How UCSF Reduced Heart Failure Readmissions by 46%

The Commonwealth Fund released a case study describing how researchers at University of California San Francisco Medical Center worked to refine transition methods to reduce heart failure readmissions in elderly patients by 46 percent within 30 days of discharge.

The study, begun in 2008 with funding from the Gordon and Betty Moore Foundation, incorporated knowledge gained from the Institute for Healthcare Improvement’s Transforming Care at the Bedside Initiative.  Specifically, UCSF carefully adapted and implemented IHI’s framework for creating an ideal transition from hospital to home as the foundation for its highly successful effort to curb heart failure readmissions for Medicare patients ages 65 and older.

In this program, UCSF researchers identified and focused on four components deemed critical for successful heart failure transitions:

1.      Enhanced Admission Assessment for Post-Discharge Needs

Floor nurses worked to perform timely, thorough and efficient assessments of patients’ needs for rehabilitation, therapy, home care, dietician consultation, social work intervention or spiritual care.  In order to tailor interventions to patients’ individual needs, nurses tracked 5 specified risk factors including whether or not the patient:

  • had a primary care physician;
  • was taking 10 or more medications;
  • had support at home;
  • had poor health literacy; or
  • had been hospitalized in the past six months

2.      Enhanced teaching and learning

Researchers worked to develop new tools that would increase health literacy and help patients recognize deterioration in their condition before emergency care became necessary.  Initially, this involved producing materials in more languages and using wording that might be easier for patients to understand and remember.  Care givers staged group and individual learning opportunities for patients and families and discovered that offering multiple short teaching sessions during a patient’s stay prevented information overload. Most importantly, hospital staff worked to develop an overall culture of teaching where “teach-back” techniques became a fundamental step in reinforcing four critical areas of focus for heart failure patients:

  • Using diuretic meds
  • Limiting salt intake
  • Monitoring and reporting weight gain
  • Calling the doctor when change occurs

3.      Postacute Care Follow-Up

During the study, it became apparent that many patients did not understand the significance and severity of a heart failure diagnosis; so, an emphasis on the importance of follow-up care was needed. Staff worked diligently to schedule followup physician visits before patients were discharged which often involved enhancing relationships with primary care physicians in the community. UCSF also worked to increase follow-up care for high-risk patients through clinic visits with cardiologists, PCPs and nurse practitioners who could review medication instructions, assess patient knowledge and provide even more education if needed. Staff also called patients within 7 days of discharge to check in and again at two weeks for reinforcement of teaching topics.

4.      Patient and Family-Centered Handoff Communication

The study’s final component involved enhancing communication with postacute care providers and the development of a more formal patient handoff procedure through which patient-specific follow-up concerns could be addressed. Researchers found that the most common postacute care concern revolved around medication reconciliation, and they found email to be an effective way of cross-coordinating patient care among care-givers and facilities.

The study’s results surpassed the researcher’s original goal of a 30 percent reduction in all-cause heart failure readmissions.  In fact, their efforts achieved a 46 percent reduction in the 30-day readmission rate, from 24 percent in 2009 to 13 percent in 2011, and a 35 percent reduction in the 90-day all-cause heart failure readmission rate.  USCF is now expanding its program to encompass all adult heart failure patients.

To view the full case study and associated teaching tools, click here.

12 Most Read Healthcare Blog Posts of 2012

2012 was a busy year for hospitals and healthcare professionals on many fronts. But we’ve crunched the numbers and aggregated a list of our top 12 stories that were most important to you in 2012.

  1. Checklist Cuts HF Readmissions from 20% to 2% – New research, conducted at St. Joseph Mercy Oakland Hospital and presented at the American College of Cardiology’s 61st Annual Scientific Session, has shown that use of a 27-question, heart failure discharge checklist reduced the  30-day readmission rate of a cardiac event from 20 percent to only 2 percent.
  2. CMS Updates Performance Measures for FY 2013 – The Centers for Medicare & Medicaid Services (CMS) issued a final rule for Medicare policy and rate changes for inpatient stays in acute-care hospitals under the Inpatient Prospective Payment System (IPPS) and for facilities using the Long-Term Care Hospitals (LTCH) Prospective Payment System (PPS) for FY 2013.
  3.  TJC To Increase 2014 Performance Measure Requirements – The Joint Commission announced that it will increase performance data collection requirements for general medical/surgical hospitals to six measure sets beginning January 1, 2014, according to an article published in its December issue of The Joint Commission Perspectives®.
  4.  CMS Releases Meaningful Use E-Specs and Tools – The Centers for Medicare & Medicaid Services (CMS) has released multiple resources intended to assist healthcare providers in demonstrating meaningful use of electronic health records (EHRs) by 2014.
  5.  Study: Soap, Swab Use Cuts Bloodstream Infections by 44% – Health Leaders Media has reported that daily implementation of a practice known as universal decolonization reduced bloodstream infections, including methicillin-resistant Staphylococcus aureus (MRSA), by 44 percent in a recent study conducted by researchers from Harvard, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention.
  6.  Healthcare Organizations Prepare to Show “Face of Quality” – Healthcare organizations across the country are gearing up to celebrate National Healthcare Quality Week, October 14 – 20, with the purpose of highlighting “The Face of Quality” within their communities.
  7.  CMS Adds CLABSI Data to Hospital Compare – The Center for Medicare & Medicaid Services on Wednesday added data provided by hospitals on central line-associated bloodstream infections to the Department of Health & Human Services’ Hospital Compare site.
  8.  Med Home Core Measures Introduced – The Commonwealth Fund released a new brief this week detailing recommendations made by the Patient-Centered Medical Home Evaluators’ Collaborative for an initial set of standardized measures for evaluating medical home initiatives.
  9. Study Shows Most Common ICU Diagnosis Errors – One in four ICU patient deaths occurs due to misdiagnosis according to a study implemented by Johns Hopkins University School of Medicine and published last month by BMJ Quality.  The study linked the findings of 31 international papers that examined 5,863 autopsies performed in 12 countries including the United States, Brazil, France, Germany and Slovenia.
  10.  CMS Updates PCP, ERSD and Home Health Rules – The Centers for Medicare & Medicaid Services recently published final rules that update the reimbursement rate for primary care providers as well as the prospective payment systems for home health and end-stage renal disease.
  11. Nationwide Celebration Illuminates “Face of Quality” – Healthcare organizations nationwide are celebrating Healthcare Quality Week (October 14 -20, 2012) with planned activities and events highlighting the significant contribution of healthcare quality and patient safety professionals.
  12. USP Sets Standards for Patient-Centered Medicine Labels – The U.S. Pharmacopeial Convention (USP) has released a new set of standards for the way information and instructions are arranged and worded on prescription drug labels to make them easier for patients to read and understand.


3 New Resources to Help You Curb Disparities

The Robert Wood Johnson Foundation (RWJF) released several helpful resources aimed at reducing disparities in healthcare.  The Roadmap to Reduce Disparities takes the form of a six-step infographic aiming to perpetuate a thoughtful approach to achieving equity by integrating disparity reduction into all healthcare quality improvement efforts.

In partnership with the University of Chicago, RWJF has also made available the Finding Answers Intervention Research (FAIR) Database. The FAIR Database is a collection of 388 categorized journal article summaries from 11 systematic reviews of racial and ethnic health disparities intervention literature.  Article topics include: asthma, cervical cancer, colorectal cancer (CRC), HIV prevention, prostate cancer, cardiovascular disease (CVD), depression, diabetes mellitus, breast cancer, cultural leverage and pay-for-performance incentives.

In addition, collaborators are also working to direct people interested in tracking up-to-the-minute dialogue regarding the reduction of racial and ethical disparities to the Finding Answers Twitter Feed.

How 100 NICUs Reduced CLABSIs By 58%

Within an 11-month period, frontline care givers in 100 neonatal intensive care units in nine states were able to reduce central line associated bloodstream infections (CLABSIs) by 58 percent through careful implementation of the Comprehensive Unit-Based Safety Program (CUSP).

The CUSP model, developed by a team at Johns Hopkins Medicine and funded by AHRQ, helped care givers focus on better communication as well as the safe catheter insertion guidelines set forth by the Centers for Disease Control and Prevention.

“The CUSP framework brings together safety culture, teamwork and best practices—a combination that is clearly working to keep these vulnerable babies safer,” says AHRQ Director Carolyn M. Clancy, M.D. “These remarkable results show us that, with the right tools and dedicated clinicians, hospital units can rapidly make care safer.”

Before launching this effort, the overall infection rate in participating NICUs was 2.043 infections per 1,000 central line days.  By the study’s end, the CLABSI rate in these hospitals had fallen to 0.855 per 1,000 central line days, representing a 58 percent reduction in such illnesses.  Researchers estimate that implementation of these practices prevented at least 131 infections and 41 deaths and saved over $2 million in healthcare costs.

This initiative to lower CLABSIs in newborns is part of an even larger study involving use of the CUSP model to reduce CLABSIs in all patients nationwide. The encouraging results of a 41 percent decrease in these particular healthcare-associated infections in an adult population were announced last September.

To learn more about all of AHRQ’s projects to reduce healthcare-associated infections, including infant and adult CABSIs, click here.  Also available is the CUSP toolkit, developed from the national implementation project and used in the NICU project.

HC Pros Develop Unique Solutions to ‘Second Victim’ Problem

Health Leaders Media reported in an online article that due to the work of medical professionals like Albert Wu, MD, director of Johns Hopkins’ Center for Health Services and Outcomes Research, hospitals are finally changing the way they respond to the needs of healthcare providers affected by adverse events.

The Institute for Healthcare Improvement has suggested that when an adverse event occurs, a hospital has three basic priorities:

  1. To care for the patients and family members who are direct victims of the event;
  2. To care for the front-line healthcare workers involved; and
  3. To address the needs of the organization.

Every healthcare worker carries with him or her the risk of becoming a “second victim,” a term coined by Dr. Wu in an article written for the British Medical Journal in 2000.

Haunted by the repeat occurrences of bullying, gossip, and blame that for years he witnessed colleagues enduring in the wake of adverse events, Wu had a hard time comprehending the industry’s long-standing reluctance to address the emotional needs of staff linked to undesirable outcomes.

When we consistently punish each other for making mistakes, Wu explains, we are creating an environment where everyone is afraid to talk and where that silence just leads to repeated mistakes and more bad outcomes.  On the contrary, Wu says errors need to be widely talked about so that true learning can happen.

According to Wu, hospitals not only have an ethical obligation to help personnel heal in these situations, but he alludes to the existence of a fiscal responsibility as well.  Wu points out that having to replace a burned out second victim can be very expensive, sometimes costing a hospital in excess of $100,000.

Susan Scott, RN, patient safety officer at University of Missouri Healthcare discovered just how critical empathy and dialogue are when it comes to helping second victims cope.  Inspired by Wu’s research and overwhelmed by the pain and defeat that she sensed over and over again in interviewing physicians following adverse events, Scott pioneered the hospital’s forYou Team, one of the first-ever organized systems for reaching out to emotionally distressed care givers.

Since Scott’s team’s establishment, the hospital has trained 99 volunteers to deliver “emotional first aid” to at least 639 second victims, and it’s important to note that many of the team’s volunteers have been second victims themselves. This fact is significant because one of the issues that Scott discovered in building her program is that second victims want to be able to talk to people who know what it’s like working in a hospital. This sort of empathy is exactly what makes this method so different from traditional employee assistance programs which typically are managed by outside professionals.

Scott also acknowledged that not all bad outcomes necessarily happen as a result of errors, but they could lead to errors down the road if not properly dealt with.  The unexpected death of a patient or even a colleague can place tremendous stress on staff.  In fact, she cited a devastating situation in which a young surgery technician experienced leg pain one  morning, suffered a pulmonary embolism that afternoon and died the very next day, but sadly, the story did not end there.  That young tech’s own team had the job of harvesting her organs for transplant.  A story like this one can only reinforce the notion that helping second victims work through traumatic experiences with the potential for leaving an unhealthy psychological imprint is a key step in building a stronger healthcare system with fewer medical errors.

Under Wu’s leadership, Johns Hopkins launched a similar program in 2011 called the RISE (Resiliency In Stressful Events) Team. This team of about 30 volunteers was begun specifically for pediatric caregivers and was partially funded by the Josie King Foundation.  Today, similar programs are in the works at hospitals including Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center in Boston and at Stanford University Hospital in California.

To learn more about efforts to support second victims, click here.

HHS Announces Key Changes to HIPAA

The Department of Health and Human Services (HHS) released a final rule significantly strengthening privacy securities for patients’ protected health information (PHI) as established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

“Much has changed in health care since HIPAA was enacted over fifteen years ago,” said HHS Secretary Kathleen Sebelius.  “The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age.”

The 563-page “omnibus rule,” as the rule has been tagged due to its breadth, not only provides fortified protections for patients, but it makes it easier for the government to enforce the law.  In addition, the rule also establishes new privileges regarding access to one’s own health information.

The announced changes and enhancements represent the most momentous modifications since the HIPAA Privacy and Security Rules were first implemented.  Until now, these rules were typically directed toward healthcare providers and insurers, but with the new provisions in place, business associates of those entities, including all contractors and subcontractors, will need to be on their toes when it comes to the handling of patients’ PHI.

The penalties for privacy breaches will be determined according to the level of negligence shown by the offender with higher levels of negligence yielding much higher fines.  Offenders can now face fines of up to $1.5 million per violation in the case of a breach.

The Omnibus Rule gives patients even more control over how and by whom their personal health information is used.  Patients can request electronic copies of their electronic medical records, and when paying with cash, patients can even dictate that a provider not share information about their treatment with their health plan.  The rule also sets new parameters for appropriate use of health information for marketing, fundraising and research purposes, and it prohibits the sale of a patient’s health information without his or her permission.

The Omnibus Rule is scheduled for official publication in the Federal Register on January 25, and it will become effective on March 26, 2013.  Compliance will be required 180 days later on September 21, 2013.

To learn more about the Omnibus Rule, click here to read the press release distributed by HHS.

2012’s Top Tools Foster Safe Start for New Year

As we have welcomed in 2013, with all the anticipation and hope that a new year brings, we have taken a moment to look back at the many resources designed over the last year to advance quality and patient safety across the healthcare industry.  In doing so, we identified ten emerging tools that certainly do not need to be packed away as mere mementos of a year gone by but utilized to their fullest in the years to come.  If you are not familiar with the following tools and resources, introduced in 2012, we encourage you to follow the provided links to learn more about implementing these devices.

Always Events ® Tool Box

Picker Institute’s Always Events® Tool Box contains specific instruments and strategies for meeting patient- and family-centered care goals based on the idea that certain practices should always be performed, no matter what the circumstance, when tending to the needs of patients in any healthcare setting.  These aspects of the patient and family experience have been termed “Always Events.”  This tool box contains recommendations for all kinds of situations where careful interaction is required including: discharge, medication management, ambulatory care, communication and transitions of care.  To learn more about the Always Events Tool Box, click here.

Ask Me 3™

Ask Me 3™ is a patient education program set forth by the National Patient Safety Foundation to promote clear communication between healthcare providers and patients.  The program is based on research indicating that outcomes are improved when patients have an understanding of the answers to three simple but significant questions:

  •  What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

The better patients understand their conditions and the instructions being set forth by their healthcare providers, the fewer mistakes they make in taking prescribed medications, preparing for medical procedures and managing chronic conditions.  To learn more about patient engagement by watching NPSF’s Ask Me 3 video, click here.

CUSP Toolkit

The Agency for Healthcare Research and Quality’s Comprehensive Unit-based Safety Program (CUSP) Toolkit helps doctors, nurses and other clinicians work together to successfully identify and solve issues that threaten the safety of their patients.  This program focuses on best practices with consideration of the science of safety, improved safety culture and an increased emphasis on teamwork.  The CUSP Toolkit was created for clinicians by clinicians and is customizable to meet individual unit needs.  Teaching tools and resources include facilitator notes as well as presentation slides and videos.

The program was used in implementing a nationwide patient safety initiative titled, On the CUSP: Stop BSI, which decreased the number of central line-associated bloodstream infections (CLABSIs) in participating intensive care units by 40 percent.  Preliminary results indicated that the endeavor prevented 2,000 CLABSIs and saved more than 500 lives and $34 million in health care costs.

HF Checklist

Dr. Abhijeet Basoor’s 27-question heart failure discharge checklist includes even the simplest reminders to instruct patients concerning diet, weight, blood pressure monitoring and appropriate drug dosage all of which support proven management practices for heart failure patients.  Research presented at the American College of Cardiology’s 61st Annual Scientific Session indicated that use of Dr. Basoor’s checklist reduced the 30-day readmission rate following a cardiac event from 20 percent to only 2 percent.  To download Basoor’s Heart Failure Checklist, click here.

 MATCH Toolkit

AHRQ’s Medications at Transitions and Clinical Handoffs Toolkit  helps reduce the number of adverse drug events occurring in hospitals.  The MATCH Toolkit, which includes a corresponding workbook, provides step-by-step instructions for improving medication reconciliation at every point in the process, from obtaining support from hospital leadership, to planning, testing, implementation and evaluation.  To download the MATCH Toolkit (PDF), click here.

NAHQ’s Call to Action

The National Association for Healthcare Quality’s white paper, Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems  is a must read. The paper supports formation of a strong and just safety culture that offers a protective infrastructure empowering all clinical professionals to share the responsibility of eliminating preventable harm in the nation’s healthcare system.  NAHQ’s Call to Action is intended to promote the advancement of care quality and patient safety and to protect the integrity of the process for reporting and evaluating issues while raising awareness of the need for improvement among leaders and policymakers.  The report, which is the culmination of more than a year’s worth of work by volunteers, leaders and partnering organizations, came after a 2010 straw poll of NAHQ members revealed that three out of four respondents had personally experienced ethical or professional concern after having brought attention to a quality or safety issue or risk. To download a copy of NAHQ’s Call to Action (PDF), click here.

One and Only Campaign

Since 1999, more than 125,000 patients in the United States have been notified of potential exposure to hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV due to unsafe injection practices.  Many of these incidents involved healthcare providers reusing syringes, resulting in contamination of medication vials or containers which were later used on subsequent patients.

Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC) are partnering to ensure that every injection administered to patients is a safe injection.  The One & Only Campaign is a public health initiative aiming to empower patients to ask questions and simultaneously re-educate healthcare professionals regarding safe injection practices.  To learn more by watching the campaign video, Safe Injection Practices: How To Do It Right, click here.

Pharmacy Survey Toolkit

A Pharmacy Survey Toolkit is available to pharmacies interested in evaluating the patient safety culture in their facilities.  The toolkit includes a 36-item survey form, which measures 11 areas of patient safety culture, including physical space and environment, patient counseling, communication about prescriptions across shifts and teamwork.  The kit also includes a survey user’s guide as well as  results from surveys conducted in 55 pharmacies during the survey’s 2012 pilot study.  Click here to download toolkit components.

Quality Indicators™ Toolkit Roadmap

The AHRQ Quality Indicators™ Toolkit Roadmap is designed to provide further understanding of AHRQ’s 17 Patient Safety Indicators and 28 Inpatient Quality Indicators by facilitating easy access to needed tools as well as support for use of these tools in improving quality and patient safety in hospitals.  The Toolkit Roadmap charts the tools available to support a hospital’s work in each of the sequence of improvement steps from “Determining Readiness to Change” to “Using Other Resources.”  The roadmap gives a brief description of each tool and identifies additional relevant information as well.

Scrub-the-Hub Protocol

The CDC’s scrub-the-hub protocol to protect dialysis patients from infections includes checklists and audit tools to implement CDC recommendations, including hand hygiene, hemodialysis catheter connection and disconnection, hemodialysis catheter exit site care observations, arteriovenous fistuala/graft cannulation and decannulation observations.


TeamSTEPPS®, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, was jointly developed by AHRQ and the United States Department of Defense.  This evidence-based teamwork system was created for healthcare professionals and offers a set of ready-to-use materials and a training curriculum rooted in 20 years of research.  Ultimately, TeamSTEPPS® aims to transform culture through the formation of highly effective medical teams that optimize the use of information, people and resources to achieve the best outcomes for patients.  To learn more about this three-step process for developing a culture of teamwork, click here.