Welcome to the February 2010 issue of the Indidge Advantage newsletter.
We often put off, what deep down in our heart, we know we should do. Our first article this month highlights the case for a well managed policy and procedure system and what can happen to the organizations that keep deferring that decision to a later time.
The second article brings you more news from the Joint Commission.
The third article raises the question of how hospitals would fare under proposed reimbursement plans.
The Indidge Advantage is produced by Indidge Systems, a healthcare software solutions company specializing in Compliance and Risk Management solutions.
by Dan Bowman
Aside from communication breakdowns, one of the most common patient safety errors at hospitals involves a simple failure to follow the organization's own policies and procedures. Whether it's adhering to certain medication administration protocols, verifying staff and temp staff competencies or sticking to assessment and monitoring protocols, too often, hospital staff and physicians fail to fully comply, as a spate of recent, costly cases so clearly documents.
Thirteen hospitals this week were each fined an average of $50,000 by California's health department after inspections revealed life-threatening compliance issues. One hospital, John F. Kennedy Memorial Hospital in Indio, was slapped with at least four fines of $25,000 each due to deficiencies in medication administration, patient monitoring and competencies verification procedures.
Other hospitals assessed administrative penalties by the state included:
- St. Jude Medical Center in Fullerton, where a man being treated for a heart attack died after his heart monitor had been disconnected -- and went unnoticed by nurses. According to an internal investigation, the patient's heart monitor alarm also wasn't loud enough for staff to hear. The hospital was fined $50,000.
- California Hospital Medical Center in Los Angeles, where a woman who had been misdiagnosed as having an ectopic pregnancy--who wasn't even pregnant--was treated with chemotherapy drugs that suppressed her immune system, causing sores to appear on her mouth, throat and skin. That hospital was fined $50,000.
At John F. Kennedy Memorial Hospital, two nurses failed to follow protocol in the case of a five-month old infant who was brought to the emergency room in June 2008 with a fever of 105.4 degrees and a an abnormally high heart rate. The first nurse, a contract nurse hired through an agency, was found to have no clinical competencies, and failed to reassess the patient after initially recording temperature, heart rate and oxygen saturation level. (Official policy called for continuous reassessment.)
The second nurse, a newly hired graduate who also failed to have any clinical competencies and who had no advanced cardiac life support or pediatric advanced life support training, documented the infant's temperature on three separate occasions, but never recorded the patient's heart rate or oxygen saturation level. None of the other vital signs were recorded until a third nurse took over.
The hospital was fined $25,000 for the incident, and also was fined three more times for other failed compliances.
To read about all of the hospitals fined:
- Read the state's press release and its reports on inspections at each hospital.
New survey agenda development process
Beginning in 2010, The Joint Commission will implement a new, more collaborative process for developing the survey agenda. The survey agenda will be similar to what organizations have historically seen and experienced; what has changed is that The Joint Commission will inform organizations before their survey about the on-site survey length and number of surveyors. Also, the organization can work with surveyors during survey to determine the best timing for the various survey activities. The new process will be more sensitive to the time demands of the health care organization and its staff during the on-site survey while still providing a thorough survey of the organization. All accreditation customers due for survey in 2010 will experience this revised agenda process (the new process does not affect certification reviews):
- The Joint Commission will send an e-mail to the organization to confirm the programs to be surveyed and to direct the organization to its Joint Commission Connect extranet page for a list of survey activities for each applicable accreditation program (the list is a planning tool that can be used with the Survey Activity Guide); and a program-specific document list that identifies initial materials surveyors will request to review at the onset of the survey.
- Shortly after an organization receives its e-mail, it will receive a phone call from its account executive to confirm that it has reviewed and understands the information on its extranet site. At this time, the account executive will provide the anticipated number of days and number of surveyors that will be assigned to the organization’s on-site survey.
- On the first day of the on-site survey, surveyors will work with the organization to confirm that the schedule considers the organization’s operations and needs.
- During the survey, organizations will work with surveyors to determine the best time for scheduling survey activities so they coincide more effectively with patient care and administrative operations. It is important to note that survey activities are not changing.
(Deborah Ryan, dryan@jointcommission.org or your account executive)
by Philip Betbeze
I was talking to a health system CEO the other day, who was angry at the deals being struck between leaders of industry lobbying groups and government leaders. Never mind that these "deals" are just handshake agreements not to oppose the president or Congress' idea of healthcare reform-whatever shape it eventually takes.
Angry may be a strong word. Let's just say he was dissatisfied. We talked about the $80 billion in dubious cost cuts over the next 10 years that drugmakers agreed to with President Obama earlier this year in order to buy not only their silence, but their support, in the face of healthcare reform. It's hard to argue that that deal hasn't since been exposed as a not-so-well-hidden gift to drugmakers.
We then talked about the $155 billion in cuts the main hospital lobby, the American Hospital Association, agreed to in principle in July, which doesn't seem nearly as lucrative, as I'll get to in a minute. In short, it doesn't look like hospital negotiators did quite as well.
Finally, we talked about the one big lobbying group that hasn't made a deal on healthcare reform: insurers. Predictably, that industry has become the villain du jour in the raucous healthcare reform debate we've been following all year. Hospitals have avoided that fate, but at what cost? My purpose is not to defend health insurers, but to ask whether any "deal" agreed to under pressure is really a good deal.
Take the hospitals. In return for agreeing not to oppose healthcare reform, the AHA, representative of the nation's more than 5,000 hospitals, said its members would collectively accept $155 billion in reimbursement cuts over 10 years in return for a reform plan that would insure effectively all of the currently uninsured-presumably through a combination of a mandate requiring all citizens to carry health insurance and a public option health plan that would facilitate that coverage.
The announcement of the deal came after administration heavies not-so-quietly suggested that $200 billion in cuts would be about right, causing hospital representatives to gulp-hard.
The health system CEO I was talking to was angry that there was no provision to keep such a public option from ratcheting back reimbursement further once it's in place. He was off about that. In fact, the deal contains a promise that "public option" reimbursement rates would not reach the low level of Medicare and Medicaid reimbursement rates, which, depending on whom you believe, come in at somewhere near 90% and 60%, respectively, of the cost of providing that care.
Further refinements of the bills in both houses revealed that the public option would have to negotiate rates with hospitals in a similar way that commercial plans do now. Fine. But nothing in the intervening time period has spelled out at what level the public plan might think is a fair reimbursement. Never mind the difficulties of negotiating with a payer that can effectively put you out of business, or, at the very least, make life very difficult for those who don't like what the government plan is offering.
So back to the question I asked in my headline. What if all your reimbursement came from Medicare? I'm guessing you wouldn't like it very much, considering that all I've heard over the years is how Medicare significantly underfunds the cost of care in its reimbursements, leaving hospitals to cross-subsidize by negotiating deals with commercial insurers that pay better. That's a hidden tax that we all currently pay for the fact that government reimburses poorly.
But if healthcare reform passes, and even if the public option pays you as much as 99% of costs, much higher than Medicare, you still come out way behind over time. And that was the crux of my friend's point.
And don't count on commercial insurers to continue making up the difference. Why should they? They haven't made a deal with the president, after all.
Join us Wednesday, February 10, 2010 from 11:00 AM - 12:30 PM MST for a free educational webinar. Just click on the register button below or if this does not fit your schedule , send Tom Reid an email at tom.reid@indidge.com or call him now at (480) 829-0479 Ext. 138 to schedule a web demo that better fits your schedule.
A little girl asked her father, "How did the human race come about?"
The father answered, "God made Adam and Eve and they had children and so all mankind was made."
Two days later she asks her mother the same question.
The mother answered, "Many years ago there were monkeys, and we developed from them."
The confused girl returns to her father and says: "Dad, how is it possible that you told me that the human race was created by God and Mom says we developed from monkeys?"
The Father answers, "That's simple, honey. I told you about the origin of my side of the family, and your mother told you about her side."
Welcome back to the January 2010 issue of the Indidge Advantage newsletter.
While we celebrate the coming of the new year, it has traditionally also been the time of the year to examine ourselves and the way we do things. What better time to step outside the box and adopt more efficient tools and methods. This is how we grow personally and how the organizations we strive for move forward into the next decade.
The first article is information you can use regarding the high performing organization we endeavor to become. The next article informs you of news from the Joint Commission on accreditation. The last article tantalizes you with the Senate healthcare reform bill that will reshape the industry.
The Indidge Advantage is produced by Indidge Systems, a healthcare software solutions company specializing in Compliance and Risk Management solutions.
by Janice Simmons, for HealthLeaders Media
This month marks the 10th anniversary of the publication of the Institute of Medicine's To Err Is Human—a study that put a new focus on how patient safety is addressed in the United States. Though the report served as a clarion call to healthcare organizations to promote safety, many in the healthcare industry would probably agree that more still needs to be done at the local level.
Earlier this week at a forum sponsored by Consumers Union's Safe Patient Project in Washington, DC, Richard Shannon, MD, chair of the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia, provided health leaders with some insights on how to move their organizations forward to becoming high-performing facilities that can effectively address patient safety concerns.
Healthcare in the U.S. today is not "a high-performing organization," Shannon said. But it could be.
Shannon, borrowing pages from colleague Steve Spear's book, Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win, suggests it could be different if healthcare organizations recognize—and try to change—a number of traits that hold them back:
- Many high-performing organizations "swarm and solve problems to build new knowledge—[where] problems are not things to be avoided," Shannon said. "They're learning opportunities." However, "in healthcare, we are the best work-around experts. We see problems every moment and absolutely do nothing about them . . . the antithesis of the high-performing organization."
- High-performing organizations tend to be "level" in structure—where individuals at all levels have a say. Many healthcare organizations, though, tend to be hierarchical—where decisions are made from the top down.
- High-performing organizations are constantly expanding the frontier of what they don't know. They must look for new ways and new ideas.
So what does this have to do with patient safety? Well, plenty. Before working at the University of Pennsylvania, Shannon was chief of medicine at Allegheny General Hospital in Pittsburgh, where he was instrumental in initiating a project that lowered central-line associated bloodstream infections and ventilator-associated pneumonia rates in the intensive care unit. He has continued with this work at Penn.
What he has discovered is that "in the end, the inability to understand in great detail how we do our work is the genesis" of many of the patient safety issues many healthcare organizations now encounter. Many times, the organization will look for the quick fix—hoping the problem goes away. "This characterizes one of the reasons why progress has been so slow," he says.
A new mindset needs to occur about patient safety. First, while it helps that patient safety is viewed as a priority, it is more important that it is seen as a "precondition of work," he says. "The foundation of quality is safety—and safety must be a precondition."
"There are hundreds of priorities that sit on my desk. If safety is one of them, it's in with the hundreds of others. But if it's a precondition, that means I begin work at 6:30 a.m. at the point of care asking 'did anything happen last night that could lead to the risk of someone getting a central line infection?’" he says. "That tells the workers that it's a precondition of coming to work."
Nurses need to be on the frontline with patient safety, he emphasizes. "It's fundamental," he says. "Nurses are the guardians of patient safety. They need to be empowered to do this. It's extraordinary what you can achieve when you partner with nurses."
Shannon recommends moving beyond data collected by the Centers for Disease Control and Prevention. This data generally does not deal with "fixing problems in hospitals." Instead, he suggests becoming a "deep observer of the current condition" within the healthcare organization.
For instance, it is important to know how a central line is "placed, maintained, and manipulated." And then, taking that knowledge and learning and "sharing it with everyone," he says. "As a leader, you must commit to fixing things that are there . . . to make sure [an infection] doesn't happen again."
And while comparative effectiveness has its benefits, it's not feasible when dealing with patient safety issues of waiting around five years or so for answers. "Safety is about making little changes at the point of care and then seeing if they worked," he says. This means listening to ideas of those on the frontline of delivering healthcare.
You may want to explain how a central line is to be "placed, maintained, and manipulated" by creating a Policy along with an accompanying Procedure and then sharing it with everyone by using our automated Policy and Procedure Management System. Call (480) 829-0479 x138 or e-mail Tom Reid for a demonstration.
Field review of proposed modifications to MS.01.01.01 (formerly MS.1.20)
At its November meeting, The Joint Commission Board of Commissioners approved the field review of proposed modifications to hospital medical staff standard MS.01.01.01 (formerly MS.1.20). The field review is available on The Joint Commission Web site and will be available through January 28, 2010 to provide all interested parties an opportunity to comment on the proposal. The proposed modifications were unanimously recommended by the MS.1.20 Implementation Task Force in March 2009 and subsequently supported by the leaders of the organizations represented among the Task Force members. An informal field review was conducted over the three month period ending on October 15. Hospitals are currently expected to be in compliance with Medical Staff standard MS.01.01.01 in the hospital accreditation manual. The current standard will remain in effect until further notice. There is an indefinite moratorium on the implementation of Element of Performance 19 of the current MS.01.01.01.. (Contact: Chuck Mowll, mailto:cmowll@jointcommission.org)
by Matthew DoBias for ModernHealthcare.com
The Senate healthcare legislation passed last week aims to reshape the U.S. healthcare system and the way hospitals, insurers and physicians do business.
The more than 2,000-page Patient Protection and Affordable Care Act, approved early Christmas Eve in a historic 60-39 vote, would greatly restructure the $2.5 trillion per year healthcare sector in just over a decade's time.
At a cost of roughly $871 billion over the next decade, the Senate's package is expected to extend coverage to 31 million Americans who currently go without it. Even so, it will leave another 23 million non-elderly residents without insurance—about a third-of who would come from the ranks of unauthorized immigrants.
The Congressional Budget Office, which analyzes legislation for its fiscal and real-world impact, predicts that 94% of legal U.S. citizens would have coverage by 2019. Of that, 26 million people would be covered through newly created insurance “exchanges,” and another 15 million would fall into expanded Medicaid and children's health insurance programs.
The bill essentially requires all legal residents to buy insurance, offering hundreds of billions of dollars in federal subsidies to help offset the cost. It also expands Medicaid to individuals making less than 133% of the federal poverty level. Those who don't purchase insurance would face a penalty of $95 starting in 2014, but increasing to $750 in 2016. Families would have to pay half the amount for children up to a cap of $2,250 for the entire family, according to the CBO.
While there is no mandate for employers to offer coverage, firms with more than 50 workers who do not offer coverage would be subject to a penalty of $750 for each full-time worker if any of those workers get subsidized coverage through the exchange. Under the bill, the exchange would include private health plans and could include two national or multi-state plans operated under contract with an office that already oversees selected federal health plans.
For their part, insurance companies would have to accept all individuals regardless of pre-existing conditions beginning in 2014 and could not vary premiums to reflect differences in enrollees' health.
By and large, much of the cost of extended coverage would come from reductions in federal dollars to the Medicare and Medicaid programs. For starters, the bill reduces the annual updates to Medicare's payment rates for most fee-for-service sectors, except physicians, by about $186 billion over 10 years. Additionally, the bill will effectively gut the Medicare Advantage program, moving participating plans to a form of competitive bidding, resulting in about a $118 billion cut.
The bill creates a so-called Independent Payment Advisory Board, which would hold sway over Medicare payment formulas. Under the legislation, the board would make annual recommendations to the president, Congress and private entities on actions they can take to improve quality and constrain the rate of cost growth in the private sector. Its Medicare recommendations are non-binding in years where Medicare growth is below the targeted growth rate. The board will develop its first recommendations in 2013 for implementation two year later.
Even though the hospitals sector struck a deal with key lawmakers and the White House itself, they're nevertheless in line for payment reductions under a reformed healthcare system. For instance, hospitals will see a major reduction in the federal dollars they receive for treating patients who can't pay the full amount of their bills. The Senate's legislation cuts disproportionate share funds by $43 billion under the assumption that the bill will expand coverage to those who currently don't have it.
The legislation also creates a pilot hospital value-based purchasing program in 2013, where a percentage of reimbursement would be tied to performance. If successful, it could be expanded. Inpatient rehabilitation facilities and long-term care hospitals will also move toward such a system.
The bill is loaded with other pilot programs and system studies. Under one, hospitals in 2013 could volunteer to receive payments for an entire episode of care rather than under the piecemeal inpatient prospective payment system, or IPPS. The bundled payment system will also be expanded to other provider types as well. It also establishes a Center for Medicare and Medicaid Innovation, which will be charged with finding new ways to improve the delivery and payment of care.
Hospitals also face new penalties. In 2012, for instance, hospitals would see their reimbursement cut for certain types of readmissions.
For physicians, a late amendment to the bill removed a 0.5% increase in Medicare reimbursement for 2010 – a move lobbied for by the physician community who wants to see a longer fix. Lawmakers said they would start work on such a measure starting early in January. A separate bill passed earlier this month allows for a more substantial re-working of the Sustainable Growth Rate formula.
The bill also begins to look at other ways doctors can get paid. Pilot programs will be created to help move physicians towards providing more integrated care, as well as docking Medicare payments—starting in 2014—for those who do not report on certain quality measures.
A key objective of the bill is to bolster the ranks of the primary care workforce. The legislation includes a raft or new funding and measures aimed to encourage doctors to move into primary care . And in a measure to help increase transparency, the legislation requires HHS to develop a “Physician Compare” web site where Medicare beneficiaries can compare measures of physician quality and a patient's perception of care.
Another provision authorizes the release and use of standardized extracts of Medicare claims data.
Additionally, the legislation will move federally qualified health centers toward a prospective payment system.