The healthcare industry was rocked by yet another series of studies and reports saying that everything from hospital-acquired infections to medication errors are killing thousands of patients each year-but this time patient-safety experts placed the task of fixing things with healthcare administrators, not clinicians. They urged senior-level healthcare executives to take infection control and nurse-staffing issues more seriously and to support the creation of a national databank on medical errors.
"We're past the point of just blaming the doctors," said David Schulke, executive vice president of the American Health Quality Association. "Management has a responsibility, and management has to take action to make sure quality problems don't occur."
"These things smolder for years and then they burst into flames, and I think that's what happened (last) week," he said.
First, the Joint Commission on Accreditation of Healthcare Organizations put senior healthcare executives on the spot to prove they're committing the attention and the money necessary to get the long-hidden scourge of hospital-associated infections under control.
Elaborating on a revised set of standards for infection control, which go into effect in January 2005, the accrediting agency said last week that it wanted to elevate the issue to a major patient-safety priority. And it laid responsibility for effective prevention and management at the feet of hospital leadership.
Declaring that hospital workers and patients "live in a sea of germs," JCAHO executive Robert Wise acknowledged that infectious agents in the hospital setting cannot be eradicated entirely. "There's a certain noise level (of microbial growth) that's always there," said Wise, vice president of the agency's division of standards and survey methods. "You'll never get rid of these infections."
But infection-control managers must have more authority and cooperation from all areas of the hospital, including the executive suite, to track outbreaks and implement measures to keep infections from spreading, he said.
The American Hospital Association applauded the push for more executive involvement and said the revised standards would help institutions comply with accreditation demands. That's because they're less prescriptive and rigid than previous approaches by the JCAHO.
"It fits philosophically with the intent of making infection control everyone's business," said Judene Bartley, an infection-control consultant to the AHA.
Like medical errors before it, the significance of controlling hospital-associated infections is increasing among hospital executives as the impact on patient safety and cost to their institutions becomes clearer, Bartley said. But an investigation of how to strengthen accreditation standards found that hospital leadership needed a nudge, Wise said.
In interviews with hospital infection-control professionals and others, the JCAHO found a lack of support and appreciation for infection-control activities. Managers responsible for tracking and controlling infectious agents felt "disconnected from the leadership of the organization, which means they feel disconnected from resources, from authority," Wise said.
At an infection-control conference last week, the JCAHO rolled out additions to existing standards that specifically require hospital leaders to allocate adequate resources, including information systems, laboratory support and staff, to meet the goals of a written plan of attack. "There is a difference (between the existing and revised standards), and the difference is the emphasis on where the buck stops," Wise said.
The conference also highlighted some of the first hard evidence of the extra expense and hospital days that could be saved by preventing hospital infections. In a study published earlier this year in the journal Clinical Infectious Diseases, such infections added an average of 10 days and $15,275 to the hospital care of a patient in the intensive-care unit of Cook County Hospital, Chicago, during 1998.
Low-cost computerized surveillance systems are starting to show evidence of reduced infection rates and financial benefits. For a startup cost of $175,000 in software and labor, Lakeland Medical Center in New Orleans reported saving $1 million in 2002. That included reducing the incidence of infections by 19% and trimming $1,500 per case from the cost of infection-related care by catching incidents earlier. Gerald Fornoff, chief executive officer of the 156-bed hospital, said any program that saves money "makes business sense" and will elevate infection control as a priority.
"We have only so many dollars, we have to keep the doors open and we have to make money off sick people," he said.
Elderly at high risk
Meanwhile, if an infection won't kill you, a medication error might. Confirming fears expressed in a recent Institute of Medicine report on nursing conditions, a study by a medication-safety advocacy group said elderly patients in hospitals are exposed to significantly more harm from medication errors than the population at large. More than one-third of the errors reaching a patient involved a hospitalized patient 65 years old or older, according to an analysis of more than 192,000 errors reported to the safety group's database last year. More than half of all cases resulting in death involved patients in that age group.
The findings, released last week by a unit of U.S. Pharmacopeia, reinforced conclusions in a Nov. 4 IOM report on nurse working conditions that found a pattern of distractions, long hours and fatigue among nurses is bound to cause errors, said Diane Cousins, vice president of U.S. Pharmacopeia's Center for the Advancement of Patient Safety.
The detailed findings, using information volunteered from 482 hospitals, arrived just as the IOM issued another patient-safety report, this one highlighting the need for HHS to establish a national database of anonymous patient information. The databank would be used to develop new interventions to prevent errors and improve safety.
That IOM report on how data standards improve patient safety, issued Nov. 20, also called on Congress to fund continuing HHS efforts to forge a public-private partnership on adopting commercial standards for creating, analyzing and reporting clinical information.
"What's first (in priority) is to get the data, and to get it in a standard format so you can look at the data in aggregate," said Paul Tang, chairman of the committee that wrote the IOM report.
An analysis of data reported to U.S. Pharmacopeia's database showed that caregiver workload issues affecting all patients are compounded with geriatric patients, who often have deteriorating body functions, multiple illnesses and various medications, Cousins said.
But problems involving flaws in systems set up for care, insufficient staffing and workload may be setting up caregivers error, Cousins said. Nearly half of the reported causes of error among geriatric patients involved failure of a caregiver to do something he or she was capable of doing. By comparison, 37% of errors overall were traced to such cases of "performance deficit." Another 26% of errors affecting the elderly were attributed to failure to follow a procedure or protocol for giving a medication, compared with 17% for all patients.
Besides citing the error potential of long hours and resulting fatigue, the IOM report on the work of nurses criticized hospitals for reducing continuing education when patients with higher acuity levels and new technology and care techniques require nurses to keep straight increasingly complex tasks (Nov. 10, p. 8). Errors involving the route or technique for administering medication caused 14% of harmful errors among seniors, though they represented only 3% of all errors.
Culture of safety needed
And what are providers supposed to do? According to an expert panel commissioned by the Leapfrog Group to rate the relative worth of safety initiatives, creating a culture of safety and ensuring an adequate nursing workforce will go a long way toward making hospitals a perfectly safe place for patients. To be exact, achieving those two objectives will go 38.2% of the way, judging from the weight assigned to them and to each of 25 other safe practices as part of a proposal for scoring hospitals on adherence to established patient-safety standards.
The Leapfrog Group, a business coalition campaigning for patient-safety practices, distributed for comment last week a list of point values for each of 27 safety practices endorsed by the National Quality Forum, a consensus-building group representing consumers, health plans, healthcare purchasers and providers. Leapfrog announced plans last month to use a weighted scoring system to expand its safety evaluation efforts (Oct. 20, p. 8). The coalition currently promotes standards for only three practices: computerized ordering by physicians, deployment of specialists in intensive-care medicine and evidence-based referrals for certain kinds of high-risk care.
The new reporting program adds up a hospital's self-reported performance in all 27 areas to determine its overall score, which will be made public on the Leapfrog Group's Web site, leapfroggroup.org, next spring. A perfect score is 1,000. According to the panel's report, which is posted on the Web site, hospitals would need three days to research the answers and about an hour to complete the survey online.
Within the assigned number of points for each safe practice, a hospital can earn partial credit in four areas: awareness of the safety issue, accountability of leadership, ability to put the practice in place and action toward closing gaps in performance. For example, creating a healthcare culture of safety by itself carries a possible 263 points, with proportional credit possible for each of the four stages of progress. At the opposite extreme, vaccinating workers against influenza would be worth 11 points.
The 34-page list of requirements to contend with is "a little overwhelming" and compliance with some practices can get too prescriptive, said Merrilee Newton, administrative director of quality for Alta Bates Summit Medical Center, Berkeley, Calif. But most practices constitute what hospitals should be doing, she said, and the survey bodes well for institutions taking patient safety seriously. "It's quite frankly basic medicine 101," Newton said. "This is a test I'd like to take, because we'd get an A+."