Institutional culture changes over an eight-year period made infection prevention and control "everyone's business," researchers say. Active surveillance was a major driver.
Hospitals run by the Department of Veterans Affairs continue to see declines in the rate of methicillin-resistant Staphylococcus aureus (MRSA) infections.
For the month of September 2015, only two MRSA HAIs were reported at the ICUs of all of the VA's 127 facilities.
A study in current edition of the American Journal of Infection Control reports that over eight years, monthly MRSA hospital acquired infection (HIA) rates dropped 87% in intensive care units, 80.1% in non-ICUs and 80.9% in spinal cord injury units.
The findings were based on data from 5,530,104 admissions and 23,153,240 patient days.
They study offers an update of previously reported results and reflects national trends. The Centers for Disease Control reportsthat rates of hospital-onset, severe MRSA infections is falling in the US, a trajectory the agency calls "encouraging."
The MRSA Prevention Initiative
Before 2007, MRSA HAI rates were "unacceptably high" in VA facilities, the authors write. That led to the 2007 launch of the MRSA Prevention Initiative. Infection rates fell as the agency implemented a "bundle of interventions" including universal surveillance on admission, transfer, and discharge, and an emphasis on hand hygiene.
A MRSA prevention coordinator oversees surveillance at each facility using software that extracts data from each patient record.
The researchers also cite the benefits of "institutional culture change… where IPC (infection prevention and control) became everyone's business." They note that they cannot pinpoint which element of the program had the most impact, but suggest the focus on MRSA infections " helped motivate healthcare workers to practice better infection prevention and control measures."
The researchers speculate, however, that active surveillance was a major driver.
"MRSA HAI rates had not changed prior to October 2007 when the initiative was fully implemented, even though formal recommendations for hand hygiene and device-related infection control bundles had been in place for several years," they write.
Few doctors are sanctioned and researchers suggest action should be taken to protect patients from unsafe care delivered by outliers.
This article was updated on January 18, 2017 for clarification purposes.
Fewer than 2% of all physicians practicing over a 25-year study period ending in 2015 were responsible for half of all malpractice dollars paid out, a total of more than $41 billion, according to a new look at the data.
At the same time, only a small percentage of those whose data was reported to the National Practitioner Data Bank (NPDB) lost clinical privileges or were subject to action by licensing boards. The results of the study, which was led by a former associate director for research and disputes at NPDB, were published online by the Journal of Patient Safety.
The study relied on the NPDB's public use file.
The analysis supports earlier findings that looked at ten years of NPDB data. That Stanford study, released a year ago, found that 1% of doctors were responsible for 32% of paid claims.
Both studies found that doctors who paid multiple claims were more likely to pay additional claims than those who paid once.
The authors of the new study suggest that action needs to be taken to protect patients from unsafe care delivered by "outlier physicians."
The findings emerge at a time when the federal approach to malpractice is likely to shift with the incoming Republican administration. While changes to medical liability rules tend to occur at the state level, health regulators in the Obama administration have seen malpractice as reflection of quality of care.
The Affordable Care Act included a $25 million Patient Safety and Medical Liability (PSML) initiative. The AHRQ notes that the program reflects "the view that medical liability and patient safety are fundamentally linked."
NPDB on Payouts
An assessment of the programs concluded that they "encountered challenges—some expected and others unexpected"—but had many accomplishments.
Whether that approach will continue under the new administration is unclear, as many Republican lawmakers view malpractice in legal rather than medical terms.
Tom Price, MD, the nominee for Secretary of Health and Human Services, has said that "lawsuit abuse" and defensive medicine are major drivers of health care costs.
He supported a bill in 2011 called "The Health Care Professionals Protection Act" that would have required hospitals to hold hearings before reporting a malpractice claim to the data bank. Price also supports the GOP "A Better Way" reform proposal, which calls for tort reform and "higher standards of evidence" for malpractice claims.
The data bank study reflects a different perspective: "There is evidence that most adverse events result from individual errors and that most malpractice suits with payouts reflect both patient injury and error."
The researchers looked at 321,682 payments made from 1990 to 2015. During that period, roughly $83 billion was paid out in malpractice claims.
The claims were parsed to determine whether "clusters" of physicians are more likely to pay claims. One quarter of all claims were paid on behalf of 6,521 doctors—0.5% of all physicians. About half of all dollars paid out were paid by 1.8% of the group—22,511 doctors.
"If their payments could be substantially reduced or eliminated, it could make a major difference in the nation's total malpractice payout," the researchers wrote.
They found, however, that within that 1.8% group responsible for half the claims, 12.6% had an adverse licensure action reported to the NPDB, and 6.3% had a clinical privileges action reported.
The risk of a future malpractice report rose with each additional claim, according to the study. Also, physicians who paid large claims and one malpractice claim payout had a 74.5% chance of another payout, more than twice the rate for all physicians who had a single payout.
A Surgeon Turned Lawyer Weighs In Larry Schlachter, MD, JD, is a former neurosurgeon and an attorney who says he turned to malpractice law after an injury to his hand.
His book, Malpractice: A Neurosurgeon Reveals How Our Health-care System Puts Patients at Risk, is more personal than revealing. Neither a policy tome nor an investigative report, it is the view of someone "with a doctor's heart" and a "lawyer's awareness that great harm is sometimes done by physicians to patients through narcissism, carelessness and ineptitude," he writes.
Schlachter contends that the malpractice system is heavily weighted in favor of doctors and insurance companies. The data bank study shows that little is being done to address the subset of errant doctors, he says.
He believes, however, that hospitals are "in a tough situation" when state medical boards fail to investigate and restrict doctors who pay multiple malpractice claims.
As a lawyer, he has not seen any malpractice cases that have been settled by formal "communication and resolution programs."
The AHRQ and others are studying that approach, where providers reveal errors and offer out-of-court settlements when appropriate. Schlachter says he is more likely to see hospitals taking the deny-and-defend approach.
Increasingly, however, he is being called upon to oversee cases that go into arbitration. Often the approach offers a quick, fair alternative to a trial, he says.
But it does not require the hospitals to admit to a shortfall in patient care.
"There has to be a cultural change… the hospital serves the community and the human beings that come into the hospitals are shareholders in their own healthcare," he says. "They have to be able to trust the hospital to be patient centered and take care of patients' needs first."
Several research teams have raised issues about the limitations of claims data to measure PSIs. Now changes are in the works.
New data promises to add fuel to the ongoing discussion over the accuracy of billing data used to calculate patient safety indicators (PSI).
A group of Ohio State University researchers has found that hospital cases "flagged with a clinically validated PSIs" are linked to greater length of stay and higher rates of 30-day unplanned readmissions, and mortality.
The study, published in the American Journal of Medical Quality, "demonstrates a strong association between clinically validated PSIs and patient outcomes."
The Ohio State researchers note that by going beyond claims data to look at patients' medical records, they controlled for "the poor validity of the current PSI algorithm."
Several research teams have raised issues about the limitations of claims data to measure PSIs. And changes are in the works.
Some of the PSIs have been refined since the Ohio State study as part of an ongoing analysis of safety measures by the federal Agency of Healthcare Research and Quality. And, an upcoming report from the National Quality Forum, which works with AHRQ on refining measures, calls for a closer look at the use of claims, or administrative data, to measure PSIs.
Darrell Gray, an OSU gastroenterologist and lead author of the study, said his team saw a gap in the literature linking validated PSIs to other key outcomes, such as readmissions. Their recent research looked at outcome for 1,874 validated cases flagged for PSIs.
The researchers found that patients flagged with validated PSIs were more likely to be readmitted. For example, 22.2% of patient flagged for pressure ulcers were readmitted, compared to 19.8 of those not flagged.
The team included OSU researcher Jennifer Hefner and built off her earlier research at Ohio State. Published in August under the title, "Navigating the Ocean with a Broken Compass," the findings involved a retrospective analysis of all flagged PSI for the year 2014.
Hundreds of medical charts were compared to the administrative data to measure the accuracy of the PSI designation. The August study concluded that improvements are needed in the quality of data and algorithms data being used to identify the PSIs.
The PSIs were developed to be a barometer of how well a hospital was doing with preventable complications, said Gray. Now, the role of PSI has expanded to being tied to the assessment of a hospitals performance.
"It's important that we know truly what they are measuring and that what we are measuring truly represents the performance and quality of the hospitals that [are] reporting it," he said.
PSIs Matter to Patients, Too
He said readmission rates, mortality and length of stays are issues that "not only clinicians or hospital administrators care about. These are things patients care about. They want to know how likely they are to go into a hospital one day, be discharged and have to come back again. Or, how long am I going to have to stay for a particular diagnosis? It's on everybody's mind."
Researchers at John Hopkins Medicine have also challenged the accuracy of PSIs and measures for hospital acquired conditions. In a recent meta-analysis, they argued that PSIs should be valid in at least 80% of cases. They found that one out of 21 measures they looked at met that 80% validity threshold. Most other PSIs were valid in between 60%–80% percent of cases.
Lead author Bradford Winters, MD, said he doesn't think PSIs are faulty. "But, we need to optimize how we measure them. I don't think we are quite there yet," he said.
Still, Winters and his team believe that the measures should not be used for programs that levy penalties on providers with low PSI scores until a "transparent" review is held on the accuracy of the measures.
Since Winters' team completed its research, the National Quality Forum has been moving in the direction of addressing some of the PSI shortfalls. NQF has been engaged in a "very vigorous discussion" of the issues, he said.
In a draft of its upcoming annual "Patient Safety 2016" report, the National Quality Forum notes the need for an effort to improve the accuracy of administrative data: "The accuracy of the data used to calculate a measure is a primary consideration when determining its validity. This can be of particular concern when measures are specified using administrative data which were not originally collected to assess quality."
The report endorses measure that may "focus efforts on improving the quality of claims data, and in doing so, increase the validity of measures across the NQF portfolio."
The rate of improvement in preventing hospital readmissions is more rapid among lower-performing hospitals than among high-performing facilities, data shows.
How hard has it been for low-performing hospitals to reduce their readmission rates? That's a question researcher at Harvard decided to explore to by looking at how quickly this group responded to Medicare's 2010 penalty programs.
The high rate of penalties these hospitals earn raised concern that they were at a disadvantage in terms of readmission by "being under resourced or serving vulnerable populations," according to study published by the Annals of Internal Medicine.
The findings suggest that the rate of improvement in preventing readmissions is more rapid among lower-performing hospitals.
The researchers examined hospitalizations for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia reported on Medicare's Hospital Compare Web.
Readmission rates have been declining since the enactment of the Medicare Hospital Readmissions Reduction Program. The researchers found that that at high-performing hospitals, the reduction was 67.6 readmissions per 10,000 discharges. At the lowest-performance hospitals, the reduction was 95.1 per 10,000 discharges.
They looked at data from before the passage of the ACA, January 2000 through March 2010, and compared it to readmission figures collected up to December 2013, more than three years following passage.
Hospitals with no penalties were considered high performing, while any hospitals penalized with a 1% reduction in Medicare payments were considered lowest-performing.
The findings contribute to a general understanding of "how policies motivate healthcare providers to improve performance." So far, the study authors note, evidence that financial incentives improve the quality of care is mixed.
After passage of the healthcare reform law in 2010, "provider organizations improved readmission rates over and above the preexisting trend."
Lead author Jason H. Wasfy, MD, the director of quality and outcomes at the Massachusetts General Hospital Heart Center, along with two of his co-authors, also wrotea commentary on their findings for STATnews, a national life science news site associated with The Boston Globe. They concluded:
"Many drugs have what's called a dose-dependent effect. The higher the dose, the more effectively it fights disease. Penalties for readmission may have a similar dose-dependent effect. Hospitals with bigger penalties appear to have reduced readmissions more than those with smaller penalties. Such a relationship increases our confidence that the penalties are actually causing the improvement, instead of being associated with some other factor that is actually driving the change."
As patient satisfaction becomes increasingly important to the bottom line, more systems are dedicating staff, money, and programs to raising their scores.
More health systems are going beyond HCAHPS to improve patient experience. They're dedicating staff, using employee incentives, and conducting multiple surveys to improve patient experience scores.
In a survey and follow-up interviews with leaders from more than 100 hospitals, more than 50% said they didn't rely on HCAHPS alone to measure patient experience, according to the report, Patient Experience 2.0: Expanding Your Horizons.
Sixty-two percent of hospitals reported conducting between one and nine surveys, and 20% reported doing more than 50, according to the survey, which was produced by Jarrard, Phillips, Cate and Hancock, a Nashville, TN consulting group focused on patient experience.
The survey also found:
85% of respondents said patient experience is a top three priority for their health system
70% of health systems reported offering leadership incentives tied to patient experience.
64% of health systems reported seeing an increase in volumes since starting patient experience initiatives.
Only 35% of health systems publish patient reviews on their websites.
Responsibility for promoting positive patient experiences is assigned to a variety of departments, including nursing, quality and operations, with 36 hospitals reporting that they have established patient experience offices.
Most patient experience offices report to the chief operating officer, the chief executive office, and the chief nursing officer.
Roughly 47% of respondents reported their hospital's annual budget for patient experience programs was $150,000, but 5% reported patient experience budgets of more than $3 million. Salaries for patient experience leadership ranged from $50,00 to $250,000, according to the survey.
Seventy percent of respondents use incentives like annual raises to reward employees for high patient experience ratings. Most of those programs—83%—are tied to HCAHPS results.
Roughly 82% rely on pre-discharge conversations with patients to encourage participation in patient experience surveys. They reported response rates of 31% for both phone and mail reminders, and 23% for email.
"No matter which way the political winds blow in Washington, the foundational dynamics underpinning the rise of patient experience, such as the shift to value-based reimbursement and increasing consumerism, are here to stay," said company CEO David Jarrard in a media release.
"As a result, the stakes have never been higher for health systems across the nation as they seek to thrive in an increasingly competitive market."
Six months after the Pulse nightclub shooting killed 49 and injured scores, clinicians who treated the dying and the wounded describe the roles they played that night, and the rules they broke.
Mark Jones, president of Orlando Regional Medical Center, remembers arriving at the hospital the night of June 12, 2016 to find a police officer with an automatic weapon blocking a crowd at the entrance.
Surgeon Michael Cheatham, MD, remembers making the decision to stop CPR on a patient who was dying from gunshot wounds so he could save another patient more likely to survive.
Director of Services and Hospitality Holly Stewart recalls how she sent a clinician to the family waiting room because so many people were fainting.
They also needed a Spanish translator. It had been Latin night at the Pulse night club, the scene of the worst mass shooting in US history.
Hospital doctors, nurses, and administrators relived that awful night during the Institute for Healthcare Improvement (IHI) Forum in Orlando last week. It was streamed live on the IHI website.
"Drill Often"
One clear message emerged: Be prepared. Be prepared. Be prepared.
Three months before the shooting, the hospital had been part of a community-wide mass casualty drill. "There is no question that the work that was done that day saved lives," said Jones.
He urged hospitals to "Drill often. Do the table-top exercises when you can. You need to do this, in our opinion, when it is not convenient. You always think the hospital is busy. Do it when you are busy. Do it at night. Practice on the weekend."
The medical center is located just blocks from the Pulse nightclub, but the usual roads to the hospital were blocked because the shooter was still inside. So many patients were transported by pick-up trucks and police cars.
Many got no pre-hospital care, and there were no calls to the hospitals in advance. White medical examiner vans backed up to the hospital, loaded up, and pulled out. Over and over.
"You're Going to be Busy"
On the IHI webinar medical team members struggled with their emotions at times as they described the roles they played and the rules they broke to get through that night six months ago.
Emergency Department nurse Elisabeth "Libby" Brown, RN, got a call from her firefighter husband that night telling her: You're going to be busy. On her way in, she saw police cars flying down Orange Avenue. Cruisers on that street were not unusual; the number of them was.
"The first patient came in and we got to work," she said. "That's what we do. Then another patient came in and then another patient came in and they just kept coming. They had wounds like I had never seen before and I started to get really scared."
Brown focused on instructions from surgeon Chad Smith, MD. He was asking nurses to step outside their roles, but she said she trusted him.
"Save as Much Life as Possible"
Smith instructed staff to follow the rules of battlefield triage. The most gravely injured were treated first. For those "in extremis" who were unlikely to be saved, there was a different rule. "Their care must be ceased," he said.
Smith had trained to make decisions like these; actually making them was difficult. Teamwork helped him get it right, he said.
"Decisions like these have to be made. They have to be made to save as much life as possible," he said.
The only way to do it "is to have the training and team attitude to know that you are going to be supported by your team members, to have worked with people and trained with people, to know that they trust in you, that they trust in each other. "
Everyone on Smith's team was experiencing something they never had before, he said. They had to rely on their training and education and each other to get through it.
Leadership is Vital
"They are going to look for a leader," he said. "Those leaders need to be calm and composed despite what they are feeling inside and lead in a way that others can follow."
Fellow surgeon Cheatham started working on patients, but assumed a different role as other surgeons arrived. He began setting up the "incident command" center. The concept is a way of bringing order to an emergency situation by setting up a central, on-site command center with key staff from different departments.
He and others suggested all hospitals make themselves familiar with the practice and train for it.
After all the patients were treated, there was more to deal with... grieving families, John Doe patients with fake IDS, news team from across the country, traumatized clinicians, and visiting dignitaries.
And there was more pizza at the hospital than the staff could ever eat. Some of it came from Boston and San Bernardino, where hospital staff had a sense of what the Orlando team was going through.
Are You Prepared for the Worst?
After all the others spoke, Orlando Health COO Jamal Hakim, MD, delivered this message:
"Ours is a story of mission and passion, of preparedness and planning, of success and… a little bit of pride in being able to handle that which is really beyond preparation. Our question for you is: Are you prepared for the worst to show up on your doorstep unannounced?"
Overuse of antibiotics was the practice most commonly cited, accounting for more than one quarter of all responses, according to survey results.
The over-use of antibiotics and opioids is contributing to resistance and addiction, but not much else in the opinion of some primary care physicians.
Primary care doctors surveyed by the American College of Physicians listed the use of the two drugs among the four most common low-value treatments that are most frequently used by doctors, according to survey data published by the Annals of Internal Medicine cited in a letter on the appropriate use of therapeutic interventions to foster high-value care. The journal also published a review aimed at addressing the overuse of opioids.
Overuse of antibiotics was the practice most commonly cited, accounting for 27.3% of the responses. The overuse of nonpalliative care was cited by (8.6%) of the respondents and pharmacologic treatments (mostly narcotics and opioids) for chronic pain management (7.3%).
The list of low-value treatments also includes "aggressive non-palliative treatment in patients with limited life expectancy' and the use dietary supplements.
The study is based on an email survey of more than 1,100 ACP members. Most respondents were male, white, and older than 40 years.
Most focused on outpatient care and were general internists, versus internal medicine specialists. The authors note "many respondents struggled to identify therapies, instead naming diagnostics."
The authors write that the "goal of this observation is to promote thoughtful discussion among clinicians, patients, and policymakers about the value of care by balancing benefits, harms, and costs.'
A Critical Assessment, Focused Inward
Current clinical guidelines recommend appropriate care, but "the results of this survey may reflect intrinsic motivations to err on the side of treatment rather than 'doing nothing,'" lead author Amir Qaseem, MD, and chair of ACP's High Value Care Task Force, according to a statement announcing the study.
"However, as health care shifts to a value driven system, this study shows that doctors are willing to critically assess their own clinical practice."
The statement also points to ACP's High Value Care recommendations as a guide for doctors who want provide care that "improves health, avoids harms, and eliminates wasteful practices. Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm."
Medical doctors need to be able to confront the fear and shame that come with medical errors, for their own sake and for the sake of their patients, says a physician and author.
Early in her career, Danielle Ofri, MD, declared an elderly patient stable and went home. The patient's altered mental status was not unusual for someone in his condition.
The next day, she learned that he had been bleeding into his brain, a problem that was later caught and addressed. If it hadn't been, the patient could have died.
The system worked. The error was caught. But it was little comfort to Ofri, who has practiced medicine at New York's Bellevue Hospital for more than 20 years.
"I was so horrified," she said at a talk at Harvard Medical School last week. "I was so ashamed, I didn't tell anyone."
Ofri's talk centered on one emotion, shame, which she said overwhelms many doctors and is a major reason many medical errors go unaddressed.
When errors are not acknowledged, even those without bad outcomes, no one learns from them, she said. And, there is little incentive for doctors to point out their shortfalls. "We want to look like we know what we are doing. When in doubt, pretend. That's what I learned in my internship. "
'Afraid of Screwing Up'
Ofri, who trained and works at Bellevue Hospital in New York City, is a prolific writer, a practicing physician and editor of the Bellevue Literary Review. Described as a "born storyteller" by the late physician and author Oliver Sacks, Ofri builds her books around narratives from her own life as a doctor in a busy public hospital.
She shares those stories in her talks as well, last week admitting to a roomful of doctors and medical students that she and other doctors must cope with another overwhelming emotions – fear. Ofri said that she "spent every waking moment terrified as a student. I was so afraid of screwing up. "
Fear, however, is not always a bad thing, she said.
When doctors have no fear, they lose some of their "grounding… Fear can be overwhelming and it can harm patients. If we eradicate all of our fears, we become one of those cocky cowboy doctors and we all know where that can lead."
Shame, Ofri said, is a particularly common emotion for doctors, who can get called out for errors in front of peers or in front of a jury. When doctors feel ashamed, they often turn that angst on themselves, she explained.
The result is a high-stress environment that can produce less-than-optimal care. She argues that hospitals can address this by creating an atmosphere where doctors can talk about their medical errors without being threatened with humiliation.
Pressure Comes from the Top
"If the dean talks about [having emotions] on the first day or medical school, or the chair, on the first day of rotation, talks about experiences with emotions…That sends the message that emotions are normal and OK."
That also goes for the grief and sadness doctors feel when a patient dies. Ofri congratulates her students when they express that they feel that way. They should feel something when a patient dies. But physicians should also have a way to process those feelings, she said.
Ofri sees the healthcare system moving toward more openness around emotions, but that more can be done. Much of the shift is patient-driven, she said. Patients want to be listened to, heard and respected.
"Good listening skills come from being emotionally solid," she said. "Emotionally stunted people they are not very good listeners. They don't intuitively know how to connect with patients and that is reflected in patient satisfaction."
Ultimately, most of medicine comes down to one-on-one encounter between two people, the doctor and the patient.
"Whenever you put two people together… emotions are in the air," Ofri said.
"They're all around us. We are all susceptible to the same emotions. What we do with that and how we use it to our advantage or disadvantage" can affect patient outcomes.
Nine hospitals are recognized as top children's hospitals, 56 as top general hospitals, 29 as top teaching hospitals, and 21 as top rural hospitals.
More than 100 facilities made the "Top Hospitals" lists produced annually and released Tuesday by the non-profit patient safety advocacy organization, Leapfrog Group.
The hospitals listed are among those that have received an "A" grade from Leapfrog's annual survey, which was released in October. Hospitals qualify for the list by having "better systems in place to prevent medication errors, higher quality on maternity care and high-risk procedures, and lower readmission rates."
Four Categories of Hospitals
The top hospitals fall into four categories for the recognition—general, children's, rural, and, for the first time, teaching hospitals. In order to win a place on the list, hospital need to meet a list of criteria, including:
At least 75% of medication orders must be made through a Computerized Physician Order Entry (CPOE) system that can alert physicians to at least 50% of common, serious prescribing errors. "
They must have intensive care units managed by dedicated intensivists on duty during the day and, when not on site or available via telemedicine, the intensivist much return pages at least 95% of the time within five minutes.
They have to comply with Leapfrog's never-event policy for some medical errors. When a never event occurs, the hospital staff has to "apologize to the patient and family, waive all costs related to the event and follow-up care, report the event to an external agency, and conduct a root-cause analysis of how and why the event occurred."
They have to perform above average on Center for Medicare & Medicaid Services' mortality measures for heart attack, heart failure and pneumonia.
The two rating programs use some of the same data, but rely on their own collections of measures, and produce different results.
None of the five top rated hospitals on the U.S. News list, teaching hospitals such as Massachusetts General and the Mayo Clinic, are on the Leapfrog list.
In fact, no teaching hospitals from Massachusetts or Minnesota made the list.
However, both the teaching hospital and general hospital Leapfrog lists include numerous California Kaiser Foundation hospital, none of which make the U.S. News "Honor Roll."
The practice of tracking medication administration electronically promises to improve patient safety, but an early look at some of the data shows that hospitals are still working through barriers that hinder compliance.
Starting this year, the Leapfrog Group began collecting data on the use of bar codes in the administration of drugs to hospital patients. Enabled by electronic medical records, the system allows nurses to scan a patient’s wristband to confirm drug delivery for each patient.
The practice promises to improve patient safety, but an early look at some of the data shows that hospitals are still working through barriers that hinder compliance.
To meet the nonprofit organization's standards, hospitals have to make sure that bar code systems are deployed in all of their medical and surgical units, including intensive care. And they have to ensure that they are being used.
Leapfrog has not yet collected a full year's worth of data, but the state of Massachusetts offers a snapshot based on three months of the group's 2016 data.
Only six of the 47 hospitals monitored were found to have fully implemented bar code checks during medication administration (BCMA). And those facilities are not the big Boston medical centers that usually score high in the rankings.
Two are in largely rural Western, Massachusetts. The other two are south of the city.
The findings are part of a much broader annual quality report from The Center for Health Information and Analysis (CHIA), a quasi-public agency. It uses its own measures, which are designed to meet the National Academy of Medicine's quality standards, said Christi Carman, the group's quality reporting manager.
A third report used a select group of measures to "tell the clearest story in terms of what the measures intended to capture and how important the measures are relative to… the conversation here in the Commonwealth about quality and value," Carman said.
The report, which looks at both providers and hospitals, used 17 measures broken down by safe care, effective and efficient care, and patient-centered care. The BCMA numbers are in the "Safe Care" chapter, which reported four hospitals in full BCMA compliance. For the rest of the 39 reporting hospitals, 18 reported they were making "substantial progress" and 21 basically said they are still working on it.
Compliance Barriers
Leapfrog reports that "BCMA implementation can be remarkably effective in reducing medication administration errors. It cites a study that found a 41.1% relative reduction in errors (from 11.5% to 6.8%) in non-timing errors in medication administration.
At Carilion Roanoke Memorial Hospital, a 763-bed academic medical center in Roanoke, VA, a root cause analysis of a near miss led back to the BCMA system.
Chad Alvarez, the hospital's pharmacy director, said numerous workarounds and other issues were keeping staff from fully using the BCMA system. These included
Unreadable bar codes
Hardware problems with scanners
Workflow challenges when the patient was off the unit or the entire system was down
One other notable factor: A high percentage of overrides, where a nurse does not scan the medication bar code or the patient's armband. The EMR system requires a reason for the override and nurses commonly check off "nursing message." When the pharmacy removed that option, compliance improved.
It took a team effort to address it, he said.
"Looking at all those things in aggregate and increasing the awareness of what medication errors cost the health system and the potential harm it can cause for patients… It was a pretty easy sell to get everybody in the room," Alvarez said.
A Path to Better Compliance
The fix involved education for more than 800 staff, analysis of overrides to identify trends, and upgrades for wireless system and faulty scanners. Carilion also equipped carts and bedside devices used for medication administration with "problem-solving quick reference cards" on medication and bar-code scanner issues.
Then it published its findings: compliance with bar code medication administration rose from 82% to 97%: "Overall our experience highlights the need to continually improve the clinical components of the medication delivery process, by using a multidisciplinary team particularly where providers and technology intersect and focus on different levels of the system. Improvement was achieved when the multidisciplinary team focused on BCMA."
