patient safety quality healthcare

AHA Advisory Group Issues Report on Interoperability

In a report released in July, the American Hospital Association’s (AHA) Interoperability Advisory Group (IAG) calls on health systems and hospitals, developers and vendors of electronic devices and information systems, and government and regulatory agencies to work together to improve the interoperability of healthcare data.

In Achieving Interoperability that Supports Care Transformation, the group observes that the United States will gain full advantage of its recent investment in electronic health records (EHR) only when information can be shared easily and securely among all who need to use it. Acknowledging that initiatives such as meaningful use and EHR certification provide starting points, the report faults the Office of the National Coordinator (ONC) for not doing enough to support interoperability. EHR certification includes standards that support data sharing, but the IAG reports that organizations need more practical help for implementation and better oversight of vendor offerings before they will be able to achieve the goal of interoperability:

…ONC generally did not provide implementation guidance for the use of the standards, allowed flexibility in how the standards are used by vendors and adopted relatively lax testing of EHRs for certification. As
a result, AHA members report very limited actual interoperability today.

Members of the IAG include administrative and clinical leaders, as well as experts in information technology, and represent the range of AHA member organizations from large academic medical centers to standalone hospitals.

In addition to wanting ONC and the federal government in general to focus more effectively on standards, certification, and testing, the IAG’s report describes things the private sector must do to advance interoperability. The private sector includes providers, vendors, health information exchanges, and organizations that represent the interests of other stakeholders. Among the ways they can support interoperability, the IAG highlights demanding that vendors adhere to accepted standards, contributing use cases that accurately represent the need for sharing information, and sharing lessons learned and best practices.

In addition to a long to-do list for the private and public sectors, the IAG suggests that a new multi-stakeholder organization may be necessary to “drive progress on interoperability.” Citing the success of CAQH—a non-profit alliance that promotes standardized sharing of financial and business data for healthcare organizations— the IAG proposes that a similar group might help navigate the competing stakeholder interests and accelerate what so far has been slow progress on interoperability.

A Dialogue on Improving Patient Experience throughout the Continuum of Care: A New Report From the Beryl Institute

The Beryl Institute has released a white paper that explores the focus on patient, resident, and family experience in various healthcare settings. A Dialogue on Improving Patient Experience throughout the Continuum of Care provides insight from healthcare leaders and reinforces the importance of patient experience.

The paper shares a community dialogue held at The Beryl Institute’s Patient Experience Conference 2015, where a panel of respected healthcare professionals engaged in discussion on practice across the continuum, including the voice of patients and families and sharing practices and new ideas to improve experience at all touch points. The panel represented perspectives from physician practice, acute care, and long-term care settings.

Leaders contributing to the discussion included:

• Dr. Larry Brown, medical director, Alegent Creighton Clinic

• Audrey Weiner, president and CEO, Jewish Home Lifecare

• Dan Wolterman, president and CEO, Memorial Hermann Health System

Core themes focused on culture, people, and communication. Panelists reinforced the need for strong leadership and organizational catalysts, the recognition that engagement is important, stories are powerful tools, and the voices of patients and families must be listened to and acted upon.

The white paper is free to members of The Beryl Institute and $29.95 for non-members. To download the paper, visit


ABMRS Administers First Exam for MR Safety Certification

On Wednesday, June 24, 2015, the American Board of Magnetic Resonance Safety (ABMRS) administered the first examination to certify individuals with the credentials MR Medical Director/Physician (MRMD) and MR Safety Officer (MRSO). More than 100 radiologists, technologists, and medical physicists took the exam for either the MRMD or MRSO. Only licensed physicians may sit for the MRMD exam. The ABMRS will also offer an MR Safety Expert (MRSE) credential, for which the inaugural exam will be administered on October 21, 2015, in Orlando, Florida. Exams for the MRMD and MRSO credentials will also be offered at that time.

The MRMD and MRSO examinations cover distinct aspects of the same MR safety knowledge domains (e.g., static magnetic fields, gradient magnetic fields, radio frequency energies, contrast agents, bioeffects, etc.). The exams focus directly on the candidates’ knowledge of the underlying MR safety concepts as well as their ability to apply that knowledge to real-world clinical and research situations.

The ABMRS was formed in 2014 to certify healthcare professionals who oversee safety in all magnetic resonance environments. For more information visit the ABMRS website.

See also “New MR Safety Certification Focuses on Radiologists, Technologists, and Physicists.”

Sanjay Saint Receives the APIC 2015 Distinguished Scientist Award

The Association of Professionals in Infection Control (APIC) has awarded Sanjay Saint, MD, with the organization’s Distinguished Scientist Award. The award is given annually to an APIC member who has made a significant and sustained contribution to infection prevention science and who exemplifies scholarly excellence and infection prevention leadership within the scientific community. The award was presented during APIC’s 42nd Annual Conference, which was held in June in Nashville, Tennessee.

“This year we are honoring Dr. Sanjay Saint with this award for his major contributions to implementation science, infection prevention, and patient safety,” said APIC 2015 President Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP. “His life-long dedication to enhancing patient safety by preventing healthcare-associated infections has helped advance APIC’s mission both domestically and abroad.” Dr. Saint is a national leader in preventing catheter-associated urinary tract infections (CAUTIs) and currently serves on the leadership team of a federally funded program that aims to reduce CAUTI across the United States.

Saint is the George Dock Professor of Internal Medicine at the University of Michigan, the director of the VA/University of Michigan Patient Safety Enhancement Program, and the chief of medicine at the VA Ann Arbor Healthcare System. Saint has authored more than 250 peer-reviewed papers, with 95 appearing in the New England Journal of Medicine, JAMA, Lancet, or the Annals of Internal Medicine. He is also the lead author of Preventing Hospital Infections: Real-World Problems, Realistic Solutions, a book recently published by Oxford University Press. He has been a visiting professor at more than 50 universities and hospitals in the United States, Europe, and Japan, and has active research studies underway with investigators in Switzerland, Italy, Japan, Australia, and Thailand.

Emergency Care Innovation Award of the Year

Application deadline is July 31, 2015.

The Emergency Care Innovation of the Year Award is an annual competition sponsored by Urgent Matters, Blue Jay Consulting, and Schumacher Group. The award recognizes multidisciplinary emergency department-based teams who have implemented a process or strategy to improve patient, clinical, and operational outcomes and can demonstrate measureable assessment of its effectiveness.

Submissions must include at least one of the following innovation categories: safety and quality, flow and efficiency, care coordination, patient experience, and cost-consciousness.

One member of the winning team will present his or her team’s innovation at the Urgent Matters Conference to be held at the American College of Emergency Physicians Scientific Assembly on October 25 in Boston, Massachusetts.

More information about the award, including deadlines, eligibility requirements, and submission forms, is available online.

AHA Recognizes Hospitals with the Equity of Care Award

Grants & Awards


Award honors hospitals for promoting diversity, reducing health disparities.

Henry Ford Health System in Detroit and Robert Wood Johnson University Hospital in New Brunswick, New Jersey, are both winners of the American Hospital Association’s second annual Equity of Care Award. The AHA award recognizes hospitals for their efforts to reduce healthcare disparities and promote diversity within the organization’s leadership and staff.

The award will be presented July 24 at the Health Forum/AHA Leadership Summit in San Francisco. AnMed Health in Anderson, South Carolina, and Rush University Medical Center in Chicago will be recognized as honorees.

This year’s winners have successfully incorporated the use of race, ethnicity, and language preference data to better understand their care processes and seek continual improvements; cultural competency to understand their community and ensure individualized care to all those in need; and diversity measurement to confirm their leadership and board reflect the community they serve.

Winner: Henry Ford Health System

Henry Ford Health System (HFHS) collects demographic data from more than 90 percent of its patients and embeds that data into equity dashboards that are part of the overall quality and service metrics tracked by all business units to spur interventions in areas like diabetes outcomes among African American patients. HFHS uses cultural competency as an ongoing training for employees and clinicians to provide high-quality care. Using Employee Resource Groups, a Healthcare Equity Scholars Program and resident training, HFHS is continually evolving and improving its approach. HFHS also is dedicated to diversity through the use of a candidate pool that reflects set goals for minorities and women. Its efforts have been rewarded with a 57 percent increase in minorities in top leadership levels and a 44 percent increase in females in top leadership levels from 2009 to 2014.

Winner: Robert Wood Johnson University Hospital (RWJ)

Robert Wood Johnson University Hospital (RWJ) is committed to addressing health inequities through its REAL Data Integrity LEAN Six Sigma Project. RWJ’s focus on clean-accurate data to identify opportunities for improved care has resulted in an increased use of interpreter services and an associated 30 percent decrease in readmissions of heart-failure patients. In addition, RWJ looked at transitional care for low-income patients to close the gap between patients’ discharge and follow-up visits to their primary care physicians. RWJ’s efforts resulted in a reduction of its overall 30-day hospital readmission rate from 13 percent in 2013 to 5.2 percent in 2014. This type of organizational-wide focus is evidenced through its work on diversity and inclusion. Since 2012, RWJ increased leadership diversity from 4 percent to 32 percent minority representation. Board diversity also has increased from 17 percent in 2011 to 22 percent today.

Honoree: AnMed Health in Anderson, South Carolina, is noted for:

  • Use of a disparities dashboard that provides access to reliable REAL data.
  • A centralized language service solution.
  • AnMed Health Differentiology Leadership Academy that has provided 80 percent of the leadership team a two-month learning experience to identify “diversity blind spots.”

 Honoree: Rush University Medical Center in Chicago is noted for:

  • Use of technology with a “disparities navigator” to examine different health outcomes among patients and target interventions.
  • A longstanding Language Interpreters Program with a documented improvement in care.
  • Pioneering work through their ADA Task Force.

 The AHA Equity of Care Award is presented annually and recognizes outstanding efforts among hospitals and care systems to advance equity of care to all patients and to spread lessons learned and progress toward achieving health equity. In 2011, the AHA joined four national healthcare organizations to issue a call to action to eliminate healthcare disparities by focusing on increasing the collection of race, ethnicity and language preference data; increasing cultural competency training; and increasing diversity in governance and leadership.

Brain and Spine Surgery No More Risky When Physicians-In-Training Participate, Study Finds

Having residents—physicians in training—participate in surgery does not in itself increase a patient’s risk of postoperative complications or of dying within 30 days of the surgery, according to a recent study of more than 16,000 brain and spine surgeries. A report on the study appears in the April issue of the Journal of Neurosurgery.

“Patients often ask whether a resident is going to be involved in their case, and they’re usually not looking to have more residents involved,” says Mohamad Bydon, MD, himself a resident in neurosurgery at The Johns Hopkins Hospital. “Some people have a fear of being treated in a hospital that trains doctors.”

To see whether that fear is borne out by real-world outcomes, Bydon worked with Judy Huang, MD, a professor of neurosurgery and director of the neurosurgery residency program at the Johns Hopkins University School of Medicine, and other collaborators to analyze data from the American College of Surgeons National Surgical Quality Improvement Program database. Specifically, they examined outcomes for all patients who had brain and spine surgeries between 2006 and 2012—16,098 in total.

The initial analysis appeared to affirm the fear, showing that patients operated on by a fully trained physician—known as an attending—plus a resident had a complication rate of 20.12 percent, while patients with only an attending had a complication rate of 11.7 percent. The patients operated on by attendings plus residents also had a slightly higher risk of death within 30 days after the surgery.

But, the research team suspected, that might not be a difference caused by the participation of the residents. Residents are most often found in teaching hospitals associated with academic medical centers, and such hospitals are also the most likely to treat higher risk, more complicated cases. So the team did a deeper analysis of the data, one that took into account patients’ conditions and severity of illness prior to surgery. That analysis showed that having a resident present in the surgery was not an independent risk factor for postsurgical complications or death.

The authors say the study’s results may help physicians reassure nervous patients about the prospect of having a trainee assist with a surgery.

Shulkin Confirmed as Under Secretary of Health for US Department of Veterans Affairs

The U.S. Senate has confirmed David J. Shulkin, MD, as the Under Secretary of Health for Veterans Affairs. As the chief executive of the Veterans Health Administration (VHA), Shulkin will lead the nation’s largest integrated healthcare system with more than 1,700 sites of care, serving 8.76 million veterans each year. VHA is also the nation’s largest provider of graduate medical education and a major contributor of medical research. Shulkin will oversee the 300,000 people who work at the VHA.

Shulkin was nominated by President Obama on March 19, 2015, to serve as under secretary and confirmed by the U.S. Senate on June 23, 2015. The vote to confirm Shulkin comes as Congress has shown concern over issues at the VA over the past year related to access and quality of care.

Shulkin, 55, of Pennsylvania, will replace interim Under Secretary Carolyn Clancy, MD, who took over shortly after Dr. Robert Petzel resigned in 2014.

At his Senate confirmation hearing, Shulkin pledged to improve the largest healthcare organization in the U.S. by using his private sector experience to help guide the VA beyond patient access problems that led to waiting lists and falsified records in Phoenix and elsewhere around the country. Dr. Shulkin told senators at his hearing on May 5, 2015, that “VA needs change” and that the time had come to create a “new VA” with “superior access and the highest standards for quality of care.”

Shulkin said that taking care of veterans is a personal mission. His father served as a captain in the Army and his grandfather was chief pharmacist at the Madison Wisconsin Veterans Medical Center. Both Shulkin and his wife, Dr. Merle Bari, worked in a number of VA facilities during their medical training.

Prior to becoming under secretary, Shulkin led a number of healthcare organizations. He most recently served as president of Morristown Medical Center and vice president of Atlantic Health System in Morristown, New Jersey, where he led the hospital during a period of significant growth and transformation. Prior to that, Shulkin was president and CEO of Beth Israel Medical Center in New York City. Shulkin has also served as the chief medical officer of the University of Pennsylvania Health System, Temple University Hospital, and the Medical College of Pennsylvania Hospital.

Shulkin’s expertise includes management in healthcare organizations and integrated delivery systems, medical education, health services research, and health technology. He has been an entrepreneur, author, researcher, and academic leader in the areas of health administration, quality, and patient safety. Dr. Shulkin founded DoctorQuality, Inc., one of the first companies in the country to help consumers choose better quality healthcare.

Shulkin, a general internist, is a graduate of Drexel University School of Medicine and did his medical training at Yale University and the University of Pittsburgh. Shulkin was a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania. Most recently he has been Professor of Medicine at Mt. Sinai School of Medicine.

National Program to Improve the Quality of Geriatric Surgical Patient Care Announced by American College of Surgeons and John A. Hartford Foundation

CHICAGO (June 11, 2015): Today, the American College of Surgeons (ACS), in partnership with the John A. Hartford Foundation (JAHF), announced it will conduct a four-year initiative that will lead to improved care of older surgical patients through a standards and verification program for hospitals.

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Iatric Systems Accelero Connect Integrates Medical Devices with the EHR

Halifax Regional Medical Center reports streamlined workflows and enhanced patient care after working with Iatric Systems, Inc., a comprehensive healthcare IT integration company, to integrate Welch Allyn and Nihon Kohden medical devices with its electronic health record (EHR) in various hospital areas.

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Press Ganey Introduces Program to Help Provider Organizations Prepare for OAS CAHPS

Press Ganey has announced the launch of its Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Early Adopter Program.

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The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is pleased to announce our formal alliance and collaboration with the American College of Physician Advisors, Inc. (ACPA).

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Predictive Analytics, Home Health Monitoring Combine for Better Care

CareSage is a new predictive analytics engine from Royal Philips that enables health systems to better monitor and care for elderly patients by combining actionable insights with wearable devices and monitoring.

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New Sentinel Event Alert Examines Safe Use of Health Information Technology

Safe use of health information technology (health IT) is the focus of a new Sentinel Event Alert recently released by The Joint Commission.

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Dr. Gary Kaplan Named Chair of NPSF Lucian Leape Institute

The National Patient Safety Foundation’s Lucian Leape Institute has named Gary S. Kaplan, MD, FACP, FACMPE, FACPE, the next chairman of the Institute.

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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