SaferPatients

Value Based Purchasing (VBP) is here.

VBP is a control scheme introduced by CMS to reduce the cost of health care. Under VBP, providers will be reimbursed for care given to Medicare patients based on patient satisfaction and the ability to get good scores on CMS core measures.

Medicare has been very clear about the impact to hospital bottom lines. Average performers won’t break even. If you have average core measures, and average patient satisfaction your institution will lose money.

The way to maximize your reimbursement and protect your budget is to have high performance compared to national benchmarks with other hospitals across the country, and to make  dramatic improvement against your own baseline scores. Either way, you must improve.

If you add the reduced reimbursements to an additional 20.4 million Medicare patients over the next decade, and then add the effect of productivity adjustments, 15 percent more institutional providers will go bankrupt by 2019, according to the former administrator of CMS.

What is the solution to value-based purchasing?

• increased use and adherence to protocols,
• real-time monitoring and feedback,
• focused scorecards, and
• better training for doctors and nurses on patient communication techniques.

You must be better than average, or you will be worse off financially next year. But how to get better?

If you are depending on individual clinicians to spectacularly rise to the challenge on their own, you will fail. Sustained results will only come from a systems approach that hard-wires daily habits all of personnel. if you don’t know how to do this, it might be time to get some help.

Watch a three-minute movie about LifeWings.

A Boston surgeon who performed the wrong procedure on the hand of an elderly woman has disclosed the excruciating details of his error in one of the nation’s most prominent medical journals.

As usual this case had all of the classic error-inducing factors: 1) The procedure was done at the end of a long day; 2) Stress was high because several other surgeons were behind schedule. When surgeons are stressed, the surgical team is stressed; 3) The patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment; 4) The surgeon didn’t have a habit of leading or actively participating in the Time Out (seeing them as an unnecessary burden); 5) There were communication issues as the patient didn’t speak English.

The surgeon did speak Spanish and spoke to the patient in that language. This exchange in Spanish was mistakenly interpreted by the Circulator in the room as a “Time Out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred.

While admittedly I wasn’t there for this event, I have personally observed many other OR situations like this one, and I have no doubt that the nurse did an internal debate with herself about whether she should speak up and question the surgeon about the Time Out and the need to do it in English for the benefit of the team. For whatever reasons, including the stress she felt from the surgeon and the fact that the surgeon didn’t typically lead, or get actively involved in the Time Out, she decided it was okay to let it slide.

If the surgeon had always made it a habit of leading the Time Out, and of making a safety statement at the end of it encouraging his team to speak up if they saw something not in the patient’’s best interest, it would have made it easier for the nurse to speak up.

A classic, effective, stop-the-line assertive statement by the circulating nurse at that moment would have changed everything.

He didn’t, and she didn’t. The result was the surgeon performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure.

What did the surgeon learn? “I no longer see these protocols (the Time Out) as a burden. That is the lesson,” he said.

It is unfortunate that so many see the proper execution of a Time Out as an unnecessary time waster until “it” happens to them.

Experience is a great teacher, but she sends in terrific bills.

Watch a three-minute movie about LifeWings.

By now almost everyone involved in health care quality improvement has heard of the checklist used to insert central lines that was developed Peter Pronovost, MD, professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine. The checklist has made Dr. Pronovost famous.

That checklist has long been known to reduce bloodstream infections when used correctly. It has now been proven to reduce patient deaths in Michigan hospitals by 10%.

The British Medical Journal (BMJ) studied the use of the checklist and discovered  a drop in patient mortality in Michigan hospitals. Though previous studies found a reduction in infections, this is the first to link the checklist program with reduced mortality.

“It’s breathtaking,” Pronovost told The Baltimore Sun. “With our program, patients are alive who wouldn’t be if they were outside Michigan.”

The results are so dramatic that the average ICU in Michigan now has better infection numbers than 95% of the ICUs in the remainder of the country.

While checklists must be well-designed, and getting staff to use them correctly can be tricky, with results like these, why isn’t every hospital using the same checklist program?

Watch a three-minute movie about LifeWings

At Brigham & Women’s Hospital in Boston, team-based inpatient care has resulted in dramatic reductions in inpatient mortality, significantly lower lengths of stay, and higher satisfaction for physicians and nurses.

Team-based care dissolves the hierarchical, traditional structure that exists among nursing, physical therapy, pharmacy and medical staff, social work staff and others to empower individual members of the team to contribute equally to the optimal outcomes for the patients.

At Brigham & Women’s Hospital and its sister Faulkner Hospital, a team-based model of care has been adopted for almost all general medicine units. This system replaces the “chaotic model,” in which residents, attending physicians and interns rotated on different cycles; physicians and nurses did not know one another; and the admissions department assigned patients to whatever beds were available.

Each unit now has a team made up of attending physicians, residents, interns and medical students, pharmacy students and a faculty supervisor, nurses, a social worker, an RN care coordinator and a physical therapist. All members of the team are assigned to work together on a specific unit for at least four weeks at a time.

Two other key changes were instituted: The admissions department assigns a patient to an intensive care unit team only if there is a bed available on its unit and interdisciplinary rounds are structured sequentially by nurse, rather than by room number.

Also, under a team-based care model the expectation is that you don’t discuss a patient until the nurse is present, Another expectation is that before a physician articulates the [patient's care] plan that you get the nurse’s input. The physician team leader will always address the nurse and ask, “Do you have anything to add about this patient?”

The perspective of other team members is equally valued, depending on the patient’s diagnosis and care plan. Sometimes the most important clinician is the physical therapist. The physician may be writing the orders and doing some of the direction, but under the team-based care model the physician does not work alone, but as part of a team.

This approach requires new standardized processes, extensive teamwork and communication training, and strong support and leadership action from top administrators.

Watch a Three-minute movie about LifeWings