Archive for October, 2008

Gotta Keep the (Healthcare) Customer Satisfied

October 31st, 2008 by Melanie Matthews

Rating the cleanliness of sleeping areas and bathrooms and nighttime noise levels may seem the stuff of hotel satisfaction surveys. In fact, hospital patients across the country are asked to evaluate these areas — along with pain management, communication and discharge processes — as part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Consumers can access patient satisfaction reviews from this national, standardized survey of hospital patient experiences at the Hospital Compare Web site.

And if you believe that clinical excellence is the one true path to improved care delivery, think again. A new study of HCAHPS data has determined a direct link between patient satisfaction and the quality of care, suggesting that the aims of providing patient-centered care and ensuring high clinical standards can be met simultaneously.

In a study funded by The Commonwealth Fund and the Robert Wood Johnson Foundation, researchers from Harvard School of Public Health assessed the performance of 2,429 hospitals across multiple domains of patients’ experiences—including communication, quality of nursing services and pain management—comparing HCAHPS patient survey data from July 2006 to July 2007 with data from the Hospital Quality Alliance and the American Hospital Association.

They found that patients have moderately high levels of satisfaction with their care, and that the quality of clinical care and certain hospital characteristics, such as a higher ratio of nurses to patient-days, were associated with greater patient satisfaction.

Key areas for improvement: nursing care, communication about medications, pain control, and provision of clear discharge instructions.

Other key findings:

  • On average, 63 percent of patients responding to the HCAHPS survey gave their care a high overall rating (9 or 10, on a scale of 0 to 10); another 26 percent rated care as 7 or 8. Only 11 percent rated care as 6 or lower.
  • Sixty-seven percent of patients said they would definitely recommend the hospital in which they received care, and another 27 percent said they would probably recommend the hospital.
  • The ratio of nurses to patient-days was associated with patients’ satisfaction: a larger percentage of patients in hospitals placing in the top quartile of nurses-to-patient-days ratio gave their hospital a 9 or 10 rating, compared with patients in bottom-quartile hospitals (66% vs. 61%).
  • Fewer patients in for-profit hospitals gave a 9 or 10 rating than patients in either private or public nonprofit hospitals (59% vs. 65% and 65%, respectively).
  • Patients’ satisfaction with care was associated with quality of clinical care for four conditions: acute myocardial infarction, congestive heart failure, pneumonia, and prevention of surgical complications.
  • Patients’ satisfaction ranged widely across regions: 72 percent of patients in Birmingham, Ala., gave 9 or 10 ratings, compared with 50 percent of patients in East Long Island, N.Y.
  • Comorbidities & Mental Health

    October 30th, 2008 by Melanie Matthews

    The term ‘comorbidities’ is defined as the presence of one or more disorders or diseases, but rarely do we associate it with one or more mental diseases. But maybe we should. Mental health is getting more national play evidenced by the mandate for mental healthcare parity signed by President Bush earlier this month. This week’s DM Update highlights emerging issues in this area: One study links COPD patients with greater risks of depression, and a care management thought leader notes that a large portion of chronically ill patients in the Medicaid population also suffer from depression and schizophrenia.

    Also, don’t miss your last chance to take HIN’s monthly survey on depression and DM by October 31, and receive a free executive summary of results compiled from more than 200 healthcare organizations.

    Has Obesity Inertia Set In?

    October 27th, 2008 by Melanie Matthews

    We have been talking about the obesity epidemic for so long that perhaps “obesity inertia” has set in. Nearly every day a new survey documents another health risk faced by the obese — from osteoarthritis of the knee in the elderly to pelvic disorders in women — yet the recent F as in Fat: How Obesity Policies Are Failing in America, 2008 report from the Trust for America’s Health and the Robert Wood Johnson Foundation indicates little progress at the state level:

    Adult obesity rates rose in 37 states this year, for the second consecutive year in 24 states and for a third consecutive year in 19 states. No state saw a decrease. Though many promising policies have emerged to promote physical activity and good nutrition in communities, the report concludes that they are not being adopted or implemented at levels needed to turn around this health crisis.

    On a more positive note, more than half of the 287 healthcare organizations that took our recent survey on obesity management and prevention efforts have initiatives afoot, with another 25 percent readying new programs for the coming year. This week’s featured white paper, Obesity and Weight Management: Weighing in on the Growing Epidemic, highlights these initiatives, including the latest reimbursement trends for obesity-related care.

    Obesity is a well-documented comorbidity — almost 80 percent of obese adults also have diabetes, dyslipidemia, coronary-artery disease, hypertension, gallbladder disease or osteoarthritis. But when the bulk of the office visit is directed at managing chronic illness, depression in this population may be overlooked. Depression management programs can help bridge this care gap. Five days remain for you to join the more than 200 healthcare organizations that have taken our October e-survey on depression DM programs. Complete the survey and you will receive an e-summary of the compiled results.

    HHS Funds Healthcare Technology for Health Centers

    October 20th, 2008 by Melanie Matthews

    In a featured Healthcare Business Weekly Update story this week, HHS is making $18.9 million available to health centers to adopt EHRs and other HIT innovations, including e-prescribing, health information exchanges, data warehouses and interoperability with outside partners such as state immunization registries and hospitals.

    Providers not ready to adopt an EHR might consider using a population-based registry as a start. In a recent HIN e-survey, more than half of 159 responding healthcare organizations told us they use registries to improve quality and efficiency of care and boost prevention efforts. UnitedHealthcare Senior Vice President of Clinical Innovations Dawn Bazarko, who spoke with us recently about UnitedHealthcare’s medical home initiative, said that an EHR is not required at this time for the most basic medical home. However, she added, “We also believe that the presence of a high-functioning well-utilized registry is very critical and oftentimes is not a component of an EHR, so we reinforce our practice sites to first start with a good population-based registry.”

    Details on how survey respondents are using paper, spreadsheet and electronic registries to better the health status of their populations are available in a complimentary white paper, Patient Registries: The Track to Better Quality Healthcare.

    Impact of Unhealthy Economy on Health Coaching, Mental Health

    October 15th, 2008 by Melanie Matthews

    The unhealthy economy can make people sicker. Rising stress levels can exacerbate such conditions as high blood pressure and cardiac conditions, weaken the immune system, disturb sleep patterns and drive individuals to revert to unhealthy lifestyles.

    Health coaches, behavioral health teams and primary care providers are being confronted with an unprecedented level of stress due to economic issues among their patients. How is your organization addressing these concerns?

    Tell us how your organization is serving your patients and members in this economic climate and we’ll share the results with you on the strategies that organizations are using in this environment.

    Impact of Unhealthy Economy on Health Coaching, Mental Health

    October 15th, 2008 by Melanie Matthews

    The unhealthy economy can make people sicker. Rising stress levels can exacerbate such conditions as high blood pressure and cardiac conditions, weaken the immune system, disturb sleep patterns and drive individuals to revert to unhealthy lifestyles.

    Health coaches, behavioral health teams and primary care providers are being confronted with an unprecedented level of stress due to economic issues among their patients. How is your organization addressing these concerns?

    Tell us how your organization is serving your patients and members in this economic climate and we’ll share the results with you on the strategies that organizations are using in this environment.

    Wellness: Crucial Component to DM

    October 13th, 2008 by Melanie Matthews

    Disease management is as much about promoting wellness and preventing disease as it is about treating existing conditions. This week’s DM Update looks at North Carolina’s latest smoking cessation program, as well as the American Heart Association’s focus on health and fitness in the workplace.

    The Economy and Stress: Women Bear Brunt

    October 13th, 2008 by Melanie Matthews

    Given the alarming state of our nation’s economy, there are few surprises in the newly released 2008 Stress in America survey from the American Psychological Association, a featured story this week. The survey found that the economy is a significant stressor for eight out of 10 Americans and that women are more stressed than men about money (83 percent vs. 78 percent), the economy (84 percent vs. 75 percent), job stability (57 percent vs. 55 percent), housing costs (66 percent vs. 58 percent) and health problems affecting their families (70 percent vs. 63 percent).

    It doesn’t take a crystal ball to predict more stress-related health conditions in the months ahead. That’s why the timing of the new mental health parity bill is fortuitous. The bill, which mandates equal coverage for mental and physical conditions by January 2010, was a surprise component of the economic bailout bill passed earlier this month. The bill reinforces or adds to existing state parity laws in Minnesota and more than 40 other states to ensure that payors already offering coverage for mental illness, addiction and other behavioral health conditions will reimburse on the same terms as medical and surgical conditions.

    This law could have implications for current and future behavioral health offerings, including those for depression management. Take our e-survey on depression and disease management programs and receive a complimentary e-summary of the results in November to help you with program planning in the year to come.

    Bailout Bill Mandates Mental Healthcare Parity

    October 7th, 2008 by Melanie Matthews

    Built into the economic bailout bill signed last Friday by President Bush is a mandate for mental healthcare parity. By January 1, 2010, the one-third of all Americans who suffer from depression, addiction, eating disorders and other mental health conditions can expect better insurance coverage for their treatments — payments on a par with those for physical conditions. For the first time, a federal law requires equal coverage of mental and physical illnesses.

    Yesterday’s New York Times provided more details on the reimbursement changes, which will require health plans, employers and providers to bring co-payments, deductibles and reimbursement for mental health conditions in line with those for physical illnesses by January 1, 2010:

    Most employers and group health plans provide less coverage for mental healthcare than for the treatment of physical conditions like cancer, heart disease or broken bones. They will need to adjust their benefits to comply with the new law, which requires equivalence, or parity, in the coverage.

    For decades, insurers have set higher co-payments and deductibles and stricter limits on treatment for addiction and mental illnesses.

    Federal officials said the law would improve coverage for 113 million people, including 82 million in employer-sponsored plans that are not subject to state regulation. The effective date, for most health plans, will be Jan. 1, 2010.

    The Congressional Budget Office estimates that the new requirement will increase premiums by an average of about two-tenths of 1 percent. Businesses with 50 or fewer employees are exempt.

    The goal of mental health parity once seemed politically unrealistic but gained widespread support for several reasons:

  • Researchers have found biological causes and effective treatments for numerous mental illnesses.
  • A number of companies now specialize in managing mental health benefits, making the costs to insurers and employers more affordable. The law allows these companies to continue managing benefits.
  • Employers have found that productivity tends to increase after workers are treated for mental illnesses and drug or alcohol dependence. Such treatments can reduce the number of lost work days.
  • The stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems.
  • Parity has proved workable when tried at the state level and in the health insurance program for federal employees, including members of Congress.
  • Eight Steps to a Culture of Safety

    October 6th, 2008 by Melanie Matthews

    Leanne Huminski, chief nursing officer of McLeod Regional Medical Center, shares the eight steps to creating a culture of safety that reduced adverse medical events at McLeod by 90 percent and greatly simplified the medication reconciliation process.

    1. Develop a Vision
    This is our vision for medication safety: We are perfecting the medication delivery system to be safe for every patient, every time, while making it easy for the caregiver to do the right thing, and impossible to do the wrong thing. You do this by building reliability into your system. I was on the committee that helped to develop this vision statement. I initially had a problem with the word “perfecting,” because I thought “perfecting” was unrealistic and we should set a less lofty goal. However, our administrative leader suggested that this is a vision, and we have to look at where we would like to be when we’ve completed the process. So, “perfecting” stayed in the vision statement.

    2. Realize It Can’t Happen Overnight
    Words matter. For example, our medication committee at that time was called the Adverse Drug Event Committee. That has a very negative tone. We changed the name of our committee to the Medication Safety Committee, which has a more positive tone. We also began to use words such as “saves” instead of “errors” when a nurse avoided a mistake due to the bar-coded medication system. Positive words matter.

    3. Involve Leaders in the Process
    That means leaders attend meetings, provide necessary resources, and remove roadblocks that stand in the way of improving the system. It’s not effective to have leadership that mandates goals but never participates in the process. Leadership even participated in developing our vision statement.
    Our group also studied together. When a group studies together they develop a common language and a common ground to develop processes and improvements.

    4. Engage and Empower the Staff
    \While leadership sets the tone, engaging the staff in the work is where you gain the biggest profit. We also worked to develop a “no blame” culture. However, the pendulum swung a little too far in the other direction. Therefore, we had to swing it back again and communicate that “no blame” does not mean “no responsibility.”

    When you’re implementing a culture change, remember that there are a wide variety of people involved in the process, and they’re going to have many different attitudes toward change. For example, when we implemented the Computerized Position Order Entry (CPOE), the nurse saw herself as the gatekeeper. She got nervous when the orders went directly to the system rather than her having an opportunity to manage them. Therefore, we had to address that issue with our nurses. The unit secretaries were concerned that they’d lose their jobs. The physicians also had to be encouraged because they had to learn to trust that the system would work and send their orders to the right place without error. Remember that physicians have a key role. It’s important to keep the medical staff informed and get their input as you’re designing your system.

    5. Develop a Sense of Urgency
    We tell a story about medication reconciliation, where a patient went home on hypertensives. They then came back into the emergency room with very low blood pressure — they had fainted. The physicians made adjustments to the medications, and then the patient was discharged to resume home meds. Of course, the patient subsequently came back to the hospital. We use that story to engage and develop a sense of urgency with our staff.

    6. Test New Ideas Before Full Rollout

    Pilot or conduct small tests prior to rolling something out system-wide. This helps you to refine and eliminate the bugs. It’s also important to celebrate successes. Look back at how far you’ve come rather than focus on how far you still have to go. Have a little party or a dessert day to celebrate that you’ve been recognized as a safe hospital. We produced a movie, and all of the staff attended the movie, had popcorn and received a T-shirt to celebrate our recognition as a safe hospital.

    7. Be Alert for Sabotage and Workarounds
    Understand that there will be early adopters, late adopters, and people that don’t want to adopt at all. Watch out for people developing “workarounds” in your safety improvement system. Encourage all of the staff — be it at the bedside, peer-to-peer encouragement, the manager of the unit, vice-president, or the administrator walking around — to look for this.

    8. Communicate the Change Vision
    We start our day with safety rounds. The administrative team visits patients in different areas of the hospital. Throughout a two-week period, we visit all areas of the hospital. Encourage the staff. We talk to the patients, delivering newspapers and have conversations with them. Also, visit organizations outside of healthcare to see what they’re doing. For example, we took a trip to the Firestone plant, which received the governor’s quality award for safety. We went to see how they communicate safety, and we learned some lessons. For example, display your safety warnings at the point of use, rather than in a newsletter or some other communication. Steal shamelessly!

    You cannot over-communicate. John Kotter says to communicate eight times in eight ways. We do that. We post the message, speak the message, publish the message and use a MAC memo, which is our bar-coded medication administration system. We developed a communication that each time we roll out something new, we publish a MAC memo and tape it to all of the computers so the staff gets the information. I also publish a nursing newsletter. Once you have communicated something, you must reinforce the message over and over again. The year after we offered “Medication 101,” we followed up with another educational offering called “Spring into Safety.” “Spring into Safety” emphasized things that we wanted to reinforce with the medication delivery system. This year we’ll add another medication safety component to our annual training.