Quality Care & Patient Safety
According to the Kaiser Family Foundation (KFF), the U.S. spends more than any other country on health care ($7,538 per capita) but does a worse job providing efficient access to quality care compared to six other industrialized countries. Statistics such as these, combined with the recognition by both government and private payers that delivering quality care also reduces costs, hospitals will continue to be scrutinized in their ability to provide quality care services and prevent medical errors. The Patient Protection and Affordable Care Act (PPACA) includes several provisions that bring greater structure to quality improvement efforts – providing the opportunity for hospital and physician quality measures to be in closer alignment. As such, hospitals have renewed their commitment to improving and aggressively addressing many quality and patient safety concerns.
Clinical integration is viewed as a key factor to improving both quality and coordinated care. The process can range from achieving coordination around a single clinical procedure to fully integrated hospital systems with closed staffs consisting of only employed physicians. Currently, most office-based physicians practice alone or in small groups focusing on a single specialty, as opposed to multi-specialty groups that are best able to support coordinated care. Because of this, patients with multiple conditions see a number of primary care physicians (PCPs) and specialists in many different settings, as opposed to a group of PCPs and specialists that work together in a group offering complete care for a patient, according to the American Hospital Association (AHA). In order for clinical integration to be successful, hospitals must establish mechanisms to monitor and control utilization of health care services; selectively choose participating physicians who will further efficiency objectives; and invest significant capital in the infrastructure and capabilities necessary to realize the efficiencies.
Despite its advantages, there are a number of legal barriers to clinical integration because of antitrust, Stark, anti-kickback and other various laws. Presently, lawmakers are looking into these regulations and are expected to implement payment and delivery reforms that would make the process of clinical integration easier.
Health care reform places more emphasis on providing quality and coordinated care for Medicare fee-for-service beneficiaries and decreasing both the frequency of visits per patient and financial expenditures by the provider. There are approximately 1.8 million Medicare beneficiaries in Illinois, according to the Kaiser Family Foundation (KFF). To better serve this population and achieve coordinated care, the Patient Protection and Affordable Care Act (PPACA) proposes Accountable Care Organizations (ACOs). ACOs offer savings to both Medicare beneficiaries and providers lowering health care costs. More so, ACOs could potentially decrease potential readmission and length of stay in skilled nursing facilities (SNFs). Despite the potential benefits of ACOs, providers are concerned about implementation, which include financial expenditures; additional effort involved with implementing; potential creation of a monopoly with larger systems predominating; additional risk; and increased demands on the provider.
MCHC implemented the MetroChicago Health Information Exchange (HIE) in April 2011, and it is expected to be one of the nation’s largest regional HIEs. The purpose of the MHIE is to develop a sustainable, value-driven system that exchanges secure health information across the greater metropolitan Chicago area, meeting health systems’ needs to achieve regional and statewide collaboration, while supporting the need for care coordination and other functions, as defined under the HITECH Meaningful Use Rules.
Additionally, Illinois has two regional extension centers (RECs) – the Chicago Health Information Technology Regional Extension Center (CHITREC) and the Illinois Health Information Technology Regional Extension Center (IL-HITREC) (for primary care physicians (PCPs) outside the City of Chicago). The mission of both CHITREC and IL-HITREC is to leverage expertise and resources to implement the outreach, education and technical assistance programs necessary to assist Illinois PCPs to advance toward the goal of improving the quality and value of care they provide by attaining or exceeding meaningful use of electronic health records (EHRs).
Health Information Technology
Studies show that the benefits of using health information technology (HIT) are extensive, and a necessary component for successful implementation of clinical integration. Using HIT can prevent duplication of tests; reduce medical errors; reduce pharmacy errors when filling prescriptions; allow patients to access critical parts of their medical records, encouraging better patient self-care; and improve care of chronic illness through a system that alerts physicians whether patients are filling required prescriptions and making recommended follow-up appointments. The integration of various exchanges through HIT would increase productivity and profits in health care.
Adoption of electronic medical records (EMRs) in hospitals lags behind previous estimates. Medical experts agree that eliminating paper records would help save lives and make health care more efficient and less costly. Yet, the adoption of inpatient EMRs is only at 61 percent, while the use of EMRs by office- based physicians is only at 44 percent, according to the American Hospital Association (AHA).
Problems transferring electronic medical data among different hospitals and medical groups have been reported. Thus, once a health information exchange (HIE) is established, resources of time and money will be needed to properly train medical professionals on how to use the system.
In a post-health care reform environment, hospitals must continue to improve their management of chronic diseases. This area provides greater opportunity for hospitals to demonstrate their value to patients and payers alike. Telemedicine and the development of statewide/regional health information exchanges (HIEs) are likely key factors to long-term success.
Health Care Disparities
The U.S. population is becoming more ethnically diverse with minorities expected to become the majority by 2042, according to the U.S. Census Bureau. This will require a culturally appropriate approach with patients. Currently, health care disparities exist in quality of care across all minority populations and the problem is only going to become more challenging as this subset grows.
MCHC continues to capitalize on advances in health care technology to help its members improve patient/provider communication and quality of care. The Illinois Video Interpreter Network for Healthcare (IVIN) is a cost-effective, live video interactive technology that helps hospitals ensure that patients have access to qualified medical interpreters in less than one minute by video or telephone.
Hospitals and providers must devote more resources to meet the needs of a regional population that continues to grow and become more diverse. In addition, MCHC members must meet new requirements for providing access to certified American Sign Language (ASL) interpreting and other language-related services. The benefits of offering these language-related services are improved communication; adherence to treatment regimens, diagnosis and treatment; and fewer complaints. Reasons for the lack of compliance among providers are a lack of training resources for the staff, costs and the broad range of languages spoken in the provider’s community.
Hospital Quality Measures
While most providers and patients agree that high quality care is an essential component of a high performing health care system, there has been much recent debate regarding how to best define “high quality” in the hospital setting. In a joint collaboration, the Centers for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance (HQA) have established the Hospital Compare Web site to promote reporting on hospital quality of care, which continues to add information on quality measures. The Patient Protection and Affordable Care Act (PPACA) also establishes a national quality improvement strategy, which includes priorities that have the greatest potential to improve patient outcomes, patient-centeredness and efficiency. The selected priorities will become the basis for further work to develop and implement measures to foster improvement and public reporting, including public reporting on hospital quality on the Hospital Compare Web site.
The Centers for Medicare and Medicaid Services (CMS) has added readmission rates as one of the hospital quality measures listed on its Hospital Compare Web site as well as announced plans for a pilot program to eliminate unnecessary hospital readmissions. Also, the Obama administration and Congress continue to see readmissions (and reduced payments to hospitals with high readmission rates) as a substantial source of budget savings.
The American Hospital Association (AHA) is urging Congress to re-examine penalties for readmissions, so that it only applies to those readmissions that were unplanned and could have been prevented.
The hospital readmissions reduction program (HRRP) was included in the Patient Protection and Affordable Care Act (PPACA) and offers financial incentives to hospitals that treat Medicare beneficiaries to reduce preventable readmissions. Starting in fiscal year (FY) 2012, those hospitals that report higher than expected 30-day readmission rates for patients who had been hospitalized with heart attacks, heart failure and pneumonia could see their Medicare reimbursements decreased by up to 1 percent the first year, up to a maximum of 3 percent in 2015 with an expanded list of relevant health conditions. The U.S. Department of Health and Human Services (HHS) will make hospital-specific readmission rates publicly available on the Hospital Compare Web site.
A study in Medical Care found that patient safety risk increases higher during weekend admissions (8 percent) and 6 percent of patients are more likely to die, when they are admitted to hospitals that are at or near their peak capacity. As such, research by the Agency for Healthcare Research and Quality (AHRQ) found that hospitals are less likely to perform a major procedure on a patient on the same day as admission if the patient was admitted over the weekend (36 percent) than on a patient admitted during the weekday (65 percent).
According to a report in the New England Journal of Medicine, hospitals can reduce the number of deaths from surgery by more than 40 percent by using a checklist that helps physicians and nurses avoid medical errors.
According to The Joint Commission, objects accidentally left inside a patient during surgery is among the top 10 sentinel events reported annually. New radio frequency technology has been created to decrease the instance of this medical error from occurring. The radio frequency detection system is a wand that can be scanned over a patient to see whether any surgical items have been left inside the patient. There has been a dramatic reduction in the presence of objects being left in a patient during procedures in the hospitals using this system.
A study in the Archives of Internal Medicine found that interruptions can cause nurses and physicians to make serious medical errors. In the study, nurses were interrupted 53 percent of the time when administering drugs, including staff inquiries; stopping to search for missing drugs or supplies; and responding to phone calls or pagers. Furthermore, of those interrupted events, 74 percent of nurses had at least one procedural failure and 25 percent had at least one clinical error. Physicians, when interrupted, feel rushed and are forced to complete their tasks in a shorter amount of time or skip them all together.
A survey commissioned by the American College of Surgeons (ACS) found that 9 percent of surgeons were afraid that they had made a major medical error within the past three months. Forty percent (40 percent) of those who responded to the survey were “burned out” and 30 percent were showing symptoms of depression.
A new type of patient safety error is referred to as “alarm fatigue.” Because of the constant beeps and buzzes caused by patient monitoring devices, nurses often tune them out or turn them off completely, which can have deadly consequences. Congress has requested that Health and Human Services (HHS) Secretary Kathleen Sebelius commission the Institute of Medicine (IOM) to analyze the problem and recommend solutions to “alarm fatigue.”
In order to reduce medical errors and ensure proper patient identification, some hospitals have stopped asking patients for their health insurance cards and filling out endless forms and, instead, identified them by scanning their palm veins, which the biometric technology then matches with the patients’ medical records, according to Reuters.
The Illinois Department of Public Health (IDPH) has launched a Web site (www.healthcarereportcard. illinois.gov), which offers quality and safety data on hospitals and surgery centers. The Web site contains information on nurse staffing, patient satisfaction, pricing information, mortality rates and surgical care quality. In January 2012, the Web site for the first time began making available information on surgical care infection rates. According to IDPH, the information helps hospitals monitor their quality and patient safety practices and highlight areas where they can make improvements.
The Obama administration favors a national reporting system for hospital-acquired infections (HAIs). Under the Obama administration, the Centers for Medicare and Medicaid Services (CMS) has established procedures for cutting pay to facilities that make preventable errors when caring for Medicare beneficiaries. Additionally, in an effort to increase transparency, the administration has created the “CMS Dashboard” for viewing the national, state, hospital and diagnosis-related group (DRG) claims payment and volume data from Medicare’s inpatient prospective payment system (IPPS).
Tracking hospital-acquired infections (HAIs) remains difficult. Medicare and an increasing number of private payers will not reimburse hospitals for certain HAIs, which provides hospitals with incentives to increase their quality improvement efforts.
The Patient Protection and Affordable Care Act (PPACA) will require more public reporting of hospital-acquired infections (HAIs) by encouraging better patient outcomes through various incentives and restrictions. Beginning in October 2012, hospitals that exceed federal performance standards for at least five measures, including certain HAIs, will receive higher Medicare payments. In 2014, the federal government will reduce Medicare payments by 1 percent for those hospitals with the highest rates of medical harm as measured by “hospital-acquired conditions,” which include certain preventable infections and medical errors, such as serious bedsores, catheter-associated urinary tract infections (UTIs) and certain types of falls and trauma.
The Midwest Alliance for Patient Safety (The Alliance), a nonprofit patient safety organization (PSO), is a joint venture between MCHC and the Illinois Hospital Association (IHA). Its mission is to promote the adoption of best practices to measurably improve the delivery
of safe and quality care to all patients. The Alliance has 73 hospital members from throughout Illinois. As a federally certified PSO, The Alliance provides a safe and protected environment for Illinois hospitals to share, learn and improve with a goal to ultimately eliminate patient harm.
Through a $2.8 million grant from the Robert Wood Johnson Foundation (RWJF), the University Medical Center at Princeton is home to one of the first on- site “health care design labs,” which are designed to help patients heal faster and cut down on staff errors. The rooms include close proximity of the bathroom to the bed; a grab rail against the wall where patients will be stepping; a sink near the door to prompt more staff members to wash their hands; and a two- way linen cabinet that can be stocked from the hall. Many hospitals in the metropolitan Chicago region have implemented such patient room improvements.
Excessive noise can keep patients awake and interfere with their recovery, research shows. To reduce excessive noise, hospitals have reduced or relocated phones and lowered the volume on remaining phones; changed the nurse call system; changed where drawers and trash bins are placed; and used sound absorbent ceiling tiles.
Furthermore, the Patient Protection and Affordable Care Act (PPACA) creates an independent Patient- Centered Outcomes Research Institute to conduct comparative effectiveness research. This research will focus on health care interventions, protocols for treatment and pharmaceutical use. The Institute will assist patients, clinicians and policymakers in making informed health decisions by advancing evidence-based knowledge of how diseases and other health conditions can effectively and appropriately be prevented, diagnosed, treated and managed.