patient safety quality healthcare

New Tool Simplifies the Process of Patient Safety Improvement

A new tool offers a straightforward approach to improvement

A new tool endorsed by the National Patient Safety Foundation aims to streamline patient safety and quality improvement efforts using a simple, evidence-based model.

"The Healthcare Adventures Graphic Gameplan for Patient Safety," released in October 2015, offers a standardized approach both leaders and clinicians can use to address gaps in patient safety. A multidisciplinary group that partnered patient safety experts with human development and organizational behavior experts created the tool and released it for free with the hope that some hospitals would be able to apply the same principles to initiatives within their facility.

Patient Safety Monitor Journal spoke with one of the guide's authors, Jay Vogt, an organizational and human development consultant and founder of Peoplesworth in Concord, Massachusetts, about the tool and how hospitals can use it to improve patient safety interventions and address cultural barriers.

Continue reading this articleon the Patient Safety Monitorwebsite. Subscribers have free access to this article in the February issue.

Study: Poor Communication Leads to Malpractice, Death

Poor communication in healthcare has tangible, measurable effects. A new study released by CRICO Strategies found that communications failures were a factor in 30% of malpractice cases between 2009 to 2013, including 1,744 deaths. The reports estimate that both the deaths and $1.7 billion in malpractice costs could have been avoided with better communication between patients and physicians. 

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CDC’s Core Elements of Hospital Antimicrobial Stewardship Programs

Just over a year after President Barack Obama issued an executive order calling for federal agencies to combat antibiotic resistance, The Joint Commission has released proposed standards that would require a broad range of healthcare providers to implement a structured, evidence-based antimicrobial stewardship program.

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JAMA: Nurses Key to Surviving Surgery

A study released in The Journal of the American Medical Association has found that surgical patients in hospitals with better nursing environments receive better care without drastically increasing costs. Researchers found the rate of 30-day mortality rates for postoperative patients was 4.8% at hospitals with more than 1.5 nurses per bed (NPB), while facilities with less than one NPB had mortality rates of 5.8%. The difference was most noticeable for patients in the highest risk quintile, with a mortality rate of 17.2% at magnet hospitals compared to 19.9% at control hospitals.

 “It wasn’t just the number of nurses that made the difference. Magnet status hospitals recognized for having excellent nursing programs and cultures do better,” said study author Linda Aiken, PhD, RN, in a release.

While there are numerous studies showing the benefits of a large nursing staff, the costs of hiring new staff has been an impediment for many facilities. Despite this, it was shown that better staffed hospitals actually paid less ($163) overall per patient than understaffed hospitals.

 “A surprising finding was that better nurse staffing throughout the hospital does not have to be more costly,” Aiken said. “Indeed, we found that magnet hospitals achieved lower mortality at the same or lower costs by admitting 40% fewer patients to intensive care units and shortening length of hospital stay.”

Olympus Recalls Duodenoscopes, FDA Approves New Model

Olympus Corp., the largest seller of duodenoscopes in the U.S., last week recalled all of its TJF-Q180V model scopes. The move came just one day after a Senate committee report linked Olympus products to 142 antibiotic-resistant infection (ARI) cases.

Duodenoscopes are flexible cameras inserted into a patient’s mouth or digestive tract to diagnose a number of cancers and are used in over 700,000 procedures annually. Recent investigations found a flaw in the scope’s design made it nearly impossible to fully disinfect—exposing patients to ARIs and resulting in 25 outbreaks in four countries over the last three years. Last year, 141 patients in Los Angeles were infected and three died from ARIs attributed to dirty scopes.

Olympus voluntarily issued the recall after the Food and Drug Administration (FDA) cleared the company’s new safety modifications to the existing model. Olympus will replace the elevator channel sealing mechanism at the tip of the scope with a new mechanism that should reduce the risk of fluid leakage in the channel, according to the report.

Olympus will begin replacing the scopes next month. There are approximately 4,400 scopes currently in use and Olympus hopes to have them all replaced or modified by August 2016. Until the scopes are replaced, healthcare facilities may continue using the unmodified TJF-Q180V models, but are urged to meticulously follow the manufacturer’s reprocessing instructions.

Editor’s note: This article was adapted from Accreditation & Quality Advisor

FDA Releases Cybersecurity Recommendations for Medical Device Manufacturers

Cybersecurity threats to medical devices are a growing concern. The FDA took a proactive step last week and released draft guidance last week encouraging medical device manufacturers to address certain cybersecurity risks to keep patients safe.

Manufacturers should look beyond the initial security measures implemented in a medical device and consider additional safety measures throughout a particular device’s whole lifecycle, according to the report.

“All medical devices that use software and are connected to hospital and healthcare organizations’ networks have vulnerabilities—some we can proactively protect against, while others require vigilant monitoring and timely remediation,” said Suzanne Schwartz, MD, MBA, associate director for science and strategic partnerships and acting director of emergency preparedness/operations and medical countermeasures in the FDA’s Center for Devices and Radiological Health, in a press release.

The guidance stresses the need for proactively planning and assessing cybersecurity vulnerabilities, information sharing between the public and manufacturers, as well as creating a cybersecurity risk management program that includes:

  • Applying the 2014 NIST voluntary Framework for Improving Critical Infrastructure Cybersecurity
  • Monitoring cybersecurity information sources to identify any vulnerabilities
  • Understanding, assessing, and detecting the presence of possible vulnerability
  • Defining essential clinical performance to identify, protect, respond and recover from a cybersecurity threat
  • Adopting a threat disclosure policy and practice
  • Implementing measures that identify cybersecurity risk early and before an incident occurs

C.diff Infection Raises Hospital Costs by 40% per Case

By Alexandra Pecci, for HealthLeaders Media

Treating Clostridium difficile adds about $7,285 in hospital costs per patient, not including readmissions, research finds.

It can be difficult to quantify the exact economic burden of C. diff on hospitals and the health system as a whole. But a recent study puts a dollar amount on the cost of C. diff, that number is not only big, but also likely underestimated.

Published in the November issue of the American Journal of Infection Control, the study found that C. diff-associated diarrhea (CDAD) increases hospital costs by 40% per case and puts those infected at high risk for longer hospital stays and readmissions.

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FDA validates revised reprocessing instructions for Model ED-530XT duodenoscopes

FUJIFILM Medical Systems issued revised reprocessing instructions late last month for Model ED-530XT duodenoscopes, according to a safety communication issued by the FDA. The instructions require exacting pre-cleaning, manual cleaning, and high-level disinfection procedures.

While these revised reprocessing instructions are for Model ED-530XT duodenoscopes, the FDA is encouraging healthcare facilities that use Fuji’s 250 and 450 duodenoscope models, to use the revised reprocessing instructions until the revised instructions for those models are final.

Key changes to the reprocessing procedure for Fuji’s ED-530EXT duodenoscope:

  • Pre-cleaning
    • During immersion of the scope tip in detergent solution, move the forceps elevator back and forth and aspirate detergent solution while the forceps is raised and while lowered.
  • Manual cleaning
    • Additional brushing of the distal tip, forceps elevator and elevator recess first using the existing Fujifilm valve cylinder cleaning brush (Model WB11002FW2) and then using the new disposable (Model WB1318DE) cleaning brush.
    • Additional flushing of detergent and rinse water onto the forceps elevator/recess while the elevator is both raised and lowered.
    • Additional flushing steps and increased channel flushing volumes of detergent and rinse water
  • Manual high-level disinfection
    • Additional flushing of disinfectant and rinse water onto the forceps elevator/recess while the elevator is both raised and lowered. Additional raising and lowering of the elevator while immersed in disinfectant solution and rinse water.
    • Additional flushing steps and increased flushing volumes of disinfectant and rinse water through the duodenoscope’s internal channels.


    In October, the FDA ordered the top three manufacturers of duodenoscopes, Olympus America, Inc., Fujifilm Medical Systems, USA, Inc., and Hoya Corp. to submit plans outlining how they were going to conduct studies to understand how the duodenoscopes are being reprocessed in healthcare settings.

    For more information visit the FDA website.

Study: Discharge notes are often written grades above patient reading levels

A study published in The American Journal of Surgery found that low literacy rates can drive up the number of hospital readmissions. Of the 497 patients studied, researchers found that only 24% had the reading skills necessary to understand their discharge instructions, with 65% reading a lower grade level than what their notes were written in.

“Even if patients believe they understand what occurred during their hospitalization and the instructions they are to follow upon dismissal, they can become confused after they leave the hospital environment as their memory can be clouded by medications they were administered, the stress of hospitalization, and, particularly, within our patient population, traumatic brain injuries such as concussions,” senior study author Martin Zielinski, MD, told Reuters.

The study also found that 65% of 30-day readmissions were for patients who didn’t have the literacy skills to understand their discharge notes. Researchers recommend writing dismissal notes at a sixth-grade level to ensure patient comprehension.

Massachusetts medical board proposes rules on simultaneous surgeries

Surgeons in the state of Massachusetts will have to document each time they enter and leave the operating room according to a new regulation approved by the Massachusetts Board of Registration in Medicine, according to a recent report in The Boston Globe.

Patients rarely know if they are sharing their surgeon with another patient, and the lack of documentation about the surgeon’s whereabouts during a procedure leaves some wondering if their doctor actually performed the entire procedure, according to the report.

Additionally, the primary surgeon will need to identify the backup doctor in the event the primary surgeon needs to leave the operating room during the procedure.

Other rules approved by the board last week include:

  • Doctors will be required to report other physicians who are impaired by alcohol or drugs while on duty
  • Online physician profiles have been expanded to include out-of-state malpractice judgments and settlements involving Massachusetts doctors

The approved rules need approval by various state agencies by the end of March before they can go into effect.

The Hidden Patient Experience

Alexandra  Wilson Pecci, for HealthLeaders Media

How well-meaning and clinically important actions can make or break the patient experience, and how leaders at Cleveland Clinic and Mount Sinai Health System are refocusing efforts.

During her hospital's monthly executive leadership rounds, Cleveland Clinic's executive chief nursing officer, K. Kelly Hancock, MSN, RN, NE-BC, met a patient who didn't seem quite happy, despite his insistence that everything was OK.

"We could just tell that he was a bit hesitant in his answers," Hancock says. So before she and her fellow executives left him, they probed a little more, asking "Are you sure there's nothing else we could to make your experience better?"

Actually, something was bothering him. Someone had come in to change his gown, and instead of addressing him by name, such as Mr. Smith, they called him "honey" and "sweetie."

"For him, he was offended," Hancock says.

It may have seemed like a small thing, but it really rubbed him the wrong way, and totally colored his experience as a patient. It was clear that it had been bothering him for quite some time.

"You've really got to dig when you're with the patients and families," Hancock says. "What's important to that patient [is something] you may miss."

Clinicians might check off all of the important clinical boxes when caring for a patient, but it's often the small--perhaps nearly imperceptible--nonclinical elements of a hospital stay that most affect whether a patient has a good experience.

"I think that patients come to us expecting to get really good clinical care," agrees Sandra Myerson, MBA, MS, BSN, RN, senior vice president and chief patient experience officer at New York's Mount Sinai Health System.

With all the effort, money, and attention that's currently being paid to the patient experience, it's important for clinicians to understand how to get to the real heart of how a patient is feeling, and to do it in real-time.

Digging In

Beginning this year, Cleveland Clinic will be starting a program in which providers, such as nurses and physicians, will actually shadow patients during their inpatient stay or outpatient visit to better understand "what their experience is through their lens." Hancock says she's "really excited" about the program and can't wait to start it, adding that they think that "it's important enough that it's clearly worth the investment to take those caregivers offline."

Shadowing could also help clinicians develop the empathy they need to really understand what patients are going through, and therefore, what they care about. Hancock says compassionate care is about being present, empathetic, and listening for key words that a patient uses that might clue clinicians into their emotions, and ultimately, their experience.

Use the right language

Hancock says it's important to meet patients where they are, and the shadowing project will very literally do that. By asking something as simple as "What's important to you during this stay?" clinicians might find out that the patient really wants his hair washed or face to be shaved. They're small things that can go a long way in providing dignity and comfort, but that may not be "important" clinically.

"We have to pay attention to those things that are concerning to the patient that we might not even think they should be concerned about," Myerson says. "We tend to be really task oriented."

Hancock says providing a template for talking about these nonclinical topics can help staff drill down into what's really important or worrying to the patient. In addition, engaging in role-playing exercises can help staff ensure that such conversations with patients happen naturally and without sounding scripted.

Myerson adds that training managers and other clinicians to ask certain open-ended questions, rather than yes-or-no questions, can elicit better responses. For instance, clinicians might ask "How did you sleep?" or "What got in the way of you sleeping well?" instead of "Did you sleep well?"

Another question that could be useful, especially if a patient is suffering, is "What's the worst part of this for you?" according to a new essay in JAMA. Asking such a question and "turning toward" suffering, the authors write, helps not only with the patient experience in the moment, but with overall, long-term healing in a way that straightforward diagnosis and treatment may not. It acknowledges that patients are whole human beings. It's also important to remember that clinicians are whole humans, too, and that these non-clinically focused interactions doesn't always come naturally. That's why they need training.

"We're spending a lot of time and effort around coaching people to be really effective communicators because it's not something that we learned in school," Myerson echoes. "It's about the human experience."

Be visible and open

Myerson says patients aren't always comfortable expressing their concerns during their hospital stay, especially if they're unhappy with a particular clinician. Patients may also not know who to complain to in the first place. That's why nurse managers have to be visible and available to patients.

"What we like to do is have the nurse manger round on every patient every day. It is a really great way for the patient know who's in charge of the unit," she says. "At the end of the day the nurse manager is really the CEO for their unit."

Nurse managers at Mt. Sinai also hand out postcards with their name, photo, and contact information—in English on one side, and Spanish on the other—so patients have it handy if they need to get in touch. Nurse managers at Cleveland Clinic also round on new patients and distribute business cards.

"If I know who's in charge I can go right to the boss," Myerson says.

But it's not only the boss who has a role to play in listening to the patient. For instance, Myerson says some of their housekeepers have a great, natural ability to interact and connect with patients, and sometimes patients will confide things in them. When that happens, they're instructed to tell either the charge nurse, nurse manager, or their own supervisor.

In fact, everyone on the nonclinical teams receive education about making eye contact with patients, smiling, and introducing themselves. Myerson adds that building services team members have huddles before each shift, and "they talk about patient experience almost every single huddle."

"Everybody has a role in the patient experience," Myerson says.

Editor's Note: This article initially appeared in HealthLeaders on January 6, 2016.




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