patient safety quality healthcare

New Sentinel Event Alert Focuses on Preventing Patient Falls

Preventing patient falls and fall-related injuries is the focus of the Sentinel Event Alert: Issue 55 released by The Joint Commission. The new alert examines the contributing factors to patient falls and includes suggested solutions to be implemented by health care organizations to help reduce patient falls and falls with injury, according to the press release.

This topic was chosen for Sentinel Event Alert because patient falls with serious injury are among the top 10 sentinel events reported to The Joint Commission Sentinel Event Database. The Joint Commission has received 465 reports of patient falls with injuries since 2009, and approximately 63 percent of those falls resulted in death. The Joint Commission defines a sentinel event as a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm where intervention is required to sustain life. Although the majority of falls reported to The Joint Commission occurred in hospitals, the ECRI Institute also reports a significant number of falls occurring in non-hospital settings such as long-term care facilities. 

 An analysis of falls with injury reported to The Joint Commission Sentinel Event Database from January 2009 through October 2014 showed the most common contributing factors include:

  • Inadequate assessment
  • Communication failures
  • Lack of adherence to protocols and safety practices
  • Inadequate staff orientation, supervision, staffing levels or skill mix
  • Deficiencies in the physical environment
  • Lack of leadership

The suggested actions in the Sentinel Event Alert address all of the identified contributing factors to patient falls. Listed resources in the alert include links to toolkits and research on falls prevention, and it introduces the Joint Commission Center for Transforming Healthcare’s Preventing Falls Targeted Solutions Tool®.

“Fall prevention is the responsibility of everyone in the organization and success is highly dependent on leadership playing a primary role. It is their commitment and approach that determines an organization’s ability to significantly reduce and sustain the reduction in falls,” said Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “There are several proactive steps in the Sentinel Event Alert that leaders can initiate such as educating and raising awareness of the need to prevent falls resulting in injury, ensuring the implementation of a validated tool to identify the risk factors for falls, and establishing an interdisciplinary falls injury prevention team.”

Sentinel Event Alert is published periodically by The Joint Commission for health care professionals. It describes the common underlying causes of sentinel and adverse events and recommends steps to reduce risk and prevent future occurrences. Sentinel Event Alert topics are determined by the Joint Commission’s Patient Safety Advisory Group comprised of external members with significant expertise in health care and patient safety, and presided over by Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission.

For more information about the sentinel event statistics and previous issues of Sentinel Event Alert, please visit The Joint Commission’s Sentinel Event Alert Web page.

Source: The Joint Commission

Study Finds Higher Rates of Perioperative Medication Errors than Previous Research

A study published in the October 2015 issue of Anesthesiology reports on the frequency of medication errors and adverse events in the perioperative setting. The rates of errors and events were significantly higher than documented by previous studies. The recent study found:

  • A drug error or adverse drug event occurred in approximately 1 in 20 medication administrations and in half of the operations observed
  • More than one-third of the errors caused patient harm
  • About one-third of the errors resulted in an adverse drug event

Following training as observers, three anesthesiologists and one nurse anesthetist documented all medications administered, medication errors, and adverse drug events during 277 randomly selected operations. In addition to the data collected by direct observation, the study discovered medication errors and adverse drug events through chart review. The anesthesia information system was queried for errors and adverse events related to the same operations. Those cases were further reviewed for duplication; errors and events that had been missed by the observers were then recorded. The study was performed at the Massachusetts General Hospital (MGH), a large academic medical center in Boston.

The study is an important contribution to published literature about rates of perioperative medication errors. Most previous studies relied on self-reported data, which may be one reason why those rates were lower than the rates found in the study performed at MGH.

The study and a related editorial were published online (for free) to coincide with the 2015 annual meeting of the American Society of Anesthesiologists, held in San Diego in October.

Study Shows Positive Effects From UVC Robot

A new study on use of UV light in the short C-wavelength (UVC) for disinfection was presented at IDWeek 2015. The study showed that Tru-D SmartUVC significantly reduced healthcare-associated infections (HAI) caused by common multidrug-resistant organisms (MDRO) in hospitals. Tru-D SmartUVC was the UVC device selected for this study and proved its ability to reduce environmental pathogens by measuring the required reflective dose to thoroughly disinfect a hospital room.

            Results of the study, Benefits of Enhanced Terminal Room Disinfection, indicated that three enhanced terminal room disinfection strategies decreased the cumulative incidence of MDROs by 10% to 30%, and the largest decreases were seen when a UVC-emitting device was added to the standard cleaning protocol. Such reduction rates, validated through a randomized clinical trial, differentiate Tru-D technology.

            The study’s primary outcome showed the clinical incidence of an MDRO in the next patient to occupy the room for at least 24 hours after disinfection. Adding a cycle of measured-dose UVC light added approximately 10 minutes to the total room turnover time.

In honor of this landmark study and to further the company’s mission of eradicating HAIs and making hospitals a safer place for patients and staff, Tru-D is donating one Tru-D robot to a hospital in the United States. Hospitals may register to win at The drawing for the robot will be held December 7.  

Source: Tru-D

Medication Management Training Improves CMS Quality Metrics, New Study Finds

Scores improve in hospitalization, readmission and high-risk disease states

A new study shows that medication management educational tools can improve key Centers for Medicare & Medicaid Services (CMS) quality measures. Following a seven-month program developed by Prescriber’s Letter drug advisory service, Quality Independent Physicians (QIP) successfully decreased patient hospitalization across all disease states by 26%. It also saw a 24% relative drop in discharges and a 7% relative decrease in 30-day hospital readmissions.

QIP, a 50-physician accountable care organization (ACO), conducted the study. The organization treats 12,000 Medicare patients annually across Kentucky and Indiana.  As a Medicare provider, QIP is required by CMS to report on a variety of strictly defined quality measures. Traditionally a fee-for-service industry, healthcare has shifted towards a quality-driven, pay-for-performance model as a result of the Affordable Care Act (ACA).

“As an ACO, our organization is addressing these new challenges and opportunities head on by participating in the Medicare Shared Savings Program (MSSP),” said QIP medical director Gregory A. Hood, MD, MACP. “Because key Medicare reimbursements are directly tied to quality metrics and related performance ratings, it is in everyone’s best interest to focus on creating optimal patient outcomes across the entire continuum. As a result, better care as defined by CMS benefits both our patients’ personal health and our practice’s financial health.”

Effective medication management is a major determinant of quality scores. QIP’s partnership with Prescriber’s Letter strengthened its quality metrics through an integrated program of current medication management recommendations delivered at the point of care. It accomplished this by leveraging tools to align medication management enterprise-wide and brought about changes in prescriber behavior, when needed, as well as supported patient education. 

“There was a strong belief that a focus on medication management would have the greatest impact on our ability to meet CMS metrics,” said Dr. Hood. “By delivering the latest drug information to the point of care, we were able to align medication management practices and related process throughout the ACO.”

The effort focused on high-risk disease states specifically targeted for CMS reporting or directly related to key quality measures. These included COPD, heart failure, bacterial pneumonia, hypertension, anticoagulation, diabetes and acute coronary syndrome.

Reaching across the continuum, Prescriber’s Letter provided customized, actionable educational resources. These included coverage of target diseases, online searchable medication management recommendations, drug comparison charts, physician training materials, and patient education handouts. All materials were incorporated into QIP standard policies, procedures and organizational culture.

After seven months, metrics during the intervention were compared with a baseline prior to program implementation. “As we hoped, medication management, specifically the Prescriber’s Letter solution, played a pivotal role in changing metrics and patient outcomes,” said Dr. Hood. “We found a statistically significant improvement on all data reported to CMS on MSSP Utilization reports required for an ACO, which yields overall cost savings and higher reimbursements for the organization.”

 “The success of the QIP study and the role Prescriber’s Letter in those results underlines our focus on providing unbiased evidence-based information to the healthcare community,” said Wes Crews, chief executive officer of Therapeutic Research Center. “Straightforward, concise information enables health systems and physician groups to streamline distribution across the entire organization, blending our information into clinician workflow. This allows providers, like QIP, to see a change in performance and a change in outcomes.”

Source: Therapeutic Research Center

AMA and MedStar Health Partner to Improve EHR Usability

In an effort to promote transparency around how electronic health records (EHRs) are designed and user-tested, and drive improvements in clinician support and patient safety, the American Medical Association (AMA) and MedStar Health’s National Center for Human Factors in Healthcare have developed a comparative EHR User-Centered Design Evaluation Framework that reveals a lack of focus among regulators and industry on user-centered design and usability testing.

The EHR User-Centered Design Evaluation Framework evaluates design and testing processes for optimizing usability in 20 common EHR products using information reported by EHR vendors to meet usability certification requirements set by the Office of the National Coordinator for Health Information Technology (ONC). The framework goes beyond the low gauge set by federal usability certification criteria and evaluates the vendor’s compliance with best practices for user-centered design (UCD) processes according to a 15-point scale developed by MedStar’s Human Factors Center in collaboration with the AMA.

“It is important to recognize that this framework evaluates conformity with best practices identified in human factors and usability literature for user-centered design and testing. We are not evaluating the actual usability of the product as experienced by end users,” said Raj Ratwani, Ph.D., scientific director of the Human Factors Center and a principle developer of the framework. “Alignment with best practices for user-centered design and testing is a starting point that regulators and industry should meet and exceed. The framework we developed is the first step in bringing greater transparency to the usability processes of EHR vendors.”

Comprehensive user-centered design and testing for EHR products is essential for ensuring that systems are useful clinical tools that will help improve patient safety and meet the cognitive workflow and information needs of physicians and other health professionals. This is emphasized by the AMA and MedStar Health in the goals of the framework, which state: “We believe EHRs should be designed with the end user in mind and that the ONC’s requirements do not go far enough to encourage fully functional and usable products. This framework can be used by the ONC to improve their certification program, and as a method to track improvements EHR vendors make as they recertify their products over time.”

The ONC requires vendors to report on the UCD processes they followed for only a handful of EHR capabilities. Since the design and testing of most EHR functions goes unverified by the ONC’s certification criteria, an optimal evaluation presented by the framework should not be considered reflective of actual usability experienced by physicians and other end-users. As such, the framework should not be interpreted as a buyer’s guide.

“Physician experiences documented by the AMA demonstrate that most EHR systems fail to support effective and efficient clinical work, and continued issues with usability are a key factor driving low satisfaction with many EHR products,” said AMA President Steven J. Stack, M.D. “Our goal is to shine light on the low-bar of the certification process and how EHRs are designed and user-tested in order to drive improvements that respond to the urgent physician need for better designed EHR systems.”

Ratwani added, “To improve the usability of EHRs we need to promote rigorous usability development processes based on recognized methods and standards.”

The framework builds on a study Ratwani wrote on EHR usability that was published by the Journal of the American Medical Association in September 2015. In that study, Ratwani et al., analyzed available reports from the top 50 EHR vendors, as measured by the number of meaningful use attestations made to the ONC between April 1, 2013, and Nov. 30, 2014. The researchers found that a significant percentage of vendors did not even follow basic federal requirements for certifying the usability of their products, yet these products were certified under the meaningful-use incentive program.

Effective usability is critical to patient safety and physician satisfaction. A study conducted by the AMA and RAND Corporation in 2013 found that EHR usability “represents a unique and vexing challenge to physician professional satisfaction” and that the current state of technology raises “concerns about effects on patient care.” The AMA-RAND report urged improved usability among federal certification criteria.

The AMA will continue to move aggressively to advance the goal of more usable EHR products based on eight usability priorities created last year by the AMA to lead EHR design improvements that would ultimately improve the health of the nation.

Sources: American Medical Association and MedStar Health’s National Center for Human Factors in Healthcare

Medfusion Launches Mobile App to Simplify Healthcare Records

To provide patients with a single destination for all of their medical records, Medfusion—a patient engagement platform dedicated to facilitating the relationship between doctors and patients—has developed a consumer mobile application called Medfusion Plus. 

For decades, if patients wanted access to their medical records, they had to request and pay for a paper copy, which could take several days if not weeks. With the advent of portals, patients gained electronic access to portions of their medical records created by individual providers.

Via a download on the App Store and Google Play, iOS and Android device users can now aggregate and access their healthcare records on their mobile devices. The information is pulled via Continuity of Care documents from patient portals and includes laboratory results, immunizations, medication lists, allergies, as well as appointments.

“Patients should have a complete view of the care provided to them across multiple provider settings—hospitals, physician practices, and from their wearables,” said Chris Fierer, director of innovation and Medfusion Plus solution manager. “We believe patients should play a more significant role in their care, and the only way they can optimize the quality and efficiency of that care is to have a total, accurate view of their medical records.”

“I regularly see patients who have recently been hospitalized who have seen multiple specialists who ran diagnostic tests on them and may have changed their medications without sending me notification or medical records pertaining to these encounters,” said internist and pediatrician John Meier, MD, MBA. “As their primary care physician, I am void of critical information that would allow me to better manage and optimize their care, which is frustrating to both me and my patients.

“Until we get to full interoperability within and among EHRs,” Meier added, “we need a solution like Medfusion Plus that allows my patients to show me their latest lab tests and current medications on their smartphones. This will enable me to create a much better care management plan based on higher quality, lower cost and most importantly better outcomes.”

Medfusion Plus, which also provides an application programming interface and is available on the Apple Watch, will continue to evolve with a significant roadmap ahead for the developers. The app is available at no cost to consumers, and a branded version will be made available to provider organizations.

Source: Medfusion

Health Systems and Harvard Pilgrim Health Care Enter Joint Venture to Improve Population Health in New Hampshire

Dartmouth-Hitchcock, Elliot Health System, and Frisbie Memorial Hospital are entering into a joint venture with Harvard Pilgrim Health Care to form a new company that will improve the quality of healthcare in New Hampshire and reduce costs.

The entity, called Benevera Health, will improve healthcare coordination by bringing together clinical, financial, and operational data from across partner institutions to provide actionable analytics for clinicians to further improve the quality and efficiency of patient care. At the center of this approach will be locally based care advocates who will identify early opportunities to engage patients—especially those with chronic, complex, or emerging conditions—and provide them with one-on-one support. Benevera Health will help physicians raise the standard of care, leading to a better patient experience and better health outcomes.

The new company will be jointly owned; all the partners will share financial and clinical outcome responsibility for the patients in their care. Together they will make significant investments in technology systems, analytics, and personnel, and will share financial risk. Benevera Health is expected to drive down the cost of healthcare, allowing Harvard Pilgrim to keep premiums lower and more competitive for members. In 2016, premiums will be about 4% lower than they would be without this partnership, with continuing improvement expected in following years.

Benevera Health is a population health improvement company—not an insurance company—owned and governed by its partner healthcare systems/hospitals and Harvard Pilgrim. The hospital/health system partners will have a voice in the design of Harvard Pilgrim’s insurance products and strategy in New Hampshire.

This new joint venture will support all of Harvard Pilgrim’s over 80,000 fully insured members in New Hampshire, regardless of which plan they have. Additionally, there are plans to support all self-insured members. Harvard Pilgrim’s product portfolio will continue to offer full-network plans as well as its ElevateHealth high-performance network plans.

Benevera Health’s sophisticated approach to population health improvement will:

  • Provide healthcare clinicians with access to more robust information about best 
practices and care outcome patterns to guide their care recommendations 

  • Offer outreach by trained New Hampshire healthcare professionals to address emerging, complex, or chronic health issues and identify appropriate solutions
  • Establish thoughtful member health monitoring systems to allow timely healthcare intervention to reduce the need for urgent care, thus reducing costs and providing
better health outcomes
  • Provide information to allow members and their physicians to make informed choices about specialty physicians, facilities, and treatments based on associated outcomes 

  • Allow for comprehensive analysis of payer and provider data to optimize care delivery
and cost, based on the New Hampshire patient experience

Benevera Health will begin its operations on January 1, 2016. The partners are beginning the process of hiring about 40 healthcare professionals, most of whom will work at the partner hospitals as patient care advocates. The new company will be led by Corbin Petro, the current president of ElevateHealth; ElevateHealth was launched in 2013 as a partnership among Harvard Pilgrim, Dartmouth-Hitchcock, and Elliot Health System and is the precursor to Benevera Health. Previously, Petro was the chief operating officer at MassHealth, Massachusetts’ Office of Medicaid. She has an extensive background in healthcare, including advising a U.S. senator on health reform, and roles at Bain and Company, Goldman Sachs, Deloitte Consulting, and American Management Systems. Petro will report to a board composed of senior leaders from each of the partners and will co-lead Harvard Pilgrim’s New Hampshire market team, bringing increased provider input to Harvard Pilgrim’s New Hampshire business.

Source: Harvard Pilgrim Health Care.

CMS Extends Funding for Hospital Engagement Networks

On September 25, 2015, the Centers for Medicare & Medicaid Services (CMS) awarded $110 million to 17 national, regional, or state hospital associations and health system organizations to fund a second round of Hospital Engagement Networks (HEN), which will extend through September 2016. The contracts are part of the Partnership for Patients, a nationwide public-private collaboration designed to protect patients from being harmed while in the hospital and suffering complications after discharge.  

Launched in April 2011, the Partnership for Patients strives to engage short-stay acute care hospitals across the nation in improving the quality of care delivered to patients. Along with the HENs, partnerships with physician, nursing, and pharmacy organizations, consumers and consumer groups, and employers have emerged to align their efforts. In addition, private health plans, local agencies on aging, and state and federal government officials have pledged to work together to meet the initiative’s goals.

The Partnership for Patients and the HENs operate within a framework established by the Affordable Care Act to deliver better care to individuals and the population, and to spend dollars more wisely. The Department of Health and Human Services has estimated that 50,000 fewer patients died in hospitals and that approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. Nationally, in that same time period, patient safety has improved, resulting in 1.3 million adverse events and infections avoided in hospitals. This translates to a 17% decline in hospital-acquired conditions during that time frame. In addition, 30-day hospital readmissions in Medicare decreased by nearly 8% between January 2012 and December 2013—translating to 150,000 fewer readmissions.

Partnership for Patients

The focus of the Partnership for Patients’ work going forward will be to sustain national progress on its existing goals:

  • Keep patients from getting injured or sicker. Decrease preventable hospital-acquired conditions by 40% compared to 2010.
  • Help patients heal without complication. Decrease preventable complications during a transition from one care setting to another so that 30-day hospital readmissions are reduced by 20%compared to 2010.

Concurrently, the Partnership will conduct evaluations to more assess its contribution to national improvements in patient safety.

Hospital Engagement Networks

The HENs will continue to identify solutions that already succeed at reducing healthcare-acquired conditions, and work to spread them to other hospitals and healthcare providers.  

HENs work at the national, regional, state, or hospital system level to develop learning collaboratives for hospitals so that they can implement the changes and innovations necessary to achieve the Partnership for Patients’ safety and care-transition goals. HENs engage in a wide array of initiatives and activities to spread established, evidence-based interventions to rapidly improve patient safety in hospitals.  

The Partnership for Patients will continue to evaluate the capacity of large improvement networks to bring about improvement in patient safety. HENs are required to focus on the following 10 core areas of harm:

  • Adverse drug events.
  • Catheter-associated urinary tract infections in all hospital settings, including avoiding placement of catheters, both in the emergency room and in the hospital.
  • Central line–associated bloodstream infections in all hospital settings, not just intensive care units.
  • Injuries from falls and immobility.
  • Obstetrical adverse events, including early elective delivery reduction. Obstetrical adverse events are to include, at a minimum, obstetrical hemorrhage, and preeclampsia treatment and management to prevent morbidity and mortality.
  • Pressure ulcers.
  • Surgical site infections (SSI), including measurement and improvement of SSI for multiple classes of surgeries.
  • Venous thromboembolism, including, at a minimum, all surgical settings.
  • Ventilator-associated events, including infection-related ventilator-associated complications and ventilator-associated conditions.
  • Readmissions.

In addition to these topics, HENs are expected to address all other forms of preventable patient harm in pursuit of safety. HENs are expected to detail their plans to address these other forms of harm, including at a minimum the aims, measures, and evidence-based best practices they propose to put in place. The Partnership for Patients recognizes that the pediatric population has unique needs related to these other forms of preventable harm. Therefore, HENs supporting pediatric hospitals and pediatric wards within general hospitals may choose to augment and delineate an alternative program of work to address highest-risk harms specific to the pediatric population, including readmissions.

Additionally, the following are some topics HENs may consider in addressing other harms:

  • Severe sepsis and septic shock
  • Hospital culture of safety that fully integrates patient safety with worker safety
  • Iatrogenic delirium
  • Clostridium difficile, including antibiotic stewardship
  • Undue exposure to radiation
  • Airway safety
  • Failure to rescue

Data Tracking and Reporting

Each HEN, in consultation with the Partnership for Patients, will identify and use appropriate process and outcome measures for each area of focus to track hospital progress on quality improvement. A new requirement in this second round of HENs will mandate that they submit data on a standard list of measures. HENs will also be strongly encouraged to use any additional measures that align with existing measurement activity already underway within their community, or that they feel would be most impactful to the populations they serve.

The HENs will also submit monthly reports to CMS describing their activities and the progress of their quality improvement efforts, including hospital progress on improvement measures for each core area. HENs will submit final reports to CMS at the conclusion of the 12-month period of performance detailing the successes, failures, lessons learned, and areas of improvement in each focus area.

To support hospital submission of measurement data, the HENs will be required to establish a secure, Web-based data collection and management portal. Through this portal, the HENs will have access to hospitals’ measurement data, and will use that information to evaluate progress and focus attention on efforts or hospitals that have yet to see improvement. Data collected by the Partnership for Patients will not be used to evaluate hospital performance for existing quality programs such as the Hospital Value-Based Purchasing Program and the Hospital Readmissions Reduction Program.  

The HENs will support approximately 3,400 hospitals during this upcoming 12-month period of performance. The competitive procurement process enabled support for a diverse group of acute care hospitals across the nation in an effort to recruit the active participation of as many of the short-stay acute care hospitals in the country as possible.   

Selected Hospital Engagement Network Organizations

The 17 HENs (listed in alphabetical order) for round two are:

  • American Hospital Association
  • Ascension Health
  • Carolinas HealthCare System
  • Dignity Health
  • Healthcare Association of New York State
  • Health Research and Educational Trust of New Jersey
  • Hospital & Healthsystem Association of Pennsylvania
  • Iowa Healthcare Collaborative
  • LifePoint Health
  • Michigan Health & Hospital Association Health Foundation
  • Minnesota Hospital Association
  • Ohio Children’s Hospital Solutions for Patient Safety
  • Ohio Hospital Association
  • Premier, Inc.
  • Tennessee Hospital Association
  • VHA-UHC Alliance NewCo Inc.
  • Washington State Hospital Association

 Source: Centers for Medicare & Medicaid Services.

NCQA’s Quality Compass Helps Plans and Consumers Compare Clinical Performance

Database features quality information for approximately 104 million insured lives.

The National Committee for Quality Assurance (NCQA) has released its latest version of Quality Compass 2015: Commercial. This comprehensive database of health plan performance compiles data from 400 publicly reporting commercial plan products, offering information on clinical performance and patient experience for approximately 104 million covered lives. 

The updated Quality Compass tool features performance data on active commercial health plans pulled from both the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®).

Quality Compass is a valuable tool for health plans, employers, and consumers. Itprovides state, regional, and national benchmarks, as well as individual plan performance. Benchmarks, or national averages for certain measures, are calculated from a total pool of 420 publicly and non-publicly reporting health plan products. Health plans use this information to help compare their performance to others in their area and across the country. Employers and purchasers use the information to choose the best-performing plans to offer their enrollees.

Quality Compass 2015: Commercial includes the following new and updated measures from the HEDIS Effectiveness of Care domain: 

  • Cervical Cancer Screening
  • Non-Recommended Cervical Cancer Screening in Adolescent Females

“Health plans, employers and other consumers look to Quality Compass to pinpoint areas where plans are performing well, or that need improvement,” said NCQA’s Chief Information Officer, Rick Moore. “Offering the most comprehensive data set available lets consumers make sound decisions when choosing their plan.”

NCQA will release the Medicaid and Medicare editions of Quality Compass later this fall.

All Quality Compass editions can be ordered online through NCQA’s website,, or by calling NCQA Customer Support at 888-275-7585.

Submissions Open for Eisenberg Awards Through October 30

Submissions are open through October 30 for the 2015 John M. Eisenberg Patient Safety and Quality Awards. These prestigious awards, given annually by NQF and The Joint Commission, recognize major achievements to improve patient safety and healthcare quality by individuals and organizations at the local and national levels in separate awards. Self-nominations are welcome.

 “Each year, the Eisenberg award winners inspire the quality field as we work together to help ensure that all patients receive the high-quality, safe care that they need and deserve,” said Christine K. Cassel, MD, president and CEO of NQF.

Launched in 2002, the patient safety awards program honors the late John M. Eisenberg, MD, MBA, former administrator of the Agency for Healthcare Research and Quality. Dr. Eisenberg also was a member of the founding board of directors of NQF.

Award criteria and eligibility requirements are available online at

The 2015 awards will be presented during NQF’s Annual Conference, “Re-engineering Quality Data for Value,” April 7-8, 2016, in Washington, DC.

Contact This email address is being protected from spambots. You need JavaScript enabled to view it. with questions about the submission process.

Comment Through Oct 16 on ISMP’s Guidelines for Communication of Medication Information in Electronic Systems

The Institute for Safe Medication Practices (ISMP) invites healthcare practitioners to comment on its Draft Guidelines for the Safe Electronic Communication of Medication Information. To view and comment on the guidelines, visit Suggestions also can be submitted via email to This email address is being protected from spambots. You need JavaScript enabled to view it. .

ISMP observes, “Health information technology vendors and users currently do not have a set of accepted standards related to the safe presentation of electronic data associated with medication information.” The guidelines address how medication information is communicated in EHRs, CPOE systems, eMARS, pharmacy computer systems, e-prescribing systems, and electronic displays that appear when using barcode scanning systems, smart infusion pumps, and automated dispensing cabinets.

ISMP plans to submit the finalized guidelines to the Office of the National Coordinator of Health Information Technology and share them with technology vendors, standard setting organizations, professional organizations, and the Centers for Medicare & Medicaid Services.

ANA Sets ‘Zero Tolerance’ Policy for Workplace Violence, Bullying

The nursing profession “will no longer tolerate violence of any kind from any source,” the American Nurses Association (ANA) declared in a new position statement on violence in health care workplaces released in August.

 “Taking this clear and strong position is critical to ensure the safety of patients, nurses and other healthcare workers,” said ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN. “Enduring physical or verbal abuse must no longer be accepted as part of a nurse’s job.”

ANA’s position statement, developed by a panel of registered nurses (RNs) representing clinicians, executives, and educators, addresses a continuum of harmful workplace actions and inactions ranging from incivility to bullying to physical violence. The statement defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress,” such as hostile remarks, verbal attacks, threats, intimidation and withholding support.

The statement calls on RNs and employers to share responsibility to create a culture of respect and to implement evidence-based strategies. The statement cites research showing that some form of incivility, bullying or violence affects every nursing specialty, occurs in virtually every practice and academic setting, and extends into all educational and organizational levels of the nursing profession.

A recent ANA survey of 3,765 RNs found that nearly one-quarter of respondents had been physically assaulted while at work by a patient or a patient’s family member, and up to half had been bullied in some manner, either by a peer (50%) or a person in a higher level of authority (42%).

Among the position statement’s recommendations to prevent and mitigate violence, in addition to setting a “zero tolerance” policy, are:

  • Establishing a shared and sustained commitment by nurses and their employers to a safe and trustworthy environment that promotes respect and dignity
  • Encouraging employees to report incidents of violence, and never blaming employees for violence perpetrated by non-employees
  • Encouraging RNs to participate in educational programs, learn organizational policies and procedures, and use “situational awareness” to anticipate the potential for violence
  • Developing a comprehensive violence prevention program aligned with federal health and safety guidelines, with RNs’ input

To prevent bullying, among ANA’s recommendations are that RNs commit to “promoting healthy interpersonal relationships” and become “cognizant of their own interactions, including actions taken and not taken.” Among recommendations for employers are to:

  • Provide a mechanism for RNs to seek support when feeling threatened
  • Inform employees about available strategies for conflict resolution and respectful communication
  • Offer education sessions on incivility and bullying, including prevention strategies

ANA has several resources to help RNs and employers address and prevent bullying in the workplace, including the booklet, Bullying in the Workplace: Reversing a Culture, and a bullying “tip card.”

AHRQ Report Finds Gaps in Evidence for Best Ways to Clean Hospital Rooms

A new report funded by the Agency for Healthcare Research and Quality (AHRQ) reviews clinical studies examining methods for cleaning and disinfecting hospital rooms to prevent healthcare-associated infections. The literature reviewed also covered strategies for monitoring rooms for cleanliness and “contextual” factors, such as organizational culture, that influence implementation and effectiveness of room cleaning.

The studies selected for review examined high-touch, hard surfaces in inpatient wards—excluding pediatric, surgical, or long-term care settings—and addressed environmental contamination by Clostridium difficile, methicillin-resistant Staphylococcus aureas or vancomycin-resistant enterococci.

The authors found few studies published between 1990 and 2015 that compare disinfection methods, monitoring strategies, or implementation efforts. Studies that assess patient outcomes—the effect of cleaning on the incidence of HAIs—are also lacking. In addition to filling those gaps, the authors call for future researchers to study and compare new cleaning technologies such as ultraviolet light and disinfectant coatings.

The review was prepared for AHRQ by individuals at the ECRI Institute–Penn Medicine Evidence-Based Practice Center. A summary of the report was published in August 10, 2015, in the Annals of Internal Medicine. The full report can be found at


MITSS Hope Award Accepting Nominations

Nominations are now being accepted for the Annual MITSS Hope Award. The award recognizes people and organizations—patients, families, healthcare providers, hospitals (or their teams or departments), academic institutions, community health centers, grass roots organizations, EAP Programs, etc.—who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The Award is being sponsored by RL Solutions, and the winner will receive a $5,000 cash prize.

Nominations are due by September 25, 2015, and the Award will be presented at the MITSS 14th Annual Dinner to be held at the Sheraton Boston Hotel on Thursday, November 12, 2015, from 5:30 to 9 pm.

For more information about the award or to nominate someone (self-nominations will be accepted), visit, call the MITSS office (617) 232-0090, or email Winnie Tobin at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Massachusetts General Hospital Expands Use of LiveData PeriOp Manager with OR-Schedule Board

LiveData, Inc. has announced that Massachusetts General Hospital (MGH) has expanded its deployment of LiveData PeriOp Manager™, adding LiveData OR-Schedule Board™ to its growing patient safety and operational intelligence deployments. A key module  in LiveData PeriOp Manager, OR-Schedule Board provides a large-screen view of the day's surgical cases, showing the real-time status of all rooms in the OR suite with case milestone indications and alerts. It dynamically updates changes in real-time and uniquely predicts the actual case flow for the day, so perioperative teams have actionable data to influence OR utilization.

LiveData PeriOp Manager synchronizes perioperative workflow throughout the entire perioperative suite. Coordinating patient flow, patient care, and related resources from preoperative assessment to discharge in real-time, PeriOp Manager streamlines OR throughput and promotes full compliance with CMS, The Joint Commission, and other critical patient safety mandates. OR-Schedule Board is a real-time view of the day’s surgical caseload. It automatically adjusts case start and end times based on real-time case workflow monitoring, and provides interactive tools to automate OR assignment and clinical staffing on the fly.

“Hospitals are under constant pressure to cut costs safely, while maintaining their commitment to patient safety and quality healthcare,” said LiveData CEO Jeff Robbins. “One of the most effective way to improve the bottom line is by optimizing the scheduling of resources, both equipment and personnel. OR-Schedule Board brings a new level of efficiency and effectiveness to clinical staff and management.” 

OR-Schedule Board has been deployed in all operating rooms at Mass General.

Web-based OR-Schedule Board is accessible from any authorized workstation throughout the OR suite – PreOp, PACU, ICU, staff lounges, and even locker rooms.

LiveData PeriOp Manager integrates real-time data with workflow automation to coordinate and manage patient care throughout the perioperative suite. PeriOp Manager includes:

  • OR-Schedule Board: a real-time view of the day’s surgical cases, enabling  scheduled procedures to be adjusted as the day unfolds to reduce unnecessary cancellations, staff overtime, and to improve overall patient throughput.
  • PreOp Board: a single, dynamic, operational view of patient status and perioperative case workflow confirms the necessary prerequisites for  surgery are completed in time to ensure on-time starts and reduce unnecessary rescheduling or cancellations.
  • OR-Dashboard: a display of patient information, visible to the entire surgical team, integrating data from hospital medical records and physiological devices with automated surgical workflow and patient safety information including Active Time Out, a real-time, interactive surgical safety checklist.
  • Patient Flow: a patient check-in process integrated into perioperative workflow tracking.
  • Family Waiting Board: a display designed for public areas to enable families to track the progress of their loved ones as they move through the surgical process.
  • Analytics: comprehensive big data analysis, transforming real-time operational data into actionable quality, compliance, and efficiency intelligence.



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