MSSPNexus Blog

Help Improve Patient Safety With These Free Web-Based Programs

Patient safety is the goal of every healthcare organization, and empowering patients to become part of their own safety team is an essential part of reaching that goal.

Emmi Solutions, a company that produces web-based patient education, is now offering free adult and pediatric patient safety programs that are available for placement on your own web site.  Each lasts about five minutes, and is a valuable addition to your organization's patient safety toolbox.

Adult:  http://www.emmisafety.com/Emmi.html

Pediatric:  http://www.emmisafety.com/pediatrics/Emmi.html

These programs are a simple and effective way to help educate patients and families about ways to keep themselves and their loved ones safe in the hospital.

Investigating Patient Complaints: The High Price of Hospital Non-compliance

By Lisa Venn, J.D., M.A., Advocate Alliance

Health care institutions beware!  Having a “Hear no evil; see no evil” patient complaint policy is an expensive proposition.  Just ask Oakland-based Kaiser Permanente which was fined $3 million by the California Department of Managed Care for, among other issues, failing to adequately handle, review and analyze patient complaints.  As quoted in the San Francisco Chronicle (7/27/07), the Department’s Director Cindy Ehnes, said “A patient has to be sure if they have a problem. . . the health plan has their ears open to hear those complaints and their arms available to tackle any of the problems that have arisen.  Those ears in particular seemed to be sometimes deaf.” 

A hospital which turns a deaf ear to patients’ complaints risk sanctions by the Centers for Medicaid & Medicare Services (CMS).  CMS’ Hospital Conditions of Participation (CoP) mandate the form and function of a hospital’s patient grievance program [42 CFR 482.13(a)]. If a hospital fails to comply with each and every CoP, CMS may terminate the hospital’s participation in the Medicare program. (www.cms.hhs.gov/SurveyCertificationEnforcement).

Read the rest of Investigating Patient Complaints: The High Price of Hospital Non-compliance

Interactive Medical Education on the Web - A New Tool for a Safer Patient Experience

You just found out that you're a candidate for surgery, or that you have a chronic medical condition; where do you turn for information beyond what your doctor provides? 

A growing majority of people look right here to the web.  A 2007 Harris poll found that 52 percent of adults sometimes or frequently go to the Web for health information, up from 29 percent in 2001.

A few years ago an entrepreneurial surgeon sat down with an interactive game developer to talk about how they could meld their areas of expertise.  The 2002 result of that conversation was a company called Emmi Solutions. Their interactive, web-based programs are designed to help patients understand what to expect, as well as provide supplemental information about the risks, benefits and alternatives to a particular treatment or procedure.  (Demo)

That collaboration created an impact on my life, as I've spent considerable time over the past few months working with the folks from Emmi Solutions and meeting with Clinic administrators, physicians, and other hospital leaders to introduce them to Emmi's web-based programs. 

Not only has the Cleveland Clinic subscribed to these programs for our patients, our wonderful MyChart and Epic electronic medical record teams have developed an HL7 (whatever that means...) interface so that the programs talk with one another. 

I have to say that it's been fascinating to be in the right place at the right time to become a participant in the development of leading-edge healthcare technology. 

P.S.
Answer to a frequently asked question:  Expectation Management & Medical Information

Simple Data Solutions - My New Alter Ego

My new alter ego:

www.SimpleDataSolutions.com

The company's first product release is a database designed to help hospitals and ambulatory surgery centers track patient comments, complaints and grievances. Developed with CMS regulatory compliance in mind.

How Does The Office of Risk Management Help Your Hospital?

What does Hospital Risk Management do?  Well, that depends on who you ask.

Every organization assigns different responsibilities to Risk Management.  Much like Medical/Professional Staff Offices, the roles can vary considerably from organization to organization.

The Yale School of Medicine / Yale New Haven Hospital posts the following about the goals of its Office of Risk Management:

Offices of Risk Management are concerned with a wide range of issues, however the overall goal is improvement of the quality of care and to eliminate or minimize the number of accidents with an eye towards claims prevention.

Goals of the Yale New Haven Hospital Office of Risk Management: 

1. Decrease severity and number of patient and visitor injuries by:

• receiving and reviewing incident and occurrence reports, as well as patient/visitor complaints.
• working closely with quality assurance/improvement committees.
• periodically reviewing credentialing procedures.
• being involved in the education of medical staff and employees via grand rounds, inservices and other venues.

2. Assure that documentation of care is adequate by:

• working closely with medical record committee.
• educating medical staff and employees.

3. Limit financial loss related to clinical care and provide a mechanism to deal fairly with issues related to claims from adverse outcomes in clinical care. The office: 

• investigates professional liability claims (i.e., malpractice) and negotiates fair resolution.
• manages certain insurance policies which have been secured by the hospital and its employees.

Whether or not you have an interest in the field, most would agree that these goals provide value, both to the organization and to it's patients.

I personally liked the YNH statement because limiting financial loss was included last.  Not because it isn't important, but because taking care of items one and two will help item number three take care of itself, and help keep patients safer in the process.

National Patient Safety Week - March 2-8, 2008

When we board a plane we put our lives in the hands of others.

We fly based on the belief that airline employees are well-trained, conscientious, and careful. We understand that it’s not just the knowledge and skill of the pilot and co-pilot that matter. Our lives also depend on the work of flight attendants, ground crew, air-traffic controllers and a host of others. In particular, our lives depend on all of those people communicating well.

When patients enter our hospitals they put their lives in our hands.

They enter based on the belief that hospital employees are well-trained, conscientious and careful. They understand that it’s not just the knowledge and skill of the physicians and surgeons that matter. Their lives also depend on the work of nurses, pharmacists, technicians, and a host of others. In particular, their lives depend on all of those people communicating well.

That analogy was the basis of Cleveland Clinic’s Chief of Staff, Dr. Joseph Hahn’s introduction of Peter Pronovost, M.D., Medical Director, Center of Innovations in Quality Patient Care at Johns Hopkins Hospital, the key-note speaker at our 2008 National Patient Safety Week Forum.

   

Dr. Pronovost opened with the statement that quality initiatives often fail because we do not view (or fund) the delivery of healthcare as a science.

He shared the sobering observation that around the nation all of our investigation, tracking and trending is not making an appreciable, measurable, difference in patient safety. Despite thorough investigation and root cause analysis, Sentinel Events continue to happen.

So what steps can we take to treat the delivery of healthcare as a quantifiable science?

A few of Dr. Pronovost’s recommendations:

• Take a lesson from industry: identify and learn from defects.
• Translate evidence to practice.
• Ask the front-line staff: Based on the action we’ve taken, do you think the risk of this happening again has been reduced? Why, or why not?
• Base change initiatives on credible, scientifically sound data, while not ignoring local wisdom. (A difficult balance.)
• Connect technical resources with culture change to continuously move toward improved patient safety.
• Develop central data management, but local ownership. (In other words, don’t assign your front-line staff data collection duties, but allow them ownership of the results.)
• Develop bi-directional communication between front-line staff and leadership.

He reminded us that without valid measurement tools we believe that we are safer than we are, and advised that we regularly ask, "How is the next patient going to be harmed?"

Could these ideas from Johns Hopkins work in your hospital?

• New physicians are assigned to round with a nurse for two hours, with the expectation that they will report back on issues they observe regarding safety and communication.

• At the beginning of a new OR case everyone in the room introduces themselves by first name and role. It was noted that initially some physicians needed reassurance that being called by their first names does not diminish their authority. All team members are encouraged to value open communication and work to overcome barriers to that goal.

Evidence shows that one of the strongest predictors for clinical excellence is whether caregivers feel comfortable speaking up if they perceive a problem with patient care.

Toward the end of his presentation Dr. Pronovost reminded us that healthcare organizations must not compete on issues of safety. Healthcare organizations must partner and collaborate with one another to develop better tools for safe patient care.

Additional patient safety information is available from the Johns Hopkins Bloomburg School of Health: http://www.jhsph.edu/ctlt/training/patient_safety.html

When Health Care Goes Wrong - Sentinel Events

We all know that mistakes happen in healthcare.  Anyone who has read the Institute of Medicine's To Err is Human Report knows they happen all too often.  Fortunately, most mistakes result in little or no harm to patients.  But what about those events where that is not the case?  The most serious events are referred to as Sentinel, because they signal the need for an immediate investigation and response.

Often, even experienced health care providers are uncertain how to define and respond to sentinel events. Here is a brief overview of both issues, with a focus on the requirements for Joint Commission accredited organizations.

Just what is a Sentinel Event?

Definition:

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

The Improving Organization Performance standard, PI.2.30, requires each accredited organization to define “sentinel event” for its own purposes in establishing mechanisms to identify, report, and manage these events.

Joint Commission Survey Review

In support of its mission to continuously improve the safety and quality of health care provided to the public, the Joint Commission reviews organizations’ activities in response to sentinel events in its accreditation process.

Organization Response:

Accredited organizations are expected to identify and respond appropriately to all sentinel events.

Appropriate response includes conducting a timely (within 45 days of the event, or the organization becoming aware of the event), thorough, and credible root cause analysis and developing an action plan designed to implement improvements to reduce risk. The organization is also expected to monitor the effectiveness of those improvements.

Reporting Sentinel Events to the Joint Commission:

Self-reporting a sentinel event to the Joint Commission is not currently required.  However, whether or not the hospital voluntarily reports the event, the same response, time frames, and review procedures are expected.

Should the Joint Commission become aware of the event, either through survey findings, news reports, a patient complaint, etc., an on-site review generally does not occur unless it appears there is an immediate threat to patient health and safety.

More often, the CEO is contacted and and an assessment of the event is made. Documentation of the root cause analysis and action plan are forwarded to the Joint Commission for review.  After working with the organization, if the JC determines that the documentation and/or response are ineffective, accreditation status can be impacted.

More information regarding Sentinel Event standards from the Joint Commission.   

Suffering Loss

This patient's catastrophic death struck me and everyone else involved in his care as a complete and utter surprise. I had been trying to help this boy, and he suddenly and unexpectedly died. Never, until the moment the process server showed up in my new office, did it occur to me that what I had and had not done could be construed as malpractice. When I opened the envelope and read these things about my being "negligent, careless, and without skill", I picked up the phone and called my personal lawyer. I thought I was being accused of manslaughter. I had suffered the loss of a patient and now I was being accused of having killed him, or so I thought.

My lawyer calmly explained that I was being sued for malpractice, not manslaughter and advised me to call my malpractice carrier. I put the envelope in my top drawer and went in to see my first patient of the day. My new practice had been open for two months.

Dr. Robert Lindeman, a pediatrician from the Boston area, blogged anonymously as Flea.  The combination of that blog and the trial noted above changed his life when he unexpectedly landed on the front page of the Boston Globe last May.

The medical blogosphere was rocked by the impact of the case, but of particular interest to those of us who work with physicians are Dr. Lindeman's words about how it felt to be named in a medical malpractice suit.  He speaks to that during an insightful interview with Eric Turkewitz, author of the New York Personal Injury Law Blog.

Patient Complaints - How Does Your ASC Handle Them?

I'm featuring a brief article here from guest writer Lisa Venn, J.D., M.A., of Advocate Alliance.  Lisa's topic is the Centers for Medicare and Medicaid Services (CMS) proposed new patient grievance regulations for Ambulatory Surgery Centers.

Ambulatory Surgery Centers’ Patient Grievance Process

In August 2007, the Centers for Medicare & Medicaid Services (CMS) responded to a 2002 Congressional report calling Ambulatory Surgical Centers (ASCs) a “System in Neglect.” CMS proposed new ASC patients’ rights which include a mandate that ASCs establish a patient grievance process.

With history as a guide, ASCs should expect the proposed standards to become reality. In recent years, CMS has mandated that, in order to participate in the Medicare program, a nursing home or hospital must establish a patient grievance process. In many respects, the proposed ASC patient grievance process mirrors the hospital patient grievance regulation.

Like hospitals, ASCs will be required to investigate, document and respond to all grievances made by a patient or the patient’s representative. Grievance is broadly defined as including, but not limited to, mistreatment, neglect, verbal, mental, sexual or physical abuse, and theft of personal property. ASCs will be required to specify time frames for review and response to grievances. As are hospitals, ASCs will be required to provide patients with written notice of the ASC’s decision, ASC contact person, the results of the grievance process and the date the grievance process was completed. Under both hospital and ASC regulations, Medicare patients are provided extra protection by accreditors and State agencies. Like hospitals, ASCs will be required to inform patients and educate staff about patients’ rights and the grievance process.

When planning for the future, ASCs need only look to their nursing home and hospital counterparts. CMS has consistently required providers to establish a patient grievance process as part of quality improvement and patient safety. ASCs should plan, sooner rather than later, to establish a patient grievance process.

All of the proposed new rules for ASCs can be found at: http://www.cms.hhs.gov/center/asc.asp

Patient Complaints - How Does Your Hospital Handle Them?

If your hospital is like most, the process for handling patient complaints is not well defined.  Whoever hears the complaint or receives the letter generally does their best to track down answers and get back to the complainant.

However, hospitals that participate in Medicare and Medicaid must meet more specific patient rights requirements in order to comply with the Conditions of Participation by which they're bound.

According to the newly released book "Complying With CMS Patient Grievance Regulations" by Lisa Venn, J.D., M.A., (Disclaimer: I work with the author and am developing a related product.) patient grievances must be handled by a centralized body (not a single individual) which has been authorized by the Governing Board to receive, investigate and resolve patient grievances on the Board's behalf. 

The CoP requires that hospitals inform the patient and/or the patient's representative of the hospital's grievance process, including the right to file a grievance with the State agency.  Hospitals are also required to keep records on all complaints and grievances and incorporate the information into the organization's quality improvement process.

The Society for Healthcare Consumer Advocacy posted the August 2005 CMS letter regarding new rules for patient grievance, along with their commentary (in red) on the SHCA web site.  Stephen Frew, J.D., of Medlaw.com also commented on the CoP revisions regarding grievance.  Joint Commission is incorporating patient grievance requirements into its Patient Rights standards, so these requirements are here to stay. 

As healthcare providers we may find the requirements a challenge to manage, but as patients, (And aren't we and our loved ones all patients are some point?) we can take comfort in knowing that hospitals must have a formal process in place to deal with serious issues that we bring to their attention.

Oh and by the way, similar requirements also apply to Ambulatory Surgery Centers.  More on that in a future post.