By Tim Lockney, School of Medicine, Class of 2013

1. “Global Trigger Tool” Shows Adverse Events May Be 10 Times Greater Than Previously Measured

An article published in Health Affairs journal April 2011 used the Institute for Healthcare Improvement’s Global Trigger Tool to look at 795 patient records at 3 tertiary care hospitals in October 2004. The study found that the adverse event detection methods commonly used to track patient safety in the U.S. today, voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators, missed 90 percent of the adverse events. The Global Trigger Tool found at least ten times more confirmed, serious events. Overall, adverse events occurred in one-third of hospital admissions.

http://content.healthaffairs.org/content/30/4/581.full.pdf+html

2. Adherence to Guideline-Directed Venous Thromboembolism Prophylaxis Among Medical and Surgical Inpatients at 33 Academic Medical Centers in the United States

A study published in the American Journal of Medical Quality collected data describing compliance with established venous thromboembolism prophylaxis guidelines in medical and surgical inpatients at 33 US academic medical centers. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. Despite guidelines, venous thromboembolism prophylaxis remains underutilized in these centers, with only 48% of patients receiving guideline-directed prophylaxis—59% of which were medical and 41% of which were surgical patients. The study remarked: “Because academic medical centers provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.

http://ajm.sagepub.com/content/26/3/174.full.pdf+html

3. “Clean Spaces, Healthy Patients” Initiative

The Association for Professionals in Infection Control and Epidemiology and the Association for the Healthcare Environment have partnered in a joint campaign “Clean Spaces, Healthy Patients: Leaders in Infection Prevention and Environmental Services working together for better patient outcomes” to improve the relationship between infection prevention and environmental services in reducing the incidence of healthcare-associated infections. Daily cleaning and disinfecting of an occupied patient room with attention to bedrails, knobs, call buttons, etc. will take 25-30 minutes per room, while a post-discharge cleaning may take 40-60 minutes. Well-established guidelines for proper cleaning exist, and should be made available. Results of a survey indicated that 51% of infection prevention and environmental services professionals find it difficult to locate resources about proper cleaning and disinfection, and 54% believe other staff should be educated about their role in cleaning.

http://www.psqh.com/latest-news/122-current-news/979-apic-and-ahe-partner-on-clean-spaces-healthy-patients-initiative.html

(Watch directly on YouTube here)
We apologize for some faulty camerawork at the beginning of the video. The recording improves 5 minutes into the video. We hope to be able to offer online recordings of all future talks that are part of our quarterly lecture series!

After the talk by Mr. Hill, Tim Lockney, Co-President of VHIG, spoke to the students about opportunities to get involved in VHIG, including our Fundamentals of QI Elective, 4th Year Medical Student QI Practicum, various officer positions, and research opportunities in patient safety and quality improvement. Looking to get involved in VHIG? Feel free to e-mail us at VHIG@vanderbilt.edu!

]]> http://www.vanderbilt.edu/vhig/2011/09/watch-the-vhig-quarterly-lecture-series-online/feed/ 0 http://www.vanderbilt.edu/vhig/2011/09/speaker-of-the-week-for-wednesday-september-28-julie-morath/ http://www.vanderbilt.edu/vhig/2011/09/speaker-of-the-week-for-wednesday-september-28-julie-morath/#comments Tue, 27 Sep 2011 01:41:27 +0000 scotthagan http://www.vanderbilt.edu/vhig/?p=675 Julianne Morath has three decades of executive leadership in healthcare and multiple faculty appointments.  Among her awards, Ms. Morath was the inaugural recipient of the John Eisenberg Award for Individual Lifetime Achievement in Patient Safety, awarded through The Joint Commission and National Quality Forum.  She is currently Chief Quality and Patient Safety Officer for Vanderbilt University Medical Center, Director of the Center for Clinical Improvement, and Associate Professor of Clinical Nursing.  She serves on the Board of the National Patient Safety Foundation and the Virginia Mason Medical Center and Health System.  Ms. Morath is a founding member of the Lucian Leape Institute. She is an elected member of the Board of Commissioners for The Joint Commission (TJC) and chairperson of the National Nursing Advisory Committee. She is published in the areas of leadership, quality, and patient safety, and a frequent speaker and consultant within the US and internationally.

Morath’s lecture will focus on the importance of addressing culture in quality improvement initiatives and techniques that have been used to implement culture change.

If you would like to attend this session on the evening of Wednesday, September 28, please e-mail us at vhig@vanderbilt.edufor more details.

By Scott Hagan, School of Medicine, Class of 2013

1. Privacy Curtains in Hospital Patient Rooms Carry Dangerous Bacteria

In a study with preliminary results presented at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy, Dr. Michael Ohl and colleagues from the University of Iowa found that the privacy curtains used in hospital carry bacteria such as MRSA carrying a significant morbidity risk. Dr. Ohl found that these infected curtains could impose a significant risk for patients, especially those in medical and surgical intensive care units who are predisposed to worse outcomes from iatrogenic infections. Dr. Ohl and his team swabbed 43 hospital curtains several times a week to determine the speed at which curtains become diffusely infected with dangerous bacteria. The researchers found that 12/13 curtains showed cultures positive for contamination within a week, and that, by the end of the study, virtually all privacy curtains (41/43) showed signs of contamination on at least one occasion.

Dr. Ohl expressed during the conference that hospitals should now take greater precautions to account for the risk of iatrogenic infections via infected privacy curtains. One potentially effective and simple intervention that Dr. Ohl suggested was for medical teams to wash their hands when entering a patient room after they had already opened the privacy curtains to prevent transfer of pathogens from curtains to the patient through the provider’s hands.

News: Reuters (9/22), Huffington Post (9/26)

2. Agency for Healthcare Research and Quality (AHRQ) Launches Initiative to Improve Communication between Patients and Providers

The AHRQ, an agency under the Department of Health and Human Services (HHS), announced a new initiative aimed to improve patient-provider communication by encouraging patients to feel more at ease in asking important questions regarding their health, and by encouraging providers to be prompt questions that allow patients to express their more important health concerns. As part of the initiative, AHRQ has developed a page on their website that helps patients prioritize the questions they wish to ask during encounters with health care professionals. The agency has also launched a series of PSA videos to help spread the message about the importance of asking questions during clinic appointments. To reach out to physicians, AHRQ is launching ads for the program in NEJM, JAMA, Annals of Internal Medicine, and other prominent medical journals.

News: AHRQ (9/21), WSJ (9/20)

3. Study Outlines Reasons for Delays in Percutaneous Coronary Intervention (PCI) for Patients with ST-Elevated Myocardial Infarction (STEMI)

In a study released by the Circulation, a journal of the American Heart Association, Dr. Timothy Henry and colleagues of the Minnesota Heart Institute Foundation found that 33% of patients experiencing an ST-Elevated Myocardial Infarction (STEMI) have delays in receiving a potentially life-saving percutaneous coronary intervention (PCI). An especially important reason for delays in care is that many community hospitals do not have the capacity to perform PCIs, thus necessitating transfer of unstable patients to tertiary care centers. The study found the following to be the most important reasons for delays in care:
  awaiting transportation ─ 26 percent;
  emergency department delays ─ 14 percent;
  diagnostic dilemma ─ 9 percent;
  initial negative test for heart attack ─ 9 percent; and
  cardiac arrest ─ 6 percent.

Of the patient sample investigated in the study, 30% received treatment within 90 minutes, and 66% received treatment within 120 minutes. Of the remaining 34% that received treatment outside of 120 minutes, over 2/3 of the delays could be attributed to the referring facility that was unable to provide invasive treatment. The study’s authors believe that this data should provide an impetus to the American Heart Association and other players to encourage better coordination of regional systems of care for patients with STEMIs.

News: Advisory Board (9/21), MedPage Today (9/19)
Study: Circulation (9/19)

Dr. Hathaway is an assistant professor in the Department of Medicine at Vanderbilt University. A graduate of the Vanderbilt University School of Medicine, Dr. Hathaway completed a quality improvement fellowship at the VA where he currently spends much of his time seeing patients, leading quality improvement initiatives, and teaching current Quality Scholar Fellows. As a faculty advisor to the Vanderbilt Healthcare Improvement Group, Dr. Hathaway has mentored several medical students completing quality improvement projects and will be lecturing for the 2011 elective on Models & Measures for quality improvement initiatives.

If you would like to attend this session on the evening of Wednesday, September 21, please e-mail us at

vhig@vanderbilt.edu for more details.

This Week’s Top 3 Stories in Patient Safety and Quality Improvement in Healthcare

By Michele Luhm Vigor, School of Medicine, Class of 2014

1. The Joint Commission Names Names: Annual Report on Quality and Safety 2011- 9/13/11

This past week, the nation’s leading hospital accreditation board released their annual report on quality and safety:Improving America’s Hospitals. The reporting is a measure of accountability, with scores based on diligence in following protocols when treating conditions like heart attack, pneumonia, and childhood asthma attacks. For the first time ever, the names of the top-performing hospitals were made public. This list of 405 represents about 14% of hospitals under accreditation and contains a disproportionately high number of rural and small hospitals, and includes 20 Veterans Affairs medical centers. The country’s highest-regarded hospitals were almost universally missing from the list, which included only those hospitals achieving quality measures above a 95% threshold. Hospital quality experts acknowledge that because these are measures of process, not of outcomes, failure to reach the 95% threshold cannot be explained away by having sicker and more complicated patients. While higher volume hospitals are busier and generally have more reporting to do, they also have more resources to meet these goals. As there is an increasing trend of hospital reimbursements being tied to quality measures like infection rates and readmissions, compliance with procedural standards will become even more consequential moving forward. The Joint Commission plans to withhold accreditation from any hospital that posts a composite score below 85 percent.

Some of the key findings were a nine year composite performance improvement of 14.8% in accountability measures in America’s hospitals Ð a significant enhancement in patient safety. Hospitals have significantly improved the quality of care provided to heart attack, pneumonia, surgical care and children’s asthma care patients, according to composite accountability measures results. Fifteen new measures were introduced last year. There is still room for improvement: some of the lowest performance measures included providing fibrinolytic therapy within 30 minutes to heart attack patients and providing antibiotics to (immunocompetent) intensive care unit pneumonia patients.

Report: http://www.jointcommission.org/assets/1/6/TJC_Annual_Report_2011_9_13_11_.pdf
Articles:Medscape; New York Times

2. AHA Fights Penalties, Says Some Readmissions Warranted – 9/14/11

While some of the 2 million annual Medicare patient hospital readmissions (within 30 days of discharge) are likely to be evidence of low-quality care, the American Hospital Association (AHA) is urging stakeholders to reassess the use of readmission rates as a determinant of payment penalties. They claim that the current language does not differentiate between unplanned and planned readmissions, and express concern that hospitals will be discouraged to appropriately admit patients in need of care and exacerbate inequities.

Article: Advisory Board Company [subscription required, free for Vanderbilt students and faculty]

3. Million Hearts Initiative Aims to Prevent Strokes, Heart Attacks – 9/13/11

In order to get all physicians on board with quality reporting, the Department of Health and Human Services (HHS) has unveiled an ambitious plan to reduce cardiovascular disease that will have a wide effect on physicians, ranging from quality bonuses to electronic health record (EHR) systems. By incentivizing a greater focus on existing cardiovascular measures of quality care, the initiative aims to prevent 1 million heart attacks and strokes over the next 5 years through clinical interventions and changes in diet, exercise, and tobacco use. The ”ABCS” of clinical prevention include aspirin for high-risk patients, blood-pressure control, cholesterol management, and smoking cessation.

Strokes and heart attacks strike more than 2 million Americans each year, half of whom die, according to HHS. “This isn’t just a human tragedy, it’s also a huge drain on our economy,” HHS Secretary Kathleen Sebelius commented during a press conference, noting that medical costs and lost productivity related to cardiovascular disease add up to roughly $450 billion a year. The cure is far less expensive, she said. “We know that most heart attacks and strokes can be prevented with simple, low-cost care.”

Campaign website: HHS Million Hearts Campaign
Articles: Medscape; New England Journal of Medicine Perspectives

Professor Michael A. Lapré is an internationally known expert on organizational learning curves. He is primarily interested in empirical research on improving organizational performance.  Lapré is an associate editor for Management Science (MS) and a senior editor for Production and Operations Management (POM). Professor Lapré joined the Owen faculty in 2001, after spending four years on the faculty at Boston University, where he was a recipient of the Broderick Prize for Excellence in Research.

Professor Lapré will provide a lecture on operations models for process improvement in healthcare delivery.Discover how operations science from the business world can be used within healthcare to improve processes and increase reliability/safety, with the specific example of the Toyota Production System.

By Kate Gurba, School of Medicine, Class of 2014

1. Aggressive medical therapy is superior to stenting for treatment of intracranial arterial stenosis – 9/7/11

Fifty institutions participated in a randomized clinical trial to determine optimal treatment for preventing additional strokes in high-risk stroke patients, defined as those who had a recent TIA or stroke and severe stenosis (70-99%) of a major intracranial artery.  The study compared percutaneous transluminal angioplasty and stenting (PTAS) to “aggressive medical management” (aspirin, clopidogrel, and management of primary and secondary risk factors with lifestyle modification).  Aggressive medical management proved superior due to high rates of periprocedural stroke in the PTAS group.  Although monitoring continues, patient enrollment was terminated for ethical reasons in April 2011.

http://www.nejm.org/doi/full/10.1056/NEJMoa1105335

2. Health care reform did not affect ED usage in Massachusetts compared to regional trends – 9/7/11

Both increases and decreases in emergency department usage have been predicted to occur after an increase in the insured population (i.e., after Massachusetts-style health care reform).  A recent study compared quarterly numbers of ED visits in Massachusetts, Vermont, and New Hampshire between January 2004 and December 2009.  Massachusetts implemented health care reform over the course of a year, from October 2006 through December 2007.  All three states experienced continuous upward trends of ED utilization throughout the study period, but trends did not differ among states. This was true both for total numbers of ED visits and numbers of ED visits resulting in hospital admission.

http://www.nejm.org/doi/full/10.1056/NEJMp1109273

3. U.S. health spending increases are primarily due to increases in cost per case and treated prevalence, not increased disease prevalence – 9/2011

In an effort to determine the primary causes of increased health spending, a recent study reviewed the clinical prevalence (number of people with a given disease), treated prevalence (clinical prevalence multiplied by fraction receiving treatment) and cost per case of multiple diseases between 1996 and 2006.  The authors conclude that, of increased per capita health care spending over that period, approximately three-fourths was due to cost per case and one-fourth was due to an increase in treated prevalence.  Thus, an increase in overall disease prevalence may not be a primary driver of increased health care costs.

http://www.ncbi.nlm.nih.gov/pubmed/21900655

By Natalie Ausborn, School of Medicine, Class of 2013

1. Handwashing signs emphasizing patient versus provider safety improves compliance – 8/29/11

A two-week study by Adam Grant, a psychological scientist at The Wharton School, University of Pennsylvania, and David Hofmann, University of North Carolina at Chapel Hill, posted two variations of a handwashing sign above soap and hand sanitizer dispensers. One stated, “Hand hygiene prevents you from catching diseases,” and the other stated, “Hand hygiene prevents patients from catching diseases.” The “patient” sign increased soap and sanitizer use by 33%, and healthcare providers were 10% more likely to wash their hands. Grant credits “the illusion of invulnerability” as the reason behind switching the wording on the signs, recognizing most people feel they are not vulnerable themselves to getting sick, while their patients are.

http://www.psychologicalscience.org/index.php/news/releases/patients-health-motivates-workers-to-wash-their-hands.html

2. Electronic Health Records and Quality of Diabetes Care – 9/1/11

An article published in the New England Journal of Medicine this month compared achievement of and improvement in quality standards for diabetes at facilities using electronic health records versus paper records. Covariates, including insurance type, patient race, age, sex, income and education were adjusted for. Care standards included measurement of hemoglobin A1c, urine microalbumin testing, eye examination, pneumococcal vaccination, and outcome standards included hemoglobin A1c <8%, BP <140/80 mmHg, LDL <100, BMI <30, and nonsmoking status. Sites utilizing electronic health records were associated with a higher achievement in eight of nine standards, greater improvement in care, and greater improvement in outcomes.

http://www.nejm.org/doi/full/10.1056/NEJMsa1102519

3. More hospital procedures => better patient safety? – 9/1/11

A new study in Health Services Research journal found hospital volume is inversely related to preventable adverse events. Stanford University School of Medicine researchers examined rates of nine adverse events in hospitalized patients and found that in almost every case, hospitals with higher surgical volume had fewer adverse events compared to hospitals with low volumes of surgery. Additionally, patients may consider hospital volume when choosing where to receive care, especially for high-risk procedures.

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01310.x/abstract

One other feature that we wish to include in conjunction with our digest this fall is the Speaker of the Week feature. As you may know, VHIG launched a Fundamentals of Quality Improvement in Healthcare Elective last year. With over 40 students enrolled from the Schools of Management, Medicine, Nursing, our elective was extremely well-received, and even gained national recognition from the Academy for Healthcare Improvement with the Duncan Neuhauser Award for Special Recognition for Excellence in a Student-Led Initiative. We are offering this elective again this fall, and have enrolled almost 60 students in the course. Because we have a larger classroom space this year, we are offering students and faculty at Vanderbilt the opportunity to attend select classes this year. The Speaker of the Week feature will allow our subscribers to gain more information about specific classes that they may wish to attend. If you would like to attend a particular class, please e-mail us at vhig@vanderbilt.edu for more information on location and time of the class.

Speaker of the Week for August 31st, 2011: Dr. Warren Sandberg

Warren S. Sandberg is Professor and Chair of Anesthesiology at Vanderbilt University Medical School.  He received his M.D. and Ph.D. from the University of Chicago Pritzker School of Medicine.  He completed anesthesia residency and twelve years as faculty at Massachusetts General Hospital. Dr. Sandberg then moved to Vanderbilt in 2010 as the 7^th Chairman of the Department of Anesthesiology.

Sandberg’s clinical interests range from ambulatory surgery to anesthesia for liver transplantation.  His research career began in structural biology and mechanisms of anesthesia, but he has now developed broad research interests in medical technology, informatics, patient safety and OR & procedure suite operations.  A particular focus is using medical information systems for process monitoring, decision support and process control.

For our first class of the year, Dr. Sandberg will be leading the students through an introduction to quality improvement. Using real examples from his career as an anesthesiologist and researcher, Dr. Sandberg explore the modern-day science of quality improvement, including the challenges, opportunities, and financial implications of quality improvement.

If you would like to attend this session on the evening of Wednesday, August 31^st, please e-mail us at vhig@vanderbilt.edu for more details.

By Scott Hagan, School of Medicine, Class of 2013

1. Michigan Keystone ICU Patient Safety Program Reduces Infections, Saves Money

With one in 20 hospitalized patients acquiring a healthcare-associated infection (HAIs) in the United States, HAIs are a leading cause of mortality, and the cost of treating HAIs has been estimated by the HHS to be up to $33 billion annually. In a study released this week from the American Journal of Medical Quality, six intensive care hospitals in Michigan, carrying out a program designed to reduce the number of central line-associated blood stream infections (CLABSIs) and ventilator-associated pneumonias (VAPs), were able to prevent these infections and reduce costs. The program, called the Michigan Keystone ICU Patient Safety Program, was created by leading patient safety expert Peter Pronovost, and has a two-fold purpose: 1) to improve teamwork and communication in ICUs by instilling a culture of safety, and 2) to improve compliance to infection-prevention strategies such as the use of checklists before inserting central line catheters. After initiating the program in 2006, researchers found that, on average, 29.9 CLABSIs and 18.0 VAPs were prevented per hospital per year. The cost of theprogram was estimated to be $3,375 per infection avoided, while the cost per treatment of an episode of CLABSIs/VAPs was estimated to be in a range of $12,208 to $56,167. When the costs of the program are weighed against its savings, the average hospital could save $1.1 million per year through this intervention.

Study: The Business Case for Quality: Economic Analysis of the Michigan Keystone Patient Safety Program in ICUs
Articles: MedPage Today; Johns Hopkins press release

2. CMS Announces Bundled Payment Program- 8/23/11

Last Tuesday, the Center for Medicare and Medicaid Services (CMS) announced a pilot initiative to bundle insurance payments for multiple procedures. CMS is offering physician participants a choice between from 4 models of care: 1) a single inpatient acute care episode; 2) a single inpatient care episodes plus associated post-acute inpatient care; 3) only post-acute inpatient care; and 4) a single prospective payment for all services rendered in an inpatient stay. Providers must submit a letter of intent for these models by November 4, 2011. Applicants are allowed to propose a specific episode of acute and post-acute inpatient care for the bundled payment.
The purpose of the new program is to incentivize provider networks to coordinate the care of a patient’s inpatient stay in a cost-effective manner. If provider networks are able to provide the inpatient care within the costs of the bundled payment, they retainthe excess payment of the bundle, thus encouraging cost-conscious care. The pilot project is one of several demonstration projects of the CMS Innovation Center, which made news this summer for releasing promising results of a Physician Group Practice (PGP) demonstration that reduced costs and increased quality of care in several clinical environments.

Articles: CMS release; Reuters; Initial Thoughts on the CMS Bundling Program, Advisory Board Company [subscription required, free for Vanderbilt students and faculty]; Medscape

3. Use of CT Scans Rise, Hospitalization Rates Drop in Emergency Departments- 8/10/11

A study in the Annals of Emergency Medicine finds that use of computed tomography (CT) scans on patients in U.S. emergency departments has risen dramatically in the past 10 years while rates of hospitalizations have dropped in the same period. In 1996, an estimated 3% of patients in EDs received a CT scan, while in 2007 that rate jumped to 14%. However, for patients who received a CT scan in the ER, the percentage admitted to an inpatient service after the scan dropped from 26% in 1996 to 12% in 2007. The American College of Emergency Physicians has defended to four-fold increase in scan rates by arguing that these scans give ED doctors the diagnostic certainty needed to send patients home. Others argue that thedecrease in hospital admissions leveled off after 2003 in the study while CT scan use in that period continued to rise, suggesting that a number of factors have affected the decline in hospitalization rates.

Study: National Trends in Use of Computed Tomography in Emergency Department, Annals of Emergency Medicine
Articles: Kaiser Health News; Medpage Today; The Hunting of the Snark, 2011 (Editorial released with study)

In the News…

1. XX-ray: when enough is enough - April 12, 2011

State investigators in New York have found that some X-rays performed at SUNY are still over radiating premature babies after initial reports from the hospital indicated that they had corrected the indiscretion of performing full body X-rays when chest X-rays were ordered. The New York State Department of health is now deciding whether or not to conduct “spot checks” all over the state to determine the severity of the problem. These problems stem from 2007 when similar allegations came to fruition prompting SUNY to institute measures to protect infant’s exposure to radiation. Unfortunately it seems as though these procedures intended to protect the most vulnerable of patients has failed to work as intended.
http://www.nytimes.com/2011/04/13/nyregion/13radiation.html?_r=1&ref=radiationboom

2. Landmark vote in Florida…Medicaid no more? – April 27, 2011

Florida is poised to oust Medicaid and switch to an H.M.O based health care system in order to manage costs, reduce waste and minimize fraud. In just the past 11 years health related costs from Medicaid in Florida has increased 2 fold, prompting a new concept to be put forth in a landmark vote set to take place prior to the legislative body in Florida breaks for the summer in a week. The program would be largely based on a pilot program dating back 5 years. This would shift Florida from a largely fee for service to a managed care model. The question is will this work, and if so at what cost to patient safety and overall patient care, specifically due to the for profit nature of the H.M.O’s they would be shifting to.
http://www.nytimes.com/2011/04/28/health/policy/28medicaid.html?scp=8&sq=hospital&st=cse

3. Use only as Directed… – April 26, 2011

According to the National Community Pharmacists Association as much as three out of four medications prescribed in the USA is not taken as directed, contributing to as many as 1.9 million Emergency Department visits between 2004 and 2008. The FDA is toying with the idea of including a simple one page pamphlet which would contain consumer information as compared to the current multipage convoluted booklet that is included with all prescription medications. The idea would be to simplify the process and indicate the typical reason for the use of this medication along with dosing protocol. The verdict is out as to when or how this new plan will be rolled out, but seems to be a promising new area to manage patient safety and quality improvement which will affect almost everyone in the USA.
http://online.wsj.com/article/SB10001424052748703521304576279123606877448.html

In the Literature…

1. ICU intervention and reduction of MRSA, VRE

According to a recent article publication in the Archives of Internal Medicine, a cleaning intervention based on a new disinfectant, education, and targeted feedback could help reduce MRSA and VRE. This is an extremely important intervention in part because ICU patients are at particular risk of acquiring a nosocomial infection that could be highly resistant to a variety of antibiotics. The quality improvement project, which was conducted at The University of California Irvine School of Medicine, concluded that a reduction of MRSA from 3% to 1.5% over a two year period and reduction of 0.8% over that same time from in VRE. The study was funded and supported in part by the NIH, and would be provide a significant intervention for ICU’s to adopt around the country.
Emma Hitt, PhD. ICU Cleaning Intervention May Reduce MRSA, VRE Transmission http://www.medscape.com/viewarticle/740222

2. Hospitalists…good or bad?

A recent article published in the American Journal of Medical Quality tackles a new paradigm in medicine, the hospitalist. According to the authors, hospitalists can improve communication within the hospital setting and more importantly improve efficiency helping to reduce costs and standardize care. Hospitalists play a vital role in providing care in hospitals all over the United States, and using a survey method this study indicated that overall satisfaction scores was higher for hospitals that had hospitalists on staff when compared to facilities that did not. Interestingly enough, teaching hospitals with hospitalists on staff showed a significant satisfaction difference. This study suggests that it might behoove hospitals to move toward a hospitalist model in order to provide the most up to date, efficient and quality healthcare.
Bradley R. Fulton, Kathryn E. Drevs, Louis J. Ayala and Donald L. Malott, Jr. American Journal of Medical Quality 2011 26: 95 originally published online 1 March 2011
http://ajm.sagepub.com.proxy.library.vanderbilt.edu/content/26/2/95.full.pdf+html

 In the News…

1. Study finds drop in deadly V.A. hospital infections- 4/13/11

Two articles in the New England Journal of Medicine examined the clinical and financial efficacy of efforts to reduce hospital-acquired infections. Over a span of 32 months, Veterans Affairs hospitals nationwide reduced methicillin-resistant staphylococcus aureus (MRSA) infections by 62% in intensive care units and by 45% in other medical and surgical units. Veterans Affairs hospitals currently screen all patients for MRSA upon admission, isolate patients who test positive, mandate contact precautions for all personnel caring for those patients, and repeat screening before discharge. However, universal and repeated screening may not be cost-effective.
http://www.nytimes.com/2011/04/14/health/14infections.html?_r=1&emc=eta1 

2. House GOP passes budget cut- 4/16/11

The House of Representatives passed a budget with significant spending cuts, many of which target healthcare outlays. The plan would replace current Medicare benefits with vouchers to help seniors purchase individual private health insurance. These changes would not be tied to inflation and would apply to people currently under 55 years of age. The budget also calls for major changes to Medicaid; it aims to cut $
771 billion from the program over the next 10 years by transforming it into a system of block grants to states. Each state would receive a limited amount of federal government money to spend on Medicaid, with fewer regulations than currently apply. http://online.wsj.com/article/SB10001424052748704495004576265013724755094.html?mod=WSJ_hp_LEFTTopStories 
Study: Half of meat, poultry tainted by staph; 1 in 4 samples have drug-resistant kind –
4/15/11
A team from the Translational Genomics Research Institute in Arizona tested 136 samples of beef, chicken, pork, and turkey from grocery stores in major metropolitan areas throughout the country. Testing for foodborne pathogens revealed that half of all samples were contaminated with Staphylococcus aureus, and half of the contaminated samples contained multidrug-resistant S. aureus. Moreover, three samples contained methicillin-resistant S. aureus (MRSA). Two other studies in recent years have found staphylococci in at least 20% of meat. The new report will be published in the journal Clinical Infectious Diseases.
http://www.washingtonpost.com/national/study-half-of-meat-poultry-tainted-by-bacteria-1-in-4-samples-have-drug-resistant-germs/2011/04/15/AFDEYpjD_story.html?fb_ref=NetworkNews
 

In the Literature…

 1. Global Trigger Tool Shows that Adverse Events in Hospitals May Be Ten Times Greater than Previously Measured- 4/30/11

Most studies of hospital safety and adverse events use either hospital-specific voluntary reporting systems or the Agency for Healthcare Research and QualityÕs Patient Safety Indicators. A recent report in the journal Health Affairs compared the efficacy of those methods to the Global Trigger Tool, developed by the Institute for Healthcare Improvement. The Global Trigger Tool randomly selects patient chart numbers, removes identifying information, and refers charts to a team including both physicians and non-physicians, who reviewed charts for ÒtriggerÓ events. These events could include Òa medication stop order, an abnormal lab result, or use of an antidote medicationÓ. After finding a trigger event, the review team examined charts in greater depth to determine if a major adverse event had occurred in the course of the patientÕs stay. Results indicated that adverse events occurred in one-third of all hospital admissions, and 90% of those were not identified by either voluntary reporting systems or the Agency for Healthcare Research and QualityÕs Patient Safety Indicators.
http://content.healthaffairs.org/content/30/4/581.full?ijkey=E8hMfgULHUTLA&keytype=ref&siteid=healthaff

2. Launching Accountable Care Organizations Ð The Proposed Rule for the Medicare Shared Savings Program- 3/31/11

On March 31, the Department of Health and Human Services (HHS) released proposed regulations for forming accountable care organizations (ACOs). These organizations of health care providers would take responsibility for all medical needs of at least 5000 Medicare beneficiaries. If an organization successfully delivers care at lower-than-expected costs, the providers would share in the savings. The HHS proposal outlines two business options for new ACOs. An organization may operate for two years without risk of loss; alternatively, it can assume risk from its inception, but retain the opportunity to keep more of its potential savings.
http://www.nejm.org.proxy.library.vanderbilt.edu/doi/full/10.1056/NEJMp1103602

In the News…

 1. Rules Aim to Reshape Medical Practices – WSJ 4/1/2011

The Center for Medicare and Medicaid Services (CMS) this week released a 429-page document covering the rules for accountable care organizations, how they will share risk with CMS, and how they must report quality of care. An additional summary is available from the Deloitte Center for Health Solutions here.

2. Arizona Proposed Medicare Fat Fee – WSJ 4/1/2011

Arizona Governor Jan Brewer proposed charging the state’s Medicaid recipients a $50 fee for unhealthy behaviors, such as obesity and smoking. This mimics the policies of some private insurance companies, but no government-run systems currently practice this. The fee was suggested along with a variety of ideas to raise money and offset recent cuts to the state’s Medicaid program. If the proposal passes, Arizona will reintroduce coverage of organ transplants and increase the number of childless adults covered.

In the Literature…

1. A Resident-Led Quality Improvement Initiative to Improve Obesity Screening

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. 
Neda Laiteerapong, Chris E. Keh, Keith B. Naylor, Vincent L. Yang, Lisa M. Vinci, Julie L. Oyler, and Vineet M. Arora. A Resident-Led Quality Improvement Initiative to Improve Obesity Screening American Journal of Medical Quality March 29, 2011 1062860610395930, first published on March 29, 2011 doi:10.1177/1062860610395930 

2. Use of Quality-Improvement Methods to Improve Timeliness of Analgesic Delivery

Despite its high prevalence, pain often is poorly managed in the emergency department. We used improvement science and quality-improvement methods to reduce delays associated with opioid delivery for children presenting to the emergency department with clinically apparent extremity fractures. On the basis of a review of the literature, interviews with key stakeholders, expert consensus, and reviews of isolated examples of patients receiving timely analgesics, a multidisciplinary improvement team identified a set of operational factors, or key drivers, believed to be critical to the performance of appropriate initial pain management for children presenting to the emergency department with acute extremity injury. These key drivers focused the development of an intervention. The intervention, termed the orthopedic evaluation process, addressed all 4 identified key drivers simultaneously by standardizing triage decisions, activating necessary health care providers, aligning the care delivery need with necessary resources, and allowing parallel-task completion between physicians and nursing staff. After implementation of this process, 95% of the patients with long-bone extremity fractures treated with intravenous opioids received a first dose within 45 minutes of arrival, compared with a preintervention baseline average of 20%. By applying quality-improvement and process improvement methodology, we identified key drivers for the rapid delivery of systemic opioids to patients with clinically apparent extremity fractures and significantly improved the timeliness of analgesic delivery for this subgroup of patients.
 
Iyer, Srikant B., Schubert, Charles J., Schoettker, Pamela J., Reeves, Scott D. Use of Quality-Improvement Methods to Improve Timeliness of Analgesic Delivery Pediatrics 2011 127: e219-e225

In the News

1. ICU Central-line Infections Drop Dramatically Nationwide - 3/14/11

The Center for Disease Control and Prevention released a report indicating that U.S. intensive care units reduced central line-associated bloodstream infections by approximately 60% over the past ten years, with an estimate of 27,000 lives saved and $1.8 billion in medical costs saved. The report compared ICU blood infection rates reported from 260 participating hospitals in 2001 to 1600 participating hospitals in 2009. Robert Wachter, MD, Division of Hospital of Medicine Chief, University of California, San Francisco Medical Center noted that scientific rigor is what has set apart the national effort to reduce bloodstream infections. The central line bundle has been well-studied by researchers such as Peter Pronovost, MD, PhD. About 25% of all patients with bloodstream infections die, and central-line infections are also a problem in other areas of the hospital outside of the ICU.

http://www.ama-assn.org/amednews/2011/03/14/prl20314.htm

2. Riddled With Metal by Mistake in a Study - 3/21/11

A breast cancer study involving a metal surgical device has left thirty women with hundreds of tiny particles of tungsten in their breast tissue. While it is not known if the metal is dangerous due to limited data, the issue has raised great concern, leading one woman to consider a radical mastectomy. The faulty device has been recalled, although initially approved by the FDA. in an abbreviated 501(k) process that did not require tests on humans.

http://www.nytimes.com/2011/03/22/health/22breast.html?pagewanted=1&_r=1&ref=health

3. HHS Releases National Quality Strategy - 3/22/11

The department of Health and Human Services (HHS) recently revealed its National Strategy for Quality Improvement in Health Care in response to the federal health reform law, which called for a strategy to guide efforts to improve health care from the local to national levels. HHS used evidence-based results to set several priorities including reducing medical errors, engaging patients and families as partners in care, promoting prevention and effective treatments for leading causes of mortality, and collaborating with communities to promote best practices.

The full report: http://www.healthcare.gov/center/reports/quality03212011a.html

In the Literature

1. Case Study: Advancing Patient Safety in the U.S. Department of Veterans Affairs

A decade ago, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients’ daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care-associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements.

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Mar/1477_McCarthy_VA_case_study_FINAL_March_v2.pdf

2. Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project

A substantial proportion of hospitalizations of nursing home residents may be avoidable. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist nursing home staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 nursing homes in three states in a 6-month quality improvement initiative. There was a 17% reduction in self-reported hospital admissions in these 25 nursing homes from the previous year. The average cost of the 6-month implementation was $7,700 per nursing home with projected savings to Medicare of approximately $125,000 per year. INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.

http://www.ncbi.nlm.nih.gov/pubmed/21410447

In the News

1. Wall Street Journal Reports Almost 5% of Americans Report Falling Asleep at the Wheel

A March 3rd article in the Wall Street Journal reported a scary statistic regarding Americans and their tendency to fall asleep while driving at the wheel. Based on numbers released by theCDC, of the 74,571 Americans surveyed, 4.7% admitted to either nodding off or falling asleep while driving in the prior 30 days. Those older than 65 reported these tendencies (2.0%) statistically more often than all other age groups: 18-24 years (4.5%), 25-34 years (7.2%), 35-44 years (5.7%), 45-54 years (3.9%), and 55-64 years (3.1%). Compared to those sleeping greater than 7 hours per night, those sleeping less than 7 reported nodding off or falling asleep while driving in the prior 30 days 7.3% of the time (versus 3.0%).

Full story here.

2. New York Times Reports FDA Orders Prescription Cold Drugs Pulled From Market

A March 2 posting on the New York Times detailed the FDA’s order of roughly 500 prescription medications used to treat coughs, colds and allergies be removed from the shelves. The FDA justified their order in saying that these prescription medications had never undergone a federal review of effectiveness and safety. Many of these medications had been on the shelves before a 1962 law requiring drugs to undergo review for effectiveness and safety. The decision is one of the latest in a FDA campaign to glean the shelves of pharmacies and remove unapproved medications. Officials from the FDA showed some concern regarding young child and infant health since some potential risks related to the ingredients in some of the over-the-counter cough, cold and allergy medications were also found in these prescription drugs. In addition, the FDA tested 6 medications that were labeled as extended-release formulations designed to release their active ingredients gradually over the first 8-12 hours. However, 3 of the 6 tested released 85% of their active ingredients in just 30 minutes. The FDA stresses that there are still plenty of cold, cough and allergy drugs available on the market that have been approved.

Full blog post

In the News

1. Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial

The culture of medicine is currently fearful of a time where antibiotic resistance renders treatment of formerly easily treatable infections almost impossible. That is why researchers at the University of Colorado chose to conduct a randomized control trial comparing methicillin-resistant Staphylococcus aureus (MRSA)contamination at the end of an 8-hour workday of physicians’ white coats with laundered, standardized, short-sleeved shirts.

Findings: There were no statistically significant differences found in the comparison of MRSA contamination of physician white coats with laundered short-sleeved uniforms. Also, there was no significant difference in contamination of skin of the wrists of physicians wearing either the white coat or laundered shirt. Regarding the rate of contamination, bacterial counts of the laundered uniforms were basically zero; however, within 3 hours of being worn, the bacterial counts were ~50% of what was counted at the end of the 8 hour workday. Thus, the data from this study does not support having physicians abandon the traditional wear of white coats for laundered, short-sleeve uniforms.

Burden M, Cervantes L, Weed D et al. Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial. Journal of Hospital Medicine. 2011 Feb 10.

An additional article covering this study.

2. Quality Improvement Initiative in Intensive Care Units and Hospital Mortality and Length of Stay

A recent publication from the British Medical Journal investigated the outcomes of the
Michigan Keystone ICU project regarding mortality and length of stay in Medicare patients. The ICU project was established with the goal of reducing central line-associated bloodstream infections and ventilator-acquired pneumonia in the ICU setting. To date, this quality improvement initiative reports having saved 1,830 lives and $271 million health care dollars in its five-year implementation. Peter Pronovost, a well-known researcher in the field of patient safety research, and others at Johns Hopkins used Medicare claims to assess outcome measures of the ICU project in a retrospective comparative study from October 2001 to December 2006. They compared the ICU outcomes from 95 different Michigan hospitals with 364 other Midwestern hospitals.

Findings: Following the implementation of ICU project, the study group was found to have significant reduction only in the post-implementation months 1-12 and 13-22 (odds ratio 0.83, p=0.041; odds ratio 0.76, p=0.007, respectively). Compared to the other Midwestern hospitals, there was no significance differences found in pre-implementation, project initiation or implementation phases. When the researchers investigated the outcome measure of length of stay, no significant differences were found between the study and comparison groups.

Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011 Jan 28.

An additional article covering this study.

3. Improving Patient Care in Cardiac Surgery Using Toyota Production System Based Methodology

Based on the Toyota premise that removing defects from a complex process will result in less variable outcomes of production and ultimately a higher quality product delivered to the consumer/customer, a heart surgery program was implemented to investigate how delivery of health care could parallel automobile production in decreasing variability and increasing quality of care delivered to the patient. The

Toyota production method (TPS) has improved their final product by reducing variability in their production process, and this methodology has been adopted and transplanted across industry lines. In the healthcare sector, this same concept was taught to the management team at a vascular center where 409 operations were ultimately performed between March 2008 and June 2010.

Findings: Regarding the mortality rate, according to data available from the

Society of Thoracic Surgeons, the risk-adjusted mortality rate from these cardiovascular operations was 61% lower than the mortality rate for the surrounding region. Also, the risk-adjusted rate for major complications was 57% lower than the regional rate. One operative death occurred in these 409 operations. Of the 409 operations, 253 were coronary artery bypass graft (CABG)procedures. Because many predicted complications were avoided in this subset of operations, $3,497 of cost savings per CABG procedure was reported.

Culig MH, Kunkle RF, Frndak DC, et al. Improving Patient Care in Cardiac Surgery Using Toyota Production System Based Methodology. Ann Thorac Surg2011;91:394Ð400.

In the News

1. HealthGrades Releases List of Top 50 Cities for Hospital Care

HealthGrades, a leading independent healthcare ratings organization, released the first-ever list of America’s Top 50 Cities for hospital care. The rankings are based on a comprehensive study of patient death and complication rates at the nation’s nearly 5,000 hospitals. HealthGradesidentified those hospitals performing in the top 5% nationwide across 26 different medical procedures and diagnoses, then ranked cities by highest percentage of these hospitals. The top cities were:

• West Palm Beach, FL
• Brownsville, TX
• Dayton, OH
• Minneapolis/St. Paul, MN
• Tucson, AZ
• Cincinnati, OH
• Phoenix, AZ
• Greenville, SC
• Chattanooga, TN
• Richmond, VA

Another key finding of the study was that if all hospitals performed at a top-rated level, 158,684 Medicare beneficiaries’ lives could have been saved and 3,511 Medicare in-hospital complications could have been potentially avoided across the study period.

http://www.healthgrades.com/cms/ratings-and-awards/2011-HG-Distinguished-Hospitals-For-Clinical-Excellence-Award-Announcement.aspx

2. Accountable Care Organizations, Explained

Accountable Care Organization (ACO) development is one of the provisions in the health care law. The Centers for Medicare & Medicaid Services is expected to release detailed rules on ACOs within a few weeks, according to NPR.

NPR states the facts that are known about ACO’s so far:

• · An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. Under the new law, ACOs would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.
• · ACOs would make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate and save money by avoiding unnecessary tests and procedures.
• · ACOs wouldn’t do away with fee for service but would create savings incentives by offering bonuses when providers keep costs down and meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases.  The law also gives regulators the ability to devise other payment methods, which would likely ask ACOs to bear more risk.
• · ACOs differ from health maintenance organizations in that patients are not required to stay in a network.

Critics of ACOs worry that the mergers formed between providers and hospitals will drive up health care costs because they will have increased bargaining power with insurance companies.

http://www.npr.org/2011/01/18/132937232/accountable-care-organizations-explained

3. Doctor Watson, I Presume? IBM Supercomputer Now Heads to Two Hospitals

Watson, IBM’s supercomputer who recently defeated two humans on the show Jeopardy!, will head to Columbia University Medical Center and the University of Maryland School of Medicine with the hope of aiding patient diagnosis. Though Watson is unlikely to be used on patients for at least two years, the supercomputer will be tested to see if it can help physicians better diagnose patients by sifting through large amounts of medical literature and by interpreting electronic health records. As seen on Jeopardy!, Watson has the power to focus more than 2,000 computer processors on one task. Watson uses millions of disconnected pieces of information stored in its database to connect patterns by linking words and phrases that often go together. Watson still needs to learn how to understand electronic health records and stockpile information from medical literature, but Columbia University and University of Maryland faculty are optimistic about the possibilities.

http://www.advisoryboardcompany.com/content/homepage/landing_daily.asp

In the Literature

1. Pay For Performance Metrics Do Not Show Benefits to Patients

Pay-for-performance targets set for general practitioners in the United Kingdom are failing to improve the health of patients with high blood pressure, according to a study in the British Medical Journal. The UK pay for performance incentive (the Quality and Outcomes Framework), was implemented in April 2004 and included specific targets for general practitioners to show high quality care for patients with hypertension and other diseases. For the study, researchers examined medical records of patients with hypertension in the UK, comparing data from before and after the pay for performance incentive was introduced. Researchers found that pay for performance had no discernible effects on processes of care or on hypertension-related clinical outcomes, and conclude that the system may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.

Soumerai, ST et al. Effect of Pay for Performance on the Management and Outcomes of Hypertension in the United Kingdom: Interrupted Time Series Study. British Medical Journal. 2011; 342:d108.

http://www.bmj.com/content/342/bmj.d108

2. Clinical Practice Guidelines to Inform Evidence-Based Clinical Practice

Clinical Practice Guidelines (CPGs) combine evidence-based medicine with expert opinion to improve health care by identifying evidence that supports the best clinical care and making clear which practices appear to be ineffective. Practitioners are challenged by two extremes, however – the high volume of medical research currently published on some conditions and the lack of good evidence published on others. This article explains that the application of high-quality CPGs improves patient care, but all too often CPGs are not used to the greatest advantage because of inadequate dissemination and incorporation into practice.

Wolf JS Jr, et al. Clinical Guidelines to Inform Evidence-Based Clinical Practice. World Journal of Urology. 2011. [Epub ahead of print, Feb. 18]
http://online.owen.vanderbilt.edu/webapps/portal/frameset.jsp

VHIG hosted a successful gathering tonight at the Vanderbilt Owen Graduate School of Management. Our event featured guest speaker Jason Hickok, MBA, RN, who is Vice President of Clinical Improvement for Hospital Corporation of America (HCA). Charged with coordinating the safety initiatives of the largest for-profit hospital chain in the world, Mr. Hickok spoke to students about the spreading best practices and patient safety initiatives across a large healthcare system.

A key lesson that Mr. Hickok wished for the students to take away is for healthcare organizations to focus on developing accurate measurements of the quality of clinical performance so that the value of quality improvement initiatives can be appreciated. Having robust pre- and post-intervention clinical data, along evidence of the financial benefits of an intervention, allows healthcare quality leaders to find buy-in from both the clinical and business leadership in health care organizations. Mr. Hickok used the example of implementing a central line bundle that utilizes a standardized kit across a healthcare organization. Managers may object to the price of such a central line kit unless quality experts are able to show how much more money could be saved by preventing a central line associated bloodstream infection (CLABSI), which costs an average of $44,000 to treat, than skimping on a high quality central line kit. Clinicians may object to standardization of a process using a bundle because they are used to performing a task a certain way, until they are shown the data that a) CLABSIs have a mortality rate of 12-25%, and b) central line bundles significantly reduce the risk of CLABSIs.

For more information on central line bundles, refer to this page on the IHI website: Implementing the Central Line Bundle.

After Mr. Hickok’s talk, Piotr Pilarski and Irving Ye, our VHIG Co-Presidents, gave a presentation about the history and accomplishments of VHIG, and how Vanderbilt students can get involved in future work. Download the full presentation here.

Click here for the VHIG fact sheet, a summary of our organization’s activities and opportunities.

We look forward to bringing new, enthusiastic Vanderbilt students from various disciplines into our organization.

Carol Callaway-Lane, Irving Ye, and Piotr Pilarski receive award from Duncan Neuhaser (right)

Last December, the Academy for Healthcare Improvement awarded VHIG for our work in creating the Fundamentals of Quality Improvement Elective, an interdisciplinary elective for management, medical, and nursing students to learn more about basic concepts in quality improvement and patient safety. We felt honored to receive the Duncan Neuhauser Award for Special Recognition for Excellence in a Student-Led Initiative. Click here for more details about our elective.

In the News

1. U.S. House of Representatives Repeals PPACA

On Wednesday, January 19, the U.S. House of Representatives voted 245 to 189 to repeal the Patient Protection and Affordable Care Act (PPACA), voting on party lines. Three Democrats joined the unanimous Republican vote: Dan Boren (D-OK), Mike McIntyre (D-NC), and Mike Ross (D-AK). Though it is unlikely repeal will receive serious consideration in the democratic-controlled Senate, the vote was a symbolic campaign promise, delivered promptly by the new congress.

As reported by Washington Post, Senate Majority Leader Harry Reid (D-Nevada) has indicated he will not allow a similar vote on a repeal of PPACA. However, House GOP leadership has announced its committee agenda, through which it hopes to eliminate significant elements of the regulation, specifically the individual mandate. Could an adaptation of PPACA be the solution? The Commonwealth Fund’s Jane Norman discusses talk of a middle ground on healthcare reform in the latest edition of itsWashington Health Policy Week in Review. In a similar vein, former Senate Majority leaders Bill Frist (R-Tennessee) and Tom Daschle (D-South Dakota) have launched a two-year project, sponsored by the Bipartisan Policy Center, aimed at building bipartisan solutions to the implementation of the 2010 Healthcare Reform Bill. For the full article, access it here. Nonetheless, last week six states joined the Florida lawsuit against PPACA, bringing the total to 26. The new additions were Iowa, Ohio, Kansas, Wyoming, Maine, and Wisconsin. To date, four district courts have heard arguments about the constitutionality of the individual mandate and, in Florida, the constitutionality of the Medicaid mandate requiring states to establish eligibility at 133 percent of the federal poverty level (FPL) and “maintenance of effort” requirements around coverage, et al. It is likely arguments will next be heard in Circuit Courts and possibly end in the Supreme Court.

2. Comparative Effectiveness Institute Ramps Up

The Patient-Centered Outcomes Research Institute (PCORI), created under PPACA, will serve as a centralized source of funding for comparative studies. The newly formed nonprofit institute recently announced members of the Methodology Committee: GOA Announcement. “The Methodology Committee has the responsibility of helping PCORI develop and update methodological standards and guidance for comparative clinical effectiveness research. The men and women named [to the committee] bring impressive credentials and experience to this important task,” said Gene Dorado, Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO), directed to appoint the committee members under PPACA. In addition to the 15 appointees, the Director of the Agency for Healthcare Research and Quality (AHRQ) and the Director of the National Institutes of Health (NIH) will also serve on the committee.

3. CMS Announces Value-Based Purchasing Incentive Plan

The Centers for Medicare & Medicaid Services proposal, issued January 7, incorporates 17 clinical process-of-care measures used in five health categories: acute myocardial infarction, heart failure, pneumonia, healthcare associated infections and surgical care improvement. It also will use eight measures from the hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that reflects how patients view their care experiences. These 25 measures will be used to generate FY 2013 DRG payments.

By 2014, it will add mortality outcome measures for the three health conditions, eight hospital-acquired condition measures and nine Agency for Healthcare Research and Quality measures. The hospital-acquired condition measures include surgical foreign object retention, air embolism, blood incompatibility, pressure ulcer stages III and IV, falls and trauma such as burns or electrical shocks, catheter-associated urinary tract infections and manifestations of poor glycemic control. The regulations will apply to discharges at 3,000 acute care hospitals. All these hospitals will have their funding reduced starting with 1% in fiscal year 2013, rising to 2% by FY 2017, but will have a chance to earn that money back, and perhaps more, under the incentives algorithm. Algorithms will be calculated to derive a Total Performance Score or TPS for each hospital.

CMS director Don Berwick, in a statement, called the proposed regulations “a huge leap forward in improving the quality and safety of America’s hospitals for both Medicare beneficiaries and all Americans. The hospital value-based purchasing program will reward hospitals for improving patients’ experiences of care, while making care safer by reducing medical mistakes.” Access the full article here.

4. Medicare Pilot Project Reduces Readmissions by 9.3%

A 14-city Medicare demonstration project has successfully lowered patient readmission rates by 9.3 percent, according to The Denver Post. The article reports that the project links nurses, social workers and other healthcare workers to elderly hospital patients at discharge to help them to coordinate drugs, doctor follow-ups and home health care aids.

It is estimated that the program has saved Medicare $100 million dollars since it began 1.5 years ago.

In the Literature

1. Private Payer Innovation in Massachusetts: “The Alternative Quality Contract”

From the Commonwealth Fund:

In 2009, Blue Cross Blue Shield of Massachusetts began paying participating health care provider groups under the Alternative Quality Contract (AQC), an alternative to fee-for-service payment in which medical groups receive fixed payments for patient care, plus rewards based on savings generated and performance targets reached. At the end of the first year of the contract, spending in all the participating groups was below the budget targets and all earned “significant” quality bonuses.

Can innovations such as this one improve quality on a large scale? The Center for Medicare and Medicaid Innovation (the Innovation Center) was created to do just that. According to innovations.cms.gov, the Innovation Center will ultimately work with the business community to scale new care and payment models that improve quality and affordability.

2. German Study shows that Diabetes Management Programs Improve Quality of Care and Reduce Costs

A study in Germany found that patients enrolled in a diabetes management program had significantly lower mortality rates than those receiving routine care for their condition. There were also fewer complications and hospitalizations and a significant difference in costs between baseline and intervention groups.

Key Findings

• For patients enrolled in the disease management program, the overall mortality rate (2.30%) in 2007 was significantly lower than the rate for those in the control group (4.07%).
• There were fewer complications – including myocardial infarction, stroke, chronic renal insufficiency, and amputation of the lower leg or foot – among patients in the program, compared with those receiving routine care.
• Average overall drug and hospital costs in 2007 were more than $600 lower in the intervention group, mainly a result of lower hospital costs. Patients receiving routine care were more likely to be hospitalized than patients in the intervention group, and their hospital stays were 1.44 days longer, on average.

Access the full article in Health Affairs, here.

Upcoming Webcasts

1. Can Regulations Limiting the Number of Hours Medical Students Work be Embraced without Compromising Continuity of Care or Education and Training?

Particularly relevant to students and anyone who practices in an academic setting, the latest set of regulations from the Accreditation Council for Graduate Medical Education (ACGME), focused especially on first-year residents, is scheduled to go into effect in July. Listen, learn, and weigh in during the next WIHI webcast, Thursday, January 27 from 2-3 pm ET. Doctors David Sweet, Program Director, Internal Medicine Residency, Summa Health System, and James Whiting, Surgical Director, Maine Transplant Program and Surgical Residency Program Director, Maine Medical Center, join host Madge Kaplan for an exploration of new, innovative approaches to residency training. Rounding out the discussion are Christopher Landrigan, MD, MPH, Director, Sleep and Patient Safety Program, Brigham and Women’s Hospital’s research on sleep deprivation and patient safety, and Don Goldmann, MD, IHI Senior Vice President, who brings his knowledge of hospital improvement and the goals of residency training.