Quality Quarterly: June 2009

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Quality Quarterly: June 2009

Top News!

The federal Agency for Healthcare Research and Quality (AHRQ) released a report this week which showed the quality of hospital care is improving at an annual rate of almost three percent, according to the National Healthcare Quality Report 2008. View the report at http://www.ahrq.gov/qual/nhqr08/nhqr08.pdf

Overall quality improvements in hospitals led all sectors. Others, such as ambulatory care settings, did not improve as much.

CMS Update:

Medicare Secondary Payer laws: New compliance requirement for reporting of claims involving Medicare beneficiaries if you are a self-insured entity, workers compensation insurer, liability insurer or no fault insurer.

Medicare requires any other insurance that has an obligation to pay a beneficiary's medical bills to pay first: i.e. Medicare now considers itself to be a "secondary payer". Medicare is the secondary payer of claims when no-fault or liability insurance is available as the primary payer, even though state law or the insurance plan or policy states that its benefits are secondary to Medicare or otherwise excludes/limits its payments if the injured party is also entitled to Medicare benefits.

Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment.)

What does this mean for hospitals?

Primary payers can be workers compensation insurers, liability insurers, self-insured companies and no fault insurers.
Medicare expects liability insurers and self-insured entities to pay first for bills arising out of a claim.
Providers are to attempt to identify other payers for Medicare– e.g. if the patient has a trauma as an admitting diagnosis– and bill conditionally.
Medicare's lien and right to reimbursement comes into existence any time a Medicare beneficiary receives funds for medical expenses from another payer – settlement, judgment, partial settlement or forgiving a bill.
Medicare determines what portion of the settlement is for [its] medical bills and what is pain and suffering. One cannot escape reimbursement by labeling payments as pain and suffering.

How do we report?

In order to report, one must register as a Responsible Reporting Entities (RRE).
Registration must be completed by the end of June 2009
RRE registration and reporting is a highly technical process which requires more than 100 data elements to be transmitted to CMS in CMS's own electronic format; registration must occur before reporting can occur and reporting will occur on a timeline assigned by CMS.
All payments made after July 1, 2009 must be reported – regardless of the date of the injury or the date agreement was reached regarding payment.
We begin actual reporting October 1, 2009, but must report back to July 1, 2009 for all events/injuries that occurred on or after December 5, 1980
Penalties for non-compliance are $1,000 per day, per claimant.
Failure to report will result in fines.

To read more, go to:

WHO Surgical Checklist

Update on implementation status: As you may have heard, the Oregon Node (six organizations that have helped Oregon hospitals with the Institute for Healthcare Improvement (IHI) interventions include: OAHHS, Acumentra, Patient Safety Commission, CareOregon, the OMA, and the ONA) are collaborating to support the IHI's call for a Sprint to accelerate progress toward testing and full implementation of the World Health Organization Surgical Safety Checklist. The checklist has three parts: Sign In – Brief - Debrief and adds an element of teamwork to the universal protocol currently in use.

Improving teamwork and communication is one of the main goals for using a checklist. Many hospitals in the US are already doing most of the items on the list but not reviewing them as a team. If there is no designated point when these items are reviewed, it is common to find that they are verified most of the time, but not every time, i.e., not reliably. The results of the WHO pilot study appear to confirm the conclusions of a number of earlier studies that indicate preoperative team introductions and briefings and postoperative debriefings contribute to improved processes and outcomes.

Recently, hospitals were surveyed to check in about their pilot experience. At this time, over half of Oregon hospitals have tested the surgical checklist in their own hospitals. The feedback is being collated to help other hospitals overcome implementation challenges.

How can I use the WHO Surgical Safety Checklist and meet the Joint Commission Universal Protocol requirements for 2009?

Your organization might consider using the version of the Checklist the WHO team adapted for use in the US (found on the IHI.org website) that includes some common elements, such as SCIP. For the most part, the US version aligns with the Joint Commission Universal Protocol. There are two differences to note:

The Joint Commission Universal Protocol includes documents, blood products, implants and special equipment in the pre-op verification. These are not noted on the WHO Checklist. They could, however, substitute for or be added to the item for pulse oximeter. (Please consult the detailed instructions that accompany the US Checklist for details.)
The Joint Commission Universal Protocol applies to non-surgical procedures that do not involve anesthesia, such as central line insertion. The WHO Checklist is designed for surgical procedures in the operating room and, thus, might not be the appropriate tool for those other procedures; however, a few items might be extrapolated to a smaller checklist you could create for such instances.

The WHO Surgical Safety Checklist was designed as a tool to improve communication and the items included are considered the most widely applicable in all surgical settings (not just those in the US). For more details on use of the Checklist and the Universal Protocols, read the Joint Commission February 2009 newsletter.

For answers to other Frequently Asked Questions about the WHO Surgical Safety Checklist, please visit the IHI.org website: http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm.

Joint Commission News

National Time Out Day is June 17

National Time Out Day on June 17 aims to raise awareness of the importance of requiring the entire surgical team to pause before all invasive procedures to communicate as a group and confirm key information about the patient and procedure to help prevent errors from occurring. Sponsored by the Association of periOperative Registered Nurses, NTOD supports The Joint Commission's Universal Protocol, which urges that a "time out" precede every surgical procedure to verify the correct patient information prior to incision. NTOD is a collaboration among AORN, The Joint Commission, the American Nurses Association, The American Association for Accreditation of Ambulatory Surgical Facilities, and the Council on Surgical & Perioperative Safety. This year's event includes a video contest in which individuals and facilities are invited to submit a tape of their surgical team's Time Out to be considered for use with the AORN new Correct Site Surgical Took Kit that will be available on the AORN Web site by June 17. The AORN has also developed a poster to remind health care providers that "Every Day is Time Out Day." The poster is available on the AORN Web site or by calling (800) 755-2676, extension 1. For more information about NTOD or the video contest, visit the AORN Web site.

Joint Commission & partners release "Measuring Hand Hygiene Adherence" monograph

Preventing infections is critical to patient safety. Effective hand hygiene practices have long been recognized as the most important way to reduce the transmission of potentially deadly germs in health care settings. To help health care organizations target their efforts in measuring hygiene performance, The Joint Commission released "Measuring Hand Hygiene Adherence: Overcoming the Challenges."

The monograph is the result of two-year collaboration with major infection prevention and control leadership organizations in the United States and abroad to identify effective approaches for measuring adherence to hand hygiene guidelines in health care organizations. In addition to The Joint Commission, participating organizations include the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO) World Alliance for patient Safety, the Institute for Healthcare Improvement (IHI) and the National Foundation for Infectious Diseases (NFID).

The monograph provides a framework to help health care workers make necessary decisions about when, why and how to measure compliance with hand hygiene. The monograph systematically reviews the strengths and weaknesses of commonly used approaches. Examples of measurement methods and tools in the monograph, which also includes references to evidence-based guidelines and published literature, were submitted by organizations through the Consensus Measurement in Hand Hygiene project. The project was supported by an unrestricted educational grant from GOJO Industries, Akron, Ohio. The monograph is available on The Joint Commission's Web site at:

http://www.jointcommission.org/PatientSafety/InfectionControl/hh_monograph.htm

Field review of potential revisions to NPSGs and Universal Protocol

Potential revisions to the National Patient Safety Goals and the Universal Protocol are available for field review through June 23, 2009. The success of the Standards Improvement Initiative (SII) demonstrated a way to thoroughly review the current NPSGs. The SII process will be used to clarify language and make sure that the NPSGs and Universal Protocol are relevant to the settings in which they apply. As a result of the extensive review that the NPSGs and Universal Protocol are undergoing this year, there will be no new NPSGs developed for 2010. To access the field review, visit the Web site.

Joint Commission to improve top four challenging requirements

The Joint Commission is currently conducting an extensive review of its National Patient Safety Goals, as reported in the December 2008 issue of This Month (at last month's Joint Commission meeting). The purpose of the review is to identify how to increase the value of the requirements in helping organizations provide safe, quality care. According to recent field input on the NPSGs and the standards, the four most challenging requirements are:

NPSG 8 (medication reconciliation)
The Universal Protocol, in particular, the site marking requirement
NPSG.02.03.01 (reporting of critical tests, results and values)
Standard PI.04.01.01 (staffing effectiveness)

Please contact Diane Waldo at 503-479-6016 or email diane.waldo@oahhs.org with any questions about these topics.

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