Quality and Patient Safety Update, Mar. 23, 2011

In this issue: 
This issue includes information on the Fourth Annual Patient Safety Symposium, Safe Surgery 2015, SC Partnership for Health and the 2011 Lewis Blackman Award Winners, in addition to AHA and IHI news highlights.

Fourth South Carolina Patient Safety Symposium

Blue Cross Blue Shield of South Carolina (BCBS SC), Health Sciences South Carolina (HSSC), Mothers Against Medical Error and PHT Services, Ltd. worked together to develop one of the most dynamic symposium’s to date. We were honored to have nearly 300 participants from all over the state! Our moderator, IHI President and CEO Maureen Bisognano challenged the group to think about health care in a different way. She asked the group to think about what it’s like to live with illness and what care givers can do to help ease the lives of patients. In trying to think about what it is like to live with illness, she asked the group to visit the New York Time’s Patient Voices and listen to two or three of their stories. (You can do this too. You have until March 28 before the subscription pay wall is enacted.) Our team would like to hear your stories as well. If you have a patient story, please submit it to mbolen@scha.org.

Now, I would like to take you through a few highlights from this year’s symposium…

Safe Surgery 2015

Atul Gawande, MD, a world leader in patient safety and practicing surgeon, officially kicked off Safe Surgery 2015, an initiative aimed at reducing surgical errors. I am proud to say South Carolina is the first pilot state to implement the checklist.

Gawande spoke to about 300 South Carolina health care professionals about the importance of implementing the checklist in all operating rooms across South Carolina by 2013 at last week’s symposium.

“We know the difficulties in using it (checklist),” he said. “The real challenge is if we are able to transform the experience of care for patients here.”

It is our time to prove South Carolina’s worth in the health care world. If we successfully implement the checklist in South Carolina, at least 500 of the 5,000 patients who die each year following surgeries in South Carolina hospitals should be saved by 2013.

Read stories published in the Greenville News (subscription required), The State and The Item (subscription required).

SC Partnership for Health

SCHA has formed a new partnership with BCBS SC and HSSC based on the IHI Triple Aim, aimed at improving health care while lowering health care costs. The South Carolina Partnership for Health was announced Wednesday at the symposium by our moderator and national leader of the triple aim, Ms. Bisognano.

She said, “I believe the IHI Triple Aim is designed to change the course of health care history. I believe the IHI Triple Aim is the way towards a healthier population at a lower cost. And I believe South Carolina is going to be one of the first states to prove this by adopting the triple aim to  reengineer health care statewide through collaborative partnerships and innovative thinking focused on better care for every patient, every time.”

Watch video or read more about the partnership.

2011 Lewis Blackman Award Winners

Each year it is our honor and privilege to host the Lewis Blackman Patient Safety Champion Awards at the symposium. These awards were created in 2008 to recognize individuals who demonstrated exemplary dedication and leadership in advancing the quality and safety of health care for patients across South Carolina. The awards are named in honor of Lewis Blackman, a bright, talented 15-year-old who died in 2000 after an elective surgical procedure due to preventable medical complications. His mother, Helen Haskell, has provided inspiration for this award with her dedication to promoting patient safety and quality improvement across the state and the nation.

Caregiver Award:

Eric Powers, MD, Chairman, South Carolina Mission: Lifeline and all South Carolina Mission: Lifeline Caregivers

Healthcare Executive:

Shawn Stinson, MD, Vice President of Clinical Quality and Patient Safety, Palmetto Health

Advocacy Award:

Teresa Arnold, Director of Governmental Affairs, AARP

Student Champion:

Ross Hilliard, University of South Carolina School of Medicine

Southeast Regional IHI Open School Forum

Immediately following the last session of the symposium, nearly 400 students from across the southeast gathered together for the inaugural Southeast Regional IHI Open School Forum. The Organizing for Health team led the students through a discussion on public narrative and how to change culture on a grassroots level. We are very pleased to continue to develop and support IHI Open School in our state. It is vital that we educate the next generation of health care leaders so that they can continue to improve the quality of care for every patient both in our state and throughout the nation.

SCHA has also partnered with IHI Open School to provide Open School’s unique integrated educational community for health professionals across multiple disciplines for a discounted rate. This is a great opportunity for hospitals to offer continuing education credit for their faculty and staff at low cost. Click here to learn more.

We are so proud of what we were able to offer at this year’s symposium. Thank you to all who participated to make this symposium not just a meeting, but an experience. We look forward to creating another experience for you next year!

South Carolina News

MySChospital.org Quarterly Data Update

MySChospital.org is part of SCHA’s Every Patient Counts statewide initiative to advance patient safety and health care quality. The website has been created by SCHA and its’ member hospitals as an educational tool focusing on the quality of care provided in South Carolina hospitals. The evidence-based measures include medical interventions and optimal care measures that correspond to heart attacks, heart failure, pneumonia and surgical infection prevention. In addition, the website includes the Hospital Consumer Assessment of Healthcare Providers & Systems patients’ experience of care information and the Agency for Healthcare Research and Quality Inpatient Quality Indicators.

MySChospital data and information will be updated on Monday, March 28, 2010 with four rolling quarterly time periods starting from 3rd quarter 2009 through 2nd quarter 2010. All hospital core measures data were validated by SCHA and The Carolinas Center for Medical Excellence. Data preview reports were sent to hospitals.

Checklists for Severe Weather

Severe Weather Awareness Week for 2011 was observed February 27 to March 5 in South Carolina. The South Carolina Emergency Management Division and the National Weather Service jointly sponsor this week to remind people that severe storms, tornadoes and flash floods are significant hazards in South Carolina and people need to take proper safety precautions. This year they released three checklists to help you prepare for the severe weather season: Power Outage Checklist, Thunderstorm Safety Checklist and Tornado Safety Checklist. These documents are located in the resource section of this newsletter.

Frequent Users of Hospital Emergency Departments in South Carolina

Emergency Departments (EDs) serve as important community resources and are an important source of patients and revenue for hospitals. EDs across our state and the country are under strain because of increased utilization, as they are increasingly used for care that should occur in a primary care setting. Inappropriate use of the ED is often linked to those who use them repeatedly. Frequent, repeated use of the ED by individual patients can have a negative effect on their quality of care.

Click here to read the South Carolina Public Health Institute’s report on frequent users of hospital EDs in South Carolina.

AHA News Highlights

HHS Releases National Strategy for Quality Improvement

The Department of Health and Human Services today sent Congress a national strategy for health care quality improvement, which aims to make health care better and more affordable and people and communities healthier. Required by the Patient Protection and Affordable Care Act, the strategy focuses on six initial priorities: making care safer; engaging patients and families as partners in their care; promoting effective communication and care coordination; promoting the most effective prevention and treatment for the leading causes of mortality, beginning with cardiovascular disease; working with communities to promote wide use of best practices to enable healthy living; and making quality care more affordable by developing and spreading new health care delivery models. Nancy Foster, AHA vice president for quality and patient safety, said the AHA "supports the development of a national quality strategy and hopes that public and private payers, as well as other regulatory stakeholders, such as states, use it as a framework to promote health care quality." In related news, HHS Secretary Kathleen Sebelius visited Nationwide Children's Hospital in Columbus, OH, to recognize Solutions for Patient Safety, an Ohio quality initiative involving general and children's hospitals.

Older Adults Comprise More than Half of ED Visits for Drug Reactions

Adults aged 50 and older comprise 51.5% of emergency department visits related to adverse reactions to medications, according to a new study by the Substance Abuse and Mental Health Services Administration. About 8 in 10 of these visits involve reactions to just one medication. Cases include a broad range of medications, led by central nervous system drugs such as pain relievers (24%). One-third of older adults treated for adverse drug reactions in the ED are admitted to the hospital. The findings are based on data from SAMHSA's 2008 Drug Abuse Warning Network, which monitors drug-related hospital ED visits.

Study: Palliative Care Could Reduce Hospital Costs in Medicaid Program

In a study of four New York state hospitals reported today in Health Affairs, the average cost of a hospital admission for Medicaid patients with certain advanced diseases was $6,900 less for patients who received palliative care. Palliative care recipients spent less time in intensive care, were less likely to die in the ICU, and were more likely to receive hospice referrals than a matched group of patients who received usual care, the study found. At the four hospitals in the study, palliative care consultation teams cared for about 4% of total Medicaid admissions. The authors estimate New York's Medicaid program could save $84 million to $252 million a year if every hospital in the state with 150 or more beds had a palliative care consultation team.

IHI News Highlights

IHI Open School “Find a Mentor” Matching Tool Invitation

The IHI Open School for Health Professions has engaged thousands of students in learning about improvement. Now, they need your expertise. As part of a new website that IHI is developing for launch in the spring, IHI has developed a matching tool called Find a Mentor, which enables students to search for professional mentors like you. IHI.org users can opt-in to Find a Mentor, specify their areas of expertise, receive requests from students who wish to be mentored and track those requests. Students will be able to enter search criteria and a list of registered IHI.org users who have opted in to Find a Mentor and who match the criteria will be returned. Then, students can send a message through IHI.org to invite users to consider their mentor requests. Mentors have the option to accept or decline requests from prospective student mentees.

Mentorship can take on many different forms and we’re leaving it open for you and the students to decide what that should be. Whether you provide one-time career advice or monthly improvement project coaching, it’s up to you. First, IHI would like to create a database of mentors. Then, they will invite students to start using the Find a Mentor tool. The first group of students will be invited to use the matching tool in early March. To begin, we’d like to invite you to become a mentor for health profession students. See the IHI Open School Mentor Tool to learn how.

Early Warning Systems: The Next Level of Rapid Response

Many hospitals have implemented rapid response teams and found that their quick reactions can help improve outcomes. While rapid response teams are a valuable resource, there can be limits to what they can accomplish once called. Because of this, many organizations have implemented early warning systems to identify deteriorating patients earlier – getting them the care they need sooner.

If your hospital is looking to improve patient outcomes and take its rapid response team to the next level, join IHI on its latest Expedition, Early Warning Systems: The Next Level of Rapid Response. Over the course of six web-based sessions, beginning April 6, expert faculty will provide you with the tools and guidance to successfully implement an early warning system in your organization.

For more information and to enroll, please click here.

Other National News

Orlikoff Reinersten Boardworks Webinar: Health Care is Still Unsafe: What Boards Need to Do About Patient Safety, March 28, 2011

Despite safety efforts by individual hospitals and regional/national campaigns, patients in hospitals, surgery centers and offices still experience an unacceptable risk of harm-harm which in many instances is clearly preventable. More disturbing, it appears that in many instances, we actually know how to make care safer and more reliable. One doesn't have to be a futurist guru to put these two observations together and come to the conclusion that regulators and payers will soon lose patience with health care leaders who can't seem to use the tools and knowledge we already have, in order to make patient care safer.

One approach to this problem would be to start rehearsing your explanations to the regulators about why your patients are still experiencing harm. Or, you could join Jim Reinertsen and Jamie Orlikoff for this comprehensive webinar on what leaders, particularly boards, actually do to improve patient safety. What works to reduce harm, and mortality rates? Where has it worked? Why hasn't it worked elsewhere? What's the role of the board in making it work? What do other members of the leadership team need to do?

Click here to register.

SBIRT Free Introductory Webinar, March 28, 2011

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a clinical service that can be very valuable in a number of inpatient and outpatient health care settings. In a health care setting many people can contribute to successful SBI implementation because they have the talent, experience, work-related responsibilities and opportunity to effectively screen and intervene. Further, individuals who make decisions about service billing and managing medical records are critical in ensuring the sustainability of SBIRT.

Click here to register for the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment’s introductory SBIRT webinar.

Calendar of Events

March 30-31, 2011

CSR for the Carolinas Workshop: This workshop is limited to CSR for the Carolinas members. It will review The Joint Commission’s accreditation decision changes, challenging standards for hospitals and has a focus on Environment of Care and Life Safety Code issues. Breakout sessions and panel discussions by recently surveyed hospitals are held on day 2. This workshop will be held at the Grove Park Inn, Asheville, NC. See the CSR Workshop Agenda to learn more and register. For other information contact Karen Reeves, kreeves@scha.org.

May 5, 2011

South Carolina Clean Hands Day


Please contact The SCHA Quality and Patient Safety Team if you have questions regarding this newsletter (803.744.3523) or to schedule a Site Visit with our team, please complete the attached form.

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