Patient Safety

IOM urges vast changes in clinical trial data sharing

The Institute of Medicine on Wednesday released four recommendations to address practices that often have left relevant medical research unpublished and useful data unattainable by independent researchers. The guidelines could represent a sea change in how the research enterprise is thinking about its responsibilities, say advocacy groups, ethicists and academic researchers.

ACOs make progress in using big data to improve care

Only a handful of the largest and most sophisticated ACOs have established a "big data" warehouse that will let them pull together information from a variety of sources to help optimize care for individual patients and for their overall enrolled population. But many ACOs are developing the capacity to track patients in real time when they go to the hospital or the emergency department so they can intervene quickly to improve cost and quality outcomes. For many of these ACOs, accessing, sharing and analyzing these smaller pools of data, then figuring out what to do with the results, present their most formidable information challenges.

CMS: Healthcare spending rises only modestly

Healthcare spending rose 3.6 percent, or $2.9 trillion, from 2012 to 2013, marking the lowest growth rate since the federal government began tracking healthcare expenditures in 1960.

Study: Risk of hospital infections increases at end of work shifts

A study published in the Journal of Applied Psychology reveals that nurses, physicians and other hospital workers tend to wash their hands less frequently as their work shift progresses, with a nearly 9 percent drop in compliance with handwashing protocols from the beginning to the end of a 12-hour shift. Researchers studied three years of hand-washing data on 4,157 healthcare workers in 35 U.S. hospitals. They attribute the decline in compliance to mental fatigue and the fact that hand hygiene is considered a low-priority task among health workers.

Hospital medical errors reduced 20 percent with improved patient handoffs

A study published in the New England Journal of Medicine indicates that medical errors could be reduced by 30 percent by improving verbal and written communications between healthcare providers during patient handoffs. Researchers from Boston Children's Hospital analyzed the results of implementing the I-PASS system of bundled communication and training tools for patient handoffs at nine hospitals, covering a total of 10,740 patient admissions.

Safety culture with supporting processes help lower and prevent HAIs - A Roundtable

Healthcare-acquired infections remain a serious patient care issue and an avoidable high expense. HAIs are preventable, yet many hospitals and healthcare systems are finding it difficult to decrease the number of injuries to patients. Read why HAI prevention and treatment depends less on procedures and more on culture, leadership and organizational commitment.

Hospitals turn to big data to improve patient care

Hospitals are using detailed customer data to create profiles on current and potential patients in an effort to identify those most likely to get sick and intervene before they do. Some hospitals are obtaining information from data brokers that collect information from public records and credit card transactions, and then using algorithms to sort the data and identify high-risk patients. Other hospitals are using household and demographic data, but some patients and advocates are concerned that this expansion into big data could harm the relationship between doctors and patients and threaten privacy.

Perioperative Efficiency Tool Kit 2013 - AORN 

Patient safety, patient satisfaction, and patient flow are all important elements of operational efficiency in the perioperative setting. Opportunities exist to improve patient safety, the coordination of care, minimize delays and wastes, increase operating room utilization, and enhance the perioperative experience for the patient and family, as well as the perioperative team members. This learning activity is intended to discuss ways to implement actions to optimize perioperative patient flow and operational efficiency with an emphasis on safe patient preparation, starting surgeries on time (first case starts), and room turnover.

ASCO to help cancer docs evaluate treatment value

The American Society of Clinical Oncology's algorithm to help oncologists evaluate the clinical benefits, side effects and costs of a cancer drug or therapy will be fine-tuned over the summer and should be available for public comment by the fall, said Dr. Lowell Schnipper, chair of the society's Value in Cancer Care Task Force.

Online reviews could help fix medicine

The University of Utah was the first healthcare system to post reviews from patients online - the good, the bad, the ugly. Think of it as Yelp for doctors. This sort of transparency can be stressful for doctors - as it would be for anyone whose performance is open to the public - but the positive effects are undeniable.

Clemson University IE department researcher focuses on patient safety initiatives

Clemson University research assistant professor Ashley Kay Childers has been selected to participate in a forum to discuss quality improvement programs in U.S. hospitals that reduce preventable readmissions, prevent medical errors, improve patient outcomes and cut costs.

Top-Five list to improve emergency medicine and reduce costs

The Daily Rx summarizes on a study led by Jeremiah D. Schuur, M.D., an emergency medicine specialist at Brigham and Women's Hospital in Boston, to reduce excess utilization and costs in the Emergency Department.

Feds eye crackdown on cut-and-paste EHR fraud

A recent article in Modern Healthcare cites that with the broader adoption of electronic health records (EHRs) the cost of Medicare claims has increased. CMS is investigating whether cut-and-paste features of some of the new EHRs is contributing to either fraudulent and inadvertent up-coding by charging for services that were never provided.

Sepsis Toolkit, Sepsis Program Implementation Guide for NSW Healthcare Facilities

Sepsis continues to be a disease with high mortality, low clinical standard adherence, and high cost variation for many healthcare organizations. This Sepsis Toolkit from down under may be a useful reference for organizations looking to improve the quality of care for treating sepsis.

IIE member research abstract promoted via YouTube

IIE Member and doctoral student Avinash Konkani is featured in a YouTube video describing research he is doing to reduce noise and medical device alarm fatigue. Avinash is attending Oakland University and is doing research at Crittenton Hospital in Rochester, Michigan. Avinash is also a member of the SHS Newsletter committee.

Visualizing conversation structure across time: Insights into effective doctor-patient consultations

This study uses a highly efficient and time economic automated computer visualization measurement technique called Discursis to analyze conversational behavior in consultations.

Can lean tools help crack the medication safety code?

Joanie Ching, RN MN, Administrative Director of Quality and Safety, blogs about how Virginia Mason Hospital in Seattle is abandoning batch administration of medications to improve patient safety. By going to just-in-time medication administration, nursing workload has been leveled, medication errors have been reduced, and nurses are better able to respond to patient needs.

Editor's note: Workload leveling and smaller batch size, like many other "lean tools," are industrial engineering concepts that have been well understood for many decades. It appears that a lean approach has helped Virginia Mason to discover the benefits in this novel application.

The importance of communication for patient satisfaction

This research investigates the effect of communication complexity level on patients' perceived quality. The amount of communication was measured by self reports regarding the patient's visit.

Bound for flight: Elevating organizational excellence using lean leadership

This engaging presentation at the 2013 Healthcare Systems Process Improvement Conference in New Orleans, describes an actionable transformational leadership roadmap for navigating common organizational obstacles using a non-biased Lean approach at Advocate Condell Medical Center in the Greater Chicago area. As a result of embracing an innovative transformational roadmap, the organization experienced a significant turnaround both financially and culturally, including a $50 million dollar financial swing and a top percentile workforce satisfaction rank.

Patient experience and physician productivity: Debunking the mythical divide at HealthPartners Clinics

It is a common presumption that patients satisfaction and physician productivity are somewhat exclusive. This study in the Permanente Journal helps dispel commonly held myths about the exclusivity of productivity and patient satisfaction, suggesting that 1) there are many physicians who excel in both areas simultaneously, and 2) there are different characteristics associated with varying levels of performance.

Kaiser Permanente's healthcare IT journey

This presentation (large download) at the 2012 World of Health IT Conference describes how Kaiser Permanente is successfully leveraging IT resources to improve patient care.

Barnes-Jewish Hospital projects show patient safety and quality success 

A recent article in Becker's Quality Control and Infection Control describe how Lean Management drives continuous improvement at 1,100-bed Barnes-Jewish Hospital. In the article, Hospital Chief Medical Officer, John Lynch, M.D., describes how physicians have embraced Lean at Barnes-Jewish. He also describes how Lean Management projects have reduced central line infections, pressure ulcers, and diabetes medication errors, and improved patient coordination between different levels of care.

Aviation crew resource management: A flight plan to patient safety

In this presentation at the SHS Healthcare Systems Process Improvement Conference 2012, the authors discuss how aircraft accidents and patient safety failures are generally related to a lack of communicating and decision making skills in dynamic environments. Crew resource management (CRM) was developed by the aviation industry resulting in dramatic improvement in airline safety. Based on this success, CRM training and methods are being adopted by healthcare organizations throughout the world to improve patient safety.

Hunterdon hospital cleans up infections

The Wall Street Journal recently featured an article on how Hunterdon Medical Center reduced hospital-acquired infections with a number of high-impact interventions aimed at improved hospital cleaning. The 178- bed hospital in New Jersey was able to reduce different types of infection by between 66 percent to 79 percent between 2006 and 2011.

Students at Kettering University use industrial engineering principles to help prevent patient falls at local healthcare facilities

By applying core industrial engineering principles, students in Dr. Matthew Sanders' senior capstone class helped Genesys Hospital in Flint, Mich., evaluate and streamline its visual cueing system to better alert hospital staff, visitors and patients about fall risks.

Central line infection reduction using Lean Sigma at Presbyterian Healthcare Services, Albuquerque, N.M.

A multidisciplinary group at Presbyterian Healthcare Services teamed together to meet the Joint Commission National Patient Safety Goal and to reduce the central line infection rate to less than 1 per 1,000 patient days. The team used a Lean Sigma improvement methodology to identify a number of countermeasures including checklists, education, defined observer, and a standardized central line kit. In the first six months of the project, the central line infection rate was reduced to .22 infections per 1,000 patient days.

Industrial and systems engineers cure some of healthcare's ills - Watson Institute for Systems Excellence at Binghamton University

A recent feature in Binghamton's Watson Review describes ongoing healthcare improvement research at the Watson Institute for Systems Excellence (WISE). Ongoing healthcare research at WISE includes research in ED throughput and supply chain. WISE researchers collaborate with a number of hospital systems including Vitua, Mayo, and Wilson and Binghamton General Hospitals. Thirteen research assistants in the WISE program have recently been placed in healthcare organizations.

 Transforming care at the bedside: increasing patient satisfaction through employee engagement and teamwork at Our Lady of Lourdes Medical Center, Camden, New Jersey

Nursing leaders at Our Lady of Lourdes Medical Center in Camden, New Jersey, engaged staff to improve patient and employee satisfaction and reduce staff turnover on a medical-surgical unit using the Transforming Care at the Bedside (TCAB) model developed by Robert Woods Johnson Foundation and the Institute for Healthcare Improvement. The team focused on a set of directed methodologies and conducted a number of experiments that resulted in dramatic improvement.

What makes a hospital great

In a recent New York Times article, Pauline W. Chen, M.D. makes a case that organizational culture is more important than technique and technology in providing quality healthcare. 

Cowboys and pit crews: 2011 Harvard Medical School commencement address

Popular author and speaker Atul Gawande challenged the 200 graduates of the 2011 Harvard Medical School to pursue a more systematic approach to delivering healthcare. He used pit crews and cowboys as examples of working as a system.

How to ace your joint commission survey with lean

In this Ezine article author Gerald Leone describes how lean tools and principles were successfully applied in preparation for a Joint Commission Survey.

 The journey to eliminating preventable harm - Nationwide Children's Hospital

In this presentation at the 2011 Society for Health Systems conference, Cindy Hafer provides a comprehensive look at how Nationwide Children's Hospital in Cincinnati is moving to eliminating all preventable harm to patients through a comprehensive safety initiative.

University of Windsor Industrial and Manufacturing Systems Engineering students help to improve lab processes in the ED at Sunnybrook Health Sciences Centre

Sunnybrook Health Sciences Centre is considering implementing recommendations made by three fourth-year students at the University of Windsor Industrial and Manufacturing Systems Engineering as part of their capstone project. Ben de Mendonca, Josh Vandermeer and Andrew Phibbs, conducted an intensive examination of the system used by the emergency department to collect and label patient blood samples.

Indiana hospital pharmacy saves $1 million annually with lean improvements

Pharmacy leaders at Elkhart General Hospital, in Elkhart, Ind., applied a number of lean concepts resulting in lower operational costs and improved patient care. Examples of improvements cited in the Modern Medicine e-zine article were to redeploy two pharmacists to clinical roles, consolidate unit medications, and reduce batching of IV medications.

Human factors engineering to reduce patient falls

In a recent presentation at the 2011 SHS Conference, Brian H. Fillipo delivered a presentation on a comprehensive approach to reducing patient falls across seven Bon Secours hospitals in Virginia.

Purdue industrial engineering researchers investigate using surgeon hand gestures to improve surgery

Vision based recognition of hand gestures is being researched at Purdue University to control a robotic scrub nurse and access images during surgical cases. The research could lead to short case lengths and reduced infections according to the Purdue University News website.

The art of implementing Lean from AORN Management Connections

A recent article in AORN Management Connections by Carina Stanton describes how three healthcare organizations are implementing lean.

Video presentation on models, measurement techniques, and tests for analyzing adherence and performance of evidenced based medicine

In this 2010 presentation at the Dartmouth School of Engineering, SHS contributor and past president, James Benneyan, Ph.D., from the School of Mechanical, Industrial and Manufacturing Engineering at Northeastern University discusses that challenges of measuring performance of evidenced-based medicine and provides solutions to address these challenges.

Audible alarms and workplace noise in nursing units: An environmental factors case study

A case study for reducing workplace noise on a pediatric nursing unit and maintaining appropriate noise levels.

University of Wisconsin-Madison researchers post final report on Industrial and Systems Engineering (ISyE) in Health Care

In research sponsored by the Agency for Healthcare Research and Quality (AHRQ), UW researchers summarize findings and associated research from a 2009 conference in a report entitled Industrial and Systems Engineering and Health Care: Critical Areas of Research.

 Using Lean to Identify Process Improvement Opportunities and Improve Effectiveness of Transfusion Professionals

Susan F. South, senior consultant, ValuMetrix® Services and Jo Ann S. Hegarty, worldwide marketing director, ValuMetrix® Services provide a description of improvements in blood transfusion processing by applying lean concepts at 14 different laboratories in three different countries. The average savings per site was more than $190,000, excluding savings associated with improved inventory management.

 Lesson from the Trenches: Implementation of an Automated Patient Safety System

In this presentation given at the 2010 SHS/ASQ Healthcare Division Conference, the authors describe how a Baldrige Award-winning hospital implemented a paperless continuous improvement patient safety system. The system is used for collecting patient safety events as well as analysis, performance improvement, classification, and organizational knowledge building involving every employee in the healthcare system. The automated patient system has dramatically improved event reporting and streamlined the analysis and follow-up.

 Using your Head(wall) - Advances in Patient Room Design

IE students at Clemson University have been involved in a multiyear study on patient room headwall design. The study included the School of Nursing at Clemson and staff and facilities at Spartanburg Regional Healthcare System.