patient safety quality healthcare

CMS Outlines The Methodology Behind Its Five-Star Hospital Ratings

CMS held a webinar on May 12 explaining the methodology and upcoming changes to its controversial five-star hospital ranking system. Under the ranking system, hospitals would receive more stars for better compliance with a set of measures that focus on mortality, safety, hospital readmissions, and the timeliness and effectiveness of care. Prior to the webinar, several groups have argued that the star ranking system is too simplified to show true quality and reported difficultly replicating CMS’s methodology in testing the five-star rating system.

Some of the changes include the elimination of 14 voluntary measures falling under the “effectiveness of care” and “timeliness of care” categories. Measures for 20-day mortality and readmission coronary bypass grafting were added in April, with two colonoscopy measures to be added in July.

One of the webinar’s speakers was Arjun Venkatesh, MD, director of quality and safety research and strategy at the Yale University School of Medicine. He said that the five guiding principles behind the hospital star ratings simplicity/accessibility, inclusivity, scientific rigor, stakeholder engagement and consistency. The ratings methodology itself comprises of five steps:

1.    CMS select measures
2.    Measures are grouped into respective categories, such as safety, mortality or patient experience
3.    Group scores are calculated based on latent variable models
4.    A weighted summary score is generated for each hospital
5.    A final star rating is awarded

In addition to the Hospital Compare data, CMS will also start providing hospital-specific reports with additional details, such as individual standardized measure scores. The release of the star system has been postponed until July.

Click here to see the CMS webinar slides.


Two Frequently Cited Joint Commission Standards Are “Catchall” for Patient Safety


EC.02.06.01 and IC.02.02.01 were the two most challenging standards for hospitals in 2015, both of which have significant patient safety implications.

The top two most frequently cited Joint Commission standards in 2015 are not necessarily surprising. Both are widely recognized as catchall standards that encapsulate a wide variety of survey violations.

However, both standards have clear patient safety implications that reveal ongoing concerns about scope reprocessing, infection prevention best practices, and managing behavioral health patients in the ED.

According to The Joint Commission, the top two most frequently cited standards for hospitals in 2015 were:

  • EC.02.06.01 - Maintaining an environment that is safe and functional (62% noncompliance)
  • IC.02.02.01 - Reducing infection risks from medical devices, equipment, and supplies (59% noncompliance)

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Wanted: Evidence That Improving Quality Cuts Costs

By Tinker Ready, HealthLeaders Media

There's hope. And there's reality. On close inspection, the link between cost and quality is actually pretty fuzzy: We just don't know.

One of the incentives for improving the quality of healthcare is the notion that it will also lower costs.

Ideally, patients will have a medical home to go to instead of an emergency room.

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Major HAIs Decline, but Antibiotic Resistance Remains Problematic

Updated infection control guidelines released by the CDC in February indicate hospitals are making strides to prevent common infections.

According to updated statistics from the CDC, central- line bloodstream infections (CLABSI) saw an 8% decline from 2013 to 2014, 50% below the national baseline. Hospital-acquired MRSA infections saw a 4% decline from 2013 to 2014, 13% below the national baseline.

Although several other infections fluctuated between 2013 and 2014, many were still well below the national baseline. C. difficile infections, for example, increased 4% between 2013 and 2014, but remained 8% below baseline. Reductions in surgical site infections (SSI) were statistically insignificant over the course of a year, but still remained 17% below baseline.

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Medical Errors Unseat Respiratory Disease as Third Leading Cause of Death

A study conducted by Johns Hopkins researchers estimates that 250,000 Americans die annually due to medical errors, nearly 100,000 more than those who die of respiratory disease. The Centers for Disease Control and Prevention (CDC) states that respiratory disease is the third leading cause of death in the nation.

The CDC uses the cause of death listed in a person’s death certificate to calculate the leading causes of mortality each year. The John Hopkins team says that since medical errors aren’t listed separately on death certificates, the CDC has been vastly underestimating their impact.

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Identifying Best Practices for Suicide Prevention

Over the last decade, suicide rates in the United States have been creepily skyward. In some states, the suicide rate is nearly twice the national average.

Suicide is the 10th leading cause of death, according to statistics from the CDC, and in certain populations it is even more pervasive. From 2005 to 2014, the national suicide rate increased from 10.90 per 100,000 people to 12.93 per 100,000, and states like Montana and Alaska have rates of 23.8 and 21.97 respectively.

Among adolescents and young adults, suicide is a shockingly prevalent cause of death. In 2014, suicide was featured as the second leading cause of death in three different age groups (10-14, 15-24, and 25-34). For those ages 35-44 and 45-54, suicide was the fourth leading cause of death.

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CMS Releases Guide to Preventing Readmissions for Racially, Ethnically Diverse Beneficiaries

Patients who are members of racial and ethnic minority groups may be more likely than others to be readmitted after discharge—particularly if they have chronic conditions, such as pneumonia or heart failure or have suffered a heart attack. Many times, it’s social, cultural, or linguistic barriers that lead to those readmissions, according to the CMS Office of Minority Health (CMS OMH).

To help healthcare practitioners combat these issues and help minority patients improve their health, CMS OMH released the “Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries.” It’s designed to help hospitals identify the reasons why readmissions occur among this group of patients and to find solutions to help prevent them.

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CMS adopts 2012 Life Safety Code®

In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals and other healthcare facilities are held to, the Centers for Medicare & Medicaid Services (CMS) has officially adopted the 2012 edition of the Life Safety Code® (LSC).

CMS has confirmed that the final rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the LSC as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code.

Healthcare providers affected by this rule must comply with all regulations by July 4—60 days from the publication date of the rule in the Federal Register.

The adoption of the rule has long been anticipated, as the LSC, which governs fire safety regulations in U.S. hospitals, is updated every three years, and CMS has not formally adopted a new update since 2003, when it adopted the 2000 edition. As a result, CMS surveyors have been holding healthcare facilities to different standards to other regulatory agencies that have gradually adopted provisions of the new LSC in their survey requirements.

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GAO Report Highlights Three Key Patient Safety Challenges


Agency finds that hospitals struggle with data collection, identifying evidence-based practices, and implementation strategies.


A recent report from a federal watchdog agency offers new insight into the barriers hospitals still face when it comes to addressing patient safety concerns, offering a concise distillation of the key gaps that remain in ongoing efforts to prevent patient harm.

Officials at the Government Accountability Office (GAO) interviewed patient safety experts at six hospitals and six insurers, as well as officials at CMS and the Agency for Healthcare Research and Quality (AHRQ). The six hospitals were selected according to their performance in certain patient safety quality measures.

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NPSF Announces DAISY Award 2016 Honorees

The National Patient Safety Foundation along with The Daisy Foundation have announced the winners of the 2016 National Patient Safety Foundation DAISY Awards for Extraordinary Nurses. The award, a derivative of The DAISY Award for Extraordinary Nurses, places special emphasis on patient and workforce safety.

Now in its second year, this award is a derivative of The DAISY Foundations’ signature program, The DAISY Award for Extraordinary Nurses which is given to nurses in more than 2,200 healthcare facilities throughout the U.S. as well as 14 other countries. Nurses who received the DAISY award from their organizations between January 2014 and June 2015 were eligible for this 2016 international award.

“The National Patient Safety Foundation DAISY Award for Extraordinary Nurses is a way to formally recognize and celebrate exceptional contributions to patient safety by nurses,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO, NPSF.

Rachel Whittaker, BSN, RN, CPN, of Children’s Hospital Colorado in Aurora, the recipient of the individual award, was chosen for her leadership, compassion, and practice of patient-and family-centered care, particularly during end-of-life decisions.

The Clinical Informatics Council of the University of New Mexico Hospitals in Albuquerque, will receive the team award for their efforts to address safety issues including an alert designed to prevent complications from ventilator use, a Pediatric Early Warning Score to predict a deteriorating patient, and a streamlined method for documenting wounds. Sheena Ferguson, MSN, RN, CNS, CCRN, chief nursing officer, noted this as a “huge improvement” in patient safety, because it allows multiple disciplines to document wounds in the same place and with consistent terminology.

“Choosing the final honorees for this international award was difficult because we had so many inspiring stories of truly compassionate nurses making a difference in patient and workplace safety,” said Bonnie Barnes, FAAN, co-founder and president of The Daisy Foundation.

The awards will be presented during the 18th Annual NPSF Patient Safety Congress in Scottsdale, Arizona at the end of May.

For more information about The DAISY Foundation, visit For updates about the award and the NPSF Patient Safety Congress, visit

Joint Commission Finalizes New Requirements for CAUTI NPSG

Proposed Joint Commission NPSG focuses on risks of pediatric CT scans

Radiology experts are split on whether the focus on head and chest scan is a valuable use of resources

A proposed National Patient Safety Goal (NPSG) released by The Joint Commission in February takes aim at judicious use of computed tomography (CT) imaging among pediatric patients, requiring hospitals to follow evidence-based guidelines when considering CTs for minor head trauma.

The proposed standard, released as NPSG.17.01.01, would apply to hospitals, ambulatory care facilities, and critical access hospitals. The Joint Commission accepted comments on the proposed requirement through the end of March.

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Taking a Patient Safety Cue from Denmark

Denmark's patient compensation program has helped transform the approach to patient safety in the country, allowing patients a full picture of a potential medical error and prompting physicians to openly confront mistakes, according to an article by ProPublica.

Denmark's approach to medical errors is drastically different from that of the United States. Instead of relying on malpractice claims to ferret out patient concerns, Denmark allows patients to file claims through a government-run system where a panel of medical experts reviews the patient's case file and awards monetary damages if an error occurred.

Patients have full access to their medical records and researchers can use the data on medical errors to hone in on national trends and concerns.

Perhaps more importantly, the system allows physicians to speak openly and honestly about patient safety failures.

For more, read the ProPublica article.

Weighing the Pros and Cons of Patient Safety Technology

Although some emerging technology promises a patient safety cure-all, hospitals need to evaluate clinician workflow before implementing new gadgets

In the 21st century, technology offers a solution to just about any everyday problem. Don't know that actor that just came onto your screen? Log onto the IMDB app. Need directions? Just type the address into your phone.

Healthcare is no different. Emerging technologies promise to solve the industry's biggest patient safety concerns, and sometimes they actually do, but not always. In some cases, healthcare technology can simplify complicated processes and improve care. In other situations, it can have negative consequences, particularly if hospitals fail to consider the technology's impact on workflow.

Just like the technology we encounter in everyday life, healthcare technology can be beneficial, but only when it is appropriately integrated into the system in which it is used. Unfortunately, in their rush to purchase cutting-edge gadgets, hospitals often neglect this step.

"Workflow needs to be assessed and made more efficient, and if possible, standardized so that when you introduce the new technology, you're not introducing something new into a bad process," says Mary Logan, president and CEO of the Association for the Advancement of Medical Instrumentation (AAMI) in Arlington, Virginia. "You're really looking at your process and making sure technology fits in with that, so it's an opportunity to improve. Hospitals historically haven't done that, but they need to."

This is an excerpt from the May issue of Patient Safety Monitor. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

Move to Refine Quality Measures Gaining Momentum

By Tinker Ready, HealthLeaders

Complaints about quality measures are as abundant as the measures themselves. But some doctors are doing something about it. They're working to identify metrics that are "realistic and actually will have an impact on patient care."

Call it pushback, validation, or measurement science. The revolt against the volume and usefulness of outcomes measures continues.  

The AHRQ alone lists 1,280 quality measures on its site.

Efforts are underway to both challenge and refine existing guidelines and requirements. And, wonks take note, providers and patients are on the job, too.

One example: The emergency department at Beth Israel Deaconess Medical Center in Boston's Longwood cluster of hospitals sees more than 50,000 patients a year. Every time a patient undergoes procedural sedation in the ED, doctors there follow up with a formal quality assurance review.

Their analyses are designed to meet a Joint Commission standard that requires monitoring and evaluation of such cases, which carry the risk that comes with sedation.

Now team, including BIDMC emergency physician Jonathan Edlow, MD, has decided to examine the utility of the review. "We are trying to find out what metrics make sense and what don't," he told me. 

In a March paper in The Journal of Emergency Medicine, Edlow and his team reported that the review "offers little advantage over existing quality assurance markers." They concluded that review of high risk cases "may be useful."

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Immersion Program for Emerging Leaders in Patient Safety

The Academy for Emerging Leaders in Patient Safety (AELPS) (aka Telluride Patient Safety Summer Camp) now offers a three-day immersion program in patient safety and quality education for risk managers, healthcare administrators, and health education faculty. This comprehensive workshop will be held July 27–30 in Napa Valley, California.

For 11 years, the AELPS faculty has convened thought leaders from around the world and nationally recognized patient advocates to develop a comprehensive patient safety curriculum for health science students and resident physicians. In response to numerous requests, the AELPS faculty has now designed a curriculum for healthcare leaders and educators who desire to broaden their knowledge in patient safety and risk reduction.

AELPS faculty members include David Mayer, MD, vice president of quality and safety, MedStar Health; Tim McDonald, MD, JD, chief quality and safety officer, Sidra Medical Center; Anne Gunderson, EdD, GNP, assistant vice president for education, safety, and quality, MedStar Health, and professor of medicine/associate dean for innovation in clinical education at Georgetown University Medical Center; Kim Oates, MD, emeritus professor of pediatrics, University of Sydney, and director of undergraduate education at the Clinical Excellence Commission.

The workshop is limited to a small number of attendees. The meeting curriculum uses case-based learning, stories and narratives, and simulation and gaming in an intimate, small group learning environment, allowing attendees to interact and work closely with faculty and peers. Attendees will leave with the knowledge, tools, and techniques necessary to lead change at their home institutions. Some key topics covered during the workshop include high reliability; disclosure and rapid remediation models; patient and family partnerships to drive safety & quality; human factors engineering; transparent and honest communication skills; and fair and just culture.

More information, including the full faculty list, is available at



ABQAURP American Society for Quality American Society for Quality Healthcare Division Consumers Advancing Patient Safety
EMPSF Institute for Safe Medical Practices
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine