February 11, 2010
- New Facility-Specific Hospital Compare Reports Available
- Engage Physicians to Prevent Health Care Associated Infections
- The Joint Commission Issues Sentinel Event Alert on Preventing Maternal Death
- FDA Extends Deadline to Transition from Steris
- Centers for Medicare and Medicaid Services Respond to Issues with QualityNet
- Upcoming Events
New Facility-Specific Hospital Compare Reports Available
The Washington State Hospital Association (WSHA) has emailed the enhanced Hospital Compare report to hospital CEOs, CMOs and quality leaders. The original reports were designed as advised by members and have now been updated based on requests for enhancement. The new reports include:
A new hospital-specific report that shows your hospital’s performance compared to the state average and national top 10 percent. (This report was created at the request of members who were finding the information very valuable but time-consuming to produce themselves.)
The report displays the data in a more focused way, providing hospitals with a new way to benchmark their performance. It provides at-a-glance information on how hospitals stack up against their peers and the best in the country.
We hope this report will highlight areas of excellence as well as opportunities for improvement in the Hospital Compare measures. If you have any questions or comments about the new report, please contact Ken Rudberg at kenr@wsha.org or (206) 577-1851. (Ken Rudberg, kenr@wsha.org)
Engage Physicians to Prevent Health Care Associated Infections
Engaging physicians and physician leaders in patient safety efforts is key to preventing infections in hospitals. During a recent Safe Table Learning Collaborative meeting, Dr. Tim Dellit, Medical Director of Infection Control at Harborview Medical Center, shared some key strategies to engage physicians. Using these strategies has helped Harborview implement the central line bundle and significantly reduced their central line infection rates. A few key strategies for engaging physicians include:
• Identifying physician champions and involving them in improvement processes
• Providing physician leaders with evidence of effectiveness of proposed changes
• Setting clear goals and expectations
• Building infection prevention into physician training
• Sharing national benchmarks and local data with physicians
• Providing service line and physician level feedback on progress
For more information on these strategies or to learn more about the Safe Table Learning Collaborative on Eliminating Hospital Acquired Infections, contact Cat Ernevad at cate@wsha.org or (206) 577-1820. (Cat Ernevad, cate@wsha.org)
The Joint Commission Issues Sentinel Event Alert on Preventing Maternal Death
The Joint Commission issued its first sentinel event alert for 2010 on preventing maternal death. The alert highlights maternal death in the U.S. as a serious problem to which hospitals and caregivers should pay more attention. Maternal death is defined as death that occurs within 42 days of birth or termination of pregnancy. The National Center for Health Statistics of the Centers for Disease Control and Prevention said that 13.3 mothers died per 100,000 live births in 2006, an increase from earlier years.
The Joint Commission recommends that hospitals comply with PC.02.01.19, which is the new location of the 2009 National Patient Safety Goal requiring that hospital staff recognize and respond to changes in patients’ conditions. In addition, the alert provides the following specific actions:
• Educate caregivers to inform their female patients with underlying medical conditions (such as high blood pressure, diabetes or morbid obesity) that if they become pregnant, they are putting their bodies at even greater risk. Additionally, caregivers should offer contraception and information about where to find preconceptual counseling.
• Identify specific protocols for how to handle changes in a pregnant woman’s vital signs, specifically for conditions such as hemorrhage and pre-eclampsia.
• Ensure that ED staff are aware that any woman who is admitted may be pregnant, whether or not she appears or claims to be. If staff are aware a woman is pregnant, they may prescribe different care.
• Refer pregnant women who have high risk conditions to experienced prenatal care providers.
• Ensure pneumatic compression devices are available for women undergoing a Cesarean section that are at risk for a pulmonary embolism. Pregnancy is in itself a risk factor for pulmonary embolism and venous thromboembolism.
• Evaluate patients at risk for thromboembolism for the use of low molecular weight heparin for care after delivery.
The entire sentinel event alert can be found on The Joint Commission web site. (Carol Wagner, carolw@wsha.org)
FDA Extends Deadline to Transition from Steris
The FDA is extending the time period for transition from Steris Corporation’s modified System 1 processor (SS1) to legally-marketed alternative devices. As the FDA announced in its December 3, 2009 notice, the Agency has not approved or cleared the SS1 for its labeled claims. Steris Corporation has chosen not to seek FDA clearance of this device and, therefore, its use should be discontinued as soon as possible. The extension is in response to health care provider concerns that a three to six month transition period could adversely affect patient care. Additional information can be found on the FDA website. Additional questions can be directed to Dr. Candace McManus at the FDA’s Office of Compliance at candace.mcmanus@fda.hhs.gov or (877) 260-3731. (Carol Wagner, carolw@wsha.org)
Centers for Medicare and Medicaid Services Respond to Issues with QualityNet
A recent memo from CMS acknowledged a large number of questions about the QualityNet system’s Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. To deal with the backlog, CMS is making changes to the information technology system to improve functionality and question response times. However, any unanswered questions submitted before November 15, 2009 were deleted from the system and will need to be resubmitted. CMS expects the problems with the system to be resolved by March 1. In the meantime, the agency has also posted several new Frequently Asked Questions documents to help hospitals. Additional information is available through the QualityNet Help Desk at qnetsupport@sdps.org or (866) 288-8912, (7 am to 7 pm Central Time, Monday through Friday). (Carol Wagner, carolw@wsha.org)
Upcoming Events
Safe Table Web Conference – Eliminating Infections
Topic: Patient Safety Culture Survey
Wednesday, February 17, 2010
9:00 – 10:00 a.m.
Safe Table Web Conference – Patient Safety Practices
Wednesday, March 3, 2010
9:00 – 10:00 a.m.
Safe Table – Eliminating Infections (In Person Meeting)
Wednesday, March 24, 2010
9:00 a.m. – 2:30 p.m.
Safe Tables are available exclusively to WSHA member hospitals. A full list of 2010 Safe Table events is posted on the WSHA website. For more information or to register for Safe Table events, please contact Janet Van Dyke at janetv@wsha.org or (206) 577-1839.