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Quality Improvement Monitor

Get the latest developments in the CMS Quality Initiative and news on QI/PI issues with this informative weekly newsletter.

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Quality Improvement Monitor

Issue 32, August 11, 2005

• Psych ER purchases cots to handle overflow

  Overcrowding at one central New York state psychiatric emergency room forced the facility to...

Issue 49, December 29, 2005

• JCAHO advisory group to engage physicians in quality

  JCAHO advisory group to engage physicians in quality

• AHRQ brochure will educate patients about surgery

  AHRQ brochure will educate patients about surgery

• AHRQ appoints five new advisory members

  AHRQ appoints five new advisory members

Issue 48, December 23, 2005

• JCAHO will not sell performance measurement data

  JCAHO will not sell performance measurement data

• AMA develops 100,000 Lives materials

  AMA develops 100,000 Lives materials

• Delmarva to form multi-state RRT network

  Delmarva Foundation, a national not-for-profit organization whose mission is to improve healthcare...

Issue 47, December 2, 2005

• Rapid response teams among draft patient safety goals

  Rapid response teams among draft patient safety goals

• NCQA issues standards for measuring hospital performance

  NCQA issues standards for measuring hospital performance

• Survey finds U.S. leading in medical errors

  Survey finds U.S. leading in medical errors

Issue 46, November 17, 2005

• CMS hands out pay-for-performance bonuses

  A substantial improvement of quality care has prevailed in participating hospitals since CMS...

• Oregon reporting plan to include patient notification

  Oregon hospitals may soon report and analyze all serious medical errors and notify patients who are...

• PA hospital infections cost more than $1 billion

  Medicare and Medicaid in 2004 paid Pennsylvania hospitals more than $1 billion to cover treatments...

Issue 45, November 10, 2005

• Second patient dies from medication error at CA hospital

  Eight months after a patient at Kaiser Permanente Santa Clara (CA) Medical Center died from an...

• Report: Patients in six nations note high error rates

  One-third of U.S. patients with health problems reported experiencing medical, medication, or test...

• NQF head to step down, take over as Medsphere

  Days after receiving word he had won a national quality award, Kenneth Kizer, MD, MPH, announced he...

Issue 44, November 3, 2005

• Medication mix-up may have led to patient death

  The August death of a 21-year-old man at Santa Teresa Medical Center in San Jose, CA, may have...

• Report: More work needed on pay-for-performance principles

  Despite much that is unknown about pay for performance, stakeholders can advance successful...

• JCAHO releases Codman award winners

  The JCAHO on November 1 named five organizations and the head of the NQF as recipients of the 2005...

Issue 43, October 28, 2005

• MA Web site produces rift between state, hospitals

  A public Web site comparing the quality of care among Massachusetts hospitals has sparked some...

• Premier: New Web tools to help with quality improvement

  Rapid improvement programs and other tools will help assist hospitals improve care, lower costs...

• Conference seeks to find common ground for improvement

  The nation needs a set of common safety goals and treatment protocols to assist in reducing medical...

Issue 42, October 20, 2005

• Blue Cross launches quality reporting program

  A national program providing quarterly performance reports to hospitals and employers aims to...

• Pay-for-performance system shows promise with improvements

  Physicians initially having the lowest quality ratings showed the most improvement under a...

Issue 41, October 13, 2005

• NQF endorses additional ambulatory quality standards

  The National Quality Forum on October 11 announced the endorsement of six additional consensus...

• Hospital IT implementation slow, but commitment exists

  Only 10% of U.S. hospitals have fully implemented information technology (IT) systems, but a recent...

• AHRQ launches program to compare medical treatments

  The federal Agency for Healthcare Research and Quality (AHRQ) announced on September 29 its new...

Issue 40, October 7, 2005

• JCAHO releases proposed leadership standards

  After proposing to regulate a culture of safety in the National Patient Safety Goals earlier this...

• Quality scores up to par for U.S. for-profit hospitals

  For-profit hospitals received quality scores close to the average for all U.S. hospitals, according...

Issue 39, September 29, 2005

• NQF receives $3 million grant to develop standards

  The National Quality Forum (NQF) received a $3 million grant from the Robert Wood Johnson...

• Patient death leads to hospital education program

  A legal settlement in a patient death will require a Seattle hospital to educate staff about the...

• Red Sox fever impacts hospital ED visits

  Perhaps baseball is more than just a game, and that sentiment may impact business at the local ED...

Issue 38, September 22, 2005

• JCAHO, NQF announce 2005 Eisenberg winners

  The JCAHO and National Quality Forum on September 20 honored healthcare professionals and...

• Groups seek psychiatric nurses for hurricane relief

  Two national nursing organizations are recruiting certified psychiatric and mental health and...

• Study: Patient-safety materials often miss the mark

  Patient-safety brochures may not always convey effective or appropriate advice, according to a...

Issue 37, September 15, 2005

• Katrina hampers data-collection efforts in the Gulf region

  Hurricane Katrina may impact the ability of some Gulf Coast hospitals to report quality data to...

• Demonstration aims to find quality improvement mechanisms

  A five-year demonstration project will find ways to identify, develop, test, and disseminate major...

• Official: Reimbursement shouldn’t punish poor providers

  Any new Medicare reimbursement system that adjusts payments based on quality shouldn’t cut...

Issue 36, September 8, 2005

• CMS posts two new quality measures on Web site

  Consumers may now view information about a hospital’s efforts to reduce surgical infections...

• Study: Many residents unprepared to treat diverse patient groups

  Many resident physicians believe they are unprepared to adequately communicate with patients from...

Issue 35, September 1, 2005

• JCAHO to include organ donation rates in Quality Reports

  The JCAHO’s Quality Reports in July began reflecting high organ donation rates of hospitals...

• Many medical groups score low in chronic care

  Few U.S. medical groups scored well on quality measures for chronic-illness care, according to a...

• Study: Responses to infectious-disease reports differ

  Local public health agencies' responses to urgent infectious-disease reports vary substantially...

Issue 34, August 25, 2005

• JCAHO to lead world effort to fight medical errors

  The JCAHO will coordinate an international effort to reduce medical errors, the World Health...

• Cummings wants Medicare to review racial disparities

  CMS needs to respond to the results of three studies published in the August 18 New England Journal...

• Study: Streamlined ED triage program cuts wait times

  An urban ED cut wait times by nearly 30 minutes with an improved registration and triage process, a...

Issue 33, August 18, 2005

• Study: Patients have much to say about adverse events

  Engaging hospitalized patients in identifying medical errors and injuries can help enhance overall...

• Late-night heart-attack patients face longer waits for treatment

  Heart-attack patients who go to hospitals at night or on the weekend wait longer for an angioplasty...

• Grassley seeks information about QIOs

  The chair of the Senate Finance Committee wants more information about the role quality improvement...

Issue 32, August 11, 2005

• Study: ICU patients at greater risk for adverse events

  Critical-care patients face a serious risk for adverse events, according to a study published in...

Issue 31, August 4, 2005

• Medicare announces reporting payment update

  Hospitals reporting select quality data to CMS will receive a 3.7% increase in inpatient-service...

• Senate Finance chair wants to move on pay for performance

  Senate Finance Chair Charles Grassley pledged to act on legislation by the fall that would attempt...

• Uninsured-treatment costs may force L.A.-area ED to close

  Costs of treating the uninsured may force a Los Angeles County hospital to close its ED, which...

Issue 30, July 28, 2005

• House passes national error-reporting bill

  The House of Representatives on Wednesday approved a national error-reporting system and sent the...

• MedPAC director: Hospitals ready for pay for performance

  The hospital setting is ready for a pay-for-performance reimbursement system, but physician...

• Florida may suspend license for wrong-site surgery

  Florida physicians could face increased fines or license suspensions for performing wrong-site...

Issue 29, July 21, 2005

• Study: Quality of care has improved in U.S.

  Hospitals showed consistent improvement in quality of care for acute myocardial infarction, heart...

• Pittsburgh hosptials reduce bloodstream infections

  Pittsburgh-area hospitals reported a 63% decline in healthcare-associated bloodstream infections...

Issue 28, July 14, 2005

• PA hospital infections cost extra $2 billion in 2004

  Nearly 12,000 patients in Pennsylvania contracted infections during a hospital stay in 2004...

Issue 27, July 7, 2005

• Terror attacks place London hospitals on alert

  A series of coordinated terrorist attacks on London’s public transportation system July 7...

• Pay-for-performance bill draws support

  Healthcare providers, quality organizations, and trade groups say a pay-for-performance bill...

Issue 26, July 1, 2005

• House seeks pay-for-performance guidance

  Leaders of the House Ways and Means Committee asked CMS to outline the agency’s plan for...

• Study: Hospitals cut surgical infections by 27% in one year

  Fifty-six hospitals from 50 states and U.S. territories cut the rate of surgical infections for...

• New OSU ED will streamline care

  Ohio State University (OSU) Hospital East recently spent $5 million to add a 25,000-square-foot ED...

Issue 25, June 23, 2005

• AMA passes pay-for-performance principles

  The American Medical Association House of Delegates on June 21 approved a set of...

• Study: Nurses with bachelor’s degrees start career earlier

  Nurses who hold a bachelor’s degree were more likely to start their careers earlier and be...

• QIOs to help hospitals implement technology

  Quality improvement organizations will begin working with hospitals to help them support use of...

Issue 24, June 16, 2005

• Be careful with additional abbreviations

  Continue to enforce compliance with abbreviations that are not on the JCAHO’s unapproved list...

• Report: QIOs may not help drive quality improvements

  Hospitals that participate with quality improvement organizations (QIOs) are not more likely to...

Issue 23, June 9, 2005

• Study: Medication safety changes coming slowly

  Medication safety has improved during the past five years, but improvements are coming slowly...

• CDC joins 100,000 Lives Campaign

  The Centers for Disease Control and Prevention (CDC) announced June 2 that it has joined the...

• AHRQ awards two-year grants for safety initiatives

  The Agency for Healthcare Research and Quality (AHRQ) will award more than $8 million in funding...

Issue 22, June 2, 2005

• JCAHO releases 2006 National Patient Safety Goals

  Hospitals must implement two new National Patient Safety Goals requirements by January 1, 2006.

• Physician, lawyer cooperation key to tort reform

  Protecting patients from medical errors and fairly compensating those that do suffer as a result of...

• Staffing shortage harms patients at LA veterans hospital

  The West Los Angeles Veterans Affairs hospital will hire more physicians for the ED after an...

Issue 21, May 26, 2005

• Medication errors continue at computerized hospital

  Errors in drug ordering, dosage, and monitoring that may have serious consequences for patients...

• Study: Training can help improve communication with minority patients

  Simple classroom lectures about different religious holidays and customs or Spanish language...

• TX hospital named top heart-failure care provider

  Harris Methodist Fort Worth (TX) Hospital received a Premier Award for Quality on May 20 in the...

Issue 20, May 19, 2005

• NQF endorses patient satisfaction survey

  The National Quality Forum on May 13 announced its endorsement of a standardized survey of...

• Dashboard helps NY hospital change its culture

  A Syracuse, NY, hospital that filed for Chapter 11 bankruptcy in 2001 and kept employees in the...

• NJ hospital receives national recognition for safety efforts

  Cooper University Hospital in Camden, NJ, received recognition for its patient-safety efforts from...

Issue 19, May 12, 2005

• Report: Physicians slow to embrace quality improvements

  Some physicians fail to provide Americans with the best care available, according to a study...

• More Medicare spending leading to lower quality of care

  States that spend more per Medicare beneficiary tend to rank lower in the quality of care they...

• Bill would prevent forced overtime for PA nurses

  Some Pennsylvania nurses are lobbying their state legislators to pass a bill that would ban...

Issue 18, May 5, 2005

• Report: Infection rates worsen in U.S. hospitals

  Hospital-acquired infections continue to be one of the major threats to patient safety in the...

• CMS: Hospital pay for performance is working

  Data from more than 270 hospitals participating in a CMS pay-for-performance demonstration project...

• Author: Barriers to improving quality exist in demonstration projects

  Demonstration projects such as those ordered under the Medicare Prescription Drug, Improvement, and...

Issue 17, April 28, 2005

• CMS proposes inpatient payment rate increase

  Acute care hospitals that submit data on 10 quality measures in the 2006 fiscal year will receive a...

• Patient satisfaction survey may launch in June

  CMS may launch a survey to determine patients’ satisfaction with hospital care as early as...

• CO teacher shortage hurts nursing schools, hospitals

  Nursing schools in Colorado have been forced to turn away students despite a nursing shortage due...

Issue 16, April 21, 2005

• ACEP: Physicians should have say in future measures

  Current hospital quality measures are improving patient care, but many emergency-medicine...

• QIOs support local hospital improvement efforts

  Quality management directors generally view quality improvement organizations (QIOs) as helpful...

• Language barriers could be obstacle to good care

  A lack of translation services could endanger patients who do not speak English and could violate...

Issue 14, April 7, 2005

• AHRQ: States show improvement, but more work needed

  States showed a 3% improvement in 14 categories of healthcare quality between 2002 and 2003...

• Nursing job satisfaction high, but many unhappy with pay

  U.S. nurses as a whole are highly satisfied with their jobs when it comes to interacting with other...

• Some physicians find loophole in disciplinary databank

  Nearly 1,000 physicians nationwide were disciplined in one state and then moved to another before...

• L.A. supervisors consider new school to help troubled hospital

  Los Angeles County supervisors on April 6 questioned whether the belaguered Martin Luther King...

• New Web site provides national patient safety resources

  A new Web site announced April 12 by the Agency for Healthcare Research and Quality is a national...

Issue 12, March 24, 2005

• Court favors hospital report to practitioner database

  An Illinois appellate court recently ruled that a hospital was not in contempt when it failed to...

• Study: Hospital-associated infections are growing problem in developing nations

  Rates of neonatal infections in hospital-born babies are nearly 20 times higher in developing...

Issue 11, March 17, 2005

• Authorities warn of imposter surveyors

  Individuals posing as JCAHO surveyors have entered three U.S. hospitals in the past three weeks...

• NQF issues quality guidance to hospital boards

  The National Quality Forum provides guidance to hospital boards of trustees about their...

• CMS set to launch hospital quality Web site

  CMS will launch its Hospital Compare Web site April 1 during a meeting of the Association of Health...

Issue 10, March 10, 2005

• Study: Patient safety performance varies across U.S.

  Patient safety at hospitals varies dramatically across the nation, but the highest performance on...

• AMA releases pay-for-performance guidelines

  The American Medical Association on March 2 released a new set of pay-for-performance principles to...

• MA hospitals find new waiting spots for patients

  Massachusetts hospitals may now place patients waiting for rooms in hallways on regular inpatient...

Issue 9, March 3, 2005

• CDC offers guidance on reporting infection data

  The Centers for Disease Control and Prevention's (CDC) Healthcare Infection Control Practices...

• MedPAC encourages pay-for-performance reimbursement

  The Medicare Payment Advisory Commission continued pushing for tying reimbursement to quality in a...

• Study: Diabetes prevention saves money in long run

  A new study in the March Annals of Internal Medicine is the first to show that it would be...

Issue 8, February 24, 2005

• Quality of care improving, but disparities remain

  Healthcare quality in the United States has improved, but disparites in care related to race...

• NQF seeks comment on patient-satisfaction survey

  The National Quality Forum seeks comment on the 27-question HCAHPS hospital patient satisfaction...

• JCAHO accepting Eisenberg Award nominations

  The JCAHO and NQF are accepting nominations for the 2005 John M. Eisenberg Patient Safety and...

Issue 7, February 17, 2005

• Kennedy bill would limit nurse overtime

  Sen. Edward M. Kennedy (D-MA) introduced legislation last week that would fine hospitals for...

• Study: Younger physicians provide higher-quality care

  Older physicians tend to provide lower-quality care than recent medical school graduates, according...

• Researchers find relation between missing data, errors

  Missing clinical information could contribute to delays in care and medical errors, according to a...

Issue 6, February 10, 2005

• NC surgeon accused of performing wrong bypass

  A North Carolina surgeon may have performed the wrong type of gastric bypass surgery on more than...

• NQF releases standards on cardiac surgery quality

  The National Quality Forum (NQF) announced on February 8 the publication of a new set of national...

• Online community allows quality improvement discussion

  A new online forum encourages open sharing of best practices to promote quality improvement in New...

Issue 5, February 3, 2005

• MedPAC chair touts pay for performance

  Medicare should reward providers financially for making progress toward delivering high-quality...

• Medicare begins performance-based reimbursement for physicians

  CMS on January 31 announced new initiatives to pay healthcare providers for the quality of the care...

• Study: Male surgeons report higher rate of mistakes

  Male surgeons report the highest rate of mistakes in patient care, according a study of...

Issue 4, January 27, 2005

• MN error reports show 20 patient deaths in 15 months

  Twenty patients died in Minnesota hospitals during a 15-month period because of medical errors...

• Report: Miscommmunication can hinder patient safety

  Poor communication and collaboration among healthcare workers, inadequate support systems, and a...

• Disease management program wins association award

  The disease management firm XLHealth received the Disease Management Association of America’s...

Issue 3, January 20, 2005

• Don't miss out on reporting quality data to CMS

  Be aware of the window after the close of a quarter to submit your quality data to CMS, agency...

• MedPAC: CMS should collect data on heart, lung surgeons

  The Medicare Payment Advisory Commission (MedPAC) says Medicare should gather data to pay...

• JCAHO accepting applications for 2005 Codman award

  Healthcare organizations may now submit applications for the 2005 Ernest A. Codman Award, the JCAHO...

Issue 2, January 13, 2005

• MedPAC recommends pay for performance

  The Medicare Payment Advisory Commission (MedPAC) voted Wednesday to recommend to Congress that...

• Study: Long shifts can lead to road dangers

  Medical interns are more than twice as likely to get in a car crash when driving after working for...

• Reconciliation programs can reduce medication errors

  Hospitals need to take the lead in compiling an accurate medication list for patients, according to...

Issue 1, January 6, 2005

• Groups reach consensus on quality improvement priorities

  A coalition of more than 250 consumer, healthcare provider, payer, and research organizations on...

• Hospital EDs see increase in flu patients

  Hospitals in New York have seen a rise in patients with the flu, pneumonia, or other respiratory...