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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 49, December 21, 2007 - VIEW THE FULL ISSUE

• Minnesota patients share opinions of hospitals online

  A new Web site created by an affiliate of Blue Cross and Blue Shield of Minnesota allows patients...

• Michigan to post quality data on the Web

  The Michigan Health & Hospital Association will launch a new Web site on January 1 that will...

• Prepare now for anticoagulation requirement

  Even though hospitals have all of 2008 to prepare for the new National Patient Safety Goal (NPSG...

• Editor's note

  The Quality Improvement Monitor will not be published the week of December 24, 2007. It will return...

Issue 48, December 13, 2007

• Study: Number of elderly patients in ER up 34%

  A new study published in the Annals of Emergency Medicine says that between 1993 and 2003...

• Texas hospital to screen all patients for MRSA

  A Texas-based hospital intends to spend $1 million per year to screen every incoming patient for...

• CMS posts info on hospital-acquired conditions

  CMS has added a page to its Web site with additional information describing reporting and coding of...

• New guideline empowers patients and families to call for rapid assistance

  Had Sorrel King been able to launch a rapid response team at the hospital where she watched her...

• Catheter removal key to infection prevention

  Editor's note: This is the third part in a series about how to prevent some of the conditions CMS...

Issue 47, December 7, 2007

• Survey: Nearly half of physicians would not report impaired colleague

  A new survey has found that almost half of all physicians say they have failed to report an...

• Utah posts price, quality info online

  The Utah Department of Health this week started posting information about hospital prices, quality...

Issue 39, December 20, 2007

• English health authority to use U.S. P4P program as guideline

  NHS North West, England's largest strategic health authority, plans to institute the country's...

Issue 46, November 30, 2007

• RI hospital once again operates on wrong side of patient's brain

  For the third time this year, a Rhode Island Hospital doctor performed brain surgery on the wrong...

• Quaid twins receive massive Heparin overdose

  The two-week-old twins of actor Dennis Quaid were among three children mistakenly given a massive...

• Senate may not have time to pass CMS proposal

  CMS' proposed value-based purchasing plan has the initial support of the Senate Finance Committee...

• Hourly rounding, huddles help prevent patient falls

  Editor's note: This is the second part in a series looking at how to prevent some of the conditions...

Issue 45, November 16, 2007

• Joint Commission: Hospital quality improving

  Hospitals are making measurable improvements in the quality of care provided for patients with...

• Analysis says CMS rule will significantly affect nursing

  The CMS rule that will halt reimbursement to hospitals for eight preventable conditions will have a...

• Senator asks government to release quality info

  Senator Judd Gregg (R-NH) has written a letter to the Department of Health and Human Services...

• How to present quality info that will engage the board of directors

  If you want to really engage your board of directors, focus on two or three high-risk measures...

Issue 44, November 9, 2007

• CMS launches Web site on hospital-acquired conditions

  CMS has launched a new Web site to provide information on the eight preventable conditions it will...

• New Jersey hospitals to report on infections

  New Jersey hospitals will start reporting statistics on all hospital-acquired infections, providing...

• New York hospital puts all MRSA patients on same floor

  A Syracuse, NY hospital is trying to halt the spread of or Methicillin-resistant Staphylococcus...

• Pilot pressure ulcer prevention programs on one unit for success

  Editor's note: This is the first part in a series that details how to prevent hospital-acquired...

Issue 43, November 2, 2007

• Report finds hospital mistakes persist

  Even though hospitals in Massachusetts have spent the last decade trying to prevent surgical...

• Report finds that hospital mistakes persist

  Even though hospitals in Massachusetts have spent the last decade trying to prevent surgical...

• California hospitals fined for errors

  California officials last week fined nine hospitals for infractions that put patients at risk of...

• Hospital association reverses stance on publishing mistakes

  The Washington State Hospital Association has changed its position on the public disclosure of...

• Pilot pressure ulcer prevention programs on one unit for success

  Editor's note: This is the first part in a series that details how to prevent hospital-acquired...

Issue 42, October 26, 2007

• AHRQ study: Teamwork breakdowns lead to medical errors

  Physicians-in-training are at risk of making medical errors because of teamwork breakdowns...

• New Zagat guide will rate physicians

  Wellpoint, one of the nation's largest health insurers, has partnered with Zagat Survey to let...

• Survey finds tracking infections is a top challenge

  Healthcare professionals say tracking infections across the entire hospital and the control of...

• Pilot pressure ulcer prevention programs on one unit for success

  Editor's note: This is the first part in a series that details how to prevent hospital-acquired...

Issue 41, October 19, 2007

• Schwarzenegger vetoes hospital reporting proposal

  California Governor Arnold Schwarzenegger on October 12 vetoed a bill passed by the state...

• New techniques aim to reduce MRSA

  Hospitals have stepped up their battle against methicillin-resistant Staphylococcus aureus (MRSA...

• TN system posts quality data on Internet

  The Mountain States Health Alliance, a healthcare system in eastern Tennessee, recently put its...

• NQF seeks steering committee members to guide IT project

  The National Quality Forum (NQF) wants nominations for Steering Committee members to guide a...

• How to score severity when conducting FMEAs

  FMEA is a key tool to help identify and prioritize potential risks in systems, processes, and...

Issue 40, October 12, 2007

• Survey: Crowded EDs lead to patient deaths

  Crowded emergency departments (ED) have led to the deaths of more than 100 patients, according to...

• AHRQ report finds hospital deaths dropping

  Hospital deaths from heart attacks and other serious conditions dropped sharply from 1994 to 2004...

• Iowa health system says safety violations resolved

  The University of Iowa Hospitals and Clinics has resolved all safety violations outlined in a...

• Pilot pressure ulcer prevention programs on one unit for success

  p>Editor's note: This is the first part in a series that details how to prevent...

Issue 39, October 5, 2007

• Pennsylvania mortality rate drops, but readmissions rise

  The overall patient mortality rate in Pennsylvania decreased significantly over a three-year...

• Joint Commission Web site offers quality information

  Patients seeking quality information about their hospitals -- even those that are not accredited by...

• Walgreen to expand number of retail health clinics

  A chain of drugstore-based health clinics owned by Walgreen Co. will triple the number of U.S...

• Pilot pressure ulcer prevention programs on one unit for success

  Editor's note: This is the first part in a series that details how to prevent hospital-acquired...

Issue 38, September 28, 2007

• Massachusetts to post hospital prices

  Massachusetts next year will start posting the prices hospitals are paid by insurers for specific...

• Leapfrog survey finds 52% of hospitals adhere to 'never event' policy

  Fifty-two percent of hospitals responding to a Leapfrog Hospital Quality and Safety Survey indicate...

• Minnesota hospitals to stop charging for serious medical errors

  Minnesota's hospitals have agreed to stop charging patients and insurance companies for egregious...

• Hospitals hustle to train staff to document conditions present on admission

  Hospitals should start training staff now to assess and document conditions present on admission to...

Issue 37, September 21, 2007

• Many Massachusetts hospitals waive charges for errors

  About half of the hospitals in Massachusetts say they have policies to waive charges for egregious...

• Leapfrog names 41 top hospitals

  The Leapfrog Group has named 41 hospitals top performers in quality and safety.

• British hospitals ban docs from wearing ties, white coats

  British hospitals have banned doctors from wearing ties, long sleeves, and even their traditional...

• FMEAs identify risks before they become disasters

  Hospitals that want to identify risks before they turn into tragedies should use FMEA as a...

Issue 36, September 14, 2007

• Leapfrog: 87% of hospitals don't have procedures to prevent infections

  Eighty-seven percent of hospitals surveyed by the Leapfrog Group do not have recommended policies...

• NJ ambulances diverted every hour of every day

  Emergency room overcrowding in New Jersey has become so dire that one ambulance is diverted every...

• New York Hospitals Corp. posts infection and death rates

  The New York City Health and Hospitals Corporation, the country's biggest public health system...

• Nonpunitive culture led to hundreds of near-miss reports

  Near-miss reporting can target potential mistakes before they become sentinel events, but...

Issue 35, September 7, 2007

• Joint Commission: Staff can report safety concerns without threat of retribution

  Physicians and medical staff members worried about the safety and quality of care at their hospital...

• Study: Fewer resident work hours don't reduce patient deaths

  Reducing the number of hours of residents work does little to reduce patient deaths, according to...

• Hospitals let families launch rapid response teams

  Some hospitals now permit patients and families to launch a rapid response team (RRT) if they feel...

• Hospitals hustle to train staff to document conditions present on admission

  Hospitals should start training staff now to assess and document conditions present on admission to...

Issue 34, August 31, 2007

• Judge orders HHS to disclose data on docs

  A federal judge in Washington, D.C., last week ruled in favor of a consumer group that sued the...

• Communication, med rec remain top noncompliance issues

  Communication, medication reconciliation, and proper storage of medications were the top...

• Newspapers praise CMS decision on preventable errors

  The Washington Times joined other major newspapers this week in praising CMS' decision not to pay...

• Education, clinician engagement led to rapid success

  Don't dive right into setting up a rapid response system without involving the frontline clinicians...

Issue 33, August 24, 2007

• New Illinois law requires hospitals to screen patients for MRSA

  Illinois will become the first state to require hospitals to screen patients for...

• CMS to stop paying for preventable errors in 2008

  Medicare will stop paying the additional costs of treating preventable errors, injuries and...

• Patient advocates: Apologizing for mistakes promotes better care

  Leading patient safety organizations are calling for fuller disclosure of medical errors and some...

• New NPSG calls for rapid response to patients' deteriorating conditions

  Kathy Duncan, RN, a faculty member of the Institute for Healthcare Improvement's (IHI) 5 Million...

Issue 32, August 17, 2007

• Michigan hospitals to start posting prices

  Nonprofit hospitals in Michigan's will start listing prices for at least 50 common medical...

• Blue Cross of California awards $31 million in P4P bonuses

  Blue Cross of California this week announced that it will award $31 million in pay for performance...

• Study: Temp nurses provide high quality care

  Hospitals that use temporary nurses don't compromise quality of care because these nurses are just...

• Nurses need to feel free to call when anything looks awry

  Hospitals that want to set up successful rapid response systems need to ensure that all nurses feel...

Issue 31, August 10, 2007

• Senate bill calls for QIO makeover

  A bill before the Senate calls for a massive makeover of the Quality Improvement Organization (QIO...

• Neurosurgeon operates on wrong side of patient's head

  As The Joint Commission reviews its standards to prevent wrong-site surgery, Rhode Island health...

• Hospitals partner with patients to improve care

  Hospitals are partnering with patients and their families to create advisory councils that will...

• Education, clinician engagement led to rapid success

  Don't dive right into setting up a rapid response system without involving the frontline clinicians...

Issue 30, July 27, 2007

• Fewer nurses lead to more VAP cases

  More patients on respirators get pneumonia when fewer nurses are on duty in an intensive care...

• CMS final rule calls for more quality reporting

  CMS' final Inpatient Prospective Payment System (IPPS) rule released this week requires hospitals...

• New Jersey legislation targets MRSA

  New Jersey yesterday became the latest state to order special infection precautions at hospitals...

• Joint Commission names new president

  The Joint Commission this week announced that Mark R. Chassin, MD, MPP, MPH, will become its next...

• New NPSG calls for a rapid response to patients' deteriorating conditions

  Kathy Duncan, RN, a faculty member of the Institute for Healthcare Improvement's (IHI) 5 Million...

Issue 29, July 27, 2007

• C. diff infections more than double

  p>The rate of infections from Clostridium difficile, or C. diff, more than doubled between 1993...

• Pennsylvania law tackles hospital-acquired infections

  Pennsylvania Governor Ed Rendell signed a law last week requiring hospitals, outpatient surgery...

• Present only pertinent data on dashboards for senior leaders, board members

  Quality improvement (QI) directors who want to build effective dashboards should present a few...

Issue 28, July 20, 2007

• Proposed CMS rule would add quality reporting measures to outpatient care

  CMS this week issued a proposed rule on the Outpatient Prospective Payment System that would...

• Study: High-quality care could save 2,200 lives

  If the lowest-ranked hospitals on quality had the same death rates as top-ranked ones 2,200...

• Project reduces pressure sores by more than 70%

  A project organized by the New Jersey Hospital Association eliminated more than 70% of bed...

• AHRQ offers sample report cards on quality

  Hospitals struggling with growing demands for transparency may want to look at a new tool...

Issue 27, July 13, 2007

• Tennessee pilot lets consumers know health prices ahead of time

  BlueCross BlueShield of Tennessee has launched a pilot program that informs patients how much...

• Medicare experiment shows docs can help lower health costs

  An experiment by Medicare that allows physicians to share in cost savings showed that doctors...

• Present only pertinent data on dashboards for the board

  Quality improvement (QI) directors who want to build effective dashboards should present a few...

Issue 26, July 6, 2007

• Report: ED workers routinely abused

  Emergency department workers in New Jersey hospital routinely suffer verbal abuse and nearly...

• Minnesota to accept only electronic claims in 2009

  Starting in 2009, Minnesota will become the first state in the nation to require all healthcare...

• AMA calls for investigations of retail clinics

  The American Medical Association (AMA) is calling on state and federal agencies to launch...

• Present only pertinent data on dashboards for board members

  Quality improvement (QI) directors who want to build effective dashboards should present a few...

Issue 25, June 29, 2007

• MRSA may infect up to 5% of hospital patients

  The superbug known as Methicillin-resistant Staphylococcus aureus (MRSA) may be infecting up to...

• Report: Every other day, a near-miss occurs in Pennsylvania

  A new report has found that every other day, a potential wrong-site surgery is caught in a...

• CMS releases 30-day mortality rates

  CMS last week released its first comparison of death rates from heart attack and heart failure...

• Texas hospital defends heart mortality rates

  Baylor Health Care System this week defended its All Saints Medical Center in Fort Worth...

• Study: ER wait times, patient satisfaction rates rise

  The average ER patient wait in the United States lasts four hours, up 18 minutes from last year...

• Hospital’s Universal Protocol form keeps it simple

  To standardize and simplify its Universal Protocol form, Blount Memorial Hospital formed a team...

Issue 24, June 22, 2007

• Colorado hospitals to post report cards

  Colorado consumers will be able to go online this fall to see a "report card" of hospital...

• Study: Long intern hours lead to more errors

  Interns who worked five or more extended shifts in a month were seven times more likely to...

• Heed these measures to see your HCAHPS scores rise

  Quality improvement directors who want to make sure that their hospitals get glowing reviews...

Issue 23, June 15, 2007

• Woman dies in ER after 911 dispatchers refuse to send her to another hospital

  A woman who lay bleeding on the emergency room floor of a Los Angeles hospital died after 911...

• Report: Costly care doesn't produce high-quality care

  A new study has found high medical payments do not necessarily buy high-quality care, according...

• Study: Wisconsin tops in providing quality care

  Wisconsin received the highest score in the nation for its quality of healthcare, according to...

• Screen for substance abuse when assessing suicide risk

  Patients coming into the emergency department (ED) with substance abuse problems should go...

Issue 22, June 8, 2007

• Study: P4P has little effect on quality

  Although a new study has found that rewarding hospitals for following quality measures makes...

• Pennsylvania hospitals oppose infection reporting requirement

  Pennsylvania healthcare officials agreed on the need to reduce hospital-acquired infections...

• AHRQ tools aim to get patients involved in their care

  The Agency for Healthcare Research and Quality (AHRQ) has developed two new tools to reach out...

Issue 21, June 1, 2007

• CMS clarifies validation of quality data

  CMS has clarified the criteria that quality improvement organizations (QIO) should use for...

• New AHRQ Web tool shows samples of quality report cards

  The Agency for Healthcare Research and Quality (AHRQ) has developed a new Web tool...

• Patient safety group to spread message worldwide

  A new group called Consumers Advancing Patient Safety (CAPS), which unveiled its Web site two...

• Order sets, checklists help hospital in P4P success

  It's called pay for performance (P4P), but the incentive program has less to do with financial...

Issue 20, May 25, 2007

• Critical test results compliance drops

  The Joint Commission has released data on compliance trends with National Patient Safety Goals...

• Alliance to target hospital infections

  VHA Inc.,a national healthcare alliance, has helped organize a group of 12 healthcare industry...

• Medicare may no longer pay for some medical mistakes

  CMS has proposed to stop paying hospitals for additional costs from preventable medical errors...

• AHRQ tools aim to get patients involved in their care

  The Agency for Healthcare Research and Quality (AHRQ) has developed two new tools to reach out...

Issue 19, May 18, 2007

• Medicare may target inefficient doctors

  Medicare has the data and computer capacity to identify doctors who are less efficient than...

• Hospitals launch battle against MRSA

  Hospitals in the Washington, DC area are launching increasingly aggressive campaigns against a...

• Hospital group offers 90-day warranty

  A hospital group in central Pennsylvania is piloting a program that will offer patients a...

• Pennsylvania pioneers mandatory near-miss reporting for hospitals

  Near-miss reporting provides rich information that could potentially reduce adverse events, yet...

Issue 18, May 11, 2007

• Hospitals link CEO pay to patient safety

  More hospitals are tying a part of their CEO's pay to a number of safety measures, from reducing...

• Hospital encourages better communication before surgery

  The Michigan Health & Hospital Association and Beaumont Hospital in Michigan have launched an...

• Program aims to take hassle out of high-deductible plans

  A pilot program started by BlueCross BlueShield of Tennessee aims to reduce the "hassle factor...

• Order sets, checklists help hospital achieve P4P success

  It's called pay for performance, but the incentive program has less to do with financial gain...

Issue 17, May 4, 2007

• Hospital offers hotel-style service

  As part of its emphasis on patient and family-centered care, a Manhasset, NY, hospital has...

• WHO unveils solutions to protect patients

  The World Health Organization (WHO) this week unveiled nine solutions to prevent healthcare errors...

• CMS issues guidance on emergency care

  One month after The New York Times reported that a specialty hospital had to call 911 because no...

• Pennsylvania pioneers mandatory near-miss reporting for hospitals

  Near-miss reporting provides rich information that could potentially reduce adverse events, yet...

Issue 16, April 27, 2007

• Study: Patient satisfaction rises, but problems persist

  Overall patient satisfaction in hospitals rose between 2003 and 2006, but communication between...

• Tennessee posts medical procedure prices online

  The Tennessee Hospital Association this week started posting on the Web how much medical procedures...

• Baystate pioneers successful surgical care strategies

  Baystate Medical Center in Springfield, MA, ranks in the top 10% in the country for both antibiotic...

Issue 15, April 20, 2007

• CMS proposed rule would increase quality measures to 32

  CMS last week announced a proposed new inpatient prospective payment system rule that would add...

• N.J. hospitals receive $6 million in P4P plan

  Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) announced this week that it awarded $6...

• Massachusetts docs getting paid for on call ER shifts

  Some hospitals in Massachusetts have begun paying doctors up to $1,000 for on call emergency room...

• Compassion, 'calming rooms' lead to patient satisfaction

  Listening, showing compassion, and trying to turn waiting rooms into "calming rooms" stocked with...

Issue 14, April 13, 2007

• AMA blasted for resisting quality-based payments

  Former House Ways and Means Chairman Bill Thomas last week lashed out at Edward L. Langston...

• Almost 25% of patients in hospitals have mental illness

  Nearly 25% of all stays in community hospitals for patients age 18 and older-7.6 million of nearly...

• Congressmen ask for study on doc's schedules effect on patient safety

  High-ranking congressmen are asking for a study of doctors’ schedules and their effect on...

• Baystate pioneers successful surgical care strategies

  Baystate Medical Center in Springfield, MA, ranks in the top 10% in the country for both antibiotic...

Issue 13, April 6, 2007

• Hospital safety mistakes rise 3%

  Patient safety mistakes in hospitals rose to 3% overall from 2003 to 2005, and the error gap...

• Patients report errors, but don't research docs

  More than 25% of Massachusetts adults said they or a family member had experienced a medical error...

• AHA backs price transparency bill

  The American Hospital Association (AHA) has endorsed the Health Care Price Transparency Promotion...

• Most stringent rules apply for new restraint regulations

  Hospitals that want to comply with CMS' new restraint and seclusion regulations that went into...

Issue 12, March 30, 2007

• CMS paper outlines P4P proposal

  CMS has released an options paper outlining proposed features of the Medicare Hospital value-based...

• ER waits in Massachusetts longest at teaching hospitals

  It takes two to three hours on average to receive care in a Massachusetts hospital emergency room...

• Minnesota health system posts quality info on its Web site

  Fairview Health Services in Minnesota has started providing details about quality and safety on its...

• Communication, med rec among top compliance challenges in 2006

  Communication among clinicians and medication storage and reconciliation were among the top...

Issue 11, March 23, 2007

• Study: Hospital quality up, but more improvements needed

  Hospitals have made dramatic gains in the quality of care they provide their patients, but there's...

• Joint Commission finds problems at Massachusetts General

  Joint Commission surveyors found problems with medication safety, handwashing, and incomplete...

• Nevada hospitals snub conference on accountability

  All major southern Nevada hospitals opted not to attend a national risk management company's...

• CMS posts FAQs on physician bonus program

  CMS has posted more than 50 Frequently Asked Questions (FAQs) about the Physician Quality Reporting...

• Mystery shoppers keep tabs on patient satisfaction

  Long a staple in the retail industry, mystery shopping has made the leap to the hospital setting...

Issue 10, March 16, 2007

• Pittsburgh businesses back Bush's transparency plan

  Representatives from dozens of Pittsburgh businesses, government agencies and health-care insurers...

• Patients with high-deductible plans visit ED less often

  People on high-deductible health plans go to the emergency room 10% less often than patients on...

• State lawmakers target hospital infections

  The high number of lethal infections in U.S. hospitals has prompted medical staffs and state...

• Communication, med rec among top compliance challenges in 2006

  Communication among clinicians and medication storage and reconciliation were among the top...

Issue 9, March 9, 2007

• Docs: Public reporting would jeopardize care

  Three of four primary-care doctors think financial bonuses would boost medical performance, but...

• 77 medical errors reported in Indiana

  Indiana, one of only two states that has a medical reporting system, had 77 reported medical errors...

• Joint Commission paper addresses patient literacy

  The Joint Commission has released a white paper that aims to bridge the communication gap between...

• How to navigate the basics of the QI data terrain

  Vivian Chun, RN, CPHQ, learned in business school how to look at data, understand an Excel...

Issue 4, June 8, 2007

• Joint Commission partners with AORN on Time Out Day

  The Joint Commission and the American College of Surgeons (ACS) have teamed up with The...

• Hospital creates new position to boost compassionate care

  Cleveland Clinic in Ohio has created a new position of chief experience officer, whose goal will...

Issue 4, April 27, 2007

• Top Boston teaching hospitals reveal RFIs

  Five large Boston teaching hospitals inspected by The Joint Commission in the past eight months...

• Mass General program addresses patients' spiritual needs

  A new program at Massachusetts General Hospital aims to better address the spiritual needs of...