Quality & Patient Safety

The route to eliminating hospital-acquired conditions

Patient Safety Monitor, December 1, 2017

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.

 

Editor’s note: This article was written by Janet Spiegel, MS, a Lean-certified management consultant in Portland, Maine, who has advised and coached several payer and provider organizations. For questions or comments, she can be contacted at jmitchellspiegel@gmail.com.


The newly released hospital safety report from the Agency for Healthcare Research and Quality tells an encouraging story: Hospital-acquired conditions (HAC) are on a double-digit decline. The study showed that these conditions decreased 21% since 2010. While that progress should certainly be commended, we shouldn't celebrate just yet. Research reminds us that patient outcomes overall are still favorable at hospitals that perform well on quality. And as the most common quality grade received by the scored facilities was a C, we know that opportunity to improve remains. 

Include RCA in corrective action plans
One of the graded measures is number of methicillin-resistant Staphylococcus aureus (MRSA) events. As CMS notes, length of stay can contribute to the occurrence of MRSA events, and of course MRSA events themselves can impact length of stay. If there is an opportunity for improvement in any of the measures at your facility, it’s important not only to have a corrective action plan (CAP) in place for audit readiness and future safety surveys, but to ensure that the CAP is based on a root cause analysis (RCA).

For example, consider a hospital that experiences a spike in MRSA events. The hospital may put a CAP in place that focuses its interventions around improving wound care or changing sterilization processes. While these may be wise in theory, without a focused RCA, the facility cannot know for sure that these interventions will reduce these specific MRSA occurrences.

Recently a hospital group shared that it was incentivizing its providers to discharge patients by noon every day. It was a clear directive that providers bought into: "Let’s move our patients back to their homes as soon as they are ready to reduce the possibility of infection or other conditions and to turn over beds for those who need care."

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.

Most Popular