Cynthia Barnard

Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit.

Introduction: Interventions to reduce preventable complications such as catheter-related bloodstream infections (CRBSI) can also decrease hospital costs. However, little is known about the cost-effectiveness of simulation-based education. The aim of this study was to estimate hospital cost savings related to a reduction in CRBSI after simulation training for residents. Methods: This was an intervention evaluation study estimating cost savings related to a simulation-based intervention in central venous catheter (CVC) insertion in the Medical Intensive Care Unit (MICU) at an urban teaching hospital. After residents completed a simulation-based mastery learning program in CVC insertion, CRBSI rates declined sharply. Case-control and regression analysis methods were used to estimate savings by comparing CRBSI rates in the year before and after the intervention. Annual savings from reduced CRBSIs were compared with the annual cost of simulation training. Results: Approximately 9.95 CRBSIs were prevented among MICU patients with CVCs in the year after the intervention. Incremental costs attributed to each CRBSI were approximately

Active surveillance using electronic triggers to detect adverse events in hospitalized patients

82,000 in 2008 dollars and 14 additional hospital days (including 12 MICU days). The annual cost of the simulation-based education was approximately

Using Patient Safety Morbidity and Mortality Conferences to Promote Transparency and a Culture of Safety

112,000. Net annual savings were thus greater than

Concerns About Using the Patient Safety Indicator-90 Composite in Pay-for-Performance Programs

700,000, a 7 to 1 rate of return on the simulation training intervention. Conclusions: A simulation-based educational intervention in CVC insertion was highly cost-effective. These results suggest that investment in simulation training can produce significant medical care cost savings.

Physician Report Cards and Implementing Standards of Practice Are Both Significantly Associated With Improved Screening Colonoscopy Quality

Background: Adverse events (AEs) occur with alarming frequency in health care and can have a significant impact on both patients and caregivers. There is a pressing need to understand better the frequency, nature, and etiology of AEs, but currently available methodologies to identify AEs have significant limitations. We hypothesized that it would be possible to design a method to conduct real time active surveillance and conducted a pilot study to identify adverse events and medical errors. Methods: Records were selected based on 21 electronically obtained triggers, including abnormal laboratory values and high risk and antidote medications. Triggers were chosen based on their expected potential to signal AEs occurring during hospital admissions. Each AE was rated for preventability and severity and categorized by type of event. Reviews were performed by an interdisciplinary patient safety team. Results: Over a 3 month period 327 medical records were reviewed; at least one AE or medical error was identified in 243 (74%). There were 163 preventable AEs (events in which there was a medical error that resulted in patient harm) and 138 medical errors that did not lead to patient harm. Interventions to prevent or ameliorate harm were made following review of the medical records of 47 patients. Conclusions: This methodology of active surveillance allows for the identification and assessment of adverse events among hospitalized patients. It provides a unique opportunity to review events at or near the time of their occurrence and to intervene and prevent harm.

Creating Organizational Change Through The Pain Resource Nurse Program

BACKGROUND Although creating a culture of safety to support clinicians and improve the quality of patient care is a common goal among health care organizations, it can be difficult to envision specific efforts to directly influence organizational culture. To promote transparency and reinforce a nonpunitive attitude throughout the organization, a forum for the open, interdisciplinary discussion of patient safety problems--the Patient Safety Morbidity and Mortality (M&M) Conference--was created at Northwestern Memorial Hospital (Chicago). The intent of the M&M conference was to inform frontline providers about adverse events that occur at the hospital and to engage their input in root cause analysis, thereby encouraging reporting and promoting systems-based thinking among clinicians. METHODS Convened under the purview of the organizations quality program, and modeled on the traditional M&M conferences historically used by physicians, the conference is a monthly live meeting at which case studies are presented for retrospective (root cause) analysis by an interdisciplinary audience. RESULTS Since its start in 2003, approximately 60 patient safety M&M programs have been presented. Audiences typically represent a mix of physicians, nurses, pharmacists, management, therapists, and administrative and support staff. Staff perceptions of culture, as measured by the Hospital Survey on Patient Safety Culture, showed statistically significant improvements over time. DISCUSSION Ensuring the patient safety M&M conference programs sustained success requires an ongoing commitment to identifying events of clinical importance and to pursuing the productive discussion of these events in an open and safe forum. Patient safety M&M conferences are a valued opportunity to engage staff in exploring adverse events and to promote transparency and a nonpunitive culture.

Radical systems change. Innovative strategies to improve patient satisfaction.

In 2003, the Agency for Healthcare Research and Quality (AHRQ) released 20 patient safety indicators (PSI) to facilitate measurement of adverse events. Though intended for internal quality measurement and improvement, several PSIs are now being widely publicly reported, including on the Centers for Medicare & Medicaid’s (CMS’s) Hospital Compare website. Additionally, on October 1, 2014 (fiscal year 2015), CMS began using AHRQ’s Patient Safety for Selected Indicators (PSI90) as a core metric in 2 of its pay-for-performance programs: the Hospital-Acquired Condition (HAC) Reduction program and the Hospital Value-Based Purchasing (VBP) program. PSI-90 is a composite measure consisting of 8 weighted component PSI measures (Table).1 In the HAC Reduction program, PSI-90 is responsible for 35% of the overall score, and the poorest-performing hospital quartile will have their CMS payments reduced by up to 1% (~

Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events

330 million). In the Hospital VBP Program, CMS will reallocate 1.5% (~

A Comprehensive Quality Assurance Program for Personnel and Procedures in Radiation Oncology: Value of Voluntary Error Reporting and Checklists

1.4 billion) of its diagnosis related group payments to hospitals according to their overall score, 30% of which is composed of PSI-90 and 4 other outcome measures. Thus, the PSI-90 composite measure has been given substantial weight in attempting to align the financial interests of hospitals with the quality of care they provide. As evidenced by a lack of continued maintenance endorsement from the National Quality Forum in 2014, numerous problems exist with the current PSI-90 composite measure: (1) flawed component measures; (2) clinical areas targeted; (3) accuracy of adverse events identified; (4) adequacy of the risk adjustment; and (5) formulation of the composite measure. These flaws may incorrectly identify problem areas for hospitals to address, unfairly penalize hospitals financially, and adversely influence clinician engagement in quality improvement. However, there are opportunities to improve this measure in hopes of more accurately monitoring hospital performance for potentially preventable complications.

Should Medical Students Track Former Patients in the Electronic Health Record? An Emerging Ethical Conflict

OBJECTIVES:Adenoma-detection rates (ADRs) are associated with decreased interval colorectal cancer (CRC) rates and CRC mortality; quality improvement strategies focus on improving physician ADRs. The objective of this study was to examine the sequential effect of physician report cards and implementing institutional standards of practice (SOP) on ADRs.METHODS:Colonoscopy metrics were prospectively evaluated at a single academic medical center over a 23-month period (November 2012 to October 2014). ADRs were evaluated over three time periods—Period 1: Before initial report card distribution or SOP (November 2012 to March 2013); Period 2: After individualized report card distribution detailing physician and institutional ADRs (April 2013 to March 2014); Period 3: After second report card and SOP implementation (April 2014 to October 2014). The SOP required physicians to have a minimum 5-min withdrawal time in normal colonoscopies (WT) and an ADR minimum of 20%; those who did not meet benchmarks would require further training or endoscopy block time alterations. Only endoscopists averaging >15 colonoscopies/month were included in this analysis.RESULTS:Twenty endoscopists met the inclusion criteria, performing 12,894 screening colonoscopies over the 23-month period. Following report card distribution, physician ADRs increased by 3% (P<0.001). SOP implementation resulted in a further significant increase in mean physician ADR of 8% (P<0.0001). Overall, mean ADR increased by 11% from Period 1 to Period 3 (P<0.0001). All physicians met the minimum 20% ADR benchmark during Period 3. Although ADRs significantly correlated with WT overall (r=0.45; 95% CI 0.01, 0.75; P=0.04), mean WT did not significantly increase from Period 1 to Period 3.CONCLUSIONS:Our data suggest that distributing colonoscopy quality report cards resulted in a significant ADR improvement. Further, we report evidence that implementing SOP significantly improved ADRs beyond report card distribution and resulted in all endoscopists meeting minimum benchmarks. This suggests that report cards and SOPs may have an additive effect in improving colonoscopy quality, and their implementation in endoscopy labs should be encouraged.