize existing Medicaid claim systems as the platform for collecting and reporting the required data.

The rule was mandated by section 2702 of the Patient Protection and Affordable Care Act of 2010 (PPACA) and will go into effect on July 1, 2011. CMS is accepting public comments on the rule until March 18, 2011.

Click here to read the proposed ruling.

Starting in late 2012, the Centers for Medicare & Medicaid Services (CMS) will begin penalizing hospitals with higher than expected readmission rates

Stephen F. Jencks, M.D., M.P.H., and Amy Boutwell, M.D., internist at Newton-Wellesley Hospital in Newton, MA and Director of Health Policy Strategy for the Institute for Healthcare Improvement are experts on the subject of patient readmissions. They have developed a list of 12 preventative strategies suggested to help hospitals reduce readmission rates. Some of their strategies have yet to be fully tested in some care settings, but high readmission rates are pushing many healthcare facilities to put these proposals to the test.

1. Discharge Summaries

Complete discharge summaries within 24 hours of discharge. Most hospitals abide by the old standard of completing discharge summaries within 30 days of discharge.

However, Boutwell says, “I was trained that the summary is a retrospective report of what happened in hospitalization. But what we need today is anticipatory guidance. Patients get discharged and go home. They can’t fill their meds, insurance doesn’t cover the med or they have questions. They’re nervous and worried. They call their primary care provider, who didn’t even know they were admitted.”

According to Boutwell, the 30-day standard practice “might have sufficed in a time gone by. But that doesn’t work anymore. Information needs to be available at the time of discharge. There’s a growing recognition of this need, but staff bylaws haven’t changed.”

2. Lengthen the Handoff Process

In every step of the patient care process, including discharge, care teams must talk to each other about the patient.  Boutwell suggests that discharges should actually be called “transitions.” Jencks says that “senders and receivers, for example hospital discharge planners and skilled nursing facility staff and home health” should meet often enough that they learn about the realities of the transitions, for both sending and receiving.

Boutwell says that “taking this person-centered approach shifts the concept from discharge, which is a moment in time and you’re done with it, to a transition—a shared accountability. We need to make sure the receiving providers understand who this patient is, with a 360-degree view.”

3. Provide Medication on Discharge

Patients should be sent home with a 30-day medication supply, packaged with clearly explained dosage directions. This may be a challenge for hospitals with Medicare patients because of distinctions between Part A and Part B payment; however, for certain high-risk patients, such as patients with congestive heart failure or those with a history of readmittance, it might be preferable for the hospital to just absorb the cost.

4. Make a Follow-up Plan Before Discharging

Hospital staff should make follow-up appointments with a patient’s physician and should only discharge the patient after this appointment is scheduled. It is important to make sure the patient has transportation to and from the physician’s office and the patient understands the value of meeting within the time frame. Staff should also follow up with a phone call to the physician to make sure that the visit was completed.

5. Telehealth

Home Healthcare Partners in Dallas utilizes health coaches, intensive care clinicians, and wireless technology to record daily vital signs for nearly 2100 discharged Medicare fee-for-service beneficiaries for periods of 60 to 120 days. So far, HHP has followed this method for about 7,000 unduplicated patients over the past two years in hundreds of hospitals.

Wayne Bazzle, HHP’s CEP, says that the method involves calling patients by phone. The 5 to 15 minute calls occur frequently enough that Bazzle says, “we have their trust. We can help them stay out of the hospital if they’re more truthful with us about what’s going on, and if we see some deterioration, we can help them cope.  Normally it’s a medication management issue, or they’ve become a little too relaxed with their diet.”

Patients targeted for intense monitoring include those with several co-morbidities, those who have a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, diabetes, Alzheimer’s or hypertension.

6. Identify High-Risk Patient Groups

Hospitals need to retool their admission and readmission rates for demographic and disease characteristics to help identify high-risk patients. This can help hospitals to use their limited resources more effectively. Some hospitals have developed special programs for certain patient demographics, such as the group of hospitals in Los Angeles that discharges certain homeless patients to a nearby facility similar to a half-way house. That program saved the hospitals $3 million after just a few months.

Continue This Article…

Check back on Tuesday 3/1/2011 for the second part of “12 Ways to Reduce Hospital Admissions.”

Physician Compare expands upon the older CMS Healthcare Provider Directory, which helped Medicare beneficiaries find physicians enrolled in the program. The catalyst for the new directory is the Affordable Care Act which promotes healthcare transparency.

The new directory includes information on doctors of medicine, osteopathy, optometry, podiatric medicine, and chiropractic. Additionally some non-physician healthcare professionals such as nurse practitioners, clinical psychologists, registered dietitians, physical therapists, physician assistants, and occupational therapists, will be included in the database.

Physician Compare Remains Limited

Currently, the data available in Physician Compare is limited. The first phase of the directory includes information on location, group practice, where educated and year of graduation, and if quality measure information was reported to Medicare (optional). At this time, the directory does not provide specific quality measure information, only whether or not it was reported.

The second phase of Physician Compare is planned to take place later in 2011. The update will indicate whether professionals chose to participate in a voluntary effort with CMS to encourage doctors to prescribe medicines electronically.

Future plans for Physician Compare include offering more detailed information on the specific quality of care that consumers receive from the professionals detailed in the database. CMS must implement this feature by 2013 according to the Affordable Care Act.

According to the Centers for Medicare & Medicaid Services (CMS), “The Medicare and Medicaid EHR incentive programs provide a financial reward for the meaningful use of qualified, certified EHRs to achieve health and efficiency goals. By implementing and meaningfully using an EHR system, providers will reap benefits beyond financial incentives – like reduction in errors, availability of records and data, reminders and alerts, clinical decision support and e-Prescribing/refill automation.”

Definition of Meaningful Use

But what is meaningful use? The criteria for meaningful use will be established in three stages over the next five years. Stage 1 begins in 2011, Stage 2 in 2013, and Stage 3 in 2015. For this reason, the full definition of meaningful use has yet to be developed; however, the criteria for Stage 1 include the following:

• The use of a certified EHR in a meaningful manner (e.g.: e-Prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

According to CMS, “Meaningful use includes both a core set and a menu set of objectives that are specific for eligible professionals and hospitals. For Eligible Professionals, there are a total of 25 meaningful use objectives. 20 of the objectives must be completed to qualify for an incentive payment. 15 are core objectives that are required, and the remaining 5 objectives may be chosen from the list of 10 menu set objectives. For Hospitals, there are a total of 24 meaningful use objectives. 14 are core objectives that are required, and the remaining 5 objectives may be chosen from the list of 10 menu set objectives.”

According to QualityNet, an official communications portal of CMS, “CMS has identified a discrepancy between the claims data that hospitals submitted and the CMS data file that was used to calculate the HAC measures.” The suspension on the release of HAC information will give CMS time to investigate the discrepancy in the data.

The HAC data would have displayed hospital specific rates of the following 8 HACs, which are also classified as “never events,” as a downloadable file via CMS’s Hospital Compare website:

1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
4. Pressure ulcer stages III and IV
5. Falls and trauma (includes: fracture, dislocation, intracranial injury, crushing injury, burn and electric shock)
6. Vascular catheter-associated infection
7. Catheter-associated urinary tract infection
8. Manifestations of poor glycemic control.

There was initial concern from the American Hospital Association about the public release of HAC information because of the limited time hospital administrators were given to verify the accuracy of their hospital’s HAC data. CMS released the data to administrators on the 16th of September, and planned to release the same data to the public on the 28th of September.

CMS has not posted an updated release date at this time.

The resolution was passed in order to raise awareness for fall prevention.  Injury and death as a result of falls is a major issue for older adults.  One out of three older adults fall each year.  Consequently, falls are the leading cause of hospital admissions for traumatic injuries among older adults.

Additionally, the financial burden of falls is immense.  The Centers for Disease Control and Prevention estimate that falls will cost the Medicare program over $32 billion by the year 2020 if the rate of falls does not decrease.

In 2007, the cost of falls in hospitals alone cost the Centers for Medicaid & Medicare Services (CMS) over $6.5 billion.

What are Never Events?

Never events are a series of medical errors that are defined by CMS as, “clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.” Included in the CMS financial year 2009 list of never events that will be denied federal reimbursement are the following medical errors:

How Dalcon Alert Helps Prevent Pressure Ulcers (Bed Sores)

Obviously, never events can be quite costly for hospitals.  Yet some occur much more frequently than others.  Preventing bed sores can be difficult, but new technology is available to help hospitals prevent bed sores. Dalcon Alert is a system that contains 3 distinct sections that help nurses treat and prevent pressure ulcers.

1. Remote Patient Monitoring
2. Alert Management Software
3. Pressure Ulcer Management System

Dalcon Alert Remote Patient Monitoring

Remote Patient Monitoring is achieved by integrating with existing patient monitoring devices in the hospital.  Dalcon Alert automatically forwards all device alerts—via a text message—to wireless phones carried by the nursing staff.

Although Dalcon Alert contains the technology for nurses to remotely monitor patients via wireless phones, the pressure ulcer management system does not require their use or purchase.  If desired, hospitals can implement Dalcon Alert‘s Alert Management software & Pressure Ulcer Management System as a stand alone system, and use it as a tool to create and manage bed turn alerts using current hospital policy.

Dalcon Alert Alert Management Software

Dalcon Alert’s Alert Management application helps caregivers actively manage the many patient monitoring alerts that are created in the hospital. The Alert Management software is similar to a web application, but it can only be accessed from the browsers of computers on the hospital network.

The function of the Alert Management software is to display, in real time, all active alerts that are being managed by the Dalcon Alert system. Combined with Dalcon Alert’s pressure ulcer management system, Dalcon Alert‘s Alert Management software makes sure no pressure ulcer treatment is overlooked by staff.

Dalcon Alert Pressure Ulcer Management System

Dalcon Alert’s pressure ulcer management system is a unique solution. When this feature is turned on, the system automatically creates a “bed turn” alert that reoccurs after a set period of time (dictated by the hospital).  This “bed turn” alert is treated the same as any other alert that Dalcon Alert manages; relevant caregivers receive the alert on their wireless phone, and the alert is reported on the system’s alert management software.  Thus, caregivers are continually reminded to attend to and turn at risk patients. Because Dalcon Alert helps nurses pro-actively prevent pressure ulcer negligence, the occurrence of dangerous pressure ulcers in at risk patients is significantly reduced.

• Removing overhead paging and piped in music.
• Removing institutionalized signage and labeling (such as closet and bathroom labels).
• Removing medicine carts and large centralized nursing stations.
• Discontinuing long term use of patient monitoring systems that use audible alarms.
• Eliminating mass-purchased furniture displayed throughout the building.

Dalcon’s unique patient care communications solution, Dalcon Alert, is designed to help nursing homes make several of these changes.  As a result, facilities using the Dalcon Alert system will meet numerous new CMS Homelike Environment guidelines, and their quality of patient care will drastically increase.

Dalcon Alert provides a communications platform that eliminates the need for:

1. Overhead Paging
2. Audible patient monitoring alarms
3. A large centralized nursing station

How Does Dalcon Alert Eliminate Audible Alarms?

Dalcon Alert is a patient care communications system that has several features.  The system provides Remote Patient Monitoring and Alarm Management by integrating with patient monitoring devices including but not limited to:

• bed exit pads
• bed fall pads
• IV-Pumps
• Patient Nurse Calls

When an alert is created by any integrated device, Dalcon Alert routes that alert to a remote nursing station where it can be actively managed on a PC monitor using Dalcon Alert’s alert management software.  Dalcon Alert also sends that alert to select staff carrying fully functional wireless phones via text message, so they are immediately made aware of that alert regardless of their location—and without the use of audible alarms.

How Does Dalcon Alert Reduce the need for Overhead Paging and a Large Centralized Nursing Station?

Equipping vital staff with wireless phones is a central piece of the Dalcon Alert system.  These phones allow staff to receive important alerts regardless of their location.  Caregivers can be reached remotely by phone, vastly eliminating the need for overhead paging.

A key component of the successful implementation of a decentralized nursing station system is staff communication.  Dalcon Alert provides staff with an effective decentralized communications platform, built around fully functional wireless phones.  Also, Dalcon Alert’s alert management software is accessed via a browser, and there is no limit to how many computers can be logged on to it at once.  Thus, each decentralized nursing station can be actively managing alerts at any given time.