During the public comment period, a citizen suggested that the County save on health care costs by having all employees and hospital Board members go to CCHHS for their care.
Interim Chief Nursing Officer Tamara Russell reported that CCHHS budgeted for 1622 nurses in 2012, and ended the year with 229 vacancies, almost all at Stroger, including in the ER. Thus this year’s budget calls for nearly 100 fewer nurses, with Russell currently determining which vacancies have priority. Chairman Edward Michael asked if the Medicaid waiver would produce a nursing shortage; Russell said no, that last year’s budgeted number of nurses was artificially high. Commr. Velazquez asked whether Russell was recruiting for bilingual nurses, and on learning she is not (CCHHS uses the Language Lines translation service instead) said at least some bilingualism should be required. Russell replied that she’s currently evaluating where in the system the need for Spanish speakers is greatest. Nursing will concentrate on four quality areas in the coming year: communication between nurses during shift change, or "handoff"; medical administration (labeling of drugs and supplies); implementing the universal protocol (a standardized checklist for patient care); and reducing hospital-acquired conditions, especially urinary tract infections produced by catheters.
Interim Director of Quality Dr. Krisha Das reported that accreditation submissions to the Joint Commission would be completed by year-end, and that the recommended changes in practice have already been made. CCHHS is collaborating with the National Association of Public Hospitals in developing a quality protocol for safety-net hospitals requested by the Center for Medicare and Medicaid Services.
Nurse-led teams at Stroger coached by an outside expert (Ed Mendez RN/MPH) are developing systems to reduce pressure ulcers and falls, while Provident addresses medication errors and various thromboses. These teams are part of CCHHS’s participation in the national Hospital Engagement Network focused on safety, which provides training and technical assistance and measures outcomes. The system, "Reliability for Quality and Safety," seeks to prevent harms in nine specific areas. American health care currently is not reliable; acquired infections affect 5-10% of patients nationally, while 1.5 million are injured annually by medication errors. To become an HRO (High Reliability Organization), a health care system needs leadership, a culture of safety (meaning participants willing to identify problems), and good processes. Leadership includes the Board’s spending 25% of its time on quality issues, basing executive compensation on safety results, and continuous monitoring of safety outcomes.
Using a handout, Mendez explained that failure in 20% of cases is considered "chaotic," so CCHHS’s 60% compliance rate in washing hands demonstrates reliability even lower than Level 1. Level 1 systems use only vigilance and hard work to assure safe outcomes. Level 2 reliability, a 95% success rating, depends on reliability engineering, including redundancy, checklists, and having the desired action be the default setting, while Level 3 (99%) required sophisticated behavioral designs such as "dangerous until proven safe" or "any system participant is authorized to interrupt the process when safety is threatened."
Michael asked if the proposed goals (40% reduction in infections, 20% in readmissions) were realistic. Mendez replied they were reasonable over two years: a 10% reduction in harm every 6 months was achievable. Michael, noting that the #1 cause of preventable deaths is failure to follow procedures, argued that reliability improvement will require simplification of processes; "if compliance is burdensome, no amount of training will work." He also pointed out that a shortage of nurses limits the amount of time they can spend improving procedures because they’re constantly at bedsides.
Michael then turned to CCHHS’s own goals. Averaging results for patient satisfaction, hospital readmission and hospital-acquired infections, the system serves 61% of patients properly. 83% of the nation’s hospitals do better than this. The staff recommends prioritizing hospital cleanliness, nurse communication skills and ER wait times but Michael asked if these were the right three areas to produce significant overall improvement. As for readmission, CCHHS doesn’t yet have the necessary data, and once again Michael pointed out that readmission could be driven by factors beyond the hospital’s control. But Dr. Das pointed out that readmission data are drawn from a Medicaid population, so all the hospitals being compared are dealing with poor people and with consequences of poverty beyond their control. CCHHS will begin generating its own readmission data next month.
Michael once again urged collecting only a limited number of data points to avoid confusion, but Dr. Das reminded him that the Federal government requires the hospital to keep track of all these data, so it’s a matter of choosing to pay attention to the most relevant. Mendez reminded the group of the need to evaluate the whole system because most patients are seen outside the hospital; Michael assured him the Public Health Strategic Plan addressed that issue. Likewise Chief Medical Officer Dr. Mason noted the importance of distinguishing outcomes in the public health system from those in the ambulatory care setting from those in the hospital itself. Das pointed out that the Medicaid waiver requires the system to monitor and assure quality of care provided by contractors as well as employees.
The Board then received the Department of Public Health Strategic Plan. Michael noted that the Department is part of the state public health system; the Department on its own might have chosen other areas of concentration but in conjunction with the state system has chosen access, teen pregnancy, youth violence and cardiovascular health. DPH will create multidisciplinary teams including outside agencies to measure and improve performance in these areas. Stroger Chief Medical Officer Dr. Goldberg reported that the hospital must prepare for a 2013 site visit to renew its National Cancer Institute designation as a certified cancer hospital. Stroger staff is working on reducing times to treatment and increasing reliability of data entry.
--Submitted by Kelly Kleiman
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