IHI's 5 Million Lives Campaign to Reduce Medical Harm Throughout the Nation

 

By Rita Bowling, RN, MSN, MBA, CPHQ, Director, Acute Care Services

 

Ohio KePRO, together with the Ohio Hospital Association (OHA) and the Ohio Patient Safety Institute (OPSI), will continue to act as the campaign node in Ohio for the Institute for Healthcare Improvement’s (IHI) 5 Million Lives Campaign. The node is known as “Ohio Quality and Patient Safety.” The Campaign seeks to dramatically reduce incidents of medical harm in U.S. hospitals. The 5 Million Lives Campaign asks hospitals to improve the care they provide in order to protect patients from 5 million incidents of medical harm over a 24-month period ending December 9, 2008. It represents a continuation of IHI’s 100,000 Lives Campaign – the largest improvement effort undertaken in recent history by the healthcare industry.

 

The Campaign was formally unveiled on December 12, 2006, and has been endorsed by the American Hospital Association (AHA), the American Nurses Association (ANA), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

 

The 5 Million Lives Campaign builds upon the success of the 100,000 Lives Campaign, in which 3,100 participating hospitals reduced inpatient deaths by an estimated 122,000 in 18 months through overall improvement in care, including improvement associated with six interventions recommended by the initiative. The new Campaign will promote the adoption of up to 12 improvements in care (detailed below) that can save lives and reduce patient injuries, and it aims to enroll even more hospitals than participated in the previous Campaign.

 

IHI estimates that 15 million incidents of patient harm occur in U.S. hospitals each year.

FIRST, DO NO HARM

“No one in healthcare can feel comfortable with the magnitude of infections, adverse drug events, and other complications that hospital patients endure,” said Donald M. Berwick, MD, MPP, FRCP, President and Chief Executive Officer of IHI. “Dozens of organizations and programs are now working to reduce that toll. They deserve encouragement. This Campaign joins those efforts, and seeks leverage and scale that our nation has never had before to make care safe—everywhere,” said Dr. Berwick. “We can, and we will, equip all willing healthcare providers with the tools they need to make the motto, ‘First, do no harm,’ a reality.”

 

IHI estimates that 15 million incidents of medical harm occur in U.S. hospitals each year. This estimate of overall national harm is based on IHI’s extensive experience in studying injury rates in hospitals, which reveals that between 40 to 50 incidents of harm occur for every 100 hospital admissions. With 37 million admissions in the United States each year (according to the AHA’s National Hospital Survey for 2005) this equates to about 15 million harm events annually—or 40,000 incidents of harm in U.S. hospitals every day.

IHI defines “medical harm” as unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death. (Please consult www.ihi.org for a detailed definition of medical harm.)

 

The 5 Million Lives Campaign aims to enlist 4,000 hospitals, challenging all to adopt up to 12 of the following interventions – six of which were included in the 100,000 Lives Campaign and six of which are new:

 

New interventions targeted at harm

• Prevent methicillin-resistant Staphylococcus aureus (MRSA) infection...by reliably implementing scientifically proven infection control practices throughout the hospital.
• Reduce harm from high-alert medications...starting with a focus on anticoagulants, sedatives, narcotics, and insulin.
• Reduce surgical complications...by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP). 
• Prevent pressure ulcers...by reliably using science-based guidelines for prevention of this common, yet serious, complication.
• Deliver reliable, evidence - based care for congestive heart failure …to reduce readmissions.
• Get Boards on board …by defining and spreading new and leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating the improvement of care.

The six interventions from the 100,000 Lives Campaign

• Deploy Rapid Response Teams…at the first sign of patient decline–and before a catastrophic cardiac or respiratory event.
• Deliver reliable, evidence - based care for acute myocardial infarction …to prevent deaths from heart attack.
• Prevent adverse drug events…by reconciling patient medications at every transition point in care.
• Prevent central line infections…by implementing a series of interdependent, scientifically grounded steps.
• Prevent surgical site infections…by following a series of steps, including reliable, timely administration of correct perioperative antibiotics.
• Prevent ventilator-associated pneumonia…by implementing a series of interdependent, scientifically grounded steps.

There is no cost for hospitals to join the 5 Million Lives Campaign. There is, however, an obligation to adopt at least one intervention and an expectation of regularly reporting hospital profile and mortality data throughout the Campaign.

 

For essential information regarding the 5 Million Lives Campaign, please see the accompanying article in this issue. For an in-depth understanding of these Campaign initiatives, please see the IHI Web site @ at www.ihi.org

 

 

 

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Reporting Estimated Glomerular Filtration Rate: The New Standard of Care

 

by Ronald A. Savrin, MD, MBA, FACS, Medical Director

 

Kidney failure is a common cause of death in the United States, accounting for more deaths than breast cancer, colon cancer or prostate cancer¹. Unfortunately, many cases of chronic kidney disease (CKD) are not recognized and subsequently progress to an advanced stage. Patients with diabetes, hypertension, advanced age, family history of renal disease, smokers and those of African American, Native American, Asian American or Latin American descent, among others, are at increased risk of developing CKD². Measures can be taken to slow its progression and control the disease process – but the first step is, as always, diagnosis.

 

Historically, physicians have used the serum creatinine and blood urea nitrogen (BUN) levels to estimate renal function. Neither is adequate for this purpose and it is widely recognized that the creatinine value is an inaccurate measure of renal status. Although serum creatinine is inversely related to creatinine clearance and glomerular filtration rate (GFR), that relationship is non-linear. Several variables, including age, gender and ethnic origin can affect the serum creatinine so that a creatinine of 1.3mg/dL in a 20-year-old African American male indicates an acceptable GFR of 91 ml/min/1.73m² while the same creatinine value of 1.3mg/dL corresponds to an GFR of only 56 ml/min/1.73m² in a white female of the same age, indicative of Stage 3 chronic kidney disease.

 

The National Institute of Health (NIH), National Kidney Disease Education Program (NKDEP), the National Kidney Foundation (NKF), and the Kidney Disease Outcomes Quality Initiative (KDOQI) recommend the Modification of Diet in Renal Disease (MDRD) equation, developed by the Modification of Diet in Renal Disease Study Group, as the method to report estimated glomerular filtration rate (eGFR). This equation is thought to be the most thoroughly validated and superior to the Gault-Cockcroft equation or a 24-hour urine collection. The Midwest Chronic Kidney Disease (CKD) Coalition and Ohio KePRO strongly support this recommendation.

 

Just as a Prothrombin Time (PT) is an inadequate measure of anticoagulation unless reported with an International Normalization Ratio (INR), a creatinine is an inadequate measure of renal function unless reported with an eGFR. All hospitals plus freestanding and independent laboratories can use routinely available demographic information to report an eGFR with every creatinine. The variables in the MDRD equation include serum creatinine, age, gender and race (African American or non-African American). The lab determines the creatinine upon request, and age and gender are available as claims data. Since the patient’s ethnic origins are not often known, the eGFR can be reported as two values – one value if African American, another value if non-African American. It is pertinent to note that this equation has not been validated in pediatric patients.

 

GUIDELINES FOR LABORATORIES

The Midwest Chronic Kidney Disease (CKD) Coalition recommends the following guidelines for reporting the MDRD eGFR:

• For eGFR values > 60 ml/min: report as >60 ml/min

• For eGFR values < 60 ml/min: report exact number

• Report TWO values for each sample

• X ml/min if African American

• Y ml/min if non-African American

• Indicate on report “Not validated in pediatric patients”

The role of hospitals and laboratories is a critical one. Knowledgeable physicians will understand the critical importance of the eGFR and will preferentially seek laboratories where their patients’ needs are met. Perhaps more importantly, hospitals, laboratories and pathologists should seek to improve the quality of care associated with their facilities. Reporting of eGFR with every serum creatinine will foster better medical care and serve to remind and educate physicians about the need to accurately assess renal function, especially in patients at high risk for chronic kidney disease and renal failure.

 

Lead the way to better care of patients with this common, potentially devastating, disorder. Institute the policy of routinely reporting the eGFR today. Using this classic “systems approach” to quality care can be simple yet extremely effective.

 

For questions or educational materials contact Ohio KePRO at 1-800-385-5080.

 

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References:

¹Mininio Natl Vital Stat Rep. 2002 Sep 16;50(15):1-119

²Bolton, Am J Kidney Dis. 2000;36(suppl 3):S4

US Renal Data System, USRDS 2000 Annual Report, NIH, June 2000

Pinto-Sietsma, Ann Int Med 2000;133:565

 

 

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Crew Resource Management, Part II

 

By Donna Moore, RN, MBA, CPHQ, Quality Improvement Project Leader

 

The concept of crew resource management (CRM) for improving healthcare was introduced in a previous issue of Quality Matters (www.ohiokepro.com > Publications > Newsletters > Quality Matters > Summer 2006. Another parallel area of focus from aviation safety is an error-tolerant culture: one that accepts errors but does not tolerate a violation of formal rules. A confidential reporting system is an integral part of this culture. Errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors, and the same error is likely to reoccur.

 

Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors¹. When caregivers are encouraged to report errors, solutions can be developed and implemented, preventing future errors and resulting in a safer culture.

 

For years, pilots have been participating in the National Aeronautics and Space Administration’s (NASA) Aviation Safety Reporting System (ASRS). A pilot completes an ASRS report when he or she believes that aviation safety was compromised. The report contains the perceptions of the pilot, crew members, air traffic controllers and other appropriate individuals. Multiple contributing factors may be identified including, but not limited to, communications breakdown, pilot error, or environmental issues such as poor lighting at an airport. This information is entered into a confidential aviation safety research database and cannot be used in enforcement action against those who submitted the report. Many safety programs and/or regulations have been implemented as a result of this type of reporting.

 

CURRENT HEALTHCARE CULTURE

Due to a lack of policies and procedures that encourage reporting of errors, the current healthcare environment does not encourage an error-tolerant culture. Policies and procedures must ensure confidentiality of reporting with no threat of punitive action for the omission or commission of an unintended error or near miss. This shift in thinking has significant implications for healthcare disciplinary and legal processes.

 

As reporting of errors and near misses increases, healthcare providers need to provide feedback to the staff and community regarding trends and actions taken to improve safety. This feedback needs to be timely, useful and constructive. Mutual trust and respect are apparent in an error-tolerant culture.

 

According to R. L. Helmreich, errors result from physiological and psychological limitations. Examples include fatigue, work overload, poor communication, imperfect information processing, and flawed decision making. They are all inter-related. As fatigue and workload increase, there is often a diminished ability to focus on the many tasks at hand. Instead, the individual focuses on one thing, rather than utilizing all the information available for decision-making. This in turn pre-disposes that individual to error. Inability to acknowledge and discuss fatigue and work overload also prevent unsafe conditions from improving.

 

Communication is the exchange of ideas, information, and instruction in an effective and timely manner so messages are correctly received and clearly understood. When information is missing, incorrect information is shared or a misinterpretation occurs, resulting in a communication error. Individuals often hear what they expect to hear. In a routine procedure, a nurse may “hear” a dosage that is routinely ordered instead of the actual dosage that was requested. Using aviation’s “read back” process may eliminate this type of communication error. Flying an aircraft into or out of an airport with a control tower requires communication between the pilot and Air Traffic Control (ATC). The pilot “reads back” all instructions provided by ATC. The next step is for ATC to verify “read back correct.” When this process is used in healthcare, communication errors decrease.

 

FOUR TYPES OF UNSAFE BEHAVIOR

There are four types of unsafe behavior: human error, negligent conduct, reckless conduct and intentional willful violation. Human error occurs when there is a general agreement that individuals should have done something differently. This may never be completely eliminated. An example of this is documenting a medication on the wrong medical record.

 

Negligent conduct occurs when a practice falls below the normal standard. Using an incorrect concentration of heparin is an example of negligence.Reckless conduct involves taking a conscious unjustified risk. Failure to wash hands between patients is an example of reckless conduct. Intentional willful violation is the conscious failure to adhere to procedures and regulations. When personnel perform a procedure or administer medication to a patient without performing two identification procedures, a violation occurs.

 

The National Transportation Safety Board (NTSB) uses the terminology “pilot error” when it has determined that the accident or incident occurred due to a mistake by the pilot, no matter what type of behavior occurred. By following the principles of the aviation industry, our healthcare system can eliminate many of the errors that threaten patient health and safety.

 

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Reference:

¹Kohn, LT, Corrigan, JM, and Donaldson, MS, Editors; Committee on Quality of Health Care in America, Institute of Medicine To Err is Human: Building a Safer Health System, 2000, pg.42.

 

 

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Implement Concurrent Monitoring to Ensure Every Patient Recieves the Right Care Every Time

 

By Patricia Nelson, RN, Quality Improvement Project Coordinator

 

In order to ensure every patient receives the right care every time and the care is documented, hospitals are strongly encouraged to implement concurrent monitoring and review. These terms are combined here because concurrent monitoring and concurrent review are often used interchangeably.

 

Concurrent monitoring facilitates care at the patient care level to prevent errors and near misses. During such reviews, errors of omission may be discovered. These errors should be corrected promptly because they too can cause morbid outcomes or death.

 

Concurrent monitoring should not to be confused with Utilization Management Concurrent Review, where guidelines define the process and quality monitoring and review is less formal and varies in application among institutions. Anecdotal information suggests using concurrent monitoring and review provides distinct advantages for identifying quality gaps and delivering appropriate care in real-time.

 

Anecdotal information suggests using concurrent monitoring and review provides distinct advantages for identifying quality gaps and delivering appropriate care in real-time.

Concurrent monitoring/review advantages may include the ability to:

• Identify cases where the appropriate care has not been given

• Provide opportunities to give this appropriate care prior to discharge

• Verify core measure care given is documented appropriately

• Provide real-time feed-back to clinicians of all disciplines

• Create opportunities for learning about core measures across disciplines and levels of staff

• Enhance the integration of quality monitoring into existing management oversight

• Help to integrate core measures into care processes

• Provide frontline staff with the opportunity to participate in quality monitoring and review

• Provide frontline staff with performance information in real-time

Concurrent quality measures monitoring and review activities/processes

• The hospitals that have been most successful have implemented some form or concurrent review to ensure that they have up-to-date information and can make appropriate changes to patient care in a timely manner. Concurrent monitoring and review interventions were shared by Appropriate Care Measures (ACM) Identified Participant Group (IPG) hospitals during an ACM Community of Practice Call on November 30, 2006. A summary of the information shared is as follows:

Interventions involving new processes

• Implement concurrent review and monitoring for all core measure patients e.g.. patients with acute myocardial infarction (AMI), heart failure (HF) and pneumonia (PN) to continually evaluate care processes for needed improvement from admission through discharge.

• Use concurrent review to identify gaps and opportunities.

• Use the principle admitting diagnosis to identify core measure patients and check related ICD-9 codes.

• Review core measures during regular care team morning and shift reports.

• Use brightly colored stickers on charts and Kardexes to alert staff that the patient has a core measure diagnosis.

• Develop and provide pocket cards listing the core measures and recommended treatments for AMI, HF and PN.

• Add contraindications check-off boxes to discharge forms to facilitate physician documentation.

• Integrate smoking cessation counseling at several levels of care delivery.

• Use an interdisciplinary screening form on admission that includes a history for all chronic illnesses. If there is a history of a core measure diagnosis, then guidelines can be addressed for these diagnoses.

• Encourage Emergency Department (ED) antibiotic administration for PN patients to eliminate delays in transfers to the Intensive Care Unit.

• Establish redundant documentation to ensure preoperative antibiotics administered by anesthesia are recorded and retrievable. Example: Use a circulator nurse to document the time the antibiotics were given.

• Revise an existing review process to include concurrent monitoring/review for core measures. For example, a nurse or case manager who is already reviewing all patients’ charts daily could easily monitor core measures simultaneously.

• Track performance daily if possible, producing analysis and feedback.

• Use computerized forcing functions to ensure documentation of tobacco cessation for HF, PN and AMI cases.

• Develop a treatment algorithm for each core measure diagnosis that can be laminated and placed on patient's chart as a reminder to clinicians about evidenced-based care.

• Place flyers on core measures information in key areas to serve as reminders.

Interventions involving staff resources:

• Identify specific staff to conduct monitoring and review. Suggestions include but are not limited to the following: Case managers, nurse managers, unit champions, and clinical nurse specialists.

• Set the expectation that these individuals will work with and support the staff nurse in core measure compliance.

• Identify and support physician champions.

• Consider having a nurse make rounds with the Hospitalist. This position could provide support to the physician and staff nurse to help ensure core measure compliance. This nurse is not assigned to direct patient care. The nurse makes telephone calls for the bedside nurse to the specialist or family when information such as immunization status is needed.

• Identify and designate nurse champions for each core measures diagnosis on each unit.

• Use pharmacy data to identify patients receiving drugs indicative of a core measure diagnosis. For example, patients receiving Lasix who may have a current diagnosis or history of heart failure.

Interventions involving education or feedback

• Provide education about core measures and evidence-based care for all levels of staff involved in direct and indirect patient care.

• Provide a process incorporating both verbal and written feedback to physicians when evidenced-based care is not provided.

• Develop weekly feedback reports and send to frontline managers and physicians. This may include ED physicians and managers for those core measures that are time- sensitive.

• Provide monthly core measure performance reports to hospital leadership.

• Make a personal request to the physician who may have forgotten to provide or document care required for a core measure diagnosis.

• Provide physician-friendly reminders to facilitate the documentation of all core measure care or rationale for not providing this evidenced –based care.

Interventions involving preparation for discharge

• Use multi-disciplinary discharge-planning rounds. Barriers to discharge are identified and discussed and a plan to deal with the barrier is put into place.

• Implement a medication reconciliation process that includes the discharge instruction sheet.

• Establish a process to ensure each item on the discharge sheet is checked For example, if the physician forgets to check a box, the item can be evaluated to ensure the heart failure patient is instructed as required and given a carbon copy.

Interventions involving patient self-monitoring

• Develop a discharge-teaching tool that incorporates self-management. Examples may include daily weight monitoring with advice to report a specified weight gain to their physician.

• Provide telemonitors to patients to decrease readmissions. Heart failure patient monitoring was used as an example, but this could apply to any diagnosis where monitoring is important to reduce readmissions.

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References

TQM/CQI Quality Links, July 09, 2006.  A collection of links related to Total Quality Management (TQM) and Continuous Quality Improvement (CQI). http://www.mytapestry.com/qlinks.html

 

MedQIC. www.Medqic.org

 

Institute for Healthcare Improvement (IHI)
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

 

 

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5 Million Lives Campaign — The Bare Essentials

 

By Barbara Stiebeling, RN, MSN, Quality Improvement Project Leader

 

In December 2006, the Institute of Healthcare Improvement (IHI) announced the new 5 Million Lives Campaign. Based on the successful implementation of the original six campaign topics of the 100,000 Lives Campaign, IHI introduced the following additional six focus areas for this 2-year campaign:

• Pressure ulcer prevention

• Methicillin-Resistant Staphylococcus aureus (MRSA) prevention

• Reducing harm from high alert medications

• Reducing surgical complications

• Providing appropriate care for patients with heart failure, and

• Enhancing hospital Boards’ roles in improving quality

Based on the successful implementation of the original six campaign topics of the 100,000 Lives Campaign, IHI introduced an additional six focus areas.

A quick reference to the new initiatives is outlined below.

 

PRESSURE ULCERS

“It is estimated that pressure ulcer prevalence (the percentage of patients with pressure ulcers at any one point in time) in acute care is 15 percent, while incidence (the rate at which new cases occur in a population over a given time period) in acute care is seven percent.”¹

 

Pressure ulcers cause needless pain and suffering. Complications include reduced functional abilities, serious infections, extended lengths of stay and increased mortality. In addition to personal cost (in the form of pain and suffering), the financial burden is great. Managing a single episode of care may cost as much as $70,000, and the total cost of treatment in the U.S. is estimated to be $11 billion.²

 

Nursing homes in Ohio are participating in a CMS project on pressure ulcers. This might be an opportunity to work with other providers in effecting a change in are and outcomes related to pressure ulcers in both settings.

 

Goal: Prevention

How: Implement the following interventions:

• Conduct a pressure ulcer admission assessment for all patients

• Reassess risk for all patients daily

• Inspect skin daily

• Manage moisture: Keep the patient dry and moisturize skin

• Optimize nutrition and hydration

• Minimize pressure

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

Treatment of healthcare-associated infections is a growing and complex issue due to antibiotic resistance. Infections caused by MRSA are particularly problematic due to their rise in incidence and strength. In hospital-acquired transmission, MRSA is found most often in intensive care units; however, community-acquired disease is rapidly emerging. Consider this project in conjunction with your work in the Surgical Care Improvement Project (SCIP) where a focus was on the inappropriate use of antibiotics as a cause of drug resistant infections.

 

The human and financial impact of MRSA is high:

• Over 126,000 hospitalized persons are infected by MRSA annually

• 3.95 MRSA infections occur per 1,000 hospital discharges

• Over 5,000 patients die as a result of MRSA infections

• Over $2.5 billion excess health care costs are attributable to MRSA infections

Finally, efforts to treat this and other resistant organisms can lead to other virulent infections such as Clostridium difficile (C. difficile).

 

Goal: Reduce Infection

How: Implement the following interventions

• Adhere to recommended hand hygiene practices

• Decontaminate the environment and equipment

• Conduct active surveillance cultures, especially of the anterior nares

• Adhere to contact precautions, especially gowns and gloves

• Institute care “bundles” to reduce device-related infections

HIGH-ALERT MEDICATIONS

High-Alert medications are those that may cause harm even when used as indicated. The most common drugs included in this category are anticoagulants, narcotics, insulin, and sedatives. Resultant harm associated with these medications includes hypotension, bleeding, hypoglycemia, delirium, lethargy, and bradycardia.

 

General interventions to reduce harm include the following actions:

• Use standardization

• Minimize variability

• Use reminders

• Institute protocols for special populations such as the elderly

• Expedite the reporting of critical lab values

• Use independent double-checks

• Develop rescue protocols

Recommended interventions for the safe management of anticoagulants

• Develop flow sheets that follow the patient through all transitions of care

• Use a dosing service or "clinic" in both inpatient and outpatient settings

• Implement weight-based protocols

• Use pre-printed order sets

• Account for use of thrombolytics and GIIg/IIIa inhibitors.

• Do not administer heparin within 6-23 hours of low molecular weight heparin (LMWH).

• Use standard concentrations

• Separate like products when using or storing.

• Dispense anticoagulant medication from pharmacy only

• Use smallest size package, concentration, and dose for floor stock

• For warfarin:

• Educate patients on how to take the medication, what medications to avoid, and identification of symptoms of harm

• Minimize available concentrations and strengths of oral drug

Recommended interventions for the safe management of narcotics:

• Standardize initiation and maintenance pain management protocols.

• Monitor for adverse effects

• Develop protocols that include guidelines for the use of reversal agents

• Utilize pain management specialists

• Increase non-pharmacologic interventions for pain and anxiety

• Program all pumps to allow for independent double-checks from pharmacy or nursing

• Perform independent double-checks for PCA and epidural narcotics

• Standardize drug strengths whenever possible

Recommended interventions for the safe management of insulin:

• Perform independent double-checks of the drug, concentration, dose, pump settings, route of administration, and patient identity before administering all IV insulin

• Use pre-typed diabetic and insulin infusion orders

• Separate look-alikes and sound-alikes

• Prepare all infusions in the pharmacy

• Standardize to a single concentration of IV-infusion insulin

• Encourage patients to manage their own insulin when possible

• Coordinate meal and insulin times

Recommended interventions for the safe management of sedatives:

• Limit the use of oral moderate sedation agents to one concentration

• Use preprinted order forms

• Monitor children receiving chloral hydrate for pre-operative sedation before, during, and after the procedure

• Have age- and size-appropriate resuscitation equipment and reversal agents available.

SURGICAL CARE IMPROVEMENT

Surgical complications increase pain and suffering, length of stay, cost and mortality. This initiative has the attention of many national organizations and is truly a collaborative effort to improve healthcare.

 

General interventions include the application of evidence-based practices: standardizing processes, redesigning care processes using human factors principles, involving patients and families and transforming the culture of healthcare to minimize blame and maximize communication and teamwork. Remember, reporting of SCIP measures is now required for full reimbursement of your Annual Payment Update from Medicare.

 

Goal: Reduce Surgical Complications

How: Implement the following interventions:

• Prevent Surgical Site Infection

  • Use antibiotics appropriately

  • When needed, remove hair with clippers

  • Monitor glucose in major cardiac surgery patients

  • Ensure immediate postoperative normothermia for colorectal surgery patients

• Administer beta blockers for patients on beta blockers prior to admission

• Provide appropriate venous thromboembolism prophylaxis when indicated

• Prevent ventilator-associated pneumonia

According to the Joint Commission Sentinel Event Statistics, communication is the root cause in more than 70 percent of postoperative sentinel events. Successful teamwork is an especially important element in the reduction of surgical complications. Each team member must feel empowered to speak up when an unsafe condition is observed.

 

CONGESTIVE HEART FAILURE

According to the 2006 Heart Disease and Stroke Statistics, congestive heart failure affects 4.9 million people. This disease, most commonly occurring in the elderly, accounts for up to 15 million office visits and 6.5 million hospital days each year. Due, in part, to inadequate treatment, discharge instructions and follow-up care, readmissions are common. The human and economic burden of this disease is expected to grow as the population ages.

 

If you are doing well in your Heart Failure care measures, it might be time for you to look at the transitions of care that occur as this type of patient moves through the entire healthcare system—acute care, primary care office, nursing home, and home health.

 

Goal: Improve care and reduce readmissions

How: Implement the following interventions

• Assess left ventricular systolic (LVS) function

• Prescribe ACE-inhibitor or ARB at discharge for patients with left ventricular ejection fraction (LVEF) <40%, unless contraindicated

• Prescribe anticoagulants at discharge for patients with chronic or recurrent atrial fibrillation (AF), unless contraindicated

• Provide smoking cessation advice and counseling

• Provide discharge instructions that address at least all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen

• Provide the Influenza vaccine according to the Advisory Committee on Immunization Practices (ACIP) guidelines

• Provide the pneumococcal vaccine according to ACIP guidelines

• . Provide beta-blocker therapy at discharge for patients without contraindications

GOVERNANCE LEADERSHIP

Based on the implementation of the 100,000 Lives Campaign initiatives, IHI studied those hospitals that were highly successful regardless of intervention chosen. As a result of this observation, a non-clinical intervention was born—that of fostering a deeply engaged leadership, starting with the Board of Trustees.

Boards of these high-performing and rapidly improving hospitals shared several characteristics that included the following:

• Providing clear direction and regularly monitoring performance

• Taking ownership of quality and addressing it at every board meeting

• Studying the gap between current performance and the best in class

• Embracing transparency

• Partnering with executives and clinicians to initiate and support improvement

• Seeking the input of patients, families and staff

• Reviewing surveys related to culture, satisfaction, outcomes and experiences of care and gaps in care

• Establishing CEO accountability for quality of care and linking compensation to it

• Establishing oversight through data reports and dashboards

• Requiring a commitment to safety in all job descriptions and an orientation to quality goals for all employees and physicians

• Establishing an interdisciplinary Board Quality Committee, meeting at least quarterly

• Filling board positions with quality leaders from health care and other industries

• Setting goals for educating board members about quality and safety

• Holding crucial conversations about system failures that result in harm

• Allocating adequate resources to improve quality

CMS and Ohio KePRO have also committed to the concept of senior leadership engagement in quality as a means of achieving high levels of quality care and culture change and to ensure care is patient-centered and effective. Hospitals are encouraged to consider these interventions in their CMS/QIO projects.

 

GOAL : Improve quality and reduce harm in their hospitals

How : Implement the following interventions

• Set aims for improvement

• Obtain and review data and listen to stories at each board meeting

• Establish and monitor system-level measures

• Establish and maintain a respectful, fair and just environment for patients, families and staff

• Establish a climate for learning and strive to be the best. Start with the Board

• Establish executive accountability for quality improvement

Ohio KePRO is committed to these campaign initiatives and looks forward to working with hospitals to achieve substantial improvements. For further information, contact the Acute Care Services Team at 1-800-385-5080; e-mail: hospital@ohqio.sdps.org.

 

The above article was adapted from topic specific “Getting Started Kits” found on the IHI Web site at www.ihi.org.

 

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References

¹National Pressure Ulcer Advisory Panel. Cuddigan J, Ayello EA, Sussman C, Editors. Pressure Ulcers in America: Prevalence, Incidence, and Implication for the Future . Reston, VA: NPUAP; 2001.

 

²Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296:974-984.

 

 

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Preventing Pressure Ulcers

 

By Leann Schaeffer, MA, RD, LD, LNHA, Quality Improvement Project Supervisor, Nursing Home Team, Ohio KePRO

 

Need help with pressure ulcer prevention and management? In addition to the Institute for Healthcare Improvement’s recent inclusion of this condition in their 5 Million Lives Campaign, many resources are available to you from Ohio KePRO.

 

Ohio KePRO’s Nursing Home Team has developed the Pressure Ulcer Resource Manual, has been offered to the more than 900 nursing homes in Ohio and is available to you as well.

Listed below are elements included in the manual:

• Facility assessment check lists

• Examples of screening and assessment tools (Braden Scale, Norton Scale, and the PUSH Tool)

• Plans of care

• Educational and training resources

We encourage you to visit the Ohio KePRO Web site at www.ohiokepro.com to find the resource manual. On the left side of the screen you will see “ Shopping Bag.” Click on this link. When the Online Catalog appears, go to the drop down menu on the right side of the screen entitled, “ Select a Category Below” and then select “Nursing Home.” Order the Pressure Ulcer Resource Manual. It will be shipped to you free of charge. You may contact us with questions or suggestions at ltc@ohqio.sdps.org or 1-800-385-5080.

 

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Acute Care Services Team

Ronald A. Savrin, MD, MBA, FACS

Rita Bowling, RN MSN, MBA, CPHQ

Jennifer Bitterman, RHIA, MBA

Susan Ferrante

Ann Fitzsimons, RN, MBA

Frances Hober, RHIA, MBA

Dawn Knopp, RN, BSN, CPHQ

Donna Moore, RN, MBA, CPHQ

Patricia Nelson, RN

Karl E. Peters

Liz Simpson

Barbara G. Stiebeling, RN, MSN

Karen S. Terlaak, RN

Mona D. Wendell, RN, BA, MBA

 

Medical Editor: Ronald A. Savrin, MD, MBA, FACS

Editor: Robert A. Feigenbaum, MS

Associate Editor: Barbara G. Stiebeling, RN, MSN

 

 

 

To Contact Us
E-Mail: hospital@ohqio.sdps.org
Provider QIC Line: 1.800.385.5080

 

Rock Run Center, Suite 100 · 5700 Lombardo Center Drive · Seven Hills, OH 44131 · www.ohiokepro.com

 

Ohio KePRO, the Medicare Quality Improvement Organization (QIO) for Ohio, is working with committed hospitals, nursing homes, home health agencies, and physicians throughout the state who are dedicated to the common goal of Continuous Quality Improvement for Medicare beneficiaries.

 

Publication No. 8031-OH-017-3/2007. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.